Abstract
Hygiene of hands, surfaces and laundry, among others, are important to prevent the spread of infection, particularly for more fragile populations such as the very young, the elderly and those who are immunocompromised. Increasingly, patients are quickly released from the hospital into home settings, where they also require protection against food borne and other infections. Nancy Goodyear of the Department of Clinical Laboratory and Nutritional Sciences, University of Massachusetts Lowell, examines the increasing need for Infection Prevention and Control (IPC) in home healthcare and some of the problems that need to be tackled.
As healthcare costs rise, hospitals seek to discharge patients as quickly as possible. Patients requiring assistance during their home recovery may enlist the services of home healthcare aides or nurses. While home healthcare nurses perform more specific medial care, home healthcare aides assist with a wide range of tasks, including wound care, personal hygiene, daily living activities, and light cleaning of bathrooms and kitchens. While home care may be more cost-effective than hospital care and more comfortable for the patient, this creates a situation in which a particularly vulnerable population can be exposed to infectious agents transmitted in the home. Patients may carry pathogens out of the hospital into the home environment, and other family members or visitors may bring pathogens into the home from other sources. Home healthcare aides may visit multiple patients in a day, creating the potential for the spread of pathogens between clients. Shang et al. reported a 3.5% infection rate in more than 7,000 home healthcare patients. 1
Scott et al. identified potential pathogens on home surfaces (unrelated to hospitalisations), including methicillin resistant Staphylococcus aureus, Pseudomonas aeruginosa and faecal coliforms. 2 Transmission of pathogens between family members has been documented. 3 Therefore, cleaning and disinfection in the home, particularly in home healthcare situations, is a critical component of effective infection control.
In hospital settings, the cleaning and disinfection of environmental surfaces is a recognised component of a comprehensive infection control programme. The Centers for Disease Control and Prevention publish guidelines and standards for cleaning and disinfection of healthcare environmental surfaces. 4 Healthcare facilities may also adopt methods for ensuring the effectiveness of their cleaning and disinfection programme, including staff training and monitoring programmes using adenosine triphosphate (ATP) luminometers, fluorescent dyes and other means.
In the home, there are no guidelines or standards for cleaning and disinfection. Home healthcare aides may not receive training or guidance from their employers, and are subject to the requests of their clients. The determination that a surface is clean is generally made either visually (if no dirt is visible, the surface must be clean), or based on actions (if the surface has been dusted, wiped or vacuumed, it must be clean). The determination of adequate disinfection in the home is impossible: there is no way to determine if potentially pathogenic microorganisms remain on a surface with no visible soil.
Most home healthcare aides perform light cleaning of the kitchen and bathroom during their visits. 5 Home healthcare aides and their clients may not understand the difference between cleaning and disinfection, the impact of surface soil on disinfectants, the significance of pathogens, how pathogens are transmitted, or proper food handling techniques. Home healthcare aides and clients may believe that they should strive to kill all ‘germs’ in the home environment. The concepts of non-harmful microorganisms on home surfaces or targeted disinfection of high-risk surfaces may be completely foreign. Most home healthcare aides and their clients are likely to get their information about cleaning and disinfection from a combination of marketing, advertisements, word of mouth and familiarity.
The desire for safer cleaning and disinfection products is understandable. Some conventional cleaning and disinfection products, including bleach and quaternary ammoniums, have been linked to occupational asthma and respiratory irritation, as well as dermal irritation and contact dermatitis. 6 Home healthcare clients may already have respiratory diagnoses like asthma or chronic obstructive pulmonary disease, or they may be more vulnerable to respiratory irritation. Home healthcare aides have frequent exposure to cleaning and disinfection chemicals, including bleach, and are therefore at risk for occupational asthma. 6 The desire to eliminate the risk of infection may result in shifting the risk to the adverse respiratory and dermal effects of conventional cleaning and disinfection agents. The ideal alternative would be both safer for the health of the users and effective in eliminating pathogens.
Those seeking purportedly safer ‘green’, ‘natural’ or ‘do-it-yourself’ (DIY) products have an increasing number of products to choose from. Products containing hydrogen peroxide, plant essential oils, vinegar, and castile soap may be perceived to be better choices than traditional bleach or quaternary ammonium-based products. While many alternatives are available, their effectiveness for either cleaning or disinfection is not well studied. A few studies have evaluated the disinfection effectiveness of alternatives such as DIY products like vinegar or vinegar mixes and commercial ‘green’ products.7,8 Cleaning effectiveness is evaluated in even fewer studies. 8
An additional consideration for alternatives is their true hazard. Just because a product is natural, it does not mean it is necessarily safer. Essential plant oils such as tea tree oil are complex mixtures that have been shown to have antimicrobial activity, but they can also cause dermatitis. 9 Tea tree oil and other plant essential oils, along with undiluted distilled white vinegar, have a very strong odour, which may, at the least, cause respiratory irritation. Metals such as silver and copper are antimicrobial, and silver nanoparticles are used in a variety of antimicrobial products; however, their safety is unclear. 10 In addition to cleaning and disinfection effectiveness studies, research on potential health effects is also essential.
One final consideration is that of how clean and how disinfected we should be. Vulnerable home healthcare patients may be at increased risk for infections and therefore home hygiene is critically important. As the number of home healthcare patients and aides increases, this becomes of greater importance to the general public health. However, the need to protect the respiratory health of home healthcare patients and the aides that assist them is equally important. Clearly, more research is needed to determine the effectiveness and health hazards of purportedly safer cleaners and disinfectants. Home healthcare patients and aides must be educated about the importance of proper hygiene and how to safely clean and disinfect critical surfaces in the home.