Don't Forget the Fomites as Face-to-Face Care Ramps Up

Diana Swift

June 19, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

As nonurgent outpatient care reverts from telemedicine to in-person consultations, many practices are focusing on measures to prevent respiratory transmission of SARS-CoV-2, the virus that causes COVID-19. But experts emphasize that clinics shouldn't ignore the role fomites can play in transmission.

Never was this more evident than in an outbreak at a university hospital in Durban, South Africa, which ran rampant across several wards and the intensive care unit (ICU), as well as in a nearby nursing home and a dialysis center.

From March 9 to April 30 of this year, 119 confirmed cases were identified at the 469-bed Netcare St. Augustine's Hospital. The outbreak likely began with the visit of a single SARS-CoV-2–infected patient to the emergency department (ED) on March 9. From that patient, the virus spread to another ED patient who was later admitted to the cardiac ICU. The frequent movement of patients between and within wards facilitated the rapid nosocomial spread, according to a lengthy external study of the outbreak, led by Richard J. Lessells, MB ChB, PhD, an infectious disease specialist at the KwaZulu-Natal Research Innovation and Sequencing Platform at Nelson R. Mandela School of Medicine in Durban.

Lessells and colleagues found no evidence that aerosol transmission — which might have been inhibited by masks and distancing — contributed to the outbreak. Rather, it spread principally from hand-to-hand contact and from high-touch shared items of equipment, such as thermometers, blood pressure cuffs, and stethoscopes.

The authors noted that although SARS‐CoV‐2 can be highly stable on certain surfaces, particularly plastic and stainless steel, it responds to standard disinfection techniques.

"The main lesson learned is that, as we should know, infection prevention and control [IPC] involves a hierarchy of measures, including administrative, environmental, and personal protective equipment, and that personal protective equipment in itself is not a substitute for weak infection prevention and control systems and practices," Lessells told Medscape Medical News. "This virus spreads very easily and quickly in a healthcare environment and will exploit any gap or weakness in your IPC."

The outbreak highlighted the importance of physically separating people who might have COVID-19 from those who probably don't have it and of rapidly isolating people who develop symptoms compatible with the infection.

"It also highlighted the importance of fomite transmission with this virus and the need to ensure regular cleaning and disinfection of common-touch surfaces and patient-care items between each use," Lessells added. He stressed that attention must be paid to all the measures across the IPC hierarchy.

Another key lesson learned was that there is clear risk of transmission between healthcare workers where physical distancing is challenging. "We've seen outbreaks that seem to be associated with transmission in common areas when masks are off, in tea rooms, changing rooms, and crowded transport to and from the hospital," Lessells said. "Unfortunately, we can't switch off at any stage. We have to remain vigilant at all times, and we must try to change our practices to reduce the risks in all these situations."

St. Augustine's adopted all of the report's recommendations, including logistical restructuring so as to provide separate entrances and separate red, yellow, and green zones. Most South African facilities in the private and public sectors have also adopted these recommendations. The zone system, which was pioneered by Asian countries during the SARS epidemic of 2002–2003, separates people in accordance with whether they are confirmed to have COVID-19 (red zone), are being investigated for the infection (yellow or orange zone), or are without COVID-19 or are very unlikely to have it (green zone). "So then you have a separate entrance to the green zone to that for the yellow and red zones and, ideally, separate flow around the hospital to avoid contamination. But this can be challenging," Lessells said.

Standard Disinfection Sufficient

He doesn't foresee, however, a need for expensive and time-consuming disinfection technologies, such as the robotic ultraviolet light zappers and disinfectant foggers used to keep nosocomial pathogens such as Clostridium difficile at bay. "The cleaning and disinfection required for SARS-CoV-2 is actually very standard and straightforward; it just needs to be done well," Lessells said. "There's no evidence that these add anything, and we worry that these might make cleaners less likely to do the basics properly."

As offices reopen in the United States, some primary care physicians may worry about whether they have the resources to meet the standards for cleaning that are followed in hospitals. But infectious disease specialist David J. Weber, MD, MPH, a professor of medicine, pediatrics, and epidemiology at the University of North Carolina at Chapel Hill (UNC) School of Medicine, says the costly, time-consuming, high-tech sanitization equipment, which is not generally available outside of hospitals, is unnecessary, although his center does use them for rooms vacated by known COVID-19 patients.

For the most part, old-fashioned elbow grease works well, but efforts must entail disinfection, not only physical cleaning. "In our system, the physical environment and shared items such as computers are regularly and rigorously cleaned and wiped down by well-trained cleaning staff with a disinfectant approved for emerging viral pathogens by the Centers for Disease Control and Prevention," said Weber, who practices in the UNC hospital system and is also a fellow of the Society for Healthcare Epidemiology of America. "Cleaning alone does not disinfect and may actually spread germs around."

UNC hospitals also use an audit approach in which an invisible fluorescent dye is randomly applied to environmental surfaces to be cleaned. "The dye shows up under black light, and supervisors can see what spots cleaners have missed and can give immediate, just-in-time coaching to the cleaning staff," said Weber. Data from these audits are reviewed by an IPC committee each month. Staff hand hygiene is also monitored in both inpatient and outpatient settings, and the observations are recorded, although these monitoring procedures might be more difficult in a small clinic or a stand-alone practice.

In addition to daily screening of staff, all patients and all people who accompany or visit patients must be screened. Those whose temperatures are elevated are sent to a diagnostic center. If they need urgent care, they are then sent to the ED. All must wear medical-grade masks and use hand sanitizers or soap and water as necessary.

"We need to follow standard CDC and WHO infection control guidelines, and if we do that rigorously, we protect patients, visitors, and healthcare personnel," said Weber. "This virus will be with us for some time, and there will be what I call a paradigm shift in the practice of medicine for months to come."

"Minimize the Risks"

Many practices now schedule wellness visits and sick visits separately, with wellness visits being conducted in the morning, and sick visits in the afternoon. Some practices use different locations for the two kinds of visits.

Ada D. Stewart, MD, FAAP, president-elect of the American Academy of Family Physicians, agrees that close adherence to recommended IPC standards is necessary to protect patients and staff from transmission via contaminated surfaces. "In addition to the usual office cleaning, we now clean thoroughly as patients leave consulting rooms. We constantly sanitize tables, chairs, door handles, light switches, phones, and computers during the day," said Stewart, who is lead family health provider at the Eau Claire Cooperative Health Center in Columbia, South Carolina. "And we now use disposable pens and toss them out after each use."

One casualty of the pandemic is the atmosphere in the clinic's once-welcoming waiting room, which used to offer abundant reading materials and play items.

Except for a 2-week period in March following a COVID-19 exposure, Stewart's facility has remained open. About 50% of their consultations are in person, and 50% are via telehealth. So far, the redoubled sanitization efforts have been successful. "Just make sure you follow the official guidelines and make sure all areas of staff and patient congregation are kept safe," Stewart said.

Added Lessells, "As with life more generally, we're not going back to what we considered normal before COVID-19, so we must find a new normal where we minimize the risks of virus transmission in all settings, particularly healthcare settings. People should not be alarmed by things being different but should be reassured that measures are being put in place to minimize the risk of them and others being infected."

Available Resources

As offices reopen for in-person consultations, doctors can find guidance on preventing transmission at the following sites.

From the CDC:

Reopening Guidance for Cleaning and Disinfecting Public Spaces, Workplaces, Businesses, Schools, and Homes

Guidance for Cleaning and Disinfecting

From the American Academy of Family Physicians:

COVID-19: Guidance for Family Physicians on Preventive and Non-Urgent Care

From the US Department of Labor:

COVID-19

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