The Brave New World of Engineered Infection Prevention (EIP)

By Barry Hunt, co-founder of the Coalition for Community and Healthcare Acquired Infection Reduction (CHAIR)

Manually disinfecting a patient room once a day with chemicals to prevent Healthcare Acquired Infections (HAIs) is like putting up an umbrella for five minutes in a hurricane and expecting not to get wet. For over 100 years, this has been the standard approach, but it simply doesn’t work. What does work is Engineered Infection Prevention (EIP) – a system of materials, technology and automation designed to continuously reduce exposure to harmful microorganisms. EIP maintains contamination levels below the Minimum Infectious Dose (MID) – the threshold at which microorganisms are unlikely to cause infection. With EIP, an umbrella isn’t needed if the rain is eliminated entirely.

Why Engineered Infection Prevention?

Figure 1: Example contact plates showing typical healthcare surface contamination levels that demonstrate TCL typically achieved with copper and/or Auto GUV. 3

At its core, EIP is about maintaining contamination levels below the MID. Research shows that keeping surface contamination below one colony-forming unit per square centimeter (CFU/cm2) reduces infection risk to less than one in a million. 1 Canadian colleagues in the Coalition for Community and Healthcare Acquired Infection Reduction (CHAIR) have taken this a step further, establishing Target Contamination Levels (TCLs) for different environments in a healthcare setting (see Figure 1): 2

  • Surfaces: <0.5 CFU/cm²
  • Air: <5 CFU/m³
  • Water: <5 CFU/ml

Why Traditional Cleaning Falls Short

Figure 2: Concept sketch of daily contamination level of surfaces comparing manual disinfection to EIP CHAIR disinfection and recontamination model 9

Healthcare surface contamination levels typically are 10 to 1,000 CFU/cm2 throughout most of the day. 4, 5 Manual cleaning and disinfection by environmental services staff only treats about 25% of high-touch surfaces, with 75% left untouched. 6 That 25% doesn’t stay pathogen-free very long, as it’s rapidly re-seeded from dry surface biofilms 7, 8 or re-contaminated by touch or bioaerosols floating in the air. By contrast, EIP maintains safe contamination levels around the clock. These contrasting cycles are shown in Figure 2.

A Bundled Approach to EIP

Figure 3: Clockwise from upper left: Fan-assisted Upper Air GUV Disinfection device; Plasma-activated water (PAW) self-disinfecting sink; Copper-infused solid-surface countertop/copper-infused solid-surface overbed table/copper-coated IV pole; AutoGUV air and surface disinfection device

EIP relies on four key technologies, designed to work together (see Figure 3): 10

  1. Continuous upper air disinfection
  2. Self-disinfecting sinks
  3. Self-disinfecting surfaces
  4. Automated self-disinfecting whole-room systems

The good news? These solutions can be retrofitted into existing facilities or integrated into new construction projects.

Game-Changing Technologies in Action

Continuous Upper Air Disinfection

Bioaerosols (i.e., tiny airborne particles containing bacteria, viruses and fungi spread by breathing or movement) are major contributors to disease transmission. Bioaerosols are in constant circulation, open to being ingested, inhaled or deposited onto mucous membranes. Bioaerosols found inside healthcare facilities are more infectious and more drug-resistant than microorganisms found outside of healthcare. Even small snippets contain the drug resistance and virulence genetic codes that can be shared with other organisms in healthcare settings, further complicating their spread. 11

Figure 4: Schematic of a fan-assisted Upper Air UV device showing air circulation and disinfection field

In contrast, Upper Air GUV systems and Far UV devices (see Figure 4) are designed to stop their reproduction, neutralizing their infectious capabilities before they reach occupants’ breathing zones. These solutions outperform traditional isolation rooms at lower costs while offering universal airborne protection. 12

The European Organization for Nuclear Research (CERN) recently added GUV to the World Health Organization (WHO) Airborne Risk Indoor Assessment (ARIA) tool, 13 based on “a conservative estimate of 184 eACH” achieved from its use, while acknowledging results “could be 10-fold higher.” Accordingly, CERN has recommended widespread adoption of GUV in Europe, based on the cost-benefit analysis. 14

Figure 5: Left: Schematic of five 11 W UV222 ceiling fixtures; Right: Graph demonstrating rapid inactivation of bioaerosols in steady-state condition. 20

As an example, patient room air typically contains contamination levels of 50 to 500 CFU/m3 or more. 15-17 A recent study showed that just five 11 W Far UV lamps can maintain near-zero levels when tested against pathogen levels of 2,000 CFU/m3 at 3 ACH 18 in such a patient room 19 (see Figure 5).

Self-Disinfecting Sinks

High-mortality infectious water-loving pathogens, like Carbapenemase-producing organisms and Candida auris, thrive in sink drains and biofilms. Self-cleaning sinks equipped with Plasma Activated Water (PAW) eliminate these threats by disinfecting mixing valves, faucets, sink bowls and drain traps. 21-24

Self-Disinfecting Surfaces

High-touch surfaces, including overbed tables and bed rails, may be touched more than 100 times a day, posing a significant threat of exposure to pathogens. 25-30 Overbed tables rarely are cleaned and disinfected during the patient’s stay. 31 Copper, copper coatings and copper ion-infused plastics or solid surfaces can provide continuous disinfection requiring only daily cleaning. In a major RCT across three major hospitals, copper surfaces reduced ICU infections by 58%. 32 A hospital-wide study of copper bed rails, overbed tables and counters demonstrated a 78% reduction in HAIs. 33

Automated Self-Disinfecting Whole-Room Systems

Figure 6: Contact and settle plates sampled at random times in a hospital bathroom equipped with AutoGUV show that TCL <0.5 CFU/cm2 typically is achieved when door-closing compliance upon exit is as low as 25%. 42

Bathrooms are responsible for nearly 50% of HAIs due to bioaerosols released during flushing or handwashing that can float and travel for hours. 34-38 Often found in bathrooms, pseudomonas is the leading HAI, and C. difficile and VRE remain a major scourge in healthcare. Automated GUV self-disinfecting whole-room systems can disinfect entire rooms quickly and effectively, reducing airborne pathogens below recommended TCL levels before they settle on surfaces or clothing (see Figure 6). 39-41

The ROI of EIP

Figure 7: CHAIR Concept Estimated Savings Calculator Model demonstrating key assumptions to test and validate.

Investing in EIP infrastructure offers significant returns to the healthcare system: lower employee absenteeism, reduced labor costs, fewer chemical expenses, lower infection rates, shorter hospital stays and increased bed availability. Over its lifecycle, EIP in healthcare can deliver up to a 100-fold ROI while improving outcomes for patients and staff alike (see Figure 7). 43

Preventing Community Acquired Infections

The biggest bang for the buck comes when EIP is implemented in high-occupancy spaces, like waiting rooms, cafeterias and break rooms, where airborne exposure is highest and personal protective equipment use is lowest. Further, EIP can be applied to all public spaces, including schools, office buildings, restaurants and public transit. By broadening the scope of EIP implementation, companies can create healthier communities across all sectors.

The Bottom Line

Thousands of people are infected every day in hospitals and hundreds die. So, what would stop the fast-tracking of the adoption of this brave new EIP world? It’s not the science or engineering. It’s not the ROI. It’s us. We’re human and like to keep on doing what we’ve always done. It feels safe, and that makes change hard. Until EIP becomes the norm, we have to be brave – leaders, educators and heroes.

Barry Hunt pioneered Engineered Infection Prevention (EIP) in 2009 and co-founded the Coalition for Community and Healthcare Acquired Infection Reduction (CHAIR) in 2014. EIP was named a Top 10 World Patient Safety Innovation by the Patient Safety Movement in 2017. This article explores how EIP can revolutionize infection prevention not just in healthcare but across public spaces like schools, daycare and restaurants. By embracing these innovative solutions, safer environments can be created for everyone. For more information on EIP, contact CHAIR at www.chaircoalition.org.

This column regularly provides insight into activities related to Healthcare Disinfection.

References

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  1. CHAIR Concept Estimated Savings Calculator Model. Available upon request at chaircoalition.org

 

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