Waging the battle against COVID-19

At the beginning of the year, the world became aware of an outbreak of pneumonia of unknown cause in Wuhan, China. The source was identified as a novel (new) strain in the coronavirus family, which has since been named severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), and the illness that it causes is now known as coronavirus disease (COVID-19). 

Viral sequencing of this new strain suggests recent emergence from an animal source. Within just a few short months, the virus had spread to six of seven continents. The first case of COVID-19 in the United States was identified on Jan. 21, 2020. Within a month, the U.S. case count was in the thousands. On March 11, 2020, the World Health Organization (WHO) declared this outbreak as meeting the criteria for a pandemic. 

The situation continues to evolve, and the case counts increase daily. By the time this article goes to press, the situation will undoubtedly have expanded. As the experts learn more and more about this virus and the illness it causes, the recommendations will also likely change. 

While concerning, this outbreak can be controlled through basic infection prevention and control measures.

Family of viruses

Coronaviruses are not new. They are a large family of viruses that are common in people and many different animal species. They cause respiratory illness ranging from the common cold to more severe diseases like SARS back in 2003 and, more recently, Middle East Respiratory Syndrome (MERS). 

This new strain, genetically related to SARS-CoV (the virus that caused SARS), had not been identified in humans until now. It is spreading so readily from person to person because it is new and humans have no immunity to it. 

The primary way this virus is spread is through respiratory droplets when a symptomatic infected person coughs or sneezes. These droplets fall within 3-6 feet of the infected person. 

While there is some evidence of transmission from infected people before they become symptomatic, people are most infectious when actively ill. 

Additionally, it may be possible to get COVID-19 if a person touches a surface or object that is contaminated with the virus, then touches their mouth, nose or eyes, but this is not thought to be the main way that this virus is spread. Studies are being published at lightning speed and indicate that the virus can survive from several hours to several days. 

Finally, it’s important to point out that this virus is not spread through food or water.

Symptoms of COVID-19 illness are very similar to influenza and include fever, cough, muscle aches, fatigue and shortness of breath. The incubation period for the virus is longer than influenza and ranges from two to 14 days, but on average is four to five days. 

Influenza and COVID-19 illness come on more suddenly than the common cold, which tends to come on more gradually. Like influenza, COVID-19 illness can range from mild to severe. The vast majority of people (80%) will experience only mild illness and will recover uneventfully. People at high risk of complications from this disease tend to have more severe illness. 

These high-risk individuals include people over 60 years old and those with chronic conditions such as heart or lung disease and diabetes. Of the older population, those over 80 years old are at highest risk of complications from COVID-19. 

Currently, there is no specific treatment to cure COVID-19, and there is no vaccine, but experts are working on both. At press time, the global mortality rate for COVID-19 was approximately 4%, meaning that four in 100 infected people will die. 

These are average mortality rates and much lower in younger people. They are based on confirmed cases only, so they are dependent on how many people have been tested.

Infection control

By now, health care professionals should all be taking aggressive infection control measures and operating as if SARS-CoV-2 is already in their facilities and communities. To prevent and control infection, they must understand how infections spread. 

The chain of infection, made up of six links, demonstrates this nicely (see graphic above). Infection occurs when each link in the chain aligns. Fortunately, this chain is relatively easy to break. In fact, breaking just one link will stop transmission of even the hardiest and most infectious of pathogens. 

The first thing that can be done in health care settings to break the COVID-19 chain of infection is prompt identification and isolation of suspect cases. This means getting a mask on patients who present with signs and symptoms of respiratory illness as soon as possible. 

Other actions include frequent hand hygiene, covering coughs and sneezes, adhering to isolation precautions, proper donning and doffing of personal protective equipment (PPE), and frequent cleaning and disinfection of environmental surfaces. 

Health care personnel, including environmental services (EVS) staff, need to stay home if they are sick, and everyone should be practicing social distancing. The table above provides a description of each link in the chain of infection and provides actions that can be taken to break each link. 

The current guidance for isolation precautions for COVID-19 from the Centers for Disease Control and Prevention (CDC) is to wear a respirator, such as an N95 mask or higher respirator, gown, gloves and eye protection. 

A negative pressure airborne infection isolation room (AIIR) is not necessary to house a COVID-19 patient, but the door to the room should remain closed, according to the CDC guidance.

If respirator supply is low, their use should be prioritized. For example, wear a regular or surgical facemask for the routine care of COVID-19 patients, and reserve the respirator for higher risk tasks and procedures such as those that generate aerosols. 

Examples of such procedures include sputum induction for specimen collection, bronchoscopy and intubation of a patient for connection to a ventilator. In addition to wearing a respirator for such procedures, they should ideally be performed in an AIIR, according to the CDC guidance. 

Additionally, in the event of supply issues, facilities may implement extended use of masks and respirators. This means that staff wear the same mask for extended periods (e.g., an entire shift), changing it only if it is damaged or soiled. In this instance, gown and gloves are changed between patient rooms and hand hygiene is performed, but the mask or respirator and eye protection remain in place.

Staff should be very careful not to touch the PPE that is on their head. It is very important that PPE is donned and doffed properly to prevent inadvertent self-inoculation with the virus. EVS professionals should review the CDC’s guidance that can be found at www.cdc.gov/hai/prevent/ppe.html. The website also includes a very useful poster that can be reviewed with EVS staff and posted in the department for later reference.

Hand hygiene remains the cornerstone of infection prevention and is the most important thing that can be done to prevent the spread of infections. The CDC recommends using alcohol-based hand sanitizers with greater than 60% ethanol or 70% isopropanol as the preferred form of hand hygiene in health care settings to prevent the spread of COVID-19.

Washing with soap and water for 20 seconds also is acceptable. The moments for hand hygiene remain unchanged and include before and after patient contact, after contact with a contaminated environmental surface, when hands are visibly soiled, before eating and after using the restroom.

Cleaning and disinfection

EVS staff play a very important role in the prevention of disease transmission, and this virus is no exception. When carrying out their daily duties, EVS staff have many opportunities to break the chain of infection.

SARS-CoV-2 is an enveloped virus that is easily killed with approved disinfectants when used as directed (see graphic above). Because this is a new virus, EVS professionals will not yet see it listed on disinfectant product labels. 

Products approved by the Environmental Protection Agency (EPA) can be found by reviewing List N at the EPA website. Disinfectant products on this list have been approved for use under the EPA’s emerging viral pathogen guidance. Although they have not been tested specifically against SARS-CoV-2 (the cause of COVID-19), they are expected to be effective against SARS-CoV-2 because they have been tested and proven effective against harder-to-kill, nonenveloped viruses. 

If products approved for use under the emerging viral pathogen guidance are not available, the EPA suggests using a product with an approved efficacy claim for the human coronavirus. These are also indicated on List N. 

As with other health care suppliers, manufacturers of disinfectants have ramped up their production, but it may be a little while before supplies stabilize. In the event of disinfectant supply issues, an acceptable alternative would be to make a diluted bleach solution for disinfection using an EPA-registered concentrated bleach product (i.e., “jug” bleach). 

It’s important to note that the dilution required for disinfection of hard nonporous surfaces against most bacteria, viruses and fungi will likely be different than the dilution required for harder to kill pathogens such as C. difficile spores and Mycobacterium tuberculosis. Consequently, EVS professionals always should follow the dilution instructions and the contact time on the product label.

With a few exceptions, cleaning and disinfection of areas and rooms that house or housed a COVID-19 patient do not differ greatly from routine procedures. In addition to these routine procedures, EVS professionals should be cleaning and disinfecting high-touch surfaces more frequently than usual. 

Now is the time to get back to basics such as cleaning in a methodical manner, like clockwise or counterclockwise, so as to not overlook anything. EVS professionals also should be cleaning from high to low and from clean to dirty. 

Teamwork has never been more important than it is now. To help preserve the PPE supply, consideration should be made to have nursing perform high-touch surface cleaning because they will be entering the room to provide patient care anyway. 

EVS professionals should use fresh cleaning cloths and mop pads for each room. For terminal cleaning, the CDC recommends delaying room entry until sufficient time has elapsed for enough air exchanges to remove potentially infectious particles. A CDC table at provides a guide on determining these times.

EVS personnel then may enter the room, wearing a gown and gloves when performing terminal cleaning. A facemask and eye protection should be used if splashes or sprays during cleaning and disinfection activities are anticipated or if they are otherwise required based on the selected cleaning products. Shoe covers are not recommended at press time for personnel caring for patients with COVID-19. 

Management of laundry, food service utensils and medical waste should also be performed in accordance with routine procedures.

Finally, it is very important that EVS staff are trained and educated about this virus, the illness it causes, infection control measures (including PPE), and cleaning and disinfecting protocols. To ensure staff understanding, EVS professionals should assess competency. 

This can be accomplished through a test or quiz, return demonstration or observation of their practices. Additionally, staff may be anxious or frightened, so EVS professionals should be prepared to address these emotions.

Unprecedented time

This is an unprecedented time: COVID-19 reached pandemic levels in just a matter of months. 

However, the virus can be contained with basic infection control measures, including hand hygiene, respiratory etiquette, isolation precautions, and frequent cleaning and disinfection of the environment (high-touch surfaces in particular). In the event of PPE shortages, the CDC has provided guidance to help the health care team prioritize its use. 

For the most part, cleaning and disinfection of the environment is per routine. The key exceptions are:

• Using appropriate EPA-registered products from List N.
• Ramping up cleaning and disinfection of environmental surfaces, especially those that are high-touch.
• Allowing time for the room to air out before entering for terminal cleaning. 

It is during times such as these that EVS professionals need to get back to the basics. This continues to be an evolving event, so they should monitor the CDC’s COVID-19 website for updates and changes to recommendations.

Riding out this pandemic is going to be a marathon, not a sprint, so EVS professionals should remain calm and patient. They should take care of themselves, including managing stress, eating a healthy diet, getting plenty of rest and finding some time each week for non-COVID-related activities.

In closing, the author would like to thank EVS professionals and their teams for all that they do to keep patients and health care teams safe. 

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Doe Kley, R.N., CIC, MPH, T-CHEST, is the senior infection preventionist for Clorox Professional Products Co. She can be reached at doe.kley@clorox.com.