Microbial air quality and bacterial surface contamination in ambulances during patient services

Indoor bacterial and fungal aerosols as predictors of lower respiratory tract infections among under-five children in Ibadan, Nigeria

BACKGROUND

This study aimed to investigate the association between exposure to diverse indoor microbial aerosols and lower respiratory tract infections (LRTI) among children aged 1 to 59 months in Ibadan, Nigeria.

METHODS

One hundred and seventy-eight (178) hospital-based LRTI cases among under-five children were matched for age (± 3 months), sex and geographical location with 180 community-based controls (under-five children without LRTI). Following consent from caregivers of eligible participants, a child's health questionnaire, clinical proforma and standardized home-walkthrough checklist were used to collect data. Participant homes were visited and sampled for indoor microbial exposures using active sampling approach by Anderson sampler. Indoor microbial count (IMC), total bacterial count (TBC), and total fungal count (TFC) were estimated and dichotomized into high (> median) and low (≤ median) exposures. Alpha diversity measures including richness (R), Shannon (H) and Simpson (D) indices were also estimated. Conditional logistic regression models were used to test association between exposure to indoor microbial aerosols and LRTI risk among under-five children.

RESULTS

Significantly higher bacterial and fungal diversities were found in homes of cases (R = 3.00; H = 1.04; D = 2.67 and R = 2.56; H = 0.82; D = 2.33) than homes of controls (R = 2.00; H = 0.64; D = 1.80 and R = 1.89; H = 0.55; D = 1.88) p < 0.001, respectively. In the multivariate models, higher categories of exposure to IMC (aOR = 2.67, 95% CI 1.44-4.97), TBC (aOR = 2.51, 95% CI 1.36-4.65), TFC (aOR = 2.75, 95% CI 1.54-4.89), bacterial diversity (aOR = 1.87, 95% CI 1.08-3.24) and fungal diversity (aOR = 3.00, 95% CI 1.55-5.79) were independently associated with LRTI risk among under-five children.

CONCLUSIONS

This study suggests an increased risk of LRTI when children under the age of five years are exposed to high levels of indoor microbial aerosols.

Airborne transmission of biological agents within the indoor built environment: a multidisciplinary review

The nature and airborne dispersion of the underestimated biological agents, monitoring, analysis and transmission among the human occupants into building environment is a major challenge of today. Those agents play a crucial role in ensuring comfortable, healthy and risk-free conditions into indoor working and leaving spaces. It is known that ventilation systems influence strongly the transmission of indoor air pollutants, with scarce information although to have been reported for biological agents until 2019. The biological agents' source release and the trajectory of airborne transmission are both important in terms of optimising the design of the heating, ventilation and air conditioning systems of the future. In addition, modelling via computational fluid dynamics (CFD) will become a more valuable tool in foreseeing risks and tackle hazards when pollutants and biological agents released into closed spaces. Promising results on the prediction of their dispersion routes and concentration levels, as well as the selection of the appropriate ventilation strategy, provide crucial information on risk minimisation of the airborne transmission among humans. Under this context, the present multidisciplinary review considers four interrelated aspects of the dispersion of biological agents in closed spaces, (a) the nature and airborne transmission route of the examined agents, (b) the biological origin and health effects of the major microbial pathogens on the human respiratory system, (c) the role of heating, ventilation and air-conditioning systems in the airborne transmission and (d) the associated computer modelling approaches. This adopted methodology allows the discussion of the existing findings, on-going research, identification of the main research gaps and future directions from a multidisciplinary point of view which will be helpful for substantial innovations in the field.

Positive and Negative Ions Potently Inhibit the Viability of Airborne Gram-Positive and Gram-Negative Bacteria

Positive and negative ions (PAIs and NAIs, respectively) generated by air ionizers curb indoor spread of airborne pathogens through cellular oxidative damage. Thus, here, we asked whether ion exposure of Staphylococcus aureus and Escherichia coli bacteria—either plated on agar or trapped in air filters—would affect their viability and whether this effect would be influenced by variations in bacterial type and load, action area, distance from the ion generator, exposure time, or filter type. We selected these two vegetative bacterium species because, besides being representative of Gram-positive and Gram-negative strains, respectively, they are widely recognized as the two most common airborne pathogens. We observed a robust ion inhibitory effect on the viability of free bacteria regardless of the experimental condition employed. Specifically, 12-h ion exposure of plated S. aureus and E. coli, at either 5 cm or 10 cm from the ion source, reduced bacterial viability by ∼95% and 70%, respectively. Furthermore, 3-h ion exposure was sufficient to reduce the viability of both bacterial species trapped in filters. Our results showing a strong antibacterial activity of PAI and NAI under all experimental conditions tested further support the use of air ionizers for preventing and/or containing airborne infection in domestic and nondomestic settings.

IMPORTANCE Indoor air is a well-established vehicle for direct and indirect spread of a wide variety of human pathogens—as bioaerosols are composed of bacteria, viruses, fungi, and other types of organisms—that may trigger some pathologies. Plasmacluster ionizers are known for their ability to generate positively or negatively charged air ions (PAIs and NAIs, respectively) that can kill/inactivate indoor airborne pathogens, through oxidative stress-induced damage, in various environments. Given these premises, the aim of this study was to evaluate the viability of Gram-positive and Gram-negative bacteria exposed to PAI and NAI under different experimental variables such as bacterial type and load, action area, distance from the ion generator, ion exposure time, and filter type. Altogether, our findings, demonstrating a remarkable PAI and NAI antibacterial activity, stress the importance of using air ionizers to prevent indoor airborne infection.

Current Applications of Absolute Bacterial Quantification in Microbiome Studies and Decision-Making Regarding Different Biological Questions

High throughput sequencing has emerged as one of the most important techniques for characterizing microbial dynamics and revealing bacteria and host interactions. However, data interpretation using this technique is mainly based on relative abundance and ignores total bacteria load. In certain cases, absolute abundance is more important than compositional relative data, and interpretation of microbiota data based solely on relative abundance can be misleading. The available approaches for absolute quantification are highly diverse and challenging, especially for quantification in differing biological situations, such as distinguishing between live and dead cells, quantification of specific taxa, enumeration of low biomass samples, large sample size feasibility, and the detection of various other cellular features. In this review, we first illustrate the importance of integrating absolute abundance into microbiome data interpretation. Second, we briefly discuss the most widely used cell-based and molecular-based bacterial load quantification methods, including fluorescence spectroscopy, flow cytometry, 16S qPCR, 16S qRT-PCR, ddPCR, and reference spike-in. Last, we present a specific decision-making scheme for absolute quantification methods based on different biological questions and some of the latest quantitative methods and procedure modifications.

Bioburden contamination and Staphylococcus aureus colonization associated with firefighter's ambulances

Ambulance vehicles are an essential part of emergency clinical services. Bioburden control in ambulances, through cleaning and disinfection, is crucial to minimize hospital-acquired infections, cross contamination and exposure of patients and ambulances' crew. In Portugal, firefighter crews are responsible, besides fire extinction, for first aid and urgent pre-hospital treatment. This study assessed the bioburden in Portuguese firefighters' ambulances with a multi-approach protocol using active and passive sampling methods. Fungal resistance profile and mycotoxins detection in ambulances' ambient, and S. aureus (SA) prevalence and resistance profile in ambulances' ambient and colonization in workers were also investigated. Toxigenic fungi with clinical relevance, namely Aspergillus section Fumigati, were found on ambulance's air in the hazardous dimension range. Interestingly, surface contamination was higher after cleaning in several sampling sites. Prevalence of S. aureus was 3% in environmental samples, of which 2% were methicillin-sensitive (MSSA) and 1% methicillin-resistant (MRSA). About 2.07 fungal species were able to grow in at least one azole, ranging from one (44% samples) to five (6% samples) species in each azole. Mycotoxins were detected in mops and electrostatic dust cloths. Colonization by S. aureus in the firefighter crew was observed with a high associated prevalence, namely 48%, with a 24% prevalence of MSSA (8/33) and 21% of MRSA (7/33). Additional studies are needed to determine the potential risk of infection transmission between different vehicle fleets and under varying conditions of use. This will strengthen the paramedic sector's mission to save lives without putting their own health and safety at risk.

Medical transport-associated infection: Review and commentary making a case for its legitimacy

The purpose of this article is to summarize existing literature about healthcare-associated infection (HAI) in the medical transport environment and to define the term medical transport-associated infection (MTAI) to unify all previous work under a single umbrella with the objective of providing a standardized definition for future research. A review of the literature yielded 34 relevant articles. These studies show that there are pathogens in the ambulance environment, that emergency medical services (EMS) personnel do not regularly comply with hygiene practices, and that patients are potentially affected by HAI as a direct result of ambulance exposure. Prospective studies must be conducted to truly understand the impact that ambulance exposure has on HAIs. MTAI is a subset of HAI and is defined as any infection acquired as a direct effect of exposure in a medical transport setting.

Efficacy of an ambulance ventilation system in reducing EMS worker exposure to airborne particles from a patient cough aerosol simulator

The protection of emergency medical service (EMS) workers from airborne disease transmission is important during routine transport of patients with infectious respiratory illnesses and would be critical during a pandemic of a disease such as influenza. However, few studies have examined the effectiveness of ambulance ventilation systems at reducing EMS worker exposure to airborne particles (aerosols). In our study, a cough aerosol simulator mimicking a coughing patient with an infectious respiratory illness was placed on a patient cot in an ambulance. The concentration and dispersion of cough aerosol particles were measured for 15 min at locations corresponding to likely positions of an EMS worker treating the patient. Experiments were performed with the patient cot at an angle of 0° (horizontal), 30°, and 60°, and with the ambulance ventilation system set to 0, 5, and 12 air changes/hour (ACH). Our results showed that increasing the air change rate significantly reduced the airborne particle concentration (p < 0.001). Increasing the air change rate from 0 to 5 ACH reduced the mean aerosol concentration by 34% (SD = 19%) overall, while increasing it from 0 to 12 ACH reduced the concentration by 68% (SD = 9%). Changing the cot angle also affected the concentration (p < 0.001), but the effect was more modest, especially at 5 and 12 ACH. Contrary to our expectations, the aerosol concentrations at the different worker positions were not significantly different (p < 0.556). Flow visualization experiments showed that the ventilation system created a recirculation pattern which helped disperse the aerosol particles throughout the compartment, reducing the effectiveness of the system. Our findings indicate that the ambulance ventilation system reduced but did not eliminate worker exposure to infectious aerosol particles. Aerosol exposures were not significantly different at different locations within the compartment, including locations behind and beside the patient. Improved ventilation system designs with smoother and more unidirectional airflows could provide better worker protection.

Rapid metagenomics analysis of EMS vehicles for monitoring pathogen load using nanopore DNA sequencing

Pathogen monitoring, detection and removal are essential to public health and outbreak management. Systems are in place for monitoring the microbial load of hospitals and public health facilities with strategies to mitigate pathogen spread. However, no such strategies are in place for ambulances, which are tasked with transporting at-risk individuals in immunocompromised states. As standard culturing techniques require a laboratory setting, and are time consuming and labour intensive, our approach was designed to be portable, inexpensive and easy to use based on the MinION third-generation sequencing platform from Oxford Nanopore Technologies. We developed a transferable sampling-to-analysis pipeline to characterize the microbial community in emergency medical service vehicles. Our approach identified over sixty-eight organisms in ambulances to the genera level, with a proportion of these being connected with health-care associated infections, such as Clostridium spp. and Staphylococcus spp. We also monitored the microbiome of different locations across three ambulances over time, and examined the dynamic community of microorganisms found in emergency medical service vehicles. Observed differences identified hot spots, which may require heightened monitoring and extensive cleaning. Through metagenomics analysis it is also possible to identify how microorganisms spread between patients and colonize an ambulance over time. The sequencing results aid in the development of practices to mitigate disease spread, while also providing a useful tool for outbreak prediction through ongoing analysis of the ambulance microbiome to identify new and emerging pathogens. Overall, this pipeline allows for the tracking and monitoring of pathogenic microorganisms of epidemiological interest, including those related to health-care associated infections.

Mixed Matrix Poly(Vinyl Alcohol)-Copper Nanofibrous Anti-Microbial Air-Microfilters

Membranes decorated with biocide materials have shown great potential for air sanitization but can suffer from biocide agent leaching by dissolution in water. In order to tackle the diffusion of biocide metal ions from the fiber matrix, composite nanofiber membranes of poly(vinyl alcohol) (PVA) cross-linked with copper (II) acetate have been successfully engineered via sol–gel electrospinning, providing a stable mean for air bactericidal microfiltration. The novelty lies in the bonding strength and homogeneous distribution of the fiber surface biocide, where biocide metals are incorporated as a sol within a polymer matrix. The electrospinning of bead-free composite nanofibers offered over 99.5% filtration efficiency for PM_2.5, with a theoretical permeance above 98%. The PVA/copper nanofiber membranes also showed satisfactory anti-bacterial performance against the gram-negative Escherichia coli within 24 h, making them promising materials for the remediation of airborne bacteria. The mechanical and chemical stability of the engineered nanocomposite electrospun nanofiber webs added to the natural biodegradability of the materials, by offering ideal low-cost sanitary solutions for the application of air disinfection in both indoor and outdoor fitting a circular economy strategy where advanced materials are redesigned to be sustainable.

Air Quality and Employee Hygiene-related Behavior in a Post Anesthesia Care Unit in Thailand

Post anesthesia care units (PACU) are sanitary spaces at hospitals. Bacterial and fungal contaminants in ambient air can pose significant threats to patient recovery. Excess waste anesthetic gases such as nitrous oxide and desflurane can also pose reproductive, genetic, and other health risks to PACU staff who suffer longterm exposure. Healthcare institutions routinely monitor and study PACU air quality as required by occupational health and safety acts and related regulations, and professional standards of care. This study presents recent data from a PACU intervention at Rajavithi Hospital in Bangkok, Thailand. Rajavithi took measurements of concentrations of airborne fungi, bacteria, desflurane, and nitrous oxide before and after installation of a new ventilation system. Concurrently, the hospital surveyed employees before and after a hazard communication and conducted a training campaign in efforts to understand employee attitudes toward health and safety procedures, and to increase their perceived importance of several PACU-specific protocols. Results showed bacterial contamination fell from 1,307 CFU/m³ to 182 CFU/m³, fungi fell from 70.4 CFU/m³ to 35.8 CFU/m³, desflurane fell from 0.25 ppm to 0.21 ppm, and nitrous oxide fell from 21.86 ppm to 20.47 ppm during the intervention while PACU worker attitudes toward health and safety improved. Additional monitoring, communication, and training are recommended for Rajavithi and other healthcare institutions.

Air Quality and Employee Hygiene-related Behavior in a Post Anesthesia Care Unit in Thailand

Background:

Airborne contaminants in Postanesthesia Care Units (PACUs) such as bacteria, fungi, and waste anesthetic gases pose serious, and sometimes fatal, risks to both patients and PACU workers. Numerous studies have linked long-term exposure to nitrous oxide and halogenated agents to, among other things, reproductive problems in PACU nurses and anesthesiologists. Microorganism contamination can result in a post-surgical complication, to which patients with diabetes and other respiratory diseases are especially vulnerable. Various researchers and governmental agencies have recommended hospitals take steps to reduce levels of airborne contaminants in PACUs. In particular, hazard communication programs are recommended to inform and train staff on relevant occupational health and safety procedures. Additionally, and perhaps more importantly, experts recommend hospitals install specialized ventilation systems to maintain low levels of airborne pollutants.

Objective:

This study has two main parts: (1) measurement of airborne contaminants in the PACU at Rajavithi Hospital in Bangkok, Thailand; and (2) assessment of PACU workers’ perceived level of importance regarding occupational health and safety protocols,viaself-reporting survey. The study also has two main objectives: (1) to determine whether, and to what extent, a new ventilation system helps reduce airborne contaminants in the PACU; and (2) to discover whether an informational campaign increases perceived importance of health and safety procedures among PACU workers (i.e. handwashing, changing shoes, wearing proper facemasks).

Methods:

Surveys and air quality measurements were collected two times – in July 2016 and April 2017 – before and after Rajavithi Hospital implemented a hazard communication program consisting of training, posters, brochures, and informational media. Survey participants included all 64 PACU workers – 61 nurses and 3 anesthetists. Air sampling measured levels of bacteria, fungi, nitrous oxide, and desflurane.

Results:

Initial levels of airborne microorganisms were very high (1307CFU/m3for bacteria and 70.4 CFU/m3for fungi) and on the high end of normal for nitrous oxide (21.86ppm). Following the informational campaign and installation of the ventilation system, levels of bacterial contamination fell to 182 CFU/m3, and fungi fell to 35.8 CFU/m3. Simultaneously, workers’ levels of perceived importance for health and safety procedures increased.

Conclusion:

Both aspects of the study were successful, however, concentration of airborne microorganisms still exceeded recommended limits at the end of the study. Hospital administration and staff are encouraged to continue training and informing workers while assessing ventilation system until contamination levels fall to within internationally acceptable ranges.

Application of Cytosense flow cytometer for the analysis of airborne bacteria collected by a high volume impingement sampler

Characterization of airborne bacterial cells requires efficient collection, concentration, and analysis techniques, particularly to overcome the challenge of their dilute nature in outdoor environments. This study aims to establish a rapid and reliable approach for quantification of bacteria in air samples. To do this, a high volume impingement sampler was applied to collect airborne bacteria from a wastewater treatment plant (WWTP). The bacterial cell density was estimated by a Cytosense flow cytometer (Cytobouy) and compared to quantitative PCR (qPCR) data based on 16S rRNA genes. The average bacterial cell density measured by Cytosense ranged from 1.1 to 2.5 × 10⁴ cells m^-3 of air and that estimated by qPCR ranged from 0.08 to 3.8 × 10⁴ cells m^-3 of air. Regression analysis showed no systematic difference in bacterial cell densities between two methods applied when the cells were analyzed in vivo, and statistical tests confirmed that Cytosense counts of unfixed samples provided realistic values. Bacterial cell densities and the amount of DNA extracted from the sample were significantly correlated with relative humidity on a sampling day. The results showed that the present method was reliable to estimate bacteria densities from the outdoor environment, and the analysis given by Cytosense was faster and more sensitive than qPCR method. In addition, the Cytosense gave valuable information about cell characteristics at different sampling conditions.

Prehospital infection control and prevention in Denmark: a cross-sectional study on guideline adherence and microbial contamination of surfaces

Background

Prehospital acute care and treatment have become more complex, and while invasive procedures are standard procedures, focus on infection control and prevention is scarce. We aimed to evaluate guideline adherence, microbial contamination, and associated risk factors.

Methods

In a nationwide cross-sectional study, we evaluated guideline adherence to thorough cleaning (TC) once a day, and moderate cleaning (MC) in-between patient courses. Microbial contamination on hand-touch sites (HTS) and provider-related sites (PRS) was assessed by total aerobic colony forming units (CFU) and presence of selected pathogens, using swab and agar imprints. Also, microbial contamination was assessed in relation to potential risk factors.

Results

80 ambulances and emergency medical service (EMS) providers were enrolled. Adherence to guidelines regarding TC was 35%, but regarding MC it was 100%. In total, 129 (27%) of 480 HTS presented a total CFU > 2.5/cm² and/or pathogenic growth, indicating hygiene failures. The prevalence of selected pathogens on HTS was: S. aureus 7%; Enterococcus 3% and Enterobacteriaceae 1%. Total CFU on the PRS ranged from 0 to 250/cm², and the prevalence of pathogens was 18% (S. aureus 15%, Enterococcus 3% and Enterobacteriaceae 0.3%). Methicillin-resistant S. aureus was found in one sample, and Vancomycin-resistant Enterococcus in two. No Enterobacteriaceae with extended-spectrum beta-lactamases were recorded.

Conclusion

Guideline adherence was suboptimal, and many HTS did not comply fully with proposed standards for cleanliness. Pathogens were demonstrated on both HTS and PRS, indicating that the EMS may be a source of infection in hospitalized patients. Moreover, cleaning effort and time appears associated with microbial contamination, but a comprehensive investigation of risk factors is needed.

The Emergency Medical Service Microbiome

Emergency medical services (EMS) personnel are an integral component of the health care framework and function to transport patients from various locations to and between care facilities. In addition to physical injury, EMS personnel are expected to be at high risk to acquire and transmit health care-associated infections (HAIs) in the workplace. However, currently, little is known about EMS biosafety risk factors and the epidemiological contribution of EMS to pathogen transmission within and outside the health care sector. Health care facility microbiomes contain diverse bacterial, fungal, and viral pathogens that cause over 1.7 million HAIs each year in the United States alone. While hospital microbiomes have been relatively well studied, there is scant information about EMS infrastructure and equipment microbiomes or the role(s) they play in HAI transmission between health care facilities. We review recent literature investigating the microbiome of ambulances and other EMS service facilities which consistently identify antibiotic-resistant pathogens causing HAIs, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus, and Klebsiella pneumoniae Our review provides evidence that EMS microbiomes are dynamic and important pathogen reservoirs, and it underscores the need for more widespread and in-depth microbiome studies to elucidate patterns of pathogen transmission. We discuss emerging DNA sequencing technologies and other methods that can be applied to characterize and mitigate EMS biosafety risks in the future. Understanding the complex interplay between EMS and hospital microbiomes will provide key insights into pathogen transmission mechanisms and identify strategies to minimize HAIs and community infection.