According to recent studies of outbreaks of Escherichia coli(E. coli)O157 and other diseases such as shigellosis, cryptosporidiosis, and giardiasis, the initially reported illnesses from contaminated food, water or other sources that “triggers” the outbreak, may represent only a small fraction of the total number of cases. A significant proportion of cases among household members and other close contacts of infected persons can arise by person-to-person transmission from the index case/s.

In a recent paper, Seto et al from the University of California reported an analysis of the US 2006 E. coli O157 outbreak due to contaminated spinach. The Centers for Disease Control (CDC) and the US Food and Drug Administration (FDA) advised consumers not to eat spinach as the primary strategy for protecting against foodborne transmission of E. coli O157, but no warnings were issued regarding the prevention of person-to-person transmission. From their findings, Seto et al concluded that rapid delivery of widespread public health messages with specific advice on how to interrupt secondary transmission of E. coli O157, even if only modestly successful, could have meaningfully reduced the number of cases.

Using an epidemiologically based transmission model, they investigated the potential impact of a hygiene intervention strategy (strongly recommending handwashing, avoiding contact with persons with diarrhoea, meticulously preparing food, and avoiding work or school when ill with gastrointestinal symptoms). Initiation of these strategies was assumed to occur at the same time as CDC’s first press release on the outbreak on 14 September 2006, 1 week later, and 2 weeks later. The model suggested that even a modestly effective strategy to interrupt secondary transmission (prevention of only 2–3% of secondary illnesses) could result in a reduction of ≈5–11% of symptomatic cases.

These investigators proposed that communication strategies could be targeted at communities in which any cases of E. coli O157 are reported and scaled to regional or national audiences when appropriate. Messages could be delivered inexpensively to large or targeted populations through a variety of media (television, radio, print and the Internet). They pointed out that the ability to launch rapid and successful infection control messages to the public has already been demonstrated during the SARS outbreak. Seto et al did not formally estimate economic tradeoffs between a public health campaign compared with the costs of hospitalizations and medical care for persons with this disease, but argued that, because the hospitalization costs of a single E. coli O157 case complicated by death from hemolytic uraemic syndrome are estimated to be as high as US $6.2 million per case, such a campaign would be highly cost-effective.

The reference to the full paper is: Seto E.Y.W., Soller J.A., Colford J.M. Strategies to reduce person-to-person transmission during widespread Escherichia coli O157:H7 outbreak. Emerging Infectious Diseases 2007;13(6):861
www.cdc.gov/eid/content/13/6/860.htm

In a recent study, Luber et al investigated Campylobacter contamination in chickens in Germany. They found that the numbers of pathogens on the surface of the chicken was much higher in comparison with low levels of internal contamination. From this, they suggest that cross-contamination during the preparation of contaminated chicken is a more important pathway for consumers’ exposure to Campylobacter than the consumption of undercooked meat. In total 100 fresh retail chicken breast fillets were analysed for surface contamination using a rinse sample and 55 fillets were analysed for internal pathogen contamination using 10 g meat and a ‘most probable number’ technique. Prevalence was 87% on the surface and 20% in the deep tissue. The mean number of Campylobacter on the surface was 1903 CFU, with a median of 537 CFU and a maximum of 38,905 CFU. Counts inside the tissue were <1 CFU g/meat (mean = 0.24 CFU, median = 0.15 CFU, maximum = 0.74 CFU). 

Luber P., Bartelt E. Enumeration of Campylobacter spp. on the surface and within chicken breast fillets. Journal of Applied Microbiology 2007;102:313-8.
http://www.ingentaconnect.com/content/bsc/jam/2007/00000102/00000002/art00002

Asthma is the most common long-term condition for children in the UK affecting 1 in 10. A new study is suggesting that severe viral infections combined with sensitivity to allergies during the first year of a child’s life may lead to the development of asthma later in childhood. The researchers suggest that viral infection may make the immune system view allergens as a threat if both are encountered at the same time. This leaves children highly sensitized to the particular allergen, which can lead to asthma attacks when their immune system reacts to any subsequent exposure. The researchers studied almost 200 children for 5 years, recording the viruses they were infected with during their first year of life and when they developed allergies. They found that those children, who had a lower respiratory viral infection during their first year of life and developed sensitivity to an allergen before they were 2 years old, were three to four times more likely to suffer from asthma at the age of 5.

The suggestion is that if you are exposed to an allergen early in life, the body usually becomes tolerant of it, but if a child is exposed to an allergen at the same time as a lower respiratory virus infection, then the child may become sensitized to that allergen instead of being tolerant. The findings contradict the view that in general infections early in life are likely to protect against developing allergies.

The World Health Organization (WHO) International Network to Promote Household Water Treatment and Safe Storage has published a new document (2007) which reviews the management of water quality in the home. It describes the Network and its objectives, gives a brief overview of low-cost technologies, and outlines some of the implementation challenges that lie ahead. A growing body of research has confirmed the key role that point-of-use (POU) water quality interventions can play in reducing diarrhoeal disease in a cost-effective manner. Taste and other aesthetic properties of the water, convenience of use, price and cultural attitudes are also important considerations in home treatment. Household-level interventions can make an immediate contribution to the safety component of Millennium Development Goal (MDG) 7, Target 10, and would significantly contribute to meeting the MDGs in situations where access to water supplies is secure, but household water quality is not assured.

Download the document from: http://www.who.int/household_water/advocacy/combating_disease/en/index.html.

The Vietnam Handwashing Initiative (HWI) is preparing to launch a nationwide communications campaign which will build on the results of two recent research studies on handwashing and soap in Vietnam as reported below:

• 92% of mothers are handwashing at critical times, though 60% do not feel soap is necessary.
• Barriers to handwashing with soap include:

• the perception that soap is only necessary when hands are visibly dirty or smell bad;
• handwashing with soap is time consuming and inconvenient; and
• the real and perceived affordability of soap.

• The number one perceived benefit of using soap is to get rid of unpleasant odours.
• More than 80% of mothers watch TV while only 15–20% listen to the radio or read newspapers.
• 87% of the sampled population currently use bar soap.
• Access to soap products is not an issue – most people surveyed (users and non-users) agree that “it is easy to find bar soap in the market”.
• The two most important factors influencing bar soap purchase are: 1) a pleasant fragrance; and 2) anti-bacterial properties.

WSP East Asia Region: http://www.wsp.org/news/news.asp?id=59.

The European Centre for Disease Prevention and Control (ECDC) Annual Epidemiological Report suggests that EU countries are generally doing well in the fight against infectious diseases. Nonetheless, the report warns that there is no room for complacency. The report analyses 10 years’ worth of data on infectious diseases reported to different EU disease surveillance networks, to the Statistical Office of the European Communities (Eurostat) and directly to ECDC. It covers the 49 most important infectious diseases and looks at the 25 countries that are EU Member States and the three EEA-EFTA countries in 2005. The incidence of most of the diseases looked at has either fallen or remained stable over the past decade. Public health systems in the EU are generally good at fighting infectious diseases. For example, their vaccination programmes have succeeded in reducing the incidence of diseases such as measles and rubella. Some diseases, such as polio, have effectively been eliminated in the EU: there have been no cases of polio occurring in the EU since 1992. The key areas of concern highlighted in the ECDC report are:

• Rising rates of healthcare associated infections, especially those due to antibiotic resistant bacteria.
• The continued threat from tuberculosis in Europe.
• The threat posed by influenza and pneumococcal infections.
• Rising rates of HIV infection.

Healthcare associated infections, particularly those caused by drug resistant microbes, are highlighted as possibly the biggest infectious disease challenge facing the EU. Every year, around 3 million people in the EU catch a healthcare-associated infection, of who approximately 50,000 die.

The report can be downloaded from: http://www.ecdc.eu.int/.

The WHO has recently published World Health Statistics 2007, the most complete set of health statistics from its 193 Member States. This edition highlights trends in 10 of the most closely watched global health statistics. It is the authoritative annual reference for a set of 50 health indicators in countries around the world. 

This volume shows:

• How much money is currently spent on health in comparison to regional burdens of disease.
• Projected patterns of major causes of death for 2030.
• Gaps in reliable information, and how estimates of maternal mortality are made
• The diseases that are killing people, and those that make them sick.
• The extent to which people can access treatment, the major risk factors for ill-health, the human resources underpinning health systems; and
• Health outcomes in the context of demographic and socio-economic status of individual countries.

World health statistics 2007 can be downloaded at: http://www.who.int/whosis/en/index.html.

An interdisciplinary international conference organized by UNEVOC, UNU, University of Bonn, Institute for Hygiene and Public Health, ILo and IHDP took place in Bonn, Germany, 9–11 May 2007. Three IFH board members lectured in the session on “Hygiene and Public Health” dedicated to assessing the contribution of hygiene to health within the context of the other factors which influence global health: Professor Martin Exner, gave the opening address entitled “Hygiene and Public Health, an Essential Tool for Reaching the Millennium Goals”. Professor K.J. Nath presented an overview on “Challenges of Sustainable Environmental Health in Developing Countries” and Professor Sally Bloomfield contributed to the session with the paper “Focus on Home Hygiene in Developing Countries”.
The culmination of the conference was the production of an action programme for the next 10–15 years for achieving sustainable health, hygiene and environment through a partnership strategy that involves scientists, policy-makers and the private sector. 
A copy of the action programme is available from: http://www.hygiene-und-oeffentliche-gesundheit.de/Int_Conf_May_2007_Bonn_Call_for_Action.pdf.

In Bangladesh, nearly 100 children die each day from diarrhoea-related disease caused by poor hygiene and sanitation. The UK Department for International Development (DFID) and UNICEF will support the Government of Bangladesh in a project which will reach 30 million people with improved sanitation and safe drinking water. The Bangladesh Department of Public Health Engineering (DPHE) and UNICEF will jointly implement the Sanitation, Hygiene Education and Water Supply in Bangladesh (SHEWA-B) project from 2007–2011. With 30 million people receiving improved sanitation, coverage will increase to almost 70%. Safe drinking water coverage will increase to 79% and arsenic risks will be reduced. Around 5.1 million of the poorest people will benefit from access to safe water delivery, 1.5 million school children will benefit from safe water delivery and improved sanitation services and 4.5 million children will receive hygiene education.
Source: UNICEF http://www.unicef.org/media/media_38126.html, 23 Jan 2007.

The Gates Foundation and the Global Water Challenge are funding a new 5-year CARE programme in Kenya’s Nyanza Province, which sets out to improve access to safe water, sanitation and hygiene for school children. In the first 3 years the Sustaining and Scaling School Water, Sanitation and Hygiene Plus Community Impact (SWASH+) programme will reach 180 schools. It will identify, develop and test innovative school-based water, sanitation and hygiene interventions, such as school water supply with chlorine and handwashing stations. In addition, the partners involved expect that the experiences in 300 schools (90,000 school children) will provide valuable information on the costs and benefits of school water, sanitation and hygiene. If proven effective at the provincial level, the experiences will provide the framework for national implementation: http://www.irc.nl/page/32186.

The WASH in Schools programme (until recently called SSHE: school sanitation and hygiene education) is a joint programme of IRC and UNICEF. It was re-established in July 2006 with the launch of the “WASH in Schools” website (www.schools.watsan.net).
Worldwide, an estimated 83% of primary school-age children attend school. In developing countries, the sanitary and hygienic conditions at schools are often appalling, characterized by the absence of proper functioning water supplies, sanitation and handwashing facilities. Schools that lack access to basic water supply and sanitation services will have an increased incidence of major childhood illnesses among their students. Poor health is an important underlying factor for low school enrolment, absenteeism, poor classroom performance and early school dropout. Hygiene, Sanitation, and Water in Schools projects can create an enabling learning environment that contributes to children’s improved health, welfare, and learning performance.

One of the key components of the WASH in Schools website is a toolkit (http://www.schoolsanitation.org/) which makes available information, resources and tools that provide support to the preparation and implementation of Hygiene, Sanitation, and Water in Schools policies and projects. This toolkit is designed to help task managers tap into sector-specific knowledge of practices and approaches that are likely to yield positive results as they coordinate multi-sector efforts to improve sanitation and hygiene in schools.

On the basis that school programmes can be an excellent entry point for improving hygiene behaviours in the home and community, as well as for educational renovation in the school, in 2003 a pilot programme for school water, sanitation and hygiene education was implemented by UNICEF in six countries: Burkina Faso, Colombia, Nepal, Nicaragua, Vietnam and Zambia. The final country assessments reports (http://www.irc.nl/page/28817) presented in March 2006 indicated that project schools performed better compared to control schools for virtually all indicators. About 80% or more of project schools had toilets and urinals that are well used by children and are kept clean. However, handwashing with soap proved to be far less prevalent than expected. Although in two of the five countries, programme schools did better than control schools, less than one-third of children in the study used soap to wash hands before eating, either because it was absent in the school or because it was not easily accessible in the school.

For more details contact Mirielle Snel: snel@Irc.nl.

From 16–20 April 2007, the Water Supply and Sanitation Collaborative Council (WSSCC) held a Planning Meeting with its National Coordinators and Regional Representatives and thematic partners. Bringing together coordinators from 36 countries in Africa, Asia, Latin America, the Caribbean, the Pacific, Central Asia and Eastern Europe, the meeting was a mix of looking back, and planning ahead.

IFH and WSSCC have been building a partnership over the past 2 years focusing on hygiene promotion in developing countries, with IFH acting as the WSSCC focal point on home hygiene promotion. The Planning Meeting provided a first opportunity for IFH to meet WSSCC National Coordinators and Regional Representatives. WSSCC’s National Coordinators represent the organization’s heart and soul, acting as the focal point for country-level activities which are actioned through National WASH Coalitions. Activities at country level include advocacy and awareness-raising, hygiene and sanitation education, policy development, monitoring progress, and the development of improved programmes, practices and approaches.

In the meeting, National Coordinators shared their experiences, and analysed the successes, obstacles and lessons learnt on key issues. On the third day of the meeting, coordinators of WSSCC’s thematic working groups presented and discussed their activities with the National Coordinators and Regional Representatives. The themes included “scaling up rural water supply services”, “environmental sanitation”, “solid waste management”, “multiple use systems” (water for productive uses), and “hygiene promotion”. Under this last theme, Professor Sally Bloomfield of IFH presented the work of the IFH, and the concepts behind the IFH-WSSCC co-published training resource on “Home Hygiene in Developing Countries”, which was produced in August 2006.

With a room full of experienced hygiene promotion professionals, discussion was rich, and the presentation was cut short by the debate. Topics included the issue of monitoring the contamination of water in the home and the need to link handwashing to safe water treatment in the home (Zimbabwe); the issue of political commitment to focus on prevention, and the example of Senegal where a Ministry for Prevention, Public Hygiene and Sanitation has been established; and the need for a holistic approach to hygiene, integrating various activities carried out by different sectors and stakeholders. As remarked by the National Coordinator from Jamaica, hygiene promotion programmes should start with what people do and know, and their realities. Therefore, it should start at the family level and from that starting point, the different sectors and stakeholders should come together to build a hygiene promotion programme that is grounded in people’s realities.

The last 2 days of the meeting were dedicated to planning action at the local, national and regional levels, as well as at the global level through the WSSCC Secretariat. With 2008 being proclaimed the International Year of Sanitation by the United Nations Secretary General, WSSCC is planning to be at the forefront of the advocacy and knowledge management activities, which will also include a continued focus on hygiene promotion and possibly the production of locally adapted versions of the Home Hygiene training resource.

For more information on the latest developments in WSSCC go to: http://www.wsscc.org/pdf/news/Microsoft_Word_672_RL_SC_let.pdf.

This article was submitted by Carolien Van der Voorden. For more information contact vandervoordenc@who.int.

The WHO’s first global patient safety challenge: clean care is safer care

Is it possible to rally support on a global level for hand hygiene – positioning it as a critical component of all strategies to combat health care-associated infections (HAI) within healthcare facilities? Furthermore, how feasible is it to mobilize countries to make ministerial commitments to tackle these infections by focusing primarily on better hand hygiene compliance among the healthcare staff within a nation? These were the questions facing the WHO’s World Alliance for Patient Safety in 2004, as it sought to establish the first of an ongoing series of patient safety challenges relevant to all its members.

Low adherence to hand hygiene guidelines is a patient safety problem, and with 1.4 million people worldwide suffering from a HAI every day, the need for action could not be more apparent. The First Global Patient Safety Challenge - Clean Care is Safer Care addresses the cleanliness of care practices, and particularly hand hygiene and the very important role hand hygiene that compliance plays in reducing the spread of infection in all healthcare facilities around the world. It centres its activity on raising awareness, securing commitment from countries to address HAI, and developing and testing the WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft) with their associated implementation strategy. These Guidelines are intended to be implemented in healthcare facilities, community settings and other settings where health care is occasionally performed, such as home care by birth attendants.

Tools and implementation strategy
Health facilities in any country of the world with an interest in enhancing their existing HAI prevention strategies or in starting new improvement activities now have access to a range of newly developed tools. Each tool is designed to help implement each component of the Five-Part WHO Multimodal Hand Hygiene Improvement Strategy. Six pilot sites across the world are officially testing the implementation strategy. The WHO World Alliance for Patient Safety further welcomes any healthcare facility, anywhere in the world to enrol as a Complementary Test Site, gaining access to an exclusive web forum and all of the tools and resources.

The work of the First Global Patient Safety Challenge continues to gather momentum and during 2007 and 2008 there will be a continued drive to raise the profile of the issue working closely with countries interested in committing to address HAI. Furthermore, partnerships with organizations with interests in this field will be strengthened and the WHO Guidelines on Hand Hygiene in Health Care will be closely tested in order to produce a final version in 2008.

Further information:
The WHO World Alliance for Patient Safety:
http://www.who.int/patientsafety/worldalliance/alliance/en/index.html.
First Global Patient Safety Challenge - Clean Care is Safer Care:
http://www.who.int/gpsc/en/index.html.

1. Infection Patterns in the World

Influenza transmission: research needs for informing infection control policies and practice. Influenza Team, European Centre for Disease Prevention and Control
http://www.eurosurveillance.org/ew/2007/070510.asp
The scientific basis of knowledge of how human influenza transmits and can be controlled remains poor. The recent attention devoted to human influenza in the context of a possible pandemic has identified a surprising number of research gaps, some of which concern issues of fundamental importance for preventing or reducing transmission.

Community-associated methicillin-resistant Staphylococcus aureus skin and soft tissue infections at a public hospital: do public housing and incarceration amplify transmission? Hota B., Ellenbogen C., Hayden M.K., Aroutcheva A., Rice T.W., Weinstein R.A. Archives of Internal Medicine 2007;167:1026-33.
To determine characteristics associated with community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA), 518 community-onset cases between 2001 and 2004 were compared with 704 controls who had community-associated Staphylococcus aureus which responds to methicillin-like antibiotics. The incidence of CA-MRSA skin and soft tissue infections increased from 24 cases per 100,000 people in 2000 to 164.2 cases per 100,000 people in 2005. The number of infections susceptible to antibiotics remained stable over this time, indicating that MRSA occurred in addition to and not in place of methicillin-susceptible Staphylococcus aureus (MSSA). For MRSA the risk factors were incarceration, African-American race/ethnicity and residence at a group of geographically proximate public housing complexes; older age was inversely related.

MRSA in children presenting to hospitals in Birmingham, UK. Adedeji A., Weller T.M.A., Gray J.W. Journal of Hospital Infection 2007;65:29-34.
The study was performed on MRSA isolates from children aged <16 years, identified between March 2004 and December 2004, from three hospitals. Fifty isolates were classified as either community-acquired (CA-MRSA) or hospital-acquired MRSA (HA-MRSA). Overall, 31 (62%) MRSA were defined as CA-MRSA. PFGE band pattern and SCCmec analysis were similar to EMRSA 15 for 72% of isolates. Over 80% of isolates contained SCCmec type IV. Genes encoding PVL were not detected. None of the isolates fulfilled the criteria for de-novo CA-MRSA.

Trends in social, political and technological impact factors of hygienic risks in German households. Heinzel M.A. International Journal of Hygiene and Environmental Health 2001;204:195-202.
This paper considers German trends of impact factors contributing to hygienic risks in domestic settings. Each of the alterations of hygiene determinants described below may appear to be marginal when looked at separately, thus disregarding any relationship to hygiene. However, as a whole to anticipate the conclusion they have clearly altered the hygiene risks in the household; some risks have decreased but others have grown worse.

Avian influenza and the threat of the next human pandemic. Nguyen-Van-Tam J.S., Sellwood C. Journal of Hospital Infection 2007;65(Suppl 2):10-3.
The paper reviews the measures which are being developed for preventing the spread of avian flu in the event of a flu pandemic related to avian influenza.

Methicillin-resistant Staphylococcus aureus (MRSA) in hospitals and the community: model predictions based on the UK situation. Robotham J.V., Scarff C.A., Jenkinsb D.R., Medley G.F., Journal of Hospital Infection 2007;65(Suppl 2):93-9.
Theoretical modelling shows that patient movements in and out of hospitals are likely to affect nosocomial transmission dynamics. The community acts as a “reservoir” and readmission of individuals colonised during previous admissions can result in sporadic transmission within hospitals. A 7-year investigation of patient movement patterns showed that an infected person has a 44.2% chance of being readmitted while still infected. This value is far higher than previous estimates (3.7%) highlighting the potential importance of transmission driven by hospital admissions. For this reason we believe consideration of readmissions from the community population to be critical to the success of hospital acquired infection control.

Transmission of influenza A in human beings. Brankston G., Gitterman L., Hirji Z., Lemieux C., Gardam M. The Lancet Infectious Diseases 2007;7:257-65.
There continues to be much debate about how influenza is transmitted. This paper is a systematic review of the literature on this subject. The authors find that data are limited on modes of transmission in the natural setting. They concluded however that transmission occurs at close range rather than over long distances, suggesting that airborne transmission, as traditionally defined, is unlikely to be of significance in most clinical settings. Further research is required to better define conditions under which the influenza virus may transmit via the airborne route.

The significance of fomites in the spread of respiratory and enteric viral disease. Boone S.A., Gerba C.P. Applied and Environmental Microbiology 2007;73:1687-96.
This paper is a detailed review of the published evidence on the spread of respiratory and enteric viral disease via fomites.

Lack of occurrence of methicillin-resistant Staphylococcus aureus on municipal public telephones.
O’Connor A., Loughrey A., Millar B.C., Lowery C.J., Dooley J.S., Goldsmith C.E., Rooney P.J., Moore J.E. American Journal of Infection Control 2007;35:285-6.

Residence time and food contact time effects on transfer of Salmonella Typhimurium from tile, wood and carpet: testing the five-second rule. Dawson P., Han I., Cox M., Black C., Simmons L. Journal of Applied Microbiology 2007;2:945-53.
Experiments were conducted to determine the survival and transfer of Salmonella Typhimurium (S. Typhimurium) from wood, tile or carpet to bologna (sausage) and bread. S. Typhimurium can survive for up to 4 weeks on dry surfaces in high-enough populations to be transferred to foods. Over 99% of bacterial cells were transferred from the tile to the bologna after 5 sec of bologna exposure to tile. Transfer from carpet to bologna was very low (<0·5%) when compared with the transfer from wood and tile (5-68%), and S. Typhimurium can be transferred to the foods tested almost immediately on contact.

Enumeration of Campylobacter spp. on the surface and within chicken breast fillets. Luber P., Bartelt E. Journal of Applied Microbiology 2007;102:313-8.
One hundred fresh retail chicken breast fillets were analysed using a rinse sample for surface and 55 fillets for internal pathogen contamination using 10 g meat and a most probable number technique. Prevalence was 87% on the surface and 20% in the deep tissue. The mean number of Campylobacter on the surface was 1903 CFU, with a median of 537 CFU and a maximum of 38,905 CFU. Counts inside the tissue were <1 CFU/g meat (mean = 0.24 CFU, median = 0.15 CFU, maximum = 0.74 CFU). Given the high numbers of the pathogen on the chicken meat surface in comparison with low levels of internal contamination, it can be concluded that cross-contamination during the preparation of contaminated chicken is a more important pathway for consumers’ exposure to Campylobacter than the consumption of undercooked meat.

Occurrence of moulds in drinking water. Hageskal G., Gaustad P., Heier B.T., Skaar I. Journal of Applied Microbiology 2007;102:774-80.  
In order to determine the occurrence of filamentous fungi in public drinking water systems in Norway, water from 14 water supply networks from all over the country was sampled and analysed.

MRSA in non-clinical areas of hospitals. Brown N.M., Lee S.D., Duerden B.I., Gillanders S.A., Cookson B., Neville L., Jenks P., Catchpole C., Wright P., Spencer R.C. Journal of Hospital Infection 2006;64:402-3.
In order to establish whether or not MRSA could be detected in non-clinical areas, a standard protocol for the detection of MRSA in the hospital environment was developed. Non-clinical areas were chosen in corridors outside wards housing MRSA-positive patients, outside intensive care units and in outpatient clinics. Items sampled included door handles and push plates, stair rails, lift buttons and equipment trolleys. No MRSA was isolated from any of the non-clinical sites in any of the hospitals.

Is your phone bugged? The incidence of bacteria known to cause nosocomial infection on healthcare workers’ mobile phones Brady R.R.W., Wasson A., Stirling I., McAllister C., Damani N.N. Journal of Hospital Infection 2006;62:123-5.
The authors undertook a study to investigate healthcare workers’ (HCWs) use of mobile phones within a district general hospital. Of the 148 HCWs sampled, 145 (98.0%) owned a mobile phone. In total, 96.2% of phones demonstrated evidence of bacterial contamination, and 15 (14.3%) of the mobile phones sampled grew bacteria that are known to cause nosocomial infection. It was found that 38.1% of phones grew one bacterial species, 38% grew two different species and 20.95% grew three or more different species.

Evaluation of real-time polymerase chain reaction for the detection of methicillin-resistant Staphylococcus aureus on Environmental Surfaces. Otter J.A, Havill N.L., Boyce J.M. Infection Control and Hospital Epidemiology 2007;28:1003-1005
Real-time polymerase chain reaction (RT-PCR) was compared with in vitro culture for detecting methicillin-resistant Staphylococcus aureus (MRSA) in samples from environmental surfaces. The sensitivity of RT-PCR, compared with culture, was 92.5%, and the specificity was 51.4%. Because of poor specificity, the RT-PCR kit tested is not suitable for the detection of MRSA on hospital surfaces.

Bacterial contamination of keyboards: efficacy and functional impact of disinfectants.
Rutala W.A., White M.S., Gergen M.F., Weber D.J. Infection Control and Hospital Epidemiology 2006;27:372-7.
This study assessed the six different disinfectants (one each containing chlorine, alcohol, or phenol and three containing quaternary ammonium) against three test organisms (oxacillin-resistant Staphylococcusaureus [ORSA], Pseudomonas aeruginosa, and vancomycin-resistant Enterococcus species) inoculated onto computer keyboards. Potential pathogens cultured from more than 50% included ORSA (4% of keyboards), OSSA (4%), vancomycin-susceptible Enterococcus species (12%), and nonfermentative gram-negative rods (36%). All disinfectants, as well as the sterile water control, were effective at removing or inactivating more than 95% of test bacteria. No damage to keyboards was observed after 300 disinfection cycles.

Prevalence of nasal colonization among patients with community-associated methicillin-resistant Staphylococcus aureus infection and their household contacts. Zafar U., Johnson L.B., Hanna M., Riederer K., Sharma M., Fakih M.G., Thirumoorthi M.C., Farjo R., Khatib R. Infection Control and Hospital Epidemiology 2007;28:966-969.
This paper describes a study of nasal colonization among patients and their household members from in an urban medical center. Skin and soft-tissue infections were seen in 50 patients (98%) and two household members. Twenty-one (41%) of 51 patients and 10 (20%) of 49 household members were colonized with methicillin-resistant Staphylococcus aureus (MRSA). Most isolates (95%; infective and colonizing) carried the mec type IV complex. Of the colonized household members, five had isolates related to the patients’ infective isolate. The report suggests that the frequency of CA-MRSA colonization among household members of patients with CA-MRSA infections is higher than among the general population. Among colonized household members, only half of the MRSA strains were related to the patients’ infective isolate. Within the same household, multiple strains of CA-MRSA may be present.

Use of cellular telephones and transmission of pathogens by medical staff in New York and Israel.
Goldblatt J.G., Krief I., Klonsky T., Haller D., Milloul V., Sixsmith D.M., Srugo I., Potasman I. Infection Control and Hospital Epidemiology 2007;28:500-502.
Findings from this study show that cellular telephones are commonly used by hospital personnel, even during patient contact. One-fifth of the cellular telephones examined in this study were found to harbor pathogenic microorganisms, showing that these devices may serve as vectors for transmission to patients.

A Study of the relationship between environmental contamination with methicillin-resistant Staphylococcus Aureus (MRSA) and patients’ acquisition of MRSA. Hardy K.J., Oppenheim B.A., Gossain S., Gao F., Hawkey P.M. Infection Control and Hospital Epidemiology 2006;27:127-32.
A prospective study was conducted in a 9-bed intensive care unit for 14 months. Methicillin-resistant Staphylococcus aureus (MRSA) was isolated from the environment at every environmental screening, when both small and large numbers of patients were colonized. On only 20 (35.7%) of 56 occasions were the strains isolated from the patients and the strains isolated from their immediate environment indistinguishable. There was strong evidence to suggest that 3/26 patients who acquired MRSA while in the intensive care unit acquired MRSA from the environment.

Prevalence of Clostridium difficile environmental contamination and strain variability in multiple health care facilities. Dubberke E.R., Reske K.A., Noble-Wang J., Thompson A., Killgore G., Mayfield J., Camins B., Woeltje K., McDonald J.R., McDonald L.C., Fraser V.J. American Journal of Infection Control 2007;35:315-8.
Forty-eight environmental samples were collected from six health care facilities. Samples were cultured for the presence of clostridium difficile (C. difficile). C. difficile was cultured from 13/48 (27%) samples. Rooms housing a patient with C. difficile-associated disease (CDAD) were more likely to be culture positive than non-CDAD patient rooms (100% vs. 33%); C. difficile was not isolated outside of patient rooms (0/12 samples). The NAP1 epidemic strain was found in 5/6 facilities.

Survival of epidemic strains of nosocomial- and community-acquired methicillin-resistant Staphylococcus aureus on coins. Tolba O., Loughrey A., Goldsmith C.E., Millar B.C., Rooney P.J., Moore J.E. American Journal of Infection Control 2007;35:342-6.
This paper describes a study which demonstrates that all epidemic nosocomial- and community-acquired methicillin-resistant Staphylococcus aureus (MRSA) do not survive when no organic protection is offered but survive well when soil (pus and blood) is present, thus offering protection from drying.

Environmental contamination makes an important contribution to hospital infection. Boyce J.M. Journal of Hospital Infection 2007;65(Suppl 2):50-4.
This paper reviews the evidence for survival and transmission of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) in healthcare facilities. Environmental surfaces frequently touched by healthcare workers are commonly contaminated in the rooms of patients colonized or infected with MRSA or VRE. Studies document that healthcare workers may contaminate their hands or gloves by touching contaminated surfaces, and that hands or gloves become contaminated with numbers of organisms that are likely to result in transmission to patients. Pathogens may also be transferred directly from contaminated surfaces to susceptible patients. There is an increasing body of evidence that cleaning or disinfection of the environment can reduce transmission of healthcare-associated pathogens.

Importance of environmental decontamination a critical view. Dettenkofera M., Spencer R.C. Journal of Hospital Infection 2007;65(Suppl 2):55-7.
The authors maintain that the level of evidence supporting different disinfection and cleaning procedures performed in healthcare settings worldwide is low. The final assessment of whether use of disinfectants rather than detergents alone reduces nosocomial infection rates in different clinical settings still awaits conclusive study. The decontamination ability of the substances used; prevention of resistance; and safety for patients, personnel and the environment; are the cornerstones that interact with each other. The authors conclude that targeted disinfection of environmental surfaces (those frequently touched) is an established component of infection control activities to prevent the spread of nosocomial pathogens, but of lesser importance than proper hand hygiene.

Decontamination of the environment. Fraise A.P. Journal of Hospital Infection 2007;65(Suppl 2):58-9.
This paper reviews the evidence related to the impact of environmental cleaning and disinfection on transmission of infection in hospitals.

The First Global Patient Safety Challenge “Clean Care is Safer Care”: from launch to current progress and achievements.Allegranzi B., Storr J., Dziekan G., Leotsakos A., Donaldson L., Pittet D., Journal of Hospital Infection 2007;65(Suppl 2):115-23.
To meet the goal of ensuring patient safety across healthcare settings around the globe, the World Health Organization launched the World Alliance for Patient Safety in October 2004. Several initiatives have been undertaken to raise global awareness and to obtain country commitment to support action on this issue. The new Guidelines on Hand Hygiene in Health Care have been issued in draft form. An implementation strategy is proposed therein to provide solutions to overcome obstacles to improvement in compliance with hand hygiene practices, together with a range of practical tools.

Evaluation of liquid and fog application of Sterilox(R) hypochlorous acid solution (HOCl) for surface inactivation of human norovirus. Park G.W., Boston D.M., Kase J.A., Sampson M.N., Sobsey M.D. Applied Environmental Microbiology 2007;May 4 [Epub ahead of print].
The study were to evaluated the efficacy of hypochlorous acid (HOCl) solution (HAS) against norovirus (NV). Exposing virus-contaminated carriers of ceramic tile (porous) and stainless steel (non-porous) to 200-20 ppm of HOCl solution resulted in >/=99.9 % (>/=3 log10) reductions of both infectivity and RNA titer within 10 min. HOCl fogged in a confined space reduced the infectivity and RNA titers of NV, MNV-1 and MS2 on these carriers by at least 99.9% (3 log10).

Integrating disease control strategies: balancing water sanitation and hygiene interventions to reduce diarrheal disease burden. Jeisenberg J.N.S., Scott J.C.S., Porco T. American Journal of Public Health 2007;97:846-52.
The paper describes a modeling framework designed to capture the interdependent transmission pathways of enteric pathogens. Results suggest that the benefits of a water quality intervention depend on sanitation and hygiene conditions. When sanitation conditions are poor, water quality improvements may have minimal impact regardless of amount of water contamination. If each transmission pathway alone is sufficient to maintain diarrheal disease, single-pathway interventions will have minimal benefit. Ultimately an intervention will be successful only if all sufficient pathways are eliminated.

Microbial inactivation by microwave radiation in the home environment. Park D.K., Bitton G., Melker R. Journal of Environmental Health 2006;69:17-24.
Kitchen sponges and scrubbing pads were contaminated with wastewater and exposed to microwave radiation. At 100% power level, the total bacterial count of the wastewater was reduced by more that 99% within 1-2 mins, and the total coliform and E. coli were totally inactivated after 30 sec. Bacterial phage MS2 was totally inactivated within 1-2 min. B. cereus spores were more resistant but were eradicated after 4 min. Similar inactivation rates were obtained in wastewater-contaminated scrubbing pads.

Diarrhea prevention in a Kenyan school through the use of a simple safe water and hygiene intervention. Migele J., Ombeki S., Ayalo M., Biggerstaff M., Quick R. American Journal of Tropical Medicine and Hygiene 2007;76:351-3.
The Safe Water System (water treatment with bleach, safe storage, and behavior-change communications) was implemented to prevent diarrhea in rural Western Kenya. Clinic visits for diarrhea peaked during the January through March period in 2002 at 130 and in 2003 at 71, but in 2004, after project implementation, only 13 diarrhea episodes were recorded. The project saved the school about $5.49 per student per year. The project has been expanded to 70 schools, and an evaluation is planned.

Behavioral indicators of household decision-making and demand for sanitation and potential gains from social marketing in Ghana. Jenkins M.W., Scott B. Social Science & Medicine 2007;64(12):2427-42
This paper develops a behavioral approach to assess household demand for improved sanitation in Ghana. Adoption decision stages of preference, intention, and choice to install a toilet are defined, measured, and used to estimate sanitation demand, identify factors affecting demand at each stage, and classify households by adoption stage to identify targeted demand-stimulation strategies. Results from a sample of 536 households indicate that of 74% of households without any home sanitation, 31% have some likelihood of installing a toilet within the next year, but only 6% are very likely to do so; 62% had not considered the idea. Motivating and constraining factors are compared at each adoption stage and strategies likely to increase toilet installation in Ghana are discussed.

Assessment of benefits from use of antimicrobial hand products: reduction in risk from handling ground beef. Haas C.N., Marie J.R., Rose J.B., Gerba C.P. International Journal of Hygiene and Environmental Health 2005;208:461-6.
Quantitative microbial risk assessment (QMRA) has been used to estimate the benefits resulting from the use of hand cleansing products (e.g., soaps and alcohol- based hand sanitizers etc). This was done by developing a model for the scenario of hand contact with ground beef contaminated with E. coli during food preparation, considering transference of bacteria to the hands, removal and inactivation by hand hygiene, and subsequent transference from the hands to the mouth.

Strategies to reduce person-to-person transmission during widespread Escherichia coli O157:H7 outbreak. Seto E.Y.W., Soller J.A., Colford J.M. Emerging Infectious Diseases 2007;13:861-866
Using data from the 2006 E. coli O157:H7 outbreak in 2006 in the United States associated with contaminated spinach, Seto et al developed a model to study secondary person-to-person transmission which showed that secondary transmission was similar to that in previous E. coli outbreaks (≈12%). The model suggests that even a modestly effective hygiene promotion strategy to interrupt secondary transmission (prevention of only 2-3% of secondary illnesses) could result in a reduction of ≈5-11% of symptomatic cases.

Use of hypochlorite solution to decrease rates of Clostridium difficile-associated diarrhea. McMullen K.M., Zack J., Coopersmith C.M., Kollef M., Dubberke E., Warren D.K. Infection Control and Hospital Epidemiology 2007;28:205-7 [Epub 2007, Jan 26].
An increased rate of Clostridium difficile-associated diarrhea (CDAD) was noted in two intensive care units of a university-affiliated tertiary care facility. One unit instituted enhanced environmental cleaning with a hypochlorite solution in all rooms, whereas the other unit used hypochlorite solution only in rooms of patients with CDAD. The CDAD rates decreased in both units.

Effect of intensive handwashing in the prevention of diarrhoeal illness among patients with AIDS: a randomized controlled study. Huang D.B., Zhou J. Journal of Medical Microbiology 2007;56:659-63.
Seventy-five patients were randomly assigned to an intensive handwashing intervention (after defecation, after cleaning infants who had defecated, before preparing food, before eating, and before and after sex) and 73 patients were assigned to the control group. Patients assigned to the intensive handwashing intervention group washed their hands more frequently compared with the control group (7 vs. > 4 times a day, respectively; P<0.05) and developed fewer episodes of diarrhoeal illness (1.24+/-0.9 vs. 2.92+/-0.6 new episodes of diarrhoea, respectively; P<0.001) during the 1-year observation.

Designing a protocol that eliminates Clostridium difficile: a collaborative venture. Whitaker J., Brown S., Vidal S., Calcaterra M. American Journal of Infection Control 2007;35:310-4.
A case-only study was conducted over a 24-month period. Interventions used to reduce the incidence of healthcare-associated Clostridium difficile (C. difficile) included 10% hypochlorite disinfection, soap and water hand hygiene, contact isolation for suspected and confirmed cases, educational tool for patients and visitors, daily isolation rounds, automated report functions, and standardized nursing unit isolation processes. A 66% reduction in the number of healthcare-associated C. difficile cases was achieved during the study.

Reduction of Clostridium difficile and vancomycin-resistant Enterococcus contamination of environmental surfaces after an intervention to improve cleaning methods. Dubberke E.R., Reske K.A., Noble-Wang J., Thompson A., Killgore G., Mayfield J., Camins B., Woeltje K., McDonald J.R., McDonald L.C., Fraser V.J. American Journal of Infection Control 2007;35:315-8.
During a 6-week period commonly touched surfaces (i.e. bedrails, telephones, call buttons, door knobs, toilet seats, and bedside tables) were cultured in rooms of patients with CDAD and vancomycin-resistant Enterococcus (VRE) colonization or infection before and after housekeeping cleaning, and again after disinfection with 10% bleach. Of the 17 rooms of patients with VRE colonization or infection, 16 (94%) had one or more positive environmental cultures before cleaning versus 12 (71%) after housekeeping cleaning, whereas none had positive cultures after bleach disinfection by the research staff. Of the nine rooms of patients with CDAD, 100% had positive cultures prior to cleaning versus seven (78%) after housekeeping cleaning, whereas only one (11%) had positive cultures after bleach disinfection. After an educational intervention, rates of environmental contamination after housekeeping cleaning were significantly reduced.

Faecal contamination of drinking water sources of Dhaka city during the 2004 flood in Bangladesh and use of disinfectants for water treatment. Islam M.S., Brooks A., Kabir M.S., Jahid I.K., Shafiqul Islam M., Goswami D., Nair G.B., Larson C., Yukiko W., Luby S. Journal of Applied Microbiology 2007;103:80-7.
During 2004/2005 a total of 300 water samples were collected from 20 different drinking water sources in Kamalapur, Dhaka city. The unacceptable level of contamination of total coliforms (TC), faecal coliforms (FC) and faecal streptococci (FS) ranged from 23.8% to 95.2%, 28.6% to 9.2% and 33.3% to 90.0%, respectively. The isolation rates of V. cholerae O1 and O139 were both 0.33%, and non-O1/non-O139 was 7.0%. Although alum potash, bleaching powder, Halotab and Zeoline®-200 were all effective general disinfectants, Halotab and Zeoline®-200 were superior to bleaching powder and alum potash against FC. The study showed that during and after floods, point of use water treatment could reduce waterborne diseases among flood-affected people.

The impact of a school-based safe water and hygiene programme on knowledge and practices of students and their parents: Nyanza Province, western Kenya, 2006. O’Reilly C.E, Freeman M.C., Ravani M., Migele J., Mwaki A., Ayalo M., Ombeki S., Hoekstra R.M., Quick R. Epidemiology and infection 2007;1-12 [http://dx.doi.org/10.1017/S0950268807008060]
A school-based safe water and hygiene intervention was carried out in 45 rural primary schools in Nyanza Province, western Kenya. A CDC team surveyed 390 students from nine schools and their parents at baseline and conducted a final evaluation of 363 students and their parents. From baseline to final evaluation, improvement was seen in students’ knowledge of correct water treatment procedure (21-65%) and knowing when to wash their hands. At final evaluation, 14% of parents reported currently treating their water, compared with 6% at baseline (P<0.01). From 2004-2005, school absenteeism in the September-November term decreased in nine project schools by 35% and increased in nine neighbouring comparison schools by 5%.

Efficacy of hospital cleaning agents and germicides against epidemic Clostridium difficile strains. Fawley W.N., Underwood S., Jane Freeman J., Baines S.D., Saxton K., Stephenson K., Owens R.C., Jr., Wilcox M.H. Infection Control and Hospital Epidemiology 2007;28: in press.
The study used in vitro methods to compare the effects of five cleaning agents and/or germicides (three containing chlorine, one containing only detergent, and one containing hydrogen peroxide) on vegetative and spore forms of Clostridium difficile (C. difficile). A human fecal emulsion was used to mimic conditions found in situ. When used at recommended concentrations, only chlorine-based germicides inactivated spores. C. difficile epidemic strains had a greater sporulation rate than non-epidemic strains. The mean sporulation rate was 13% for strains not exposed to cleaning agent/germicide, and was significantly increased by exposure to cleaning agents or germicides containing detergent alone (34%), combined detergent and hypochlorite (24%), or hydrogen peroxide (33%). By contrast, the sporulation rate did not change substantially after exposure to germicides containing either both combined detergent and dichloroisocyanurate (9%) or dichloroisocyanurate alone (15%).

Bacterial resistance to biocides in the healthcare environment: should it be of genuine concern? Maillard J.-Y. Journal of Hospital Infection 2007;65(Suppl 2):60-72.
From a review of the evidence base the author concludes that the documented response from bacteria exposed to biocide in conditions close to those found in practice suggests that intrinsic resistance does not adequately describe bacterial survival mechanisms, and that terms such as biofilm resistance and environmental resistance would be more appropriate. The inability to correlate emerging bacterial resistance from in vitro experiments with practical situations is a major drawback when attempting to ascertain whether emerging bacterial resistance in healthcare facilities is of genuine concern. Microbial resistance to in-use biocide concentration has been described in practice, but is uncommon. The efficacy of biocides in healthcare facilities has to be questioned with the increasing use of products with low bactericidal activity, as is the selection of less susceptible bacteria following such exposure.

Acinetobacter lwoffii and Lactococcus lactis strains isolated from farm cowsheds possess strong allergy-protective properties. Debarry J., Gam H., Hanuszkiewicz H., Dickgreber N., Blümer H., Von Mutius E., Bufe A., Gaterman S., Rens H., Holger H. Journal of Allergy and Clinical Immunology 2007;119:1514-21.
The paper evaluates the potential allergy-protective properties of microbes isolated from the farming environment. Of a number of bacterial species identified in cowsheds of farms, two were selected, namely Acinetobacter lwoffii F78 and Lactococcus lactis G121. Both isolates were able to reduce allergic reactions in mice, to activate mammalian cells in vitro, and to induce a TH1-polarizing program in dendritic cells. The data strongly support the hygiene hypothesis, which states that an environment rich in microbiologic structures, such as a farming environment, might protect against the development of allergies.

Early-life respiratory viral infections, atopic sensitization, and risk of subsequent development of persistent asthma. Kusel M.H., de Klerk N.H., Kebadze T., Vohma V., Holt P.G., Johnston S.L., Sly P.D. Journal of Allergy and Clinical Immunology 2007; in press [http://www.jacionline.org/article/PIIS0091674907002382/abstract ].
This study suggests that severe viral infections combined with sensitivity to allergies during the first year of a child’s life may lead to the development of asthma later in childhood. The researchers studied almost 200 children for 5 years, recording the viruses they were infected with during their first year of life and when they developed allergies. They found that those children who had a lower respiratory viral infection during their first year of life and developed sensitivity to an allergen before they were two were three to four times more likely to suffer from asthma at the age of 5.

REVIEW: Behavioural considerations for hand hygiene practices: the basic building blocks. Whitby M., Pessoa-Silva C.L., McLaws M.-L., Allegranzi B., Sax H., Larson E., Seto W.H., Donaldson L., Pittet D. Journal of Hospital Infection 2007;65:1-8.
In October 2005, the WHO World Alliance for Patient Safety launched the first Global Patient Safety Challenge “Clean Care is Safer Care”, to tackle healthcare-associated infection on a large scale. Within the Challenge framework, international infection control experts and consultative taskforces met to develop new WHO Guidelines on Hand Hygiene in Healthcare. This paper explores aspects underlying hand hygiene behaviour that may influence its promotion among healthcare workers.

Warned, but not well armed: preventing viral upper respiratory infections in households. Larson E.L. Public Health Nursing 2007;24:48-59.
Public health nurses can use several strategies for prevention of upper respiratory infections (URIs): (a) provide more tailored educational messages on preventive strategies (vaccination, hand hygiene, spatial separation of infected household members, avoidance of antibiotics to treat viral URI, and environmental cleaning), which are delivered personally rather than passively; (b) use patient encounters to encourage vaccination for risk groups; (c) encourage use of alcohol hand sanitizers by householders during the cold and flu season; and (d) provide opportunities for skill development (e.g., cover your cough).