Hospital Studies

TEST ONE

Surgery Center

Overview: 
Twenty different sample sites were used over the course of a six-week study. One part of the sample site was treated with the antimicrobial and the other part of the sample site was left untreated. The basis of the study was that the sample sites were tested at the end of the day, left overnight, and then sampled again in the morning. What we were looking for was the difference of bioburden between the treated and untreated surfaces.

Results: 
In very simple terms the conclusion of the study shows that the control, or untreated surface increases in bioload (or germs on the surface), while the treated surface actively decreases the amount of bioload.
This is a good example of what happens if a “dirty” spot is missed or improperly cleaned. Without protection, the spot is able to amplify growth, while if protected, the spot actively decreases the number of germs on the surface.

Please see below for test information.

TEST TWO

Click to jump to Test Two details.

Hospital

Overview & Results:
This study was conducted by a third party for us in a northeastern hospital over the course of 8 weeks. Two identical rooms were used, one treated and one not treated. The simple comparison between the two rooms shows that the treated room has an average ATP score of 17.9 and the untreated room has an average ATP score of 78.3.

Please see below for test information.

TEST ONE

Improved Control of Microbial Exposure Hazards in Hospitals:
A 30 - Month Field Study

R.A. Kemper 1 , L. Ayers 2 , C. Jacobson 3 , C. Smith 4 , and W.C. White 5

Abstract

The microbial colonization of environmental surfaces in hospitals and other buildings can produce infective, allergenic, and toxigenic risks for occupants. Traditional disinfectant/sanitizer formulations do not provide sustained control of microbial contamination at low levels and their extended use is potentially dangerous to ma n and the environment.

This study evaluates the effectiveness of a new class of antimicrobial agents that covalently bond to surfaces and are not chemically reactive with the microbial cells. This organosilicon antimicrobial, 3 – trimethoxysilylpropyldimeth yloctadecyl ammonium chloride (ÆGISâ„¢ Antimicrobial , now referred to as mPale Antimic robial with Aegis Microbe Shield ), produces antimicrobially active surfaces on a variety of substrates.

After modifying the interior surfaces of a flood-damaged hospital with this antimicrobial, we evaluated airborne microbial concent rations for 30 months. The results show a significant and sustained reduction of viable airborne microorganisms.

1 Kemper Research Foundation, Cincinnati, Ohio 45150
2 Ohio State University Hospitals, Columbus, Ohio 43210
3 Arthur G. James Cancer Hospital and Research Institute, Columbus, Ohio 43210
4 Ohio State University, Columbus, Ohio 43210
5 Dow Corning Corporation, Midland, Michigan 48686

Introduction
The use of chemical disinfectants to reduce microbial colonization of hospital surfaces can be traced to the 1860’s when Joseph Lister atomized a 5% Phenol solution to control “hospital gangrene.” Since that time, there have been many advances in the design of antimicrobial/disinfectant chemistries to provide an increasing toxic arsenal for our war on germs. Methods to deliver antimicrobials have also improved significantly. Micro – aerosol dispersion, microencapsulation, and impregnation of the biocide into a variety of polymeric resins have been used to expand the capabilities of these agents and to reduce toxic consequences for man and the environment.

These advances gave rise to many types of antimicrobial agents with varying disinfection mechanisms, but the basic principle of microbial destruction has not changed. Although antimicrobial agents today are more toxic and can be delivered effectively in a variety of ways, each is defined by the principle of chemical reactivity with the cell or its components. And each requires dissociation of the disinfectant from the surface and intimate involvement in one or more components of the life processes of the cell.
Since the principle of disinfection did not change, the new antimicrobial agents shared the same limitations. The agent had to leach or diffuse into the surrounding environment for association with a cell; diffusion reduced the concentration below the effective dose, leading HospitalStudy Abstract The microbial colonization of environmental surfaces in hospitals and other buildings can produce infective, allergenic, and toxigenic risks for occupants. Traditional disinfectant/sanitizer formulations do not provide sustained control of microbial contamination at low levels and their extended use is potentially dangerous to man and the environment. This study evaluates the effectiveness of a new class of antimicrobial agents that covalently bond to surfaces and are not chemically reactive with the microbial cells. This organosilicon antimicrobial, 3 – trimethoxysilylpropyldimeth yloctadecyl ammonium chloride (ÆGISâ„¢ Antimicrobial , now referred to as mPale Antimicrobial with Aegis Microbe Shield and Healthy Mama), produces antimicrobially active surfaces on a variety of substrates. After modifying the interior surfaces of a flood-damaged hospital with this antimicrobial, we evaluated airborne microbial concentrations for 30 months. The results show a significant and sustained reduction of viable airborne microorganisms. to resistance and adaptation; and, diffusion required solubility of partitioning, resulting in exposure consequences for man and the environment.

The first change in the principle of disinfection occurred in 1969 with the development of organosilicon antimicrobials. Using an alkoxysilane – coupling agent reacted to a quaternizedamine, Plueddemann was able to covalently link this novel antimicrobial directly to surface molecules. The bound monomers then reacted with each other to form a crosslinked polymer of extremely high molecular weight, thereby producing an essentially permanent antimicrobial surface.

Speier and Malek (1) were able to demonstrate the antibacterial, antifungal, antiviral, antialgal, and antiprotozoal activity of this surface bonded agent against a broad spectrum of microorganisms, even after repeated washings. Isquith et al (2) were able to demonstrate, by radioisotope analysis and bioassay, that its antimicrobial activity did not result from the release of the material and is a surface – associated phenomena. This is also supported by its lack of a classic zone of inhibition. Thus, chemical reactivity with the cell or its components was not required for activity.

The immobilization of an antimicrobial agent could produce self – sanitizing surfaces that provide significant advantages over conventional approaches to disinfection. Since antimicrobial activity does not involve the release of the material and the material remains present at adaptation minimizes the same concentration, Gettings (3) was able to show that resistance and do not occur. This not only extends the predicted activity of the agent but the possibility of cross-linked antibiotic resistance, as well. Since the antimicrobial remains chemically bonded to the surface molecules, there is a low potential for irritational, toxic, or other human exposure consequences. The permanent attachment of the antimicrobial to the surface molecule also minimizes the environmental risks associated with conventional antimicrobial usage.

The modification of interior surfaces with a bound antimicrobial agent could prevent the development of microbial reservoirs in a building. The destruction of airborne microorganisms upon contact with antimicrobial surfaces would further reduce human exposure potential, producing an environment with lowered risk of allergenic, infective, or toxigenic consequences for building occupants.

Hayes and White (4) have shown that antimicrobial activity can be imparted to a variety of substrates with this agent and Kemper et al (5) have shown that antimicrobial activation of interior building surfaces with this agent reduces airborne microbial concentration. This potential was further explored to determine the usefulness of this technology in a variety of building conditions, treatment surfaces, and levels and types of microbial contamination.

The present study was conducted to determine the level of microbial control possible from the comprehensive use of the material in a severely contaminated building, and to assess the duration of effective control.

Background
The study building is a 12 – story comprehensive cancer center and research institute located in Columbus, Ohio. Just prior to its opening in January 1990, a ruptured water pipe on the 12 th floor flooded the building with an estimated 500,000 gallons of water. Ceilings, walls, carpeted floors and upholstered furnishings were either wet or exposed to high humidity.

After assuring that its structural integrity had not been compromised, attention focused on restoring the microbiological quality of the building to levels consistent with its intended use, particularly in Bone Marrow Transplant and other areas where immunosuppressed patients would be housed. Despite high-efficiency air filtration and widespread use of a chlorine-based disinfectant fog throughout the building and its ventilation system, large numbers of fungi and bacteria were retrieved from the air in all areas of the hospital. Large numbers of water – associated bacteria, such as Acinetobacter sp., as well as fungi were retrieved from carpeting.

Prior to the flood, hospital and university researchers had designed a study protocol to investigate the effect of surface modification with silane antimicrobials on infection rates within Bone Marrow Transplant, Hematology and Oncology areas in the hospital. The flood and subsequent microbial contamination preempted the study. But, investigation of various antimicrobial systems to achieve sustained microbial control during the study provided an important tool for use in remediation and beyond.

The present study was conceived to evaluate the effectiveness of this technology as an active interdictive method for control of gross microbial colonization under extreme conditions and to assess the duration of activity achieved during restoration.

Materials and Methods

Microbiological Sampling
Microbial retrievals were obtained using an Andersen 2 – stage viable impact sampler and a New Brunswick high volume sampler. The Andersen sampler was loaded with plastic petri dishes containing 20ml Malt Extract Agar and operated for 18 minutes at a calibrated volume of 1 cubic foot per minute. The New Brunswick sampler was loaded with a plastic petri dish HospitalStudy containing Malt Extract Agar and operated for 1 hour at a calibrated volume of 50L per minute.

Exposed petri dishes were incubated at 30°C for 120h. Colony Forming Units (CFU’s) were enumerated at 48 and 72 hours, with final counts reported as those recorded at 72h.

Pretreatment samplings were performed at cart height (30’) with the Andersen sampler at 209 sites. The first post-treatment samplings were performed at cart height at 643 sites. The second and final samplings were performed at cart height and floor level simultaneously using a remote probe on the New Brunswick sampler. Sample site locations for the second and final post-treatment samplings were randomly selected by floor using a random number generator.

Surface Modification
All accessible interior surfaces (including carpeting, ceilings, walls, above ceiling space, furnishings, elevator shafts, mechanical and ele ctrical chases) were treated with the organosilicon antimicrobial 3 – trimethoxysilylpropyldimethyloctadecyl ammonium chloride (ÆGISâ„¢ Antimicrobial) (6) in water in accordance with the manufacturer’s application specifications. The applicatio ns were randomly tested for uniformity and penetration throughout the treatment process.

Results
The results of the samplings are presented to Table 1. Two of the post – treatment sampling periods contain data from retrievals at floor level. These data are included as additional information and should not be used to compare pre – post microbial levels.

Pre – treatment retrievals were in a range of 721 – 2,800 CFU’s/m 3 . Of the 209 sample sites, 122 (58%) sites produced 2,800 CFU’s/m 3 , the upper detectio n limit of the sampler.

Post – treatment sampling during the seven months following restoration of the building produced an average of 4.1 CFU’s/m 3 at 643 sites. Retrievals were in a range of 0 – 25 CFU’s/m 3 . Of the sample sites, 289 sites (45%) produced 0 CF U’s/m 3 ; an additional 231 sites (36%) produced retrievals in a range of 1 – 5 CFU’s/m 3 .

The second post – treatment samplings were performed in 1991 at 82 sites randomly selected by floor. The samplings produced retrievals in a range of 0 – 9 CFU’s/m 3 , with an average retrieval of 0.8 CFU’s/m 3 . 40 sites (48%) produced 0 CFU’s.

The final post – treatment samplings were performed in 1992 at 86 sites randomly selected by floor. The samplings produced retrievals in a range of 0 – 4.7 CFU’s/m 3 , with an average retrieval of 0.4 CFU’s/m 3 . 56 sites (65%) produced 0 CFU’s.

Each of the 24 Bone Marrow Transplant patient rooms were negative for microorganisms during all of the post – treatment samplings.

Figure 1 shows the retrieval averages of pre and post – tre atment samplings in the building.

Figure 2 shows the calculated reduction in microbial retrievals during the 30 – month study period.

Discussion
The microbial colonization of interior surfaces in buildings, particularly carpeting, is well known. The aerosolization of large numbers of bacteria and fungi from these microbial reservoirs has also been repeatedly demonstrated. Yet, the range of acute and chronic effects of airborne microorganisms and their metabolites on morbidity and mortality has not been fully explored.

Despite the fact that, with a few major exceptions, airborne transmission of bacterial infections still remains a hypothesis which lacks both proof and universal acceptance, the infective, allergenic, toxigenic, and other untoward potentials of these organisms are increasingly confirmed. The medical significance of airborne microbial contamination in hospitals, schools, offices, and other buildings is likely to be much greater than traditional beliefs suggest.

A cursory review of the literature compels one to reassess the importance of effective microbial control measures in our buildings:

Charley (7) reported a decrease in infection rates following clean air precautions in the operating room;

Rhame et al (8) have shown a direct correlation between the concentration of airborne Aspergillus spores in hospital air and the incidence of aspergillosis among immunosuppressed patients;

Arnow et al (9) reports “our findings strongly suggest that the inanimate hospital environment i s a major determinant of the risk of endemic or epidemic nosocomial aspergillosis”;

Brundage et al (10) observed a 50% increase in respiratory infections among recruits housed in energy efficient buildings with recirculated air when compared to recruits housed in older, drafty buildings;

Spengler et al (11) reported a 40 – 100% increase in respiratory illness among children in homes with moisture and mildew problems;

Several studies (12, 13, 14, 15) have implicated airborne microbial contaminants in the development of Building-Related Illnesses and Sick Building Syndrome.

There is an abundance of empiric and anecdotal data that amplify the need to control human exposure to airborne microorganisms and microbial metabolites. However, the availability of good scientific data on safe, efficacious control methods is more elusive. Our search for improved methods of disinfection/microbial controlled to an array of products and processes. Yet, each possessed limiting characteristics that rendered them unacceptable for our purpose:

All traditional disinfectant products have a vapor pressure, potentiating occupant exposure concerns; The duration of antimicrobial activity of traditional disinfectants is relatively short (ranging from a few minutes to several days) unless incorporated within a substrate with slow – release characteristics; Although many disinfectant formulations appear to possess increased activity against specific classes of microorganisms, this selectivity precluded broad – spectrum control.

None of the disinfectant chemistries available could demonstrate, by published data or interpretation of their disinfection mechanisms, a reduced potential for the development of microbial resistance. The development of microbial resistance would not only reduce the duration of effective activity of the antimicrobial but presents additional concerns in a hospital environment, as well. The idea of microorganisms conferring antimicrobial resistance to antibiotic tolerance is neither new nor unpredictable. As Russell et al (16) described in “Principles and Practices of Disinfection, Preservation, and Sterilization,” increased resistance to antimicrobial and antiseptic preparations (as demonstrated by increased Minimum Inhibitory Concentration) was directly linkable to the number of antibiotics to which the microbial strains were resistant. Nor is it surprising that the authors concluded about the use of QACs and other cationic preparations “These results suggest to us that a policy which relies heavily on the use of cationic antisepsis is likely to select for a hospital flora of notoriously drug-resistant species.

Location Pre – treatment 1990
1991 1992
M – 1
01 1
M – 3
03 2
M – 1
01
M – 1
03
Total
Building
Average
Sites
2,655.2
209
4.1
643
1.8
83
0.8
82
0.7
105
0.4
86
1st Floor
Average
Sites
2,708.8
29
2.7
76
2.7
7
1.0
7
1.0
7
0.3
7
2nd Floor
Average
Sites
2,614.0
14
16.0
76
1.0
7
0.6
7
1.0
7
0.7
7
3rd Floor
Average
Sites
2,642.3
19
0.9
72
1.1
7
0.8
7
1.3
7
0.9
7
4th Floor
Average
Sites
2,691.9
20
4.8
48
1.0
10
0.6
10
0.3
24
0.3
8
5th Floor
Average
Sites
2,658.4
22
1.6
68
0.6
11
0.4
11
0.7
13
0.3
11
6th Floor
Average
Sites
2,618.0
9
2.1
19
2.0
7
1.2
7
0.5
7
0.1
7
7th Floor
Average
Sites
2,758.0
12
4.7
40
2.3
7
0.5
7
0.4
7
0.0
6
8th Floor
Average
Sites
2,640.6
17
1.2
58
1.1
7
0.5
7
0.4
7
0.0
7
9th Floor
Average
Sites
2,627.0
19
0.8
61
N/D
0
N/D
0
0.8
7
0.2
7
10th Floor
Average
Sites
2.608.0
17
1.3
48
1.6
7
0.5
7
0.9
7
0.9
7
11th Floor
Average
Sites
2,619.6
13
4.5
36
0.9
8
1.1
7
1.1
7
0.8
7
12th Floor
Average
Sites
2,633.6
18
6.3
43
7.0
7
2.3
7
0.8
7
0.2
7

Filtration, particularly with high efficient particulate air (HEPA) filters, has been claimed to provide significant control of transient microbial populations (17), but it is also reported that the effectiveness of this control method is limited by the development of propagative sources of microorganisms within the hospital. This is consistent with our pre-treatment sampling data, during which, despite central and terminal HEPA filtration in Bone Marrow Transplant patient rooms, microbial retrievals remained above 70 CFU’s/ft3 (18).

Conclusions
The data from this study show that significant control of airborne microorganisms results from the modification or interior building surfaces with an organosilicon antimicrobial. Even when evaluated under severe environmental conditions, the antimicrobial activity of these modified surfaces provides a substantive reduction of airborne microbial concentration.

The initial reduction of airborne microorganisms and the sustained control of microbial levels during the 30 months of this study are unprecedented in the literature. When viewed collectively, the safety, efficacy, and durability of this technology provide a unique opportunity to control the risks associated with microbial contamination in buildings.

References
I. Speier, J.L. and Malek, J. R., Destruction of Microorganisms by Contact with Solid Surfaces, Journal of Colloid and Interface Science, 1982: 89: 68 – 76.

II. Isquith, A.J., Abbot, A.E., and Walters, P.A., Surface – Bonded Antimicrobial Activity of an Organosilicon Quatern ary Ammonium Chloride, App. Micro., 1972; 24: 859 – 863.

III. Gettings, R.L., Personal communications with the author; and Gettings, R.L. and Triplett, B.L., A New Durable Antimicrobial Finish for Textiles, Book of Papers, AATCC National Conference, 1978.

IV. Hayes, S.F. and White, W.C., How Antimicrobial Treatment can Improve Nonwovens, American Dyestuff Reported, 1984.

V. Kemper, R.A., Sustained Reduction of Aerobiological Densities in Buildings by Modification of Interior Surfaces with Silane Modified Quaternary Amines, Indoor Air Pollution, Chapter 5, 1991.

VI. EGIS™ Antimicrobial is a trademark of EGIS Environmental Management, Inc., Midland, Michigan (formerly Sylgard™ Antimicrobial Treatment manufactured by Dow Corning C orporation, Midland, Michigan).

VII. Charnley, J., Clean Air in the Operating Room, Cleveland Clinic Quarterly, 1973; 40: 99 – 114.

VIII. Rhame, F.S., Streifel, A.J., Kersey, J.H. Jr., and McGlave P.B., Extrinsic Risk Factors for Pneumonia in the Patie nt at High Risk of Infection, American J. of Med., 1984; 76: 42 – 52.

IX. Arnow, P.M., Sadigh, M., Costas, C., Weil, D., and Chudy, R., Endemic and Epidemic Aspergillosis Associated with In – Hospital Replication of Aspergillus Organisms, J. Inf. Dis., 1991 ; 164: 998 – 1002.

X. Brundage, J.F., Building Associated Risk of Febrile Acute Respiratory diseases and Army Trainees, JAMA, 259:14, 1988.

XI. Spengler, J. and Su, H., Survey of Indoor Microbiological Contaminants and Association with Home Factors and Health, Developments in Industrial Microbiology, 1990; 31.

XII. White, W.C. and Kemper, R.A.,, Building Related Illness: New Insights Into Cases and Effective Control, EGIS Environmental Management, Inc., 1992; Form No. 4729 – 92.

XIII. Kr eiss, K., The Epidemiology of Building Related Complaints and Illness, Occupational Medicine: State of the Art Reviews – Vol. 4, No. 4, Oct – Dec, 1989; pp. 575 – 592.

XIV. WHO Reports, Biological Contaminants in Indoor Air, World Health Organizati on Meeting in Rutabaga, 1988; Euro. Report.

XV. Miller, J.D., Fungi as Contaminants in Indoor Air, Proceedings of the International 5 th Conference on Indoor Air Quality and Climate, Indoor Air™ 90, Toronto, Canada, Jul 29 – Aug 3, 1990, pp. 51 – 64.

XVI. Russell, A.D., Hugo, W.B. and Bailiff, G.A.J., Principles and Practice of Disinfection, Preservation and Sterilization, Blackwell Scientific, 1982.

XVII. Reedman, R.E., Murielle, P.M., Davis, G.B., Georgitis, J.W., a nd DeMassi, J.M., A Double Blind Study of the Effectiveness of a High – Efficiency Particulate Air (HEPA) Filter in the Treatment of Patients with Perennial Allergic Rhinitis and Asthma, J. Allergy Clin. Immunol., 1990; 85: 1050 – 1057.

XVIII. Kemper, R.A. a nd Jacobson, C., Modification of Interior Surfaces Using EGIS™ Antimicrobial System to Reduce Filtration Requirements for Bioaerosol Control in a Hospital, Proceedings, 1992 Indoor Air Quality Congress, Boston, MA, 1992.

This study was originally completed using Aegis Antimicrobial or Aegis 5700. In 2003, mPact Environmental Solutions, LLC entered into an agreement with Aegis to take over their Aftercare Market business. The product used in the aftercare market is now called mPale Antimicrobial with Aegis Microbe Shield and Healthy Mama.

Aegis Environments has entered into an agreement with mPact Environmental Solutions, LLC to represent the former Aegis antimicrobial products. The product Aegis Antimicrobial is now known as mPale Antimicrobial with Aegis Microbe Shield and Healthy Mama.

TEST TWO

Fungal Remediation and Protective Antimicrobial Treatment Of a Grossly Contaminated Ten Story Hospital

Kumar. S 1 , Satish 2 and White WC 3 1 IAQ Consultants, 2 Aegis Asia Pte Ltd, Singapore 3 ÆGIS Environments, Midland, Mi chigan USA

Abstract
After over five years of planning and construction and two months after opening, Hospital Sultan Ismail was infested with potentially deadly fungus. The areas of the extensive visible mold growth (Dominant Species: Aspergillus fumigat us) were widespread throughout the entire ten storey hospital which has 704 beds and 3004 rooms.

A focused environmental investigation was undertaken for microbial growth within the building using organoleptic observations, records review, and microbial s ampling techniques along with environmental condition measurements of temperatures, relative humidity, carbon monoxide, carbon dioxide, and laser particle measured particles. Infrared scans of all building areas were done to determine areas of moisture con centration within the structural materials and spaces. These studies uncovered abnormally favorable conditions for microbial growth and revealed moderate to high levels of fungi on interior surfaces and air sampling results showed >1000CFU/m 3 in most areas.

The mycological goals of the building restoration project were to reduce microbial reservoirs and control of fungi on all exposed surfaces to the lowest attainable level. All visibly colonized materials in the building were discarded and al l fine dust on interior surfaces was removed by vacuuming and/or damp wiping. A chemically bonded durable broad spectrum long – lasting organosilane antimicrobial treatment (EGIS™), 3 – trimethoxysilylpropyldimethyloctadecyl ammonium chloride, was selected to treat all building and furnishing surfaces during restoration.

Testing of the facility at five months following restoration showed 12% of the indoor environment to be free of airborne fungi, 53% with < 100 CFU/m 3 (colony forming units per cubic meter) of a ir, and 35% with over 100 – 200 CFU/m 3 . This represented an on – average reduction from the 307 sampling sites of 88% or almost nine times.

Introduction
Since the mid – 1800’s there has been a growing concern about adverse health effects of fungal contamination on hospital occupants, patients, visitors, and staff. Then, as now, the morbidity and mortality resulting from microbial exposure encouraged the advancement of general disinfection, aseptic technique, and a variety of practices and procedures to control occupant exposure to exogenous microflora. The basic principles of infection control established by Pasteur, Lister, Semmelweiss, and others provided focus on infective organism dose and virulence and host susceptibility. Most practical avoidance, prevention, and remediation practices have evolved around dose control. This is an important principle as one looks at fungal contamination and control. Fungi are potent pollutants causing deterioration, staining, musty odors, and health problems from simple discomfort, irritation, allergenic sensitization, toxic response, infectious disease, illness, and death all associated with growth of fungi in buildings. 1, 2, 3 & 4

Control of microorganisms in indoor environments has traditionally focused on source control, ventilation, and air cleaning. Disinfecting compounds are often toxic. Harmful substances interfere with vital body processes by destroying enzymes, blocking oxidation, restricting the functions of various organs and initiate cellular changes and mutations. Ordinary cleaning can be effective in places that can be easily reached but the hard – to – reach places and the “out – of – sight out – of – mind” places often become reservoirs and amplification sites for contaminating microbes. Cleaning also has limitations in its effectiveness and it is often expensive. This concern has encouraged researchers to look for other solutions.

Researchers in 1969 discovered a novel antimicrobial, using an alkoxysilane – coupling agent reacted to a quaternized amine. Plueddemann was able to covalently link this and related reactive silane chemistries directly to surface molecules. The bound monomers then reacted with each other to form a crosslinked polymer of extremely high molecular weight, thereby producing an essentially permanent antimicrobial surface. The physical interruption of the cell membranes of one-celled organisms by this reacted nano – polymer durably bonded to surfaces has was well described. 5, 6, 7, 8 & 9

The modification of interior surfaces with a bound antimicrobial agent could prevent the development of microbial reservoirs in a building and the easy recolonization of cleaned or disinfected surfaces. The destruction of airborne microorganisms upon contact with antimicrobial surfaces would further reduce human exposure potential, producing an environment with lowered risk of allergenic, infective, or toxigenic consequences for building occupants.

The present study was conducted to determine the level of microbial control possible from the comprehensive use of the EGIS organofunctional silane quaternary ammonium compound in a severely contaminated building and to assess the duration of effective control.

Materials and Methods

Background
This study was done over a five-month period from November 2005 through March 2006 at the Hospital Sultan Ismail located in Johor, Malaysia. On September 25, 2004 the Ministry of Health closed the hospital because of the potentially deadly fungal infestation which was present throughout the hospital. The remediation process and protective EGIS treatment began in March 2005 and was completed in four months.

Microbiological Sampling
Airborne fungal samples were obtained from 307 sites using an Andersen air sampler loaded with a Petri – dish containing 20 ml of Potato dextrose agar ( PDA) at a constant sampling rate of 28.3 l/min. (liters per minute). Air was impacted on the plates for one to four minutes at each site. Exposed plates were incubated at room temperature and examined over a five day period. The number of CFU/m 3 was calcul ated from the number of CFU’s counted and the collected air volumes. Samples were collected at designated intervals during pre and post-treatment.

Decontamination
The contaminated areas with open walls were decontaminated using a 20% Ox Bio + solution. After decontamination residual spores and visible contamination were removed by physical removal from vertical and horizontal surfaces using disposable cleaning items. The surfaces had to be cleaned twice with frequent disposal of contaminated cleaning cloths. Ceilings were initially cleaned back and front using a HEPA – filtered vacuum. All non – egress doors were taped shut after cleaning to help assure contamination control. Workers wore appropriate personal protection gear treated with the EGIS treatment for antimicrobial protection.

Surface Modification
All accessible interior surfaces (including ceilings, walls, above ceiling space, furnishings, elevator shafts, mechanical and electrical chases) were treated with the 3 – trimethox ysilylpropyldimethyloctadecyl ammonium chloride (EGIS™ Antimicrobial) in 6 water in accordance with the manufacturer’s application specifications. The applications were randomly tested for uniformity and penetration throughout the treatment process us ing analytical methods appropriate for the active ingredient.

Results
The results of the samplings are presented in Table 1. Pre – treatment retrievals were in a range of 35 – 4730 CFU/m 3 and the average sample concentration was 791.4 CFU/m 3 in the March 2 005 sample set. The high level of airborne fungal contamination was associated with the growth of visible mould verified by surface samples and identifications. Intrusion of fungi from the outdoor environment was noted but the dominant and pervasive Asperg illus fumigatus was not part of this population.

Location Pre – treatment

CFU/m3
2005
Nov Dec
2006
Jan Feb March
Total
Building
Average
Sites
791.4
307
48.1
307
56.4
307
72.2
307
101.4
307
96.6
307
1st Floor
Average
Sites
367.4
35
65.8
35
75.1
35
77.1
35
99.3
35
117.9
35
2nd Floor
Average
Sites
533
38
55.1
38
71
38
54.5
38
111.2
38
111.8
38
3rd Floor
Average
Sites
715.7
42
65.8
42
80.3
42
47.2
42
109.2
42
111.3
42
4th Floor
Average
Sites
502.8
42
79.4
42
59
42
89.6
42
91.4
42
102.4
42
5th Floor
Average
Sites
424.1
42
46.3
42
42.1
42
58.1
42
93
42
95.6
42
6th Floor
Average
Sites
1978.2
36
58.1
36
45
36
97.7
36
94.9
36
70.1
36
7th Floor
Average
Sites
738.5
24
32.3
24
29.3
24
66.5
24
90.3
24
121.6
24
8th Floor
Average
Sites
1336.8
24
30.8
24
41.1
24
65
24
96.3
24
87.3
24
9th Floor
Average
Sites
695
12
20.6
12
62.1
12
95
12
127.5
12
74
12
10th Floor
Average
Sites
622.1
12
26.5
12
59.1
12
71
12
100.7
12
74
12

Table 1. Concentration of airborne fungi (CFU/m 3 ) at Hospital Sultan Ismail, Johor, Malaysia – Pre – and Post – EGIS Treatment.

Post – EGIS treatment sampling during the first month following restoration of the building produced an average of 48 CFU/m 3 at 307 sites. Retrievals were in a range of 0 – 178 CFU/m 3 . Of the 307 sample sites, 24% had 0 CFU/m 3 . Figure 1 displays the level of reduction of airborne contamination on each floor during this evaluation period.

Figure 1: Reduction in microbial air retrievals after EGIS treatment. Hospital Sultan Ismail, Johor, Malay sia.

Subsequent routine air sampling was performed at one month intervals for another four months from December 2005 to March 2006. These samples had an average of 56.4, 72.2 101.4 and 96.6 CFU/m3 respectively (Fig. 2). The samplings produced retrievals in a range of 0 – 178 CFU/m 3 .

Figure 2: Retrieval averages of pre and post – EGIS treatment samplings in the building. Hospital Sultan Ismail, Johor. Malaysia.

Swab sampling in March 2005 showed >300cfu/cm 2 fungi with Aspergillus fumigatus. Fogging with Ox Bio + followed by application of EGIS TM demonstrated no Aspergillus fumigatus recovered from the horizontal and vertical surfaces. The absence of Aspergillus fumigatus in the post – cleaning phase assured that the contaminant was removed.

Discussion
The microbial colonization of interior surfaces in buildings is well known when extensive and often normal water damage occurs during the construction period or during the use of the building. Building construction materials are susceptible to water damage and mold growth during storms when the exterior of the building is compromised or while new plumbing and fire management systems are being tested. Additionally, water damage can occur due to high humidity or roof, plumbing, and window leaks. These water events are often hidden inside the building construction and easily colonized by microorganisms. These microbial reservoirs can be significant sources of bioaerosol emissions in so-called mold problem houses and buildings. 10, 11 & 12

Several studies have implicated airborne microbial contaminants in the development of Building-Related Illnesses and Sick Building Syndrome and are life and death hazards to compromised patients. 13, 14, 15 & 16

Rhame et al 8 have shown a direct correlation between the concentration of airborne Aspergillus spores in hospital air and the incidence of aspergilliosis among immunosuppressed patients; Arnow et al 9 report “our findings strongly suggest that the inanimate hospital environment is a major determinant of the risk of endemic or epidemic nosocomial aspergillosis”.

All traditional disinfectant products have vapor pressure and water solubility properties that allow for migration. This magnifies occupant exposure concerns and the potential for sublethal doses to which microbe s could adapt. The duration of antimicrobial activity of traditional disinfectants is also relatively short (ranging from a few minutes to several days) unless incorporated within a substrate with slow – release characteristics. Although most disinfectant formulations appear to possess increased activity against specific classes of microorganisms, this selectivity precludes broad-spectrum control. Also, many disinfectant active ingredients have been shown to give rise to an adapted microbial population. This is unacceptable in almost all end – uses.

Environmental sampling of both air and surfaces has proved valuable for detecting and ensuring the removal of the potentially hazardous agents from critical and normal environments and was used as the prime indicator in this study.

During this study, the normal housekeeping staff was used to clean the rooms in a standard manner before occupancy. The final occupancy cleaning occurred some months after the certification of the original remediation and contamination removal. Ongoing air – sample surveillance has shown satisfactory air quality as full occupancy of the building is being implemented.

The relative humidity, temperature, carbon monoxide, carbon dioxide, particle distribution, and other environmental measurements were used to decide clearance approval and help suggest air handling and cleaning protocol adjustments. During this study, the building was not under ASHRAE (American Society of Heating, Refrigeration, and Air-conditioning Engineers) recommended levels of relative humidity and temperature compliance was highly variable throughout the building. In all circumstances, the indoor and outdoor environmental conditions favored the growth of fungi.

Conclusions
With the continuing increase in the number of severely immunocompromised patients, hospitals and all indoor public spaces are faced with being the source of fungi that cause problems of invasive aspergilliosis and other opportunistic fungal infections. Since treatments of these infections are difficult and outcome is often fatal, preventive measures are of major importance in the control of invasive filamentous fungal infections. Further to this, fungi produce allergenic and irritational spores and a wide variety of toxigenic chemicals including known human carcinogens. On the non – medical side of impact, fungi cause deterioration of building materials and furnishings, musty discomforting odors, and unsightly stains that affect the usefulness and life of affected materials.

Data from this study indicate that surfaces modified with a reactive – silane antimicrobial (EGIS Treatment) provide substantive reduction of airborne microbial concentrations even under extreme environmental conditions that favor fungal growth. Sustained control of microbial levels has been demonstrated through this first five months of the ongoing study providing a cleaner, healthier environment of care for this specialty healthcare facility. During this study period the previously heavy visible and widespread growth on surfaces was eliminated.

When viewed collectively, the safety, efficacy, and durability of the EGIS technology and application procedures has provided a unique way for the control of risks to building materials and occupants associated with microbial contamination in buildings without continuous care of normal and hard to reach surfaces.

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