Nightmare Bacteria: Superbugs, Shoes, and Public Transportation

Introduction

Cities across the nation have acted to improve their transportation systems for the better. Modern transportation options now include bike sharing, trolleys, and improved local bus routes connecting to light rail systems that feed into the city areas. Tragically, the same cities that are enjoying the benefits from improved transportation options are also suffering from a superbugs infection in hospitals, nursing homes, and schools (CDC example: CRE, MRSA and C. difficile). 

* Introduction

* University of Houston C.diff Study

* Public Transportation in Proximity to Hospitals, Nursing Homes, and Schools

* Conclusion and Recommendations

* References and Notes

The proximity of public transportation in relation to hospitals, clinical facilities, and schools begs for attention in infection control considerations for expansion planning and maintenance of existing routes. Hospital and community surveillance of C.diff contamination provides vital feedback to researchers in the form of infection rates by origin, see University of Houston C.diff study results discussion below. 



Also discussed are improved materials infused with copper that have assisted in lowering Healthcare Associated Infection (HAI), such as CRE and C.diff, rates in hospital sections outfitted with this new material as well as garments infused with antimicrobial and bactericidal substances.

This piece is not written with an alarmist approach, but rather with an intention to recognize best practices employed by those directly in charge of infection control and provide recommendations on improvements towards lowering superbugs infection rates.

University of Houston C. diff Infection Rates Study

In the Department of Pharmacy Practice and Translational Research, professor and chair, Kevin W. Garey performed a study on Clostridium difficile (C.diff.) contamination rates, recurrent disease, antibiotics treatment and consideration of many other factors.

Beginning around 2011, the University of Houston started to test surfaces and collect stool samples from patients with C.diff hospitalized in the Texas Medical Center and the results are displayed a little further below. 

What is Clostridium difficile?

“Antibiotic resistance is one of the biggest public health challenges of our time.”

Centers for Disease Control and Prevention

Clostridium difficile is an antibiotic resistant bacteria that causes diarrhea and colitis and is life-threatening to many. These superbugs infections leave more than 2 million sick and cause at least 23,000 deaths annually. The CDC ranked the top 18 antibiotic-resistant threats into 3 categories, Urgent Threats, Serious Threats, and Concerning Threats, see graphic below. 

Carbapenem-resistant Enterobacteriaceae (CRE), also known as Nightmare bacteria, Clostridium difficile, and Drug-resistant Neisseria gonorrhoeae are all considered Urgent Threats, the highest measure in the CDC Antibiotic resistance scale (19).

Studies show much as 50% of antibiotics prescribed in hospitals are unnecessary or incorrect. When a patient is given a broad-spectrum antibiotic, the beneficial bacteria commonly present in the human gut are suppressed for up to months afterward. Patients may get sick during this time from C.diff picked up from contaminated surfaces due to a lack of defense against it (18).

Where do the infections come from?

The results were rather easy to read once I read through the refresher on ribotyping and the tracking of what C.diff strain you are dealing with. This ribotyping shows where the C.diff may have come from based on testing for superbugs in other areas. 

In summary, strains produce band patterns based on the size variation of the 16S-23S rDNA intergenic spacer region. 



Simply (in the way I believe I understand it), ribotyping the Clostridium difficile (example: ribotype 027) presents a unique identifier that can then be compared to infections in other places to map the origin of infection or outbreak. 

The Centers for Disease Control (CDC) generated a Press Release in 2015 stating that C. difficile affected almost half a million patients in a single year (2014). At least 100,000 nursing home patients are infected with C.diff yearly and the CDC showed that “Unnecessary antibiotic use and poor infection control may increase the spread of C. difficile within a facility and from facility to facility when infected patients transfer, such as from a hospital to a nursing home.”

“C. difficile infections cause immense suffering and death for thousands of Americans each year.”

Tom Frieden, M.D., M.P.H., CDC Director

One limitation in the data of this study above was the lack of inpatient health care exposure in the statistics of those with a C.diff diagnosis. Another, separate CDC study showed 82 percent of patients infected with C.diff had visited an outpatient facility, such as doctor or dentist, in the 12 weeks prior to diagnosis.

https://video.wixstatic.com/video/5aadc3_2efb3d5a2ca0450b9157f3fe32ad49cd/1080p/mp4/file.mp4

The statistics regarding multi-drug resistant organisms are grim.

Previous studies have shown that C. difficile has become “the most common microbial cause of healthcare-associated infections in U.S. Hospitals and costs up to $4.8 billion each year in excess health care costs for acute care facilities alone.”

The CDC showed that a recurrence of C.diff occurred in 1 out of 5 patients and that 1 out of 11 patients over age 65 with a healthcare-associated C.diff infection died within 30 days of the diagnosis (18).

In addition to improvements in refining antibiotics prescriptions, hospitals are now deploying new technology to fight infections such as materials infused with copper and other microbial substances. New copper oxide-infused materials and a new EPA-Registered whole room disinfection process are part of the effort to reduce HAIs. 

Whole-Room Disinfection

At least 700 hospitals were penalized during 2016 due to patient injuries including hospital associated infection rates. These penalties totaled over $430 million in fines enforced by Medicare and Medicaid to motivate hospitals in proactively preventing infections (8).

In an effort to reduce HAIs, hospitals are now using an EPA-Registered whole-room disinfection process that produces a dry mist that can be used around electronics, it’s nontoxic, and there is no need to wipe because the residue evaporates. 

Commercial facilities, ambulance companies, schools, apartments, and residential properties also use this hospital-grade process to rid their units and vehicles of superbugs infection such as Nightmare bacteria CRE, MRSA, and C.diff (“kills 99.9999% of bacteria”) with this whole-room fogging of bactericidal solution.

Antimicrobial, Bactericidal Copper-Infused Materials for Surfaces

In additional to whole-room disinfection, hospitals are also built and retrofitted with microbial materials such as copper alloy and copper-infused materials including cloth and plastic. With an infection-control-centric approach, hospital rooms are now outfitted with “bed rails, toilet flush levers, grab bars, soap dispenser push plates, light switches, IV poles and other high touch” surfaces made of copper-infused materials (3).

The Sentara Leigh Hospital Study looked at the performance of copper-infused materials at Sentara Leigh Hospital in Norfolk, Sentara Princess Anne Hospital Virginia Beach, and Sentata Va Beach General Hospital in 2015.

This study measured the expansion of copper-infused material in patient gowns, linens and hard surfaces from half to all inpatient rooms and the results were a reduction in healthcare associated infection at the Sentara hospitals, specifically a 28% reduction in C.diff and MDRO infections (32). 

New Public Transportation Examples

An example of close coordination in between government and industry is the city of El Paso in deploying a 4.8-mile, 27 stop streetcar system. This streetcar route will be run the for the first time In El Paso, TX since 1974. Camino Real Regional Mobility Authority is managing the construction of the project using Texas Department of Transportation funding with the City of El Paso providing the design.

Once opened, Sun Metro will operate and maintain the restored vintage streetcars that are the same vehicles that operated on El Paso’s streets until 1974 (27). 

The industry and government coordination in El Paso follows successful launches of similar systems in the Dallas/Fort Worth and Houston metropolitan areas. Molly the Trolley is operated in the DFW area by Trinity Metro and takes customers on a route that includes the Fort Worth Convention Center and Sundance Square every day of the week (23).

In comparison to the Molly the Trolley and El Paso Streetcar systems, METROLift in Houston provides a “curb-to-curb” public transportation service as a complementary service (22).

When looking at public transportation rail maps, most maps will note destinations such as a hospital, school, theater or any other popular destination on the route. The METRORail in Houston provides public transportation in the Houston Medical Center. One can leave a visit in a hospital room, ride an elevator, and then be steps from the stops on the light-rail line that connect to local bus routes and METROLift.

Cross-Contamination

Many studies have now shown that hospitals and care facilities harbor surfaces that test positive for CRE, C.diff, and MRSA. These hospitals and care facilities are visited by many brought by public transportation that connects to routes that stop at schools and businesses.



Cross-contamination is the transfer of the infection from one area to another by a contaminated surface. Cross-contamination continues to be a threat with hospitals and nursing homes so close to each other and connected by public transportation. The close proximity of the hospitals and clinical facilities to nearby public transportation is a challenge to those managing infection control because of the constant reintroduction of an infected surface such as a hand, shoe, or wheelchair wheel. 

Public transportation works by providing the closest routes to popular stops. The infection control practices of management and travelers are the most important factors in keeping public transportation clean and disinfected. For a public transportation consumer, the most important protection is to be informed and take steps to protect yourself, your family, and/or your coworkers. 

Hospital and clinical facilities communicate the hazards of superbugs to employees and manage robust infection control practices in their facilities. Those that visit these clinical facilities need to be aware of the potential superbugs infection harbored on visitors’ shoes and/or wheel chairs and take measures to disinfect clothing that may have touched affected surfaces.

Conclusion

To conclude, I believe most should develop infection control plans for their home or business and include local providers of disinfection services in case you encounter an outbreak of CRE, C.diff or any other superbug that affects your business operations and/or your nursing home facility or residential property. 

In these plans, consider infection control by choosing new surfaces such as bactericidal countertops and flooring, light switches, toilet flush levers, etc. After traveling, please disinfect your shoes or wheel chair wheels as well as purses and briefcases that sit on the floors of bathrooms and in public transportation.

Recommendations for C. difficile, MRSA infection control approaches:

1. Antimicrobial Surfaces in Hospitals and Public Transportation - In the way hospital rooms are outfitted with copper alloy to fight infection, use the same materials in public transportation with the same approach to surfaces infection control.

Including this vital infection control approach in public transportation planning could incorporate the same bactericidal copper-infused materials in the high touch surfaces (handles, antimicrobial flooring, seat fabrics or covers) in public transportation to fight infection similar to a hospital approach. Ensure proper disinfection housekeeping measures are in place to disinfect the vehicles after use.

2. Antimicrobial and bactericidal surfaces should also be considered for delivery trucks. Not only should laundry trucks that pick up from and deliver to hospitals be outfitted with antimicrobial materials but also other delivery trucks such as food trucks’ delivery counters where countless customers gather their food, napkins, utensils, and spices.

3. The cost to retrofit countless buses, trains, subways, and trollies with new copper alloy surfaces is tremendous. Considering this, a more cost-effective approach may be an easy to apply surface coating option (paint, clear coat, etc.) that incorporates antimicrobial copper (or a similar material) into the coating that should provide a surface difficult for superbugs to harbor on and spread when others come into contact with it.

Thank you for your time.

USA Decon, CEO

October 29, 2018

References and Notes:

1. MOVE: Putting America’s Infrastructure Back in the Lead, Rosabeth Moss Kanter, Copyright 2015, W. W. Norton & Company, Inc. New York, NY

2. “The United states generates the largest amount of carbon emissions in the world; it emitted a total of more than 5 billion metric tons in 2012. The transportation sector accounts for 1.7 billion metric tons, or 34 percent of U.S. carbon emissions. In total, the transportation sector accounted for 28 percent of U.S. greenhouse gas emissions, second only to electricity generation in environmental impact. Personal automotive transportation – cars and light trucks, SUVs, and minivans – accounted for and astonishing 61.5% of the sectors emissions, or 17% of total US carbon emissions.” (MOVE, pg. 13).

3. modernhealthcare.com, Best Practices: Using copper to fight infections, Elizabeth Whitman, November 5, 2016

4. curbed.com, 9 U.S. transportation projects to watch in 2018, Megan Barber, January 18, 2018

5. halosil.com, Fighting C.diff Beyond the hospital, January 24, 2017

6. halosil.com, As the Drug-Resistant Bacteria Epidemic Worsens, Halosil Gives Hospitals Options in the Fight, October 10, 2016

7. halosil.com, The Common Ground: Exchange 2016 Survey Reveals Shared Disinfection Priorities, November 23, 2016

8. halosil.com, Penalty to Performance: With More than 700 hospitals Facing HAI Penalties, Whole Room Disinfection Provides a Compelling Alternative, Healthcare Associated Infections (HAI), July 5, 2017

9. texasmonthly.com, Field of Nightmares, Patricia Hart, April 30, 2006

10. reuters.com, Reuters Investigates: A most unwanted list, Yasmeen Abutaleb, Ryan McNeill, and Deborah J. Nelson, September 7, 2016

11. reuters.com, Reuters Investigates: Superbug’ scourge spreads as U.S. fails to track rising human toll, Ryan McNeill, Deborah J. Nelson and Yasmeen Abutaleb, September 7, 2016

12. reuters.com, Reuters Investigates: One life, two donated organs and $5.7 million in bills - a tale of superbugs’ deadly costs, Yasmeen Abutaleb, Ryan McNeill and Deborah J. Nelson, November 18, 2016

13. reuters.com, Reuters Investigates: As ‘superbugs’ strengthen, an alarming lack of new weapons to fight them, Andrew Chung, Yasmeen Abutaleb, and Deborah J. Nelson, December 15, 2016

14. reuters.com, Reuters Investigates: How hospitals, nursing homes keep lethal ‘superbug’ outbreaks secret, Deborah J. Nelson, David Rohde, Benjamin Lesser and Ryan McNeill, December 22, 2016

15. urbanrail.net, Houston, Boston, London, Los Angeles, and Seoul transportation maps original images; Photoshop Image Enrichment to support fair use by John DiGulio

16. urbanrail.net, Rail original images by R. Schwandl, Jon Bell, J. Perbandt, Pedro Munoz Roman; Photoshop Image Enrichment to support fair use by John DiGulio

17. cdc.gov, Superbugs’ Categories, MRSA graphic Photoshop Image Enrichment to support fair use by John DiGulio 

18. cdc.gov, Press Release: Nearly half a million Americans suffered from Clostridium difficile infections in a single year, Media Relations, February 25, 2015

19. cdc.gov, Antibiotic Resistance Threats in the United States, 2013

20. uh.edu, University of Houston College of Pharmacy, Texas-wide Surveillance of Clostridium difficile, Kevin W. Garey, PharmD, MS, FASHP, Professor and Chair, Department of Pharmacy Practice and Translational Research

21. seoulmetro.co.kr, Seoul Metro Cyber Station maps

22. ridemetro.org, METRO Houston, About METRO, METRO Services Statistics by Bus and METRORail, METROLift Original Image; Photoshop Image Enrichment to support fair use by John DiGulio

23. ridetrinitymetro.org, Trinity Metro, About New Commuter rail line (TEXRail) from downtown Fort Worth, northeast through North Richland Hills to Grapevine, and then into Dallas/Fort Worth (DFW) International Airport Terminal B, Molly the Trolley Original Image; Photoshop Image Enrichment to support fair use by John DiGulio

24. thehealthjournals.com, The Copper Cure: Hospitals bank on copper-infusion to drop patient infection incidents, 2013

25. cuverro.com, Bactericidal Copper Features & Benefits, October 2018

26. rsc.org, Periodic Table, Atomic number 29, Copper, Royal Society of Chemistry, October 2018

27. sunmetro.net/streetcar, Safety, The Route, The Cars, The Project, October 2018

28. mbta.com, Massachusetts Bay Transportation Authority Red Line Schedule, October 2018

29. commons.wikimedia.org, Siemens S70 Image by User: Koman90

30. siemens.com, S70 Low-Floor Light Rail Vehicle, Portland, Oregon Example, Stats, October 2018

31. railway-news.com, USA: Siemens S70 Light Rail Vehicles Selected for Southwest LRT, October 28, 2016, “The S70s will be built at Siemens rail manufacturing facility in Sacramento, Calif. The plant, which has been in operation for almost 30 years, is powered in part by two megawatts of solar energy and currently employs nearly 1,000 people. Siemens is currently the leading supplier of light rail vehicles in North America.” 

32. cupronmedicaltextiles.com, Sentara Leigh Hospital 2015: Copper Hard & Soft Surfaces, published in the International Journal of Infection Control in 2018

33. Title Graphic: John DiGulio’s shoes, CDC: C.diff