Dental InfectionControl Updates

Presented by Nebraska ICAP

Housekeeping

• Guidance presented during this presentation is accurate as of 5.21.2021

• Guidance is changing on a regular basis and should be reviewed if this presentation is viewed at a later date

• This webinar is not approved for dental CE hours. If you would like a certificate of attendance for this webinarplease reach out to us.

Questions and Answer Session• Use the QA box in the webinar platform to type a question. Questions

will be read aloud by the moderator at the end of the presentation• If your question is not answered during the webinar, please either e-

mail it to NE ICAP or call during our office hours to speak with one of our Infection Preventionists

Slides and a recording will be made available on the ICAP website:https://icap.nebraskamed.com/coronavirus/

https://icap.nebraskamed.com/covid-19-webinars/

Panelists today are:

• Dr. Richard Hankins• Dr. Charles Craft• Kate Tyner, RN, BSN, CIC• Rebecca Martinez, BSN, BA, RN, CIC• Dan German

State Oral Health Update

Dr. Charles Craft,

NE State Dental Director

COVID-19 VariantsRichard Hankins, MD

Assistant Professor, Division of Infectious Diseases

Associate Medical Director, Nebraska ICAP

SARs-CoV2 Spike Protein Mutations

SARS-CoV2 Variants- CDC classificationVariant of Interest:A variant with specific genetic markers that have been associated with changes to receptor binding, reduced neutralization by antibodies generated against previous infection or vaccination, reduced efficacy of treatments, potential diagnostic impact, or predicted increase in transmissibility or disease severity.

Variant of Concern:A variant for which there is evidence of an increase in transmissibility, more severe disease (e.g., increased hospitalizations or deaths), significant reduction in neutralization by antibodies generated during previous infection or vaccination, reduced effectiveness of treatments or vaccines, or diagnostic detection failures.

Possible attributes of a variant of concern:In addition to the possible attributes of a variant of interest• Evidence of impact on diagnostics, treatments, or vaccines

– Widespread interference with diagnostic test targets– Evidence of substantially decreased susceptibility to one or more class of therapies– Evidence of significant decreased neutralization by antibodies generated during previous

infection or vaccination– Evidence of reduced vaccine-induced protection from severe disease

• Evidence of increased transmissibility• Evidence of increased disease severity

Variant of High Consequence:A variant of high consequence has clear evidence that prevention measures or medical countermeasures (MCMs) have significantly reduced effectiveness relative to previously circulating variants.

CDC/ WHO Variants of Concern

1. VOC ( Variants of Concern):

• B.1.1.7 ( UK variant)

• B. 1.351 ( South Africa)

• B.1.427 ( California)

• B.1.429 ( California)

• P1 ( Brazil)

2. VOI : (Variants of Interest) 8

Of note, CDC Closely monitoring Indian variant B.1.617

3. Variant of High Consequence

Currently no variants of High Consequence detected

Estimated Proportions of SARS-CoV-2 Lineages-HHS Region 7- With Forecast

https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/variant-proportions.html

Some Variants of Concern in NE

B.1.1.7 Known as the UK variant

✓ Approximately 50% increased transmission

▪ It spreads twice as easily

▪ It infects more people

▪ It will become more predominate among circulating strains

✓ Potential increased severity based on hospitalizations and case fatality rates

▪ It make people sicker

▪ More people die

B.1.427 & B.1.429Known as the California variant(s)

✓ Approximately 20% increased transmission▪ It spreads more as easily▪ It infects more people▪ It can become more predominate among circulating

strains

✓ Modest decrease in susceptibility to the combination of bamlanivimab and etesevimab monoclonal antibody treatments

▪ Could be more difficult to treat▪ Patients can’t benefit as much from some monoclonal

antibody treatments so alternatives used▪ For more information visit the NE Antimicrobial

Stewardship Assessment and Promotion (ASAP) program website at https://asap.nebraskamed.com/monoclonal-antibody-project/

▪ Complete the survey for new COVID-19 cases eligible for receive bamlanivimab-etesevimab in HD centers at https://redcap.nebraskamed.com/surveys/?s=9N4JEADFL3

✓ Reduced neutralization by convalescent and post-vaccination sera▪ The vaccine helps but the protective benefits of the

vaccine to this specific variant is reduced

https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/variant-surveillance/variant-info.html

• 875 variants of concern (VOC) identified among Nebraska residents

• 764 B117, 12 P1, 6 B1.351, 87 B1.429/427, 6 B1.526

• Sequencing roughly 200 specimens per week, ~10% of positive NE specimens

• >90% of sequencing runs are VOCs; B117 remains predominant

• 214 possible reinfections, no substantial trends relating to outcome or VOCs

• 380 possible vaccine breakthroughs (BTs), most confident in 146 of these; 9 hospitalized, 1 died

Variant, Reinfection, and Vaccine BT Updates**

**Information courtesy of Nebraska DHHS

VariantRegion 7

PrevalenceClass

Primary Mutation(s)

Bam Bam-Ete Cas-Imd

B.1.1.7 64.9% VOC N501Y ✅ ✅ ✅

B.1.429 9.6% VOC L452R ❌ ✅ ✅

B.1.1.519 6% N/AT478K P681H

NED NED NED

B.1.2 4.8% N/A Q677P NED NED NED

B.1.526 3.6% VOIE484K S477N

❌ ✅ ✅

B.1.427 2.3% VOC L452R ❌ ✅ ✅

B.1.526.1 1.9% VOIE484K S477N

❌ ✅ ✅

P.1 1.4% VOCN501Y E484K K417N

❌ ❌ ✅

Velazquez FR. Spokane Regional Health District.@jpogue1. https://twitter.com/jpogue1/status/1380513072826159105

Zhou et al. https://www.biorxiv.org/content/10.1101/2021.03.24.436620v1https://www.color.com/wp-content/uploads/2021/04/SARS-CoV-2-variants-memo-v2-20210330-update.pdf

NED = Not enough data

Monoclonal Antibody Efficacy Against Variants

Disinfectants: Best Practices

Sterilization vs. DisinfectionPatient Contact Examples

Device Classification

Minimum Disinfection Level

Intact skin

radiographic equipment, blood pressure cuffs, facebows, pulse

oximeters, examination and curing lights, and computers

Non-criticalLow-level or intermediate disinfection

Mucous membranes or non-intact skin

Mouth mirrors, amalgam condensers, reusable dental

impression trays, cheek retractors, orthodontic pliers

Semi-criticalHigh level

disinfection

Sterile areas of the body and devices used to

penetrate soft tissue or bone

surgical instruments, periodontal scalers, scalpel blades, burs, and

explorersCritical Sterilization

Sterilization and Disinfection of Patient-care Items in Oral Healthcare Settings https://www.cdc.gov/oralhealth/pdfs_and_other_files/BESC7-Sterilization-508.pdf

Sterilization vs. Disinfection

https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a2.htm

Efficacy of Disinfectants

Factors to consider when looking at disinfectant efficacy:

• Number and Location of Microorganisms

– Large colonies of microorganisms can be harder to kill and decrease efficacy of disinfectants

– Location of microorganisms on equipment and instruments can decrease the efficacy of disinfectants, hard to clean areas may not be easily accessible for the disinfectant to penetrate and be effective

• Concentration and Potency of Disinfectants

– Different disinfectants can be more or less concentrated, affecting contact time and efficacy of the disinfectant

• Physical and Chemical factors

– Temperature, pH, relative humidity and water hardness can all have an effect on different types of disinfectants

https://www.cdc.gov/infectioncontrol/guidelines/disinfection/efficacy.html

Efficacy of DisinfectantsFactors to consider when looking at disinfectant efficacy:

1. Organic and Inorganic Matter/ Biofilm

1. Organic matter, like serum, blood, infectious materials, saliva and lubricants can interfere with the efficacy of disinfectants

2. Inorganic matter, like salts or other deposits can interfere with the efficacy of disinfectants

3. Biofilm can create a protective layer over microorganisms that disinfectants can’t penetrate (up to 1,000 times more resistant to disinfectants than normal bioburden)

4. This is why it is important to pre-clean all surfaces, equipment and instruments prior to disinfection to remove any organic/ inorganic materials

2. Duration of exposure

1. Wet contact time must be met in order to ensure the efficacy of the disinfectant

2. Follow manufacturers instructions for use for the disinfectant in your clinic to identify the minimum contact time

https://www.cdc.gov/infectioncontrol/guidelines/disinfection/efficacy.html

Disinfectant Uses Advantages Disadvantages

alcohols Skin antiseptic, surface disinfectant

Bactericidal, tuberculocidal, fungicidal, virucidal; Fast acting, no residue, no staining, good for small surfaces like rubber vial stoppers

No sporicidal, volatile, evaporation diminishes concentration, no detergent or cleaning properties, not EPA registered, may harden rubber or cause glue deteriorization

chlorine Disinfect surfaces after blood spills, surface cleaning, water treatment

Bactericidal, tuberculocidal, fungicidal, virucidal, low cost, fast acting, readily available in non-hospital settings, EPA registered

Corrosive, inactivated by organic material, irritant to skin and mucous membranes, shelf live shortens when diluted, release of toxic chlorine gas when mixed with acid or ammonia

Improved hydrogen peroxide

Disinfect surfaces Bactericidal, virucidal, tuberculocidal, some newer preparations are sporicidal, safe for workers, fast acting, breaks down into water and oxygen, unaffected by organic matter, non-staining, EPA registered

More expensive then some low level disinfectants; strong vapor profile (vinegar odor)

phenolics Cleaning hard surfaces that don't touch mucous membranes,

Bactericidal, tuberculocidal, fungicidal, virucidal, Leaves a residual film, commercially available with added detergents to provide 1 step cleaning and disinfecting

Not sporicidal, not for use in nurseries, not for use on food contact surfaces; may be absorbed through skin or rubber

Quaternary ammonium compounds

Clean floors, walls, and furnishings. Clean blood spills

Bactericidal, fungicidal, virucidal against enveloped viruses, usually have detergent properties, generally not irritating to hands

Not sporicidal, generally not tuberculocidal, and virucidal against nonenveloped viruses; not for use on instruments, narrow microbiocidal spectrum

Disinfectants used for environmental disinfection and new room decontamination technology. W.A. Rutala, D.J. Weber / American Journal of Infection Control 41 (2013) S36-S41 https://www.ajicjournal.org/article/S0196-6553(13)00010-2/pdf

Cleaning and Disinfection

Remember:

• Wear appropriate PPE for the task

• You must clean the surface first to remove any bioburden (disinfectants will not work if there is bioburden)

• 1 wipe per surface should be used for both cleaning and disinfection, you can spread microorganisms from surface to surface (1 for chair, 1 for counter, 1 for delivery unit, 1 for hoses)

• If you drop a wipe on the floor, get a new one

• Surface should have enough disinfectant on it to remain wet for the entire contact time (a dry wipe is doing nothing)

• Clean and disinfect in a methodical manner to prevent missed areas (high to low, left to right)

https://my.clevelandclinic.org/-/scassets/files/org/employer-solutions/covid-19-cleaning-guide.ashx

Types of Surfaces

1. Clinical Contact Surfaces

1. Any surface that is touched frequently with a gloved hand that could potentially be contaminated with blood or other potential infectious material

2. Barriers should be used on hard to clean areas in the treatment room (ex: light handles, chair switches) and should be disinfected regularly even with barrier use

3. Surfaces should be disinfected with an intermediate level EPA registered disinfectant with a Tuberculocidal claim

4. Precleaning of clinical contact surfaces must be done to remove any bioburden before disinfecting the surface (wipe-wait-wipe)

https://www.cdc.gov/infectioncontrol/guidelines/disinfection/healthcare-equipment.html

Types of Surfaces

1. General Housekeeping Surfaces

1. Walls, floors, countertops that are not considered clinical contact areas, bases of patient chairs, sinks, etc.

2. Cleaned with soap and water OR an EPA approved hospital disinfectant depending on the type of contamination present

1. If housekeeping surfaces are visibly contaminated with blood or body fluids, an EPA approved hospital disinfectant should be used for disinfection

3. Cleaning should be done on a regular basis for housekeeping surfaces

1. Cleaning schedules should be identified in your OSHA Bloodborne Pathogens Standard Policies (ex: walls cleaned 1x per week, sinks cleaned daily)

https://www.cdc.gov/infectioncontrol/guidelines/disinfection/healthcare-equipment.html

Pandemic Q and A

Is there a special type of disinfectant that should be used for SARS-CoV-2?

EPA List N

• EPA List N Tool: https://cfpub.epa.gov/wizards/disinfectants/

• Verify that your disinfectants are on this list to be effective against SARS-CoV-2

Pandemic Q and A

We have jugs of liquid disinfectant; can we make our own wipes if wipes are still unavailable?

Making Wipes*Making your own wipes should be a last resort and only considered when premade wipes are not available for purchase*

Before you make your own wipes, you want to consider:

• Regulatory issues: Anytime a chemical is used outside of it’s manufacturers instructions for use a risk assessment should be done with a timeline on how long the practice will be in use

• You can be cited for off-label use of disinfectants as they have an impact on your overall infection control plan within your facility

http://vtwqt464m234djrhbie88e10-wpengine.netdna-ssl.com/wp-content/uploads/2018/04/RiskAssessQuatAlcApril2018.doc

Making Wipes

Best Practices:

• Make sure any secondary containers are properly labeled with chemical and manufacturer information per OSHA’s Hazard Communication Standard

• Quat disinfectants (check your disinfectant but a lot of dental disinfectants are quat based) bind with cellulose after a couple of minutes, premaking wipes with cotton or paper towels will inactivate the disinfectant and you will essentially be wiping with water

• Non-cellulose, dry wipes are available if your facility has quat based disinfectants and has a need to make wipes

Making Wipes

Best Practices:

• When premaking wipes, you do not want to store them long term; One week at most and then discard any unused wipes and make another batch

• Containers used to hold premade wipes should be thoroughly cleaned and dried between batches of wipes; Ex: On Friday, discard unused wipes for the week, wash container with soap and water and leave to dry over the weekend before making new wipes on Monday morning

• Ready to use disinfectants should be used to make wipes as they are shelf stable; Do not use disinfectants that you may have to mix to activate

EVS Training Series ICAP

https://icap.nebraskamed.com/practice-tools/educational-and-training-videos/draft-environmental-cleaning-in-healthcare/

Not in today's talk, but coming soon to a podcast near you...

Liquid chemical sterilants and high level disinfectants

• Only for heat sensitive critical and semicritical devices

• Highly toxic

• Personnel must adhere to the manufacturers instructions (for example; dilution, immersion time, temperature and safety precautions)

• Operationally, heat tolerant (I.e., able to be steam sterilized) or disposable alternatives are much easier to manage

Sterilization and Disinfection of Patient-care Items in Oral Healthcare Settings https://www.cdc.gov/oralhealth/pdfs_and_other_files/BESC7-Sterilization-508.pdf

Glutaraldehyde Safety• Most commonly used as a high-level

disinfectant (cold sterile solution) in dentistry

• Can cause asthma attacks, reactive airway disease, contact dermatitis, and tissue burns

• OSHA requires that it be identified as a hazard in your hazard communication plan along with conducting a risk assessment before use and identifying protection for employees

• Occupational exposure limits have been identified as 0.05 ppm of chemical aerosol concentration

Glutaraldehyde SafetyOSHAs Identified Exposure Controls:

• Safest option: Don’t use cold sterile (removing the hazard), consider using all heat sterilizable items or single use items

• There are other options for a cold sterile solution in dentistry, talk to your distribution rep

• OSHA recommends employees wear a fit tested respirator when working with glutaraldehyde products (must have a written respiratory protection plan)

• Gloves, eyewear and protective clothing must be worn along with a respirator

• General ventilation must be used with a minimum air exchange rate of 10 exchanges per hour

• Local exhaust must be used in addition to the general ventilation

• Processes should include ways to limit splash and spray to limit the aerosolization of glutaraldehyde

• Always check with your local and State regulations to ensure proper disposal of glutaraldehyde solutions

https://www.osha.gov/sites/default/files/publications/glutaraldehyde.pdf

Announcements/ Updates

Respiratory Protection Taskforce

https://icap.nebraskamed.com/nebraska-respiratory-protection-task-force/

Respiratory Protection Taskforce

https://icap.nebraskamed.com/nebraska-respiratory-protection-task-force/

CDC Update 4/9/21

• PPE Strategy/ Use Update• Respirator supply has drastically increased over

the last months• Facilities should not continue Limited Reuse of

Respirators (multiple uses of a single respirator)• Extended use can continue (wearing respirators

for more than one patient encounter)• Facilities should not continue with UV disinfection

for respirators

https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html

Domestic Travel Recommendations for Fully Vaccinated People (4/2/21)

After travel:

– Self-monitor for COVID-19 symptoms; isolate and get tested if you

develop symptoms.

– Follow all state and local recommendations or requirements after travel.

https://www.cdc.gov/coronavirus/2019-ncov/travelers/travel-during-covid19.html

CDC Update 3/10/2021

https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated-guidance.html

• Vaccinated staff do not need to quarantine from work after an exposure as long as they are asymptomatic

• Non-vaccinated staff if exposed to COVID-19 will still need to quarantine.

• Fully vaccinated staff who is immunocompromised may need to be restricted from work for 14 days if exposed to COVID-19

• After international travel staff may have to be restricted from work regardless of vaccination status as per the CDC and state guidance

COVID-19 Reporting: Best Practices

How to report if you or your staff is positive:

1. Call your Local Health Department

2. Ask for the Communicable Disease Department

3. Tell them you’re a healthcare worker and are positive for COVID-19

Do you need more resources?

You can always contact the Ne ICAP team if you need:

• Contact information for the local health department

• Information on next steps when a COVID-19 positive case is identified in staff or a patient

• Information on discontinuation of isolation for staff or patients

• Information on best practices for testing after exposure, environmental cleaning and disinfection and respiratory protection

PPE Requests from NE DHHSUse this link to request support with PPE:

•PPE Request from NE DHHS https://form.jotform.com/NebraskaDHHS/PPERequestForm

•This form goes to both the local health department and NE DHHS

•Requests are for PPE needs for next 2 weeks.

•Requests must be made by Wednesday 11:59 AM for next week delivery.

•Local Health Departments are responsible for approving requests, work with them directly for urgent needs

Coming up!• Dental webinars will be hosted on the Third Friday of every month

at 12:00 CST, Next Webinar: Friday, May 21, 12:00 pm CST

• If you have infection control topic suggestions, submit them to Sarah Stream at sstream@nebraskamed.com

• Register through the Facebook Event page or at:https://unmc.zoom.us/webinar/register/WN_hVqe0-K3TBm0ui_0NOfh4w

Infection Prevention and ControlOffice Hours

Monday – Friday 8:00 AM – 10:00 AM Central Time

2:00 PM -4:00 PM Central TimeCall 402-552-2881

Email NebraskaICAP@nebraskamed.com

Questions and Answer Session

Panelists:

• Dr. Richard Hankins• Dr. Charles Craft• Kate Tyner, RN, BSN, CIC• Rebecca Martinez, BSN, BA, RN, CIC• Dan German

Don’t forget to Like us on Facebook for important updates!

Use the QA box in the webinar platform to type a question. Questions will be read aloud by the moderator, in the order they are received

A transcript of the discussion will be made available on the ICAP website