ECJ EUROPEAN Cleaning Journal

When an outbreak of disease occurs in an enclosed space - such as on a cruise ship or in a hospital ward - the management has to act fast to eliminate any risk to other passengers or patients. Ann Laffeaty finds out how to go about cleaning up after an outbreak.

When an outbreak of illness occurs we all feel vulnerable. But in an enclosed space – such as in a hospital ward or on a cruise ship – the danger to our health is potentially greater.

Both types of environment face particular challenges. A hospital will house a high proportion of people who are frail and ill who will be particularly vulnerable to infections. Resources are thinly stretched which means that curbing an infection will be a challenge.

However, dedicated infection control teams will be on hand and the sight of staff wearing protective clothing and face masks will reassure patients and visitors that the problem is being dealt with efficiently.

On a cruise ship, on the other hand, passengers may be alarmed and discomforted to see the crew wearing personal protective equipment and sealing off sections of the ship. Here any outbreak needs to be handled carefully to avoiding ruining people’s holidays and blackening the cruise company’s name.

But on the plus side, a shipping line will probably have sufficient funds to train and deploy dedicated cleaning teams in the event of an outbreak. And the fact that most passengers are healthy to begin with means they are potentially less vulnerable than hospital patients.

But cruise ships by their very nature are particularly susceptible to outbreaks of illnesses such as Norovirus. Consultant for steam cleaning company Osprey Deepclean Mike Rollins said: “Managing a cruise ship is a nightmare because of the open-all-hours feeding that goes on. Cruise lines have become wise to this and tend to rotate the opening hours of their restaurants and have planned closures to allow for cleaning.

“But as we know, Norovirus can strike swiftly and with a vengeance. And when it does there are certain sensible measures that can be carried out to prevent it from spreading.”

He said that ideally the contaminated areas should be closed for thorough cleaning and disinfection. “Infected cruise ship patrons should then be restricted to their cabins until symptoms clear, which would be around 72 hours,” he said.

Cleaning teams should then backtrack to ascertain that all affected areas of the ship are cleaned and disinfected, said Rollins. He recommends cleaning the entire area from floor to ceiling using a hypochlorite solution. “Particular attention should be paid to the toilet area and cleaning up any vomit since this will help to reduce environmental contamination,” he said.

According to Rollins soft furnishings such as carpets, curtains and upholstery are difficult to surface clean since a hypochlorite solution could damage them. “In these cases, steam cleaning would be effective since Norovirus is inactivated at temperatures above 70 degrees C,” he said.
He claims a hospital would be somewhat easier to disinfect. “In a hospital ward there are not so many complex surfaces and the infection control teams are well prepared,” he said. 

“Deep cleaning would be carried out around the patients and anyone infected could be isolated. Staff would be equipped with personal protective equipment and would bag anything soiled or contaminated.”

According to Rollins, steam cleaning and fogging systems are becoming more popular since they provide a reassurance that disinfection is taking place. “Disposable microfibre cloths also provide a greater efficiency and effectiveness in surface cleaning compared with conventional janitorial cloths or wipes,” he added.

OCS has had many years of experience in supporting healthcare clients after infection outbreaks. Cleaning director Paul Thrupp said: “Hospitals are in constant use so after an outbreak we would generally provide a thorough surface clean using a hypochlorite solution.” In a typical-sized ward this would take around four hours and the ward would be immediately available for use
on completion.

Fogging option

He says fogging systems can also be used to kill harmful pathogenic organisms, whether these are airborne or on surfaces. “However, fogging should be used only in non-populated areas,” he added.

OCS uses the Otex sanitising unit which converts oxygen into ozone, a naturally-occurring disinfectant. “If using a hydrogen peroxide fogging system the ward would need to be vacated during cleaning and for a minimum of four hours afterwards,” he said.  “However with the Otex fogging system the area can be inhabited as soon as the process is finished.”

The challenges involved in cleaning up after a cruise ship outbreak are entirely different from those involved in a hospital ward says Mark Phelps, company microbiologist for ISS facility services healthcare UK.

“Hospitals contain ill patients and can house a host of pathogens from viruses and bacteria to multi-drug resistant Gram-negative rods and others,” he said. “Cruise ships on the other hand are generally associated with viruses such as Norovirus.

“The main intention is to remove the offending pathogen from the environment, but micro-organisms have varying survival rates. Respiratory viruses are highly transmissible at the time of the outbreak but will die out when the source of the organism (people) is no longer present.

“On the other hand, the spores of C.Difficile can survive for extremely long periods - and in a busy hospital with a high bed occupancy a robust deep cleaning regime will be required.”

The type of cleaning method used depends on the needs of the customer, he says. “Chlorine dioxide-based products are gaining greater popularity with some hospital trusts, while the use of fogging systems - using either hydrogen peroxide or ozone - are also particularly useful in clinical areas exposed to a nosocomial pathogen such as C.Difficile.

“The use of microfibre is also gaining momentum as this is an excellent tool for cleaning the patient environment and is a very 'green' solution. Steam cleaning may also be used for difficult-to-clean items such as beds.”

According to Phelps it is impossible to clean and disinfect every surface and piece of equipment with conventional cleaning.  “The only technology capable of achieving this is a ‘whole room decontamination’ system using a vapour or fog,” he said.

After a major outbreak, a ward would need to be sealed off and taken out of service and a thorough deep clean would take several days, says Phelps. “If a fogging system is used, this would take the best part of half a day depending on the size of the area, labour resources and whether there is somewhere to temporarily house the patients,” he said.

“A cruise ship would also be very variable since the contaminated areas may be either the passengers’ cabins or the public areas of the ship, which would be more difficult to decontaminate.”

Mike Rollins agrees that the decision whether or not to take a stricken cruise ship out of service would depend on the size of outbreak. “Cruise ship companies are well aware of the Norovirus hazard and have trained personnel to cope with the threat,” he said. “So usually, only known contaminated areas would have to be restricted until the decontamination process has been completed.”

Specialist agent

One recent example of an outbreak at sea occurred in July 2009 when the Marco Polo – a passenger liner operated by Transocean Tours of Bremen – was hit by an outbreak of Norovirus as the ship cruised around the UK coast. Hundreds of passengers and crew were infected and the operator had to end the 10-day cruise after only a few days at sea.

Infection control specialist SitexOrbis was responsible for decontaminating the ship. According to head of marketing Debansu Das: “Using our fogging service we were able to totally disinfect 375 staterooms on 11 decks as well as public spaces, lifts and communal areas in just five hours once the ship was back at Tilbury docks. This type of cleaning task would take days using more traditional methods.”

The SitexOrbis fogging system works by irreversibly binding, penetrating and immobilising bacteria, viruses and fungi so that they cannot replicate, says Das. It is said to be non-toxic, non-irritant and non-corrosive.

“The vaporisation machine produces a fine mist of a specialist cleaning agent that breaks through the cell wall of the microbe,” said Das. “The fact that the system produces a vapour means it can penetrate hard-to-reach places.”

The chemical – DuoMax - is said to be effective against bacteria, fungi and yeasts including E.Coli, Clostridium Difficile, H1N1 Swine Flu and the Norovirus.

SiexOrbis has also been called upon to deep clean hospitals, care homes and hotels. “Following an outbreak in a hotel there is often no need to shut,” said Das. “For example, 60 guests were infected after a Norovirus outbreak at the Grand Hotel in Scarborough. Fogging removed the outbreak and there were no further cases of infection reported from the staff or guests.”

He says there has been increasing demand for the company’s deep cleaning services - and that this may be partly due to new, more stringent legislation.

“Contractible diseases are not exempt under law,” he said. “This means an organisation will be guilty of an offence if a person’s death is caused through the way the company has been managed. Organisations take this very seriously and want to be seen to be taking every precaution possible.”