Virginia Research Day 2021

Changes in Hospital Disinfectants with Covid-19 Pandemic Tyler Steve 1 , Chang Xu 1 , Rachel A. Hall 1 , Richard Antoun 1 , Brook D Burwell 1 , Caroline G Horne 1 , Alekhya Peruri 1 , Theresa J McCann 1 , Terry C Hrubec 1 1. Edward Via College of Osteopathic Medicine, VA Campus

Abstract

Results

It is hypothesized that use of disinfectants and, in particular, QAC Disinfectants, has increased in hospitals during the Covid-19 pandemic. Hypothesis secondary to the synergism of two or more QACs in the newer disinfect products. These effects may be mediated by decreased mitochondrial function and impaired sterol biosynthetic pathways, which are impaired in a dose-dependent relationship with QAC concentration in chronically exposed individuals. This study will survey 500 hospitals of various sizes from across the United States to better understand how disinfection practices have changed with the onset of the Covid-19 pandemic. Survey questions will be a combination of multiple choice and open ended questions to determine disinfectant use in specific locations within the hospital and identify changes in disinfectant protocols in response to the pandemic. Descriptive statistics with means and proportions will be used to describe the data. Normality and distribution of data will be assessed. Paired t-tests or non-parametric equivalents will be used to compare changes in disinfection practices. All analyses will be 2-tailed with statistical significance set at p<.05, and 95% confidence intervals will be provided for outcomesWe hypothesized that the use and exposure to disinfectants, specifically QACs, has increased since the beginning of the COVID-19 pandemic. This is the first study to survey hospitals on a national level to measure the changes in disinfectant use in response to the COVID-19 pandemic. Disinfection is necessary in hospital settings to prevent spread of diseases, but results in exposure of healthcare workers and patients to the disinfectants used. With the onset of the COVID-19 pandemic, changes in use of disinfecting products must be examined. Quaternary AmmoniumCompounds (QACs) are a group of chemicals used in many disinfectants in the healthcare settings. Of the 516 disinfectants approved by the Environmental Protection Agency (EPA) for use against COVID-19, 241 contain QACs as the active ingredient. In fact, since the pandemic began, studies have found increased indoor exposure to QAC compounds. While they historically were considered safe, recent studies have suggested that QAC-containing disinfectants may have teratogenic effects, and also impair reproductive and immune functions • States Selection • Ranked all states on 28 health metrics (Kaiser Family Foundation database) • Three states immediately above and below the national average were selected • The incidence of selected states was tallied and ranked • Highest ranking states: Pennsylvania (score 9), Arizona (score 8), Florida (score 8), Illinois (score 7), Michigan (score 7). • Survey Creation (figure 3). • Both open ended and dichotomous questions were utilized for the survey. • Hospital areas of interest were inpatient wards, outpatient wards, ICU, operating theaters, immunocompromised wards, labor and delivery, and nurses stations. • Questions focused on changes in disinfectant product, changes in concentration, methods of cleaning (e.g. soaking, mopping, sprays, wiping), and changes in frequency were asked for each area of the hospital. • Survey Administration • The American Hospital Directory was utilized to create a list of all hospitals within the selected state; hospitals on the list were randomized and called. • Both completed surveys and declined surveys were entered to be recorded by the survey instrument. Every call was recorded in theVCOMQualtrics survey online • Upon Survey Completion • We expect to enroll a total of 500 hospitals in the survey. • Descriptive statistics with means and proportions will be used to describe the data. • Paired t-tests or non-parametric equivalents will be used to compare changes in disinfection practices Methods/Materials

Changes in Cleaning Methods

Disinfectant use in different hospital areas

• No change in disinfectant type • Hydrogen peroxide used

• The frequency of cleaning methods

70 80 90 100

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

increased within all areas of the hospitals

0 10 20 30 40 50 60

most frequently

# OF HOSPITALS USE DISINFECTANTS

Outpatient Inpatient

ICU

Surgery

Immuno

Labor delivery

Nurse station

Percentage Of Hospitals That Increased Use

Outpatient

Inpatient

ICU

Surgical Theater

Immuno. Ward Labor and Delivery

Nurse Station

Spray

Wipe

Soak

Mop

Hydrogen Peroxide

QAC

Parecetic Acid

Bleach

Figure 1. The percentage of hospitals surveyed that reported increased usage of specific cleaning methods

Figure 2. The total number of hospitals using each disinfectant class in the different designated areas

Discussion

Table 1. Summary of hospital demographics by state

PA

FL

Total

• This study was designed to asses for a potential increase in QAC use among hospitals on a national scale. • While long considered safe, numerous studies have identified toxic effects with exposure • Exposure in mice causes decreased sperm concentration and motility in males, decreased ovulations and implantations in females 3 neural tube birth defects 2 • While the effects of QAC exposure on human health is unclear, the increased QAC exposure from the pandemic, identified in this study, may pose a risk and should be further studied.

Number Called

45

52

97

Total Responded

8

6

14

Urban

3

2

5

Community Type

Suburban

3

2

5

Rural

2

2

4

Response Rate (%)

17.7

11.5

14.4

Avg. Number of Hospital Beds

303

Disinfection protocol changed (%)

78.6

Outside Cleaning Service used (%)

14.3

Conclusion

Reference: Hora PI, Pati SG, McNamara PJ, ArnoldWA. 2020. Increased use of quaternary ammonium compounds during the sars-cov-2 pandemic and beyond: consideration of environmental implications. Environmental Science & Technology Letters, 7:622-631. DOI: 10.1021/acs.estlett.0c00437 Hrubec TC, MelinVE, Shea CS, Ferguson EE, Garafola C, Repine CM, ChapmanTW, Patel HR, Razvi RM, Sugrue JE, Potineni H, Magnin-Bissel G, Hunt PA. 2017. Ambient and dosed exposure to quaternary ammonium disinfectants causes neural tube defects in rodents. Birth Defects Res 109(14):1166-1178. MelinVE, MelinTE, Dessify BJ, Nguyen CT, Shea CS, Hrubec TC. Quaternary ammonium disinfectants cause subfertility in mice by targeting both male and female reproductive processes. ReprodToxicol. 2016 Jan; 59:159-66. doi: 10.1016/j.reprotox.2015.10.006. Zheng G, Filippelli GM, Salamova A. 2020. Increased Indoor Exposure to Commonly Used Disinfectants during the COVID-19 Pandemic. Environmental Science &Technology Letters 2020 7 (10), 760-765. DOI: 10.1021/ acs.estlett.0c00587 • Hospitals have changed their disinfection protocol due to the COVID-19 pandemic • Hospitals that use QAC compounds have increased their frequency of cleaning • Most, if not all, hospitals have increased their mopping frequency due to the pandemic.

Figure 3 . Sample from survey showing question from outpatient wards

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