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Monkeypox Update August 29th 2022

Monkeypox TRANSMISSION RISK

An earlier recommendation of the International Hygiene Advisory Committee (IHAC) on the transmission risk of the Monkeypox virus is dated from May 23rd last. On request of CINET, today the IHAC provides an update based upon recent research on international publications and data, including those of CDC, ECDC and the Dutch RIVM. This concerns answers to below questions:

  • To what extend is Monkeypox (MPX) contagious?
  • Are the existing guidelines regarding COVID19 sufficient or should they be altered?
  • What other recommendations can IHAC provide for safe treatment for laundry employees and customers using linen?

The conclusions are summarized below. Further relevant background information is enclosed.

To what extend is Monkeypox contagious?

  • The MPX virus is an enveloped virus (like the Corona virus) and should not be mixed up with smallpox. It has to be mentioned here that the last case of the sometimes fatal infectious disease smallpox has been observed in 1977 in Somalia.
  • There can be a significant aerosolization of the MPX virus during specific activities. In general the risks of getting infected via aerosol seem small, but can’t be ruled out.
  • Transmission can take place when small lesions are present on the skin. Even when wounds are not visible to the naked eye.
  • The chance that the MPX virus survives the recommended disinfecting wash process is nope. Dosing of a disinfecting bleach creates an additional safety barrier.
  • Handling of infected linen should always be taken seriously.

Recommendations and Guidelines

As for Monkeypox: the existing COVID19 guidelines and laundry protocols are applicable to prevent contamination of staff as well as textiles, with the exception of the storage of contaminated textiles. That  5 day storage rule is not recommended here..

  1. The infected linen should be packed by the healthcare customer[s] in recognisable clearly colour coded bags .
  2. Face masks are highly recommended when sorting the linen and when loading the washing machines.
  3. Wearing gloves when working in the sorting department or when loading the washing machines – is essential in preventing infection with the virus. This vital recommendation is part of the EN 14065 RABC as well as  CERCLEAN Quality Management System. Next to wearing face masks and protective work wear.
  4. Wearing gloves is crucial, because transmission can take place when small lesions are present on the skin. Even when wounds are not visible to the naked eye!
  5. Recommended Cleaning processes:

 

The Monkeypox virus is a so-called enveloped virus.  And from the COVID19 pandemic we know that most enveloped viruses can be destroyed by thermal disinfection or chemo-thermal disinfection.
On top of that it has to be mentioned here that these enveloped viruses are sensitive to high pH and surface-active agents. Both parameters being present in the pre wash of all healthcare wash processes. So, the MPXV de-activation already starts in the first minute of the dedicated wash process.
In short: the chance that this monkeypox virus survives the recommended disinfecting wash process is nope.
Dosage of a listed disinfecting bleach creates an additional safety barrier.

Exception to the above: effective disinfecting wash processes for fabrics that can’t be washed at high temperature [such as clothing] or fabrics that can’t withstand high pH, need an extra safeguard. We recommend that you discuss this with your detergent supplier. Dosing a product based on 6-phthalimido peroxy hexanoic acid [PAP] sounds the most logical route to follow.

Storage of MPX contaminated textiles and linen is not recommended.

Further relevant data:
Monkeypox and handling linen
The rash associated with monkeypox can be confused with other diseases that are encountered in clinical practise – such as secondary syphilis, herpes, chancroid, and varicella zoster. The  implication for healthcare workers and laundry [sorting] staff is that handling infected linen should always be taken seriously.

The dominant variant [or better clade in WHO Monkeypox terminology]  that is present in the current outbreak is known as the West African Clade (WAC) or clade IIb.
The recommendation to the [specialised] health care facilities is to:
First of all – rule out that the patient has not been travelling to the Democratic Republic of Congo, Central African Republic, Eastern Cameroon or Gabon in the prior 21 days.
Secondly –  Analyse – by PCR – which clade is present. To make sure that the patient has not been infected by clade 1 Virus, also known as the Congo Basin Clade [CBC].

The CDC recommends to vaccinate those persons that are at risk for occupational exposure. This is particularly valid for healthcare workers.
The question has been raised if the virus could be airborne by handling infected linen. Before this question is answered we found that the CDC made a remark regarding transmission via the respiratory tract. In a report of June 9th the CDC reported that the virus “may” spread through respiratory secretions when people have close face to face contacts.  Translated this implies that the risk of getting infected via aerosol in the air – for instance when handling / sorting infected linen – is small. But can’t be ruled out.
However, a recent report *** by an NHS team reported presence of the virus in the air and on healthcare staff uniforms after changing bed linen in occupied patient rooms. The conclusion of this medical team was that there is significant aerosolization of the MPX virus during specific activities.

TRANSPORT SAFETY

The Department of Transport [The PHMSA in the USA] – in conjunction with OSHA – are responsible ensuring safe transportation of hazardous materials throughout the United States. These organizations state that testing is needed to ensure that the suspected case is not the Congo Basin clade of the monkeypox virus, which is classified as a Category A infectious substance and thus subject to more stringent transportation requirements under the HMR. Waste from the Congo Basin clade is not eligible to be transported as UN3291, Regulated medical waste. After consultation with the CDC, PHMSA understands that in the United States no Congo Basin cases have been identified, and laboratory testing has continued to indicate that the current outbreak is associated with the West African clade of monkeypox virus. Therefore, a patient who tests orthopox-virus positive can be assumed to be infected with the West African monkeypox virus. Waste, generated during diagnosis, treatment, and immunization of suspected or confirmed cases, can be safely transported as UN3291, regulated medical waste in accordance with the Hazardous Materials Regulations [HMR], provided that screening , mentioned earlier, indicates no risk factors for the Congo Basin Clade.

***        Air and surface sampling for monkeypox virus in UK hospitals | medRxiv

IHAC BACKGROUND AND OBJECTIVES

The overall objective is creating consistent recommendations for the laundries, their customers
[such as hospital, food and hospitality industry] and their staff. This in order to maximise hygiene
awareness and minimise or even better avoid any hygiene related incidents. Not only restricted to
COVID-19.

FOOTNOTES:

The Advisory Committee will:

  • Not be individually or collectively liable for the independent protocols and guidelines.
  • Make sure that the PTC industry will be updated on a regular basis.
  • Prepare answers to topics like: Which linen should be handled as infectious ? and : Should laundry staff wear a mask? If yes – when ? How does the vaccination recommendation for laundry staff look like?
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Monkeypox outbreak May 2022

Monkeypox. Is this a pandemic ?

It’s all about definitions. This outbreak is now officially a pandemic – since at least two cases have been confirmed by the Australian Government.
The concept / or definition of a pandemic is based by the World Health Organization on the fact in how many continents the disease has broken out. And NOT – as many people think – based on the number of patients in such an outbreak. Continue reading “Monkeypox outbreak May 2022”

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HYGIENE BULLETIN INTERNATIONAL HYGIENE COMMITTEE

COVID19 : It was back in November 2021 that the WHO had defined the Omicron variant as a Variant of Concern [VoC].

As of today (25 Feb 2022) we now know that this variant wasn’t only highly transmissible but at the same time much milder. This has resulted in a situation where Omicron has replaced Delta as the dominant variant. Continue reading “HYGIENE BULLETIN INTERNATIONAL HYGIENE COMMITTEE”

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Hygiëne protocol update: FACE MASKS

Backgrounds:
The current CINET laundry hygiene protocolls recommend using face masks type 1. This recommendation was based on the work carried out by reknown hygiene laboratories.

Recent developments however have changed the scene and now CINET proposes to change the minimum requirement for the face mask to type II or type IIR – also known as surgical masks.
One might ask: why this change of recommendation? The reason to do so has been based on the following.

Continue reading “Hygiëne protocol update: FACE MASKS”

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COVID 19

Global perspective – an introduction:

This article reflects our views on how the pandemic may come to an end, deals with the latest information on Variants Of Concern and discusses the theme of herd immunity. This update ends with the most likely scenario that is going to happen and how this will affect the laundry industry.

The number of COVID 19 cases isn’t falling rapidly. With globally 650.000 new cases and a mortality of between 8000 and 9000 per 24 hrs shows us that the pandemic is not over yet. Having said that: there are already various geographies where vaccination is showing to be THE only route to go.

Herd immunity* is a result of a combination of two factors: The number of people that already got infected plus the number of people that are fully vaccinated. These two together could create a situation where most social gatherings and activities will become possible again. Critics would argue that high vaccination scores don’t guarantee a COVID free society – and these people point to a recent increase in Covid 19 cases in Israel.

Variants of Concern:

With vaccines proving to be effective one could argue that the curve of number of infections is bending in the right direction – but the variants of concern are the ones that threaten this curve to move down rapidly. Many variants have been detected in the last 12 months. But four of them have had a major impact on the speed of the outbreak and created second and third waves.

The potential consequences of these variants are

  • Increased transmissibility, morbidity, mortality and risk of long-COVID.
  • Decreased susceptibility to anti-viral drugs
  • Ability to evade natural immunity and ability to infect vaccinated people.

A new variant will be listed as a VOC or in full: Variant Of Concern If and when a new variant has one or more of the above characteristics. The most dominating variant at this moment of time is Delta.

Vaccination

There is growing evidence that vaccinations are responsible for the reduction in number of patients that need hospitalisation and in addition a sharp reduction in fatalities. The main reason why this reduction isn’t as high as expected is that the effectiveness of the vaccines is minimal for those people having an immune deficiency as a result of immune suppressive medication. Like: rituximab, people with hematologic cancers as well as haemodialysis patients.

But as a whole the international approach should be: maximise the acceptation of vaccination. The roll out of the vaccines is in full swing in most West European countries, U.A.E., Uruguay, Singapore, Israel and Qatar.

The countries that had a strategy of strict lockdown – even when there is only one case of COVID in the country – are now finding out that this tactic isn’t going to work. These countries are now stepping up their vaccination speed. This includes Australia, New Zealand, South Korea and Japan.

China and Singapore are the exceptions in this lockdown strategy – since they have combined stringent lockdowns with high vaccination scores.

The slower than required vaccination roll-out is mainly a result of lack of production capacity. The good news is that new factories are being build. Biontech is increasing production but also The co-operation between Moderna and Lonza will rapidly increase availability of mRNA-based vaccines – with new production plants in Europe [Visp and Geleen], South Africa, Australia, Canada and Singapore.

While COVAX and other access initiatives are working to close the gap, many low-income countries may not receive enough doses to vaccinate all adults until well into 2022. The world is on pace to manufacture enough to achieve 80 % coverage [Or even 100% of all adults] at the end of 2021. However, the distribution of these doses might remain asymmetric. This goal of 100 % global coverage might be disturbed by the tendency to start booster shots in “first world” countries.

The laundry industry

Healthcare

There are large regional differences - as regards hospital occupancy. Hospital staff was and is fully focussed on COVID-19 patients occupying ICU and isolation beds. Routine hospital operations are postponed in most countries worldwide – due to this lack of staff. This has had an impact on the total volume of linen to be washed. The expectations are that these volumes will slowly move to pre-COVID numbers in the coming months.

Hospitality

A dramatic drop in international travel – both business and tourist – has had its toll on both the airline industry and hospitality industry [drop in occupancy rate]. As a result: the laundry industry experienced the worst situation since decades. Many countries closed their borders and only now we see that these travel burdens are slowly removed. The figures of improvement are closely monitored by the United Nations World Tourism Organization (UNWTO). 1) [see below] Large recovery differences can be observed when comparing regional data. Just as example the hotel booking and occupancy for Europe looks like:

Looking into the crystal ball - Expectations:

Given the likely timing of “herd immunity” in various geographies and the uncertain duration of protection from vaccines (both duration of immune response and efficacy versus new variants), it is likely that some measures such as booster vaccines are likely to be required indefinitely. Herd immunity is not the same as eradication. SARS-CoV-2 will continue to exist. Ongoing surveillance, booster vaccines, and potentially other measures may be needed, even when a country reaches “herd immunity”.

Or with other words there will never be a “pre-pandemic normal”. There will always be a seasonal COVID – that will have the characteristics of a seasonal flu. Provided that the majority of the population appreciates and understands the need for a vaccination and the second disclaimer – of course – is that no variant will emerge that has capabilities of bypassing all existing defence systems.

Literature: 1) UNWTO data: https://www.unwto.org/unwto-tourism-recovery-tracker

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CANDIDA AURIS OUTBREAK!

CANDIDA AURIS:

This yeast can - in some hospital patients - enter the bloodstream and spread throughout the body, causing serious invasive infections. This yeast often does not respond to commonly used antifungal drugs, making infections difficult to treat.
The lethality is between 30 and 60 %. Especially lethal for immuno compromised patients.

Candida Auris outbreak

Health Authorities in Hong Kong and China are worried about the rising numbers of Candida Auris infections. The latest number in Hong Kong is 136 people got infected in 2020 [where there were only 20 reported cases in 2019]. The USA alone count is - as of June 2021 - 2386 cases - mainly in New York, California, Florida and Illinois.

  • Multiple cases of Candida Auris have been reported from Australia, Bangladesh, Canada, China, Colombia, France, Germany, India, Israel, Japan, Kenya, Kuwait, Malaysia, the Netherlands, Oman, Pakistan, Panama, Russia, Saudi Arabia, Singapore, South Africa, South Korea, Spain, Sudan, Switzerland, the United Kingdom, the United States, and Venezuela; in some of these countries, extensive transmission of Candida Auris has been documented in more than one hospital.

HOW DOES CANDIDA AURIS SPREAD ?

  • Candida species reside in our intestine microbiome. Candida Auris spreads from person to person via direct contact or by coming in contact with contaminated surfaces or equipment. Candida patients also shed skin particles that contain the yeast.
  • The most common symptoms of invasive Candida infection is fever and chills that do not improve after antibiotic treatment.

HOW CAN LAUNDRIES HELP STOPPING THIS GLOBAL THREAT?

The number one priority is sticking to the standard hygiene guidelines.
In addition:

  • Thermal or chemo-thermal disinfection
  • Never use starch in a hospital or care home laundry
  • Make sure that the cleaned linen – when leaving the laundry – has a relative moisture level below 5 %
  • Dosing a Quaternary Ammonium based product in the last rinse reduces the hygiene risks