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Hygiene in the non-clinical environment
Dirk Bockmühl
Hygiene at home?
Gerd had rather spent more money in toilet cleaning agents…
Home hygiene: the consumer’s view
Hygiene threats are mostly found outside my home
According to a GfK survey for the „Apotheken-Umschau“ 2006
Notifiable infections in Germany (2008)
Source: RKI
Household-associated infections
Norov
irus
Rotav
irus
Salmon
ella
Campy
lobac
ter
Hepat
itis A
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
outside
at home
Krause et al.: Emerg Inf Dis 13(10) (2007)
The key message
• The domestic environment is one of the most important sources for infectious diseases
• These infections are predominately food-borne
The risk of infection at home
7
Risk
Source: IFH
Risk
Source: IFH
The risk of infection at home
Decontamination of food contact surfaces
The dishwasher: a risk?
Dishwashers host black yeasts
Zalar et al. (2011)
Dishwashers host black yeasts
?But is there a risk of infection?
Estimation of infection risk
1.Pathogenic microbes?
2.Routes of infection?
3.Exposition?
4.Risk factors?
Groups of higher risk: YOPIsYoung Old
Pregnant Immunocompromised
Antibacterial effect of hand dishwashing
Mattick et al.: Int J Food Microbiol 85 (2003) 213– 226
47 50 53 57 600
10
20
30
40
50
60
Soa
king
tim
e [m
in]
Temperature [°C]
Water
Water + Detergent
Time needed to reduce 99,9% of Salmonella
The „killer“ sponge
Enriquez et al. Dairy Food Environ. Sanitation. 17:20-24.
102 – 107 microbial cells
per gramm
SEM-photograph: A. Hinnemann, Rhine-Waal University of Applied Sciences
How to sanitize a kitchen sponge
Sharma et al. Food Control 20 (2009) 310–313
The dishwasher kills…
The dishwasher kills…
…bacteria!
Thus it is an important means to ensure decontamination of food-contact surfaces
The risk of infection at home
Risk
Source: IFH
The washing machine as source of germs
Will we all die now?
Infections and laundering
Fungal infections(Athlete‘s foot, Candida)
Viral infections(Noroviruses)
Inactivation of Norovirus via laundering
Lemm et al. Tenside, Surfactants, Detergents (submitted)
Detection of viral RNA on fecally contaminated textiles
Challenge: low temperatures
1972 1987 1996 2001 2005 2008 2009 20100
10
20
30
40
50
60
70
0
10
20
30
40
50
60
70
80
90
100
T [
°C]
%
Medium washing temperature
Textiles washed at ≥60°C
Survey on german householdsSource: IKW Sustainability Report 2010
Wearing
Drying
WashingStorage
Hygiene in the wash- and use-cycle
Inpu
t of
m
icro
orga
nism
sR
educ
tion
of
mic
roor
gani
sms
Wearing
Drying
WashingStorage
Hygiene in the wash- and use-cycle
Inpu
t of
m
icro
orga
nism
sR
educ
tion
of
mic
roor
gani
sms
Wearing
Drying
WashingStorage
skin floraexcretions
biofilms
crosscontami-
nation
fungal spores
dust
dehydrationtemperature
chemistrymechanics
temp.
dehydration
Hygiene in the wash- and use-cycle
Challenges
Challenges
Wich microbes?
Quantity?
Challenges
Machine impact?
Challenges
Impact of drying and ironing?
10
100
1000
10000
100000
cfu/
cm2
After drying
After laundering
After use
What happens when you wash your towels?
Blümke et al., EDC conference 2011
10
100
1000
10000
100000
cfu/
cm2
After drying
After laundering
After use
What happens when you wash your towels?
Blümke et al., EDC conference 2011
10
100
1000
10000
100000
cfu/
cm2
After drying
After laundering
After use
What happens when you wash your towels?
Blümke et al., EDC conference 2011
The washing machine as a reservoir for germs
• Microbial colonisation of the rinsing chamber is independent of the chosen temperature
• Contamination after the main wash cycle
Another real-life study…
Analysis of Laundry in Nursery Homes
Analysis of Laundry in Nursery Homes cf
u /
100
cm
2
Before laundering
After laundering
After drying
Survey on 16 nursery homes in the district of KleveBertelmann et al., DGHM conference 2012
Individual reduction factors
Nursery home #
Log
redu
ctio
n (b
efor
e/af
ter
laun
derin
g)
Bertelmann et al., DGHM conference 2012
Impact factors on laundry hygiene
Nursery school # 1 2 3 4 5 7 8 9 12 13 16 17 18 21 23 28
Reduction factor before/after washing
0,3 9,7 1,1 12,8 6,5 11,0 5,2 0,1 1,6 3,3 9,0 23,0 1,2 28,5 7,5 1,2
Machine age (y) 15 2 15 7 5 4 5 6 1 10 6 15 10 7 4 16
Use of Hygiene rinser - - - - - + - + - - + - + - - -
Use of bleach - - - - - + + + + + + + + - + +
Washing temperature (°C)
40 60 60 90 60 60 60 60 40 60 60 60 60 60 60 60
Machine cleaning + + - - + + + - + + - + + + - +
Bertelmann et al., DGHM conference 2012
Impact factors on laundry hygiene
Nursery school # 1 2 3 4 5 7 8 9 12 13 16 17 18 21 23 28
Reduction factor before/after washing
0,3 9,7 1,1 12,8 6,5 11,0 5,2 0,1 1,6 3,3 9,0 23,0 1,2 28,5 7,5 1,2
Machine age (y) 15 2 15 7 5 4 5 6 1 10 6 15 10 7 4 16
Use of Hygiene rinser - - - - - + - + - - + - + - - -
Use of bleach - - - - - + + + + + + + + - + +
Washing temperature (°C)
40 60 60 90 60 60 60 60 40 60 60 60 60 60 60 60
Machine cleaning + + - - + + + - + + - + + + - +
Bertelmann et al., DGHM conference 2012
Impact factors on laundry hygiene
Nursery school # 1 2 3 4 5 7 8 9 12 13 16 17 18 21 23 28
Reduction factor before/after washing
0,3 9,7 1,1 12,8 6,5 11,0 5,2 0,1 1,6 3,3 9,0 23,0 1,2 28,5 7,5 1,2
Machine age (y) 15 2 15 7 5 4 5 6 1 10 6 15 10 7 4 16
Use of Hygiene rinser - - - - - + - + - - + - + - - -
Use of bleach - - - - - + + + + + + + + - + +
Washing temperature (°C)
40 60 60 90 60 60 60 60 40 60 60 60 60 60 60 60
Machine cleaning + + - - + + + - + + - + + + - +
Bertelmann et al., DGHM conference 2012
Impact factors on laundry hygiene
Nursery school # 1 2 3 4 5 7 8 9 12 13 16 17 18 21 23 28
Reduction factor before/after washing
0,3 9,7 1,1 12,8 6,5 11,0 5,2 0,1 1,6 3,3 9,0 23,0 1,2 28,5 7,5 1,2
Machine age (y) 15 2 15 7 5 4 5 6 1 10 6 15 10 7 4 16
Use of Hygiene rinser - - - - - + - + - - + - + - - -
Use of bleach - - - - - + + + + + + + + - + +
Washing temperature (°C)
40 60 60 90 60 60 60 60 40 60 60 60 60 60 60 60
Machine cleaning + + - - + + + - + + - + + + - +
Bertelmann et al., DGHM conference 2012
Impact factors on laundry hygiene
Nursery school # 1 2 3 4 5 7 8 9 12 13 16 17 18 21 23 28
Reduction factor before/after washing
0,3 9,7 1,1 12,8 6,5 11,0 5,2 0,1 1,6 3,3 9,0 23,0 1,2 28,5 7,5 1,2
Machine age (y) 15 2 15 7 5 4 5 6 1 10 6 15 10 7 4 16
Use of Hygiene rinser - - - - - + - + - - + - + - - -
Use of bleach - - - - - + + + + + + + + - + +
Washing temperature (°C)
40 60 60 90 60 60 60 60 40 60 60 60 60 60 60 60
Machine cleaning + + - - + + + - + + - + + + - +
Bertelmann et al., DGHM conference 2012
Analysis of Laundry in Nursery Homes cf
u /
100
cm
2
Before laundering
After laundering
After drying
Very low counts after tumble drying
Bertelmann et al., DGHM conference 2012
Do hygiene rinsers help?
Hygiene
+
Source: Forum Waschen
Do hygiene rinsers help?
Claim: Kill 99,9(99)% of germsSubstantiated via suspension tests
Source: Forum Waschen
Efficacy in the washing machine?
• Additional detergency effect
• Textile effect
• Different germs
• etc.
Powder detergent with hygiene rinser
30°C+PD 30°C+PD+HR 40°C+PD 40°C+PD+HR 60°C+PD 60°C+PD+HR0.0
20.0
40.0
60.0
80.0
100.0
18.8
100.0 99.0 100.0 98.8 100.0
% r
edu
ctio
n
Lucassen et al., Tenside, Surfactants, Detergents (2013)
Akimitsu et al.: Antimicrob Agents Chemother 1999;43:3042-3
Cross resistance between antibiotics and biocides
Cross-resistance
Lambert: Journal of Applied Microbiology 2004, 97, 699–711
Lambert et al.: Journal of Applied Microbiology 2001, 91, 972±984
Resistance profile vs. origin
TSI: Total Susceptibility Index
Anz
ahl
Klinische Isolate
# Is
olat
es
Clinical Isolates
Clinical isolates are more resistance in general
Antibiotic resistance is predominately found in clinical isolates
Clinical environment fosters resistance
Lambert et al.: Journal of Applied Microbiology 2001, 91: 972-984
Does biocide use enhance antibiotic resistance?
Biocides at home?
Biocides at home?
Hygiene rinsers:only for special cases
Biocides at home?
Hygiene rinsers:only for special cases
http://londoncleaning-services.co.uk
Detergents with activated oxygen bleach ensure sufficient hygiene
Are we too clean? The hygiene hypothesis
Strachan (1989):
20th century rise in allergic diseases is related to lower incidence of infection in early childhood
Hygiene hypothesis: the consumer‘s view
„We need some bacteria to train our immune system“
„Too clean is harmful“
Hygiene hypothesis: the consumer‘s view
Hygiene hypothesis: the scientific view
Taken from: Smith et al.: The Hygiene Hypothesis and its implications for home hygiene, lifestyle and public health, IFH review 2012; based on: Rook G Clin Exper Immunol 2010; 160:70-79.
Old friends hypothesis (Graham Rook)
Microorganisms that were once abundant (but aren‘t any more) trained our immune system to be more tolerant:
- Lactobacilli- Saprophytic Mycobacteria- Parasitic worms
Are we too clean?
Cleaning does most probably not increase the risk for allergy and asthma
Are we too clean?
Cleaning does most probably not increase the risk for allergy and asthma
The targeted use of cleaning and antimicrobial products may help to reduce the risk for household-associated infections
Targeted Hygiene
Risk
Source: IFH
Thanks
Britta Brands, Angelina Eckert, Marlitt Honisch, Davina Lemm,
Ralf Lucassen, Nadine Merettig, Ramona Steiner
Thank you