Do We Need Fumigation In Our Indian Operation Theatres??

- Dr. Ajita Mehta

President HIS-I Consultant Microbiologist P. D. Hinduja National Hospital & MRC Veer Savarkar Marg, Mahim (West) Mumbai 400 016

Points to be discussed

Critical Parameters for ideal Operation Theatre (OT) Indian Scenario about OT What is Fumigation / Fogging Do we need fumigation in India? What will be the Take Home Message?

Critical parameters for OT

Filter air through 2 layer beds in series

(efficiency of the 1st filter bed being >30% & that of the 2nd filter bed being >90%)

HEPA filters (to remove > 0.3 m with an efficiency of 99.97%) Positive pressure Requirement of 15-20 air changes /hour with a minimum of 3 air changes of fresh air (20%). Air should flow from the ceiling & be exhausted near the floor

Temperature of 20- 220C, is comfortable & inhibits bacterial growth

Relative humidity 30-60% to slow down bacterial growth

Laminar airflow (ultra clean air) & UV radiation have been suggested as additional measures in certain situations (orthopedic operations)

Heating Ventilation Air Conditioning (HVAC) Systems

HVAC system maintain indoor air temp. & humidity, control odours, remove contaminated air & minimize the risk of transmission of airborne microorganisms

Consists of air inlets, filter beds, humidity modification mechanisms, heating & cooling equipment, fan ducts

& air exhausts

Fumigation is no longer used in the Western Literature

as they have all the modern critical parameters required for OT

Indian Scenario

In India, there are extreme situations in operation theater (OT) facilities, ranging from rooms with fans, window air conditioning, to the more sophisticated laminar airflow systems More than 60-80% of OTs, donot have air handling unit (AHU) & other modern facilities with critical parameters In hospitals that lack heat ventilation air conditioning (HVAC) systems the quality of air in the OT cannot

be guaranteed

What can we do in such circumstances??

Fogging

Nebulization of a disinfectant to decontaminate rooms

vacated by patients with communicable diseases.

The origin of fogging can be

traced to the 19th century when

Lister aerosolized carbolic acid to improve antisepsis in

operative practice

What Is Fumigation?

Fumigation consisted of a mixture of formalin (280 ml) and potassium permanganate (150 gm) being placed in a bowl. The room would then be sealed & opened 12-24 hours later. Later on this changed formalin being sprayed with humidification by a spraying device or automist.

Temperature 180C & Humidity should be maintained to 600C

Different Methods
1. Carboxyl acid & fumigation with Formaldehyde Advantages Established age old technique Cost effective Disadvantages a. Carboxylic acid has efficacy as scouring and disinfecting agent b. Time consuming, min 24 hrs turn around time c. Self defeating OT fumigated with Formaldehyde needs to be force de-aired with unclean air d. Unsafe Formaldehyde is carcinogenic

2. Aldehyde based germicides Glutaraldehyde & formaldehyde (200 ml in 10 liters of water i.e 2%) through fogging machine is the commonly used procedure. AdvantagesEffective

Disadvantages a. Leaves sticky residue because of surfactant base

b. Self defeating OT fumigated with Formaldehyde needs to be force de-aired with unclean air c. Unsafe- Formaldehyde has been

identified as a carcinogen

3. Silver (Ag) and Hydrogen Peroxide (H2O2) Advantages a. Has deep penetrating capability b. Has no known resistant strains

c. Effective against Bacteria, Viruses, Mycobacteria, Amoeba, Fungi and spore forming organisms

A fogging system Droplets~7microns thrust by a motor running at 20,000 RPM to a distance of 15 m

Solution
Ecoshield 11% Hydrogen Peroxide and 0.01% dilute sliver nitrate

Efficacy of Fumigation / Fogging method

Viable bacteria may fail to grow when cultured in the presence of disinfectants

Neutralization of disinfectant (ammonia vapours or water) is must before collecting air samples or swabs Lecithin & Tween 80 in appropriate concentrations are suitable neutralizing agents
Environmental contaminants are generally associated with organic residues that bind & deactivate most disinfectants, (least likely to be benefit in those areas contaminated
with organic materials such as blood, feces or pus)

Fogging hastens the process of setting of airborne microorganisms. Mist, generated by a disinfectant or water would achieve the same process

Air

sampling is useful to detect aerosols or particles of

microorganisms. (requires particle counter & practical method for

evaluating efficiency of filters)

Air sampler

The Unresolved issues of microbiologic sampling are:

Lack of standards Lack of Standard protocols for testing Sensitivity of sampler used Such sampling should largely be reserved for epidemiological investigations during outbreaks

No studies to demonstrate that fogging actually reduces

the incidence of nosocomial infection. The role of contaminated environmental surfaces in causing nosocomial infection remains to be elucidated*

Controlled studies at CDC have demonstrated that quaternary ammonium fog does not produce a significant (one log )reduction in bacterial counts of S. aureus or E. coli, even in areas in completely saturated with residual

disinfectant*
*CDC: National Nosocomial Infections Study Quaterly Report, Third Quarter. 1971: isuued May 1972)

In India, studies have not compared standard cleaning practices with fumigation/fogging. No substitute for vigorous scrubbing, washing of surfaces & removing the organic matter

Safety of repeated exposure of humans to disinfectant & fog has not been established Inspite of these drawbacks it is the best alternative for - litigation - good & safe hospital practices, - check up of human default - favourable psychological effect on staff & patients - to improve the standard of hospital hygiene & asepsis

Points to support

Significant reduction in the number of bacteria in the ambient air Effective decontamination of exposed environmental surfaces

Decreased risk of infection for housekeeping personnel

engaged in terminal cleaning

Decreased housekeeping costs

Secondary psychological benefits for hospital personnel

Take Home Message

Fumigation is the only alternative however following precautions should be taken Replace formalin with a safer agent like a H2O2 stabilized with a silver salt It has no role in OTs with modern day HAVCs

For litigation after fogging do the air sampling & keep the record
This is not an alternative to mechanical cleaning of surfaces If surgeries are being performed with window airconditioners fogging would be required on a daily basis not on weekends alone as is practiced (WHO guidelines on
prevention & control of Hospital Associated infections SEA-HLM-343. Jan 2002)