Assessment of glove stretch and storage temperature on fentanyl permeation: Implications for standard test methods and PPE recommendations.

The National Institute for Occupational Safety and Health recommends the use of nitrile gloves with a minimum thickness of 5.0 ± 2.0 mil [0.127 ± 0.051 millimeters] in situations where it is suspected or known that fentanyl or other illicit drugs are present. However, there is limited data available on fentanyl permeation through gloves. Current test methods used to measure fentanyl permeation do not consider the effect of glove fit and flexion. Furthermore, first responders need to have PPE readily available in the field, and storage conditions may affect the protective performance of the gloves. The objective of this study was to evaluate the effects of glove stretch and storage temperatures on glove durability and barrier performance against fentanyl. Nine nitrile glove models previously shown to be resistant to fentanyl permeation were selected for this investigation. These nine models were stretched 25% in one linear direction, to consider glove fit and flexion, and tested against fentanyl hydrochloride permeation. Additionally, four of the nine glove models were stored at 48 °C, 22 °C, and -20 °C, and evaluated for tensile strength, ultimate elongation, and puncture resistance after up to 16 wk of storage and fentanyl permeation after up to 8 wk of storage. At least one sample for six of the nine tested models had maximum permeation over the test method fail threshold when stretched. The tested storage temperatures showed no effect on glove tensile strength, ultimate elongation, and puncture resistance. The findings of this study can be used to inform PPE recommendations, with consideration to storage practices and proper sizing for first responders with potential exposure to fentanyl and other illicit drugs. The results of this study can be used to assess the need for new standard test methods to evaluate the barrier performance of gloves and shelf-life determination with consideration to glove fit.

Evaluation of the risk of occupational exposure to antineoplastic drugs in healthcare sector: part I - medical gloves.

Antineoplastic drugs (ADs) are essential tools in cancer treatment, but their cytotoxicity poses a risk to workers involved in their handling. In a hospital environment fundamental strategies for minimising exposure involve proper use of safety cabinets and closed-circuit transfer devices, along with personnel training and increased awareness of risks. However, medical gloves remain the first line of defence. In this respect the evaluation of glove materials and best choices can improve hospital safety management and prevent potential hazards and long-term consequences. The aim of this study was to assess contamination of gloves in samples taken from AD administration and preparation units of nine Italian hospitals and to raise awareness of the importance of evaluating chemico-physical properties of gloves. Our findings show that 33 % of the analysed gloves were positive for at least one AD, with contaminations ranging from 0.6 to 20,729 pg/ cm2. We proposed the alert glove values (AGVs) for each AD as a limit value for contamination assessment and good practice evaluation. Our findings also point to multiple AD contamination (43 % of positive findings in preparation units), calculated as total AGV (AGV-T), and confirm that gloves should be replaced after 30 min of AD handling, based on cumulative permeation and area under the curve (AUC), to maintain safety and limit dermal exposure.

Influence of repeated contacts on the transfer of elemental metallic lead between compartments in an integrated conceptual model for dermal exposure assessment.

Transfer of contaminants to and from the skin surface has been postulated to occur through a number of different pathways and compartments including: object(s)-to-skin, skin-to-skin, skin-to-clothing, skin-to-gloves, air-to-skin, skin-to-lips, and skin-to-saliva. However, many identified transfer pathways have been only minimally examined to determine the potential for measurable transfer. The purpose of this study was to quantitatively evaluate repeated transfer between different compartments using elemental metallic lead (Pb) in the solid form using a series of systematic measurements in human subjects. The results demonstrated that some transfer pathways and compartments are significantly more important than others. Transfer of Pb could not be measured from skin to cotton clothing or skin to laminate countertop surfaces. However, transfer was consistently measured for skin-to-skin and between the skin and the surface of nitrile gloves, suggesting the potential for significant transfer to or from these compartments in real-world exposure scenarios, and the importance of these pathways. With repeated contacts, transfer increased non-linearly between 1 and 5 contacts, but appeared to approach a steady state distribution among the compartments within 10 contacts. Consistent with other studies, relative to 100% transfer for a single contact, the quantitative transfer efficiency decreased with repeated contacts to 29% after 5 contacts and 11-12% after 10 contacts; for skin-to-skin transfer measurements, transfer efficiency after either 5 or 10 contacts was approximately 50% of the single contact transfer. These data are likely to be useful for refining current approaches to modeling of repeated contacts for dermal exposure and risk assessment.

Review of Wearable Sensor-Based Health Monitoring Glove Devices for Rheumatoid Arthritis.

Early detection of Rheumatoid Arthritis (RA) and other neurological conditions is vital for effective treatment. Existing methods of detecting RA rely on observation, questionnaires, and physical measurement, each with their own weaknesses. Pharmaceutical medications and procedures aim to reduce the debilitating effect, preventing the progression of the illness and bringing the condition into remission. There is still a great deal of ambiguity around patient diagnosis, as the difficulty of measurement has reduced the importance that joint stiffness plays as an RA identifier. The research areas of medical rehabilitation and clinical assessment indicate high impact applications for wearable sensing devices. As a result, the overall aim of this research is to review current sensor technologies that could be used to measure an individual's RA severity. Other research teams within RA have previously developed objective measuring devices to assess the physical symptoms of hand steadiness through to joint stiffness. Unfamiliar physical effects of these sensory devices restricted their introduction into clinical practice. This paper provides an updated review among the sensor and glove types proposed in the literature to assist with the diagnosis and rehabilitation activities of RA. Consequently, the main goal of this paper is to review contact systems and to outline their potentialities and limitations. Considerable attention has been paid to gloved based devices as they have been extensively researched for medical practice in recent years. Such technologies are reviewed to determine whether they are suitable measuring tools.

Lifestyle, behavior, perception and practices of Nepalese during lockdown due to COVID-19 pandemic.

INTRODUCTION: COVID-19 infection is caused by a new strain of SARS CoV-2 virus, which transmits directly from person-to-person and has become a pandemic. To counteract this, actions related to mass quarantines or stay-at-home orders have been used termed as lockdown. This study aims to study lifestyle, behaviour, perception and practice of people regarding during the lockdown. METHODS: An online survey was conducted with structured questionnaire in Google forms after ethical approval from Nepal Health Research Council (Ref-2631). The attributes of knowledge, attitude and practices were explored using multiple-choice questions and results were statistically analysed using Microsoft excel. RESULTS: Five hundred fifty-five respondents completed the survey with 280 (50.5%) males and 275 (49.5%) female. The knowledge regarding viral pandemic was increased in 496 (89.3%) respondents. 424 (76.4%) people developed stress due to pandemic. Three hundred fifty three (63.6%) were adversely affected by professional works or suffered economic loss in business. More than 42% participants are using their time for study in personal development, online classes etc. Conclusions: The knowledge of viral pandemic as well as personal hygiene habits have improved in majority of people but many also developed stress. They were convinced that lockdown lowered transmission of infection which in turn affected lifestyle behaviour and practices. Practicing social distancing becomes too difficult for the poor in the absence of proper social security system and government support. E-Learning has become more acceptable due to lockdown. Further studies with in-person interviews are warranted.

Current state of occupational latex allergy.

PURPOSE OF REVIEW: During the 1980s, natural rubber latex (NRL) emerged as a major cause of occupational allergy and asthma, especially in healthcare workers using powdered NRL gloves. Increased recognition of NRL allergies and transfer of research findings into prevention strategies resulted into an almost elimination of this health problem. Here, the current knowledge on allergens, their use in diagnostics, prevalence data of occupational NRL allergy and the status of prevention strategy are summarized. RECENT FINDINGS: While the current studies conducted in high-income countries show that prevention measures have reduced NRL allergy, this does not yet apply worldwide. For latex allergy diagnosis, it is important that recombinant allergens as reliable tools are available, because in several European countries and the United States, NRL skin prick test extracts and powdered latex gloves for bronchial challenge test are no longer commercially available, leading to a deficit in diagnostic tools. Due to the fact that latex is suitable with good properties as a raw material for gloves, alternatives with significantly lower protein content and without cross-reactive structures to latex proteins are sought. SUMMARY: Awareness of the sensitization risk associated with the use of latex gloves should still be present in all occupational settings.

Development and performance assessment of electrically heated gloves with smart temperature control function.

A pair of lightweight electrically heated gloves (EHG) with smart temperature control function was developed. To evaluate the thermoregulation properties of the EHG, human trials were conducted in a climate chamber (2.5 °C, 60% RH). The changes in skin temperature at all fingers and the opisthenar, and the subjective thermal sensation were recorded over 60 min. The effects of two air velocities (i.e., 0.17 and 0.50 m/s) on the cold protective performance of the EHG in scenarios of heating and control were also investigated. For heating scenarios, skin temperature and thermal sensation at all fingers and the opisthenar were found significantly higher than those in control conditions. Moreover, the air velocity at 0.50 m/s greatly reduced the cold protective performance of the gloves. The research findings can be applied to improve thermal comfort and extend working times for persons in cold environments.

Management of latex hypersensitivity in the perioperative setting.

Despite the introduction and use of latex-free gloves, natural rubber latex hypersensitivity is still an issue in hospital medicine both for patients and healthcare professionals. Clear understanding of the groups at risk as well as perioperative assessment and management is key to reducing complications and improving safety. In this literature review, we cover the perioperative management of patients with latex hypersensitivity, as well as the implications for healthcare professionals. We also review the cost analyses of latex hypersensitivity in the healthcare system and the evidence available.

Assessment of Mouse Handling Techniques During Cage Changing.

Mouse handling during cage changing and health evaluation has traditionally been performed by using forceps. This method was adopted as a biosecurity measure but can adversely affect employee ergonomics and rodent behavior. In this study, we evaluated alternative methods of rodent handling and their potential implications for efficiency, biosecurity, and animal welfare. Study groups included plastic cups, gloved hands, 2 methods of tunnel handling, and forceps. Evaluations included speed of cage change, ATP-based assessment of sanitization, and retrospective analysis of colony health and breeding data. The time to change 14 cages was significantly faster at each time point for the gloved hands and forceps groups as compared with the other methods. Overall speed did not increase significantly with each subsequent study week for any group. ATP levels after sanitization with hydrogen peroxide-peracetic acid mixture differed significantly between gloves and forceps. When ATP level was evaluated on a per-cm² basis, no significant difference between gloves and forceps was detected. Although tunnel and cup handling both increased the time for cage-changing, the tunnel served as both an indirect handling method and a shelter when left within the cage. Retrospective analysis revealed that breeding performance and colony health were similar among groups. Although efficiency is a concern for large-scale implementation of novel handling methods, the tunnel method may prove beneficial for sensitive strains or studies requiring indirect handling. In addition, using gloved hands to directly handle mice during cage changing is efficient and avoids the ergonomic strain associated with forceps. Precautions should be taken when handling mice with gloves, given that the increased contact area carries an increased load of organic debris. Changing gloves between rack sides or before proceeding to the animals belonging to a different investigator minimizes the potential for cross-contamination.

Factors influencing health and safety practices among Vietnamese nail salon technicians and owners: A qualitative study.

OBJECTIVE: This qualitative study explored factors that influence health and safety practices among Vietnamese nail salon technicians and owners. METHODS: We conducted semi-structured focus group discussions and individual interviews with a sample of 17 Vietnamese nail salon technicians and owners in the Philadelphia metropolitan area, Pennsylvania. RESULTS: Analysis of transcripts revealed perceived health benefits/concerns, knowledge about work-related hazards, salon's management and policies attributed to owners, client influence, external policies/regulations, and protective equipment-specific challenges were among factors affecting workplace health promotion practices at the salons. CONCLUSIONS: The study highlighted a complex interplay among the various stakeholders including nail technicians, owners, clients, policy makers, and enforcers. Interventions addressing barriers at the personal and organizational levels, as well as public policy change and enforcement are needed to create sustainable behavioral and organizational change in nail salons.

Improving the knowledge and behavior of workplace chemical exposures in Vietnamese-American nail salon workers: a randomized controlled trial.

OBJECTIVES: We assessed the efficacy of trainings with Vietnamese nail salon owners and workers on knowledge and behaviors that could reduce exposures to toxic chemicals in nail products. METHODS: We trained Vietnamese salon owners in California (n = 77) who then trained their workers (n = 200) on best practices. In a cluster randomized controlled trial, we assessed the efficacy of the training on change in knowledge and self-reported behaviors. Data were collected from 2013 to 2016 and analyzed from 2016 to 2017. RESULTS: Compared to the control group, the intervention group had significantly greater increases in knowledge about: safer nail polishes [odds ratio (OR) 3.7 (95% confidence interval (CI) 1.9, 7.2)]; proper ventilation methods (OR 4.2; 95% CI 2.2, 8.1); recommended glove types (OR 3.4; 95% CI 1.9, 6.3); and recommended product handling and storage (OR 4.1; 95% CI 1.7, 9.9). The intervention also increased best practices: using safer nail polishes (OR 3.6; 95% CI 1.9, 6.8); reading product labels (OR 2.6; 95% CI 1.3, 5.0); and wearing long sleeves (OR 2.4; 95% CI 1.3, 4.2). CONCLUSIONS: The owner-to-worker intervention with culturally and linguistically appropriate training for salon owners who then trained workers was effective in promoting knowledge and self-reported behaviors that can reduce workplace chemical exposures.

[Individual prevention of occupational contact dermatitis: protective gloves and skin protection recommendations as part of the patient management scheme by the public statutory employers' liability insurance]. / Individualprävention beruflicher Kontaktekzeme: Schutzhandschuhe und Hautschutzempfehlungen im berufsgenossenschaftlichen Heilverfahren.

The dermatologist's procedure is a pivotal tool for early recognition of occupational contact dermatitis (OCD), for reporting OCD cases to the statutory accident insurance and for treating the diseases. The employer is in charge of implementing skin protection measures at the workplace. However, in terms of an individual prevention approach it may be necessary to propose targeted skin protection recommendations in specific patient cases. The patient's own skin protection behavior significantly contributes to regenerating and maintaining healthy skin. This behavior includes the use of occupational skin products, and in particular the correct use of appropriately selected protective gloves. Protective gloves are the most important personal protective measure in the prevention of OCD. Prevention services, occupational health and safety specialists, occupational physicians and centers specialized in occupational dermatology can support the identification of suitable protective measures. Nowadays, suitable protective gloves exist for (almost) every occupational activity and exposure. However, improper use in practice can become a risk factor by itself for the skin (e. g., incorrectly used gloves). Therefore, it is of utmost importance to identify application errors, to educate patients in terms of skin protection and to motivate them to perform an appropriate skin protection behavior. With particular focus on protective gloves, this article gives an overview of various types, materials and potentially glove-related allergens, presents strategies for reducing occlusion effects and discusses some typical application errors and solutions.

Laboratory Validation and Field Assessment of Petroleum Laboratory Technicians' Dermal Exposure to Crude Oil Using a Wipe Sampling Method.

Crude oil may cause adverse dermal effects therefore dermal exposure is an exposure route of concern. Galea et al. (2014b) reported on a study comparing recovery (wipe) and interception (cotton glove) dermal sampling methods. The authors concluded that both methods were suitable for assessing dermal exposure to oil-based drilling fluids and crude oil but that glove samplers may overestimate the amount of fluid transferred to the skin. We describe a study which aimed to further evaluate the wipe sampling method to assess dermal exposure to crude oil, with this assessment including extended sample storage periods and sampling efficiency tests being undertaken at environmental conditions to mimic those typical of outdoor conditions in Saudi Arabia. The wipe sampling method was then used to assess the laboratory technicians' actual exposure to crude oil during typical petroleum laboratory tasks. Overall, acceptable storage efficiencies up to 54 days were reported with results suggesting storage stability over time. Sampling efficiencies were also reported to be satisfactory at both ambient and elevated temperature and relative humidity environmental conditions for surrogate skin spiked with known masses of crude oil and left up to 4 h prior to wiping, though there was an indication of reduced sampling efficiency over time. Nineteen petroleum laboratory technicians provided a total of 35 pre- and 35 post-activity paired hand wipe samples. Ninety-three percent of the pre-exposure paired hand wipes were less than the analytical limit of detection (LOD), whereas 46% of the post-activity paired hand wipes were less than the LOD. The geometric mean paired post-activity wipe sample measurement was 3.09 µg cm-2 (range 1.76-35.4 µg cm-2). It was considered that dermal exposure most frequently occurred through direct contact with the crude oil (emission) or via deposition. The findings of this study suggest that the wipe sampling method is satisfactory in quantifying laboratory technicians' dermal exposure to crude oil. It is therefore considered that this wipe sampling method may be suitable to quantify dermal exposure to crude oil for other petroleum workers.

Dynamic Functional Assessment of Hand Motion Using an Animation Glove: The Effect of Stenosing Tenosynovitis.

BACKGROUND: The aim of the present study is to determine whether an animation glove can be utilized to provide a reliable and reproducible assessment of dynamic hand function and whether this assessment is altered in the setting of hand pathology. METHODS: Ten subjects without known hand pathology and 11 subjects with known stenosing tenosynovitis were assessed on tasks involving hand function at varied speeds, including forceful and gradual making of a fist and the quick and slow grip of a baseball using an animation glove to record range of motion and measures of velocity (CyberGlove II). RESULTS: In normal subjects, peak extension and flexion velocity of the index and middle finger was highest in the metacarpophalangeal and lowest in the distal interphalangeal; however, the converse was true in the ring finger. In those subjects with stenosing tenosynovitis, the animation glove was able to detect a triggering event during assessment. Furthermore, there was a significant decrease in the maximum velocity of the proximal interphalangeal joint observed with the slow fist task in both flexion and extension (55%, P < .01) in the affected hand when compared with the unaffected hand. CONCLUSIONS: The CyberGlove II can be utilized in the dynamic functional analysis of the hand and is able to detect a triggering event in subjects with known stenosing tenosynovitis. Those subjects demonstrate a significant decrease in maximum velocity in slow fist tasks, highlighting the need for comprehensive assessment to ascertain the full extent of functional limitations that can occur in the setting of hand pathology.

Assessment of User, Glove, and Device Effects on Performance of Tourniquet Use in Simulated First Aid.

BACKGROUND: The effects of users, glove types, and tourniquet devices on the performance of limb tourniquet use in simulated first aid were measured. MATERIALS AND METHODS: Four users conducted 180 tests of tourniquet performance in eight glove groups compared with bare hands as a control. RESULTS: Among tests, 99% (n = 179) had favorable results for each of the following: effectiveness (i.e., bleeding control), distal pulse stoppage, and tourniquet placement at the correct site. However, only 90% of tests ended with a satisfactory result, which is a composite outcome of aggregated metrics if all (patient status is stable, tourniquet placement is good, and pressure is good) are satisfactory. Of 18 unsatisfactory results, 17 (94%) were due to pressure problems. Most of the variance of the majority of continuous metrics (time to determination of bleeding control, trial time, overall time, pressure, and blood loss) could be attributed to the users (62%, 55%, 61%, 8%, and 68%, respectively). Glove effects impaired and slowed performance; three groups (cold gloves layered under mittens, mittens, and cold gloves) consistently had significant effects and five groups (examination gloves, flight gloves, leather gloves, glove liners, and glove liners layered under leather gloves) did not. For time to bleeding control and blood loss, performance using these same three glove groups had worse results compared with bare hands by 26, 18, and 17 seconds and by 188, 116, and 124mL, respectively. Device effects occurred only with continuous metrics and were often dominated by user effects. CONCLUSION: In simulated first aid with tourniquets used to control bleeding, users had major effects on most performance metrics. Glove effects were significant for three of eight glove types. Tourniquet device effects occurred only with continuous metrics and were often dominated by user effects.

A Motion Analysis Protocol for Kinematic Assessment of Poly-Articulated Prosthetic Hands With Cosmetic Gloves.

To provide upper-limb amputees with devices that best fit their needs and to test innovative solutions, it is necessary to quantitatively appraise a device performance with rigorous measurement methods. The aim of this work was to define an optimal motion analysis protocol, suitable for optoelectronic systems, to measure the kinematics of poly-articulated hands even when covered by a cosmetic glove. This is a fundamental aspect, because gloves can decrease device speed and range of motion and, ultimately, patients' acceptance of the artificial limb. In this work, different mathematical models of the joints and marker-sets for motion analysis were conceived. A regression model to choose a reduced marker-set for studying the hand performance with different cosmetic glove models was developed. The proposed approaches for finger motion analysis were experimentally tested on the index finger of the i-Limb, a commercial myoelectric poly-articulated prosthetic hand, but the results can be easily extended to the whole hand and to other poly-articulated prosthetic hands. The methods proposed for the performance analysis of prosthetic hands points out that the cosmetic gloves imply a reduction of the finger flexion/extension (F/E) angles and of the motion velocity. This draws attention to the need for performing independent cyclic tests on commercial products with various cosmetic solutions to better guide component selection.

Compliance with occupational exposure risk management procedures in a dental school setting.

Background The Dental Institute at King's College London has recently implemented changes focusing on infection control, including safety needle provision, personal protective equipment campaigns, mandatory lectures and formal assessment for students. We explored the effect of these changes over a five-year period.Methods We observed 49 clinical consultations in 2010 and 50 in 2014, examining clinician attire, personal protective equipment, dental operatory management, sharps hazards and aseptic technique.Results One hundred percent of operators wore gloves, apron and masks, 94% wore eye protection, 98% had uncovered wrists and 88% had tidy hair. Ninety-four percent wore safe shoes, 86% were of appropriate material, and 70-82% demonstrated correct zoning technique. Safe sharps bin placement improved from 78% to 100%, 92% were not overfilled, and 96% were free from protruding items. Sixty-eight percent of bays were appropriately barrier wrapped, 78-88% were kept tidy and 96% were free of items that could have been disposed of immediately following use. Ninety to ninety-eight percent of ultrasonic tips and 64% of burs were removed from handpieces when not in use.Conclusion Dental healthcare workers are at risk of significant occupational exposures, which can be minimised by technological advances, implementation of best practice guidelines, optimisation of the clinical working environment and reinforcement of infection control policy.

Development of an Economical Method to Reduce the Extractable Latex Protein Levels in Finished Dipped Rubber Products.

Natural rubber latex (NRL) allergy is caused by the extractable latex proteins in dipped rubber products. It is a major concern for the consumers who are sensitive to the allergenic extractable proteins (EP) in products such as NRL gloves. Objective of this research was to develop an economical method to reduce the EP in finished dipped NRL products. In order to reduce the EP levels, two natural proteases, bromelain from pineapple and papain from papaya, were extracted and partially purified using (NH4)2SO4. According to the newly developed method, different glove samples were treated with a 5% solution of each partially purified enzyme, for 2 hours at 60°C. Residual amounts of in treated samples were quantified using the modified Lowry assay (ASTM D5712-10). Bromelain displayed a 54 (±11)% reduction of the EP from the dipped rubber products, whereas it was 58 (±8)% with papain. These results clearly indicate that the selected natural proteases, bromelain, and papain contribute significantly towards the reduction of the total EP in finished NRL products. Application of bromelain enzyme for the aforementioned purpose has not been reported up to date, whereas papain has been used to treat raw NRL towards reducing the EP.

Assessment of Healthcare Worker Protocol Deviations and Self-Contamination During Personal Protective Equipment Donning and Doffing.

OBJECTIVE To evaluate healthcare worker (HCW) risk of self-contamination when donning and doffing personal protective equipment (PPE) using fluorescence and MS2 bacteriophage. DESIGN Prospective pilot study. SETTING Tertiary-care hospital. PARTICIPANTS A total of 36 HCWs were included in this study: 18 donned/doffed contact precaution (CP) PPE and 18 donned/doffed Ebola virus disease (EVD) PPE. INTERVENTIONS HCWs donned PPE according to standard protocols. Fluorescent liquid and MS2 bacteriophage were applied to HCWs. HCWs then doffed their PPE. After doffing, HCWs were scanned for fluorescence and swabbed for MS2. MS2 detection was performed using reverse transcriptase PCR. The donning and doffing processes were videotaped, and protocol deviations were recorded. RESULTS Overall, 27% of EVD PPE HCWs and 50% of CP PPE HCWs made ≥1 protocol deviation while donning, and 100% of EVD PPE HCWs and 67% of CP PPE HCWs made ≥1 protocol deviation while doffing (P=.02). The median number of doffing protocol deviations among EVD PPE HCWs was 4, versus 1 among CP PPE HCWs. Also, 15 EVD PPE protocol deviations were committed by doffing assistants and/or trained observers. Fluorescence was detected on 8 EVD PPE HCWs (44%) and 5 CP PPE HCWs (28%), most commonly on hands. MS2 was recovered from 2 EVD PPE HCWs (11%) and 3 CP PPE HCWs (17%). CONCLUSIONS Protocol deviations were common during both EVD and CP PPE doffing, and some deviations during EVD PPE doffing were committed by the HCW doffing assistant and/or the trained observer. Self-contamination was common. PPE donning/doffing are complex and deserve additional study. Infect Control Hosp Epidemiol 2017;38:1077-1083.