Aflatoxin exposure may not play a role in liver cancer development in Mongolia.

BACKGROUND/AIMS: The incidence of hepatocellular carcinoma (HCC) in Mongolia is growing at an alarming rate. Traditional dried food was suggested as the major reason for high HCC numbers, due to possible aflatoxin contamination during manufacturing. We thus aimed to measure aflatoxin concentrations in Mongolian food samples. METHODS: Samples of traditional Mongolian food ('aaruul', dried meat, and dried noodles; in total 11 samples) were collected and shipped to Germany. The food samples were analyzed for aflatoxins by extraction, immunoaffinity purification, and subsequent HPLC with fluorescence detection. RESULTS: The traditional Mongolian food samples did not contain any detectable amounts of aflatoxin. CONCLUSION: Since Mongolian food does not contain aflatoxins, the cause for the increasing HCC incidence in Mongolia is probably due to a high prevalence of viral hepatitides. Further studies to identify the reason for this development are warranted.

Can the adenosine triphosphate (ATP) bioluminescence assay be used as an indicator for hospital cleaning? - A pilot study.

Background: In hospital cleaning, there is currently no standard for uniform monitoring of surface cleaning, either in Germany or internationally. One possibility for monitoring is the use of so-called objective methods for checking cleaning performance (e.g. fluorescence or adenosine triphosphate (ATP) method). Aim: The aim of the study was to monitor and evaluate the implementation of the adenosine triphosphate (ATP) bioluminescence assay as a cleaning indicator in everyday hospital cleaning, in order to verify its utility and effectiveness. Methods: In three phases, five frequently touched surfaces were examined with the ATP bioluminescence assay at different time points. 846 measurements were performed on the dermatology ward of a university hospital (phase 1), 1,350 measurements were performed on five different wards of the university hospital (phase 2), and 1,044 measurements were performed on five wards of another large hospital (phase 3). For this purpose, one structurally old and one structurally new ward as well as an intensive care unit (ICU), an outpatient clinic and a radiology department were selected for phases 2 and 3. Results: With the ATP bioluminescence method, we were able to demonstrate a reduction in values after cleaning: before cleaning mean of ATP, 907 relative light units (RLU) (95% confidence interval [CI] 777; 1,038); after cleaning mean=286 RLU (CI=233; 495) (phase 1) and by intervention (five hours after daily cleaning mean=360 RLU (CI=303; 428); five hours after daily cleaning and two additional cleanings mean=128 RLU (CI=107; 152) (phase 3). The ATP values increased five hours after cleaning in phases 1 and 2, and eight hours after cleaning in phase 3. The structurally old wards had the highest ATP content, the ICU and the radiology department, among others, the lowest. In all phases, door handles showed both a reduction after cleaning or intervention and a subsequent increase in ATP values. Chair armrests, examination tables and door handles had high ATP values overall. Conclusion: The study shows ward differences both for cleaning effects and for the soiling characteristics of surfaces during the course of the day. In addition, it demonstrates the benefit of intermediate cleaning twice a day. It is noteworthy that structurally old stations and older inventory were more heavily soiled and, in some cases, more difficult to clean. The results show that the ATP bioluminescence method is suitable for detecting cleaning effects and can be used in everyday clinical practice for simple cleaning monitoring. Furthermore, it enables the detection of risk surfaces and easy-to-clean surfaces with significant re-soiling.

Two fatal cases of plague after consumption of raw marmot organs.

Marmots are an important reservoir of Yersinia pestis and a source of human plague in Mongolia. We present two fatal cases of plague after consumption of raw marmot organs and discuss the distribution of natural foci of Y. pestis in Mongolia.

Children and adolescents in the CoVid-19 pandemic: Schools and daycare centers are to be opened again without restrictions. The protection of teachers, educators, carers and parents and the general hygiene rules do not conflict with this.

In the opinion of the medical societies of hygiene and pediatrics undersigning the present statement, the analyses published to date regarding transmission of SARS-CoV-2 and the course of CoVid-19 show that children play a much less significant role in the spread of the virus than do adults. According to the findings available to date, not only do children and adolescents less frequently fall ill with CoVid-19, they also generally become less severely ill than do adults. The vast majority of infections in children and adolescents are asymptomatic or oligosymptomatic. Even the first analyses from China demonstrated that children and adolescents play a subordinate role in the transmission of the virus - not only to other children and adolescents, but also to adults. Taking into account regional infection rates and available resources, daycare centers, kindergartens and elementary schools promptly should be reopened. For children, this should be possible without excessive restrictions, such as clustering into very small groups, implementation of barrier precautions, maintaining appropriate distance from others or wearing masks. A factor more decisive than individual group size is the issue of sustaining the constancy of respective group members and the avoidance of intermixing. Children can be taught basic rules of hygiene such as handwashing and careful hygiene behavior when coming into contact with others during mealtimes and/or when using sanitary facilities. Independent of the prevention measures implemented for children and adolescents, the protection of teachers, educators and caregivers is crucial, (e.g., the maintenance of appropriate distance from others, use of medical masks, situation-dependent hand disinfection, when necessary, supported by regular pool testing). Children over the age of 10 and adolescents up to school graduation age are more capable of actively understanding and conforming to specific hygiene rules. For this group, maintaining appropriate distance from others (1.5 meters), wearing a mouth-and-nose protection (whenever they are not sitting in their assigned classroom seats) and consistent education regarding the basic rules of infection prevention may provide increased options for normalizing teaching activities. Children and adolescents suspected of infection with SARS-CoV-2 should be tested immediately in order to either confirm or rule out such an infection. Evidence of individual infections in children or students must not automatically lead to the closure of the entire daycare center or school. A detailed analysis of the chain of infection is a prerequisite for a balanced approach to infection control. The opening of schools and children's facilities should be accompanied by specifically structured, model surveillance studies that further clarify outstanding questions about infectious disease events and hygiene control. These prospective, concomitant examinations will be essential for the purpose of evaluating and verifying the effectiveness of the required hygiene measures.

Air quality in the operating room: Surgical site infections, HVAC systems and discipline - position paper of the German Society of Hospital Hygiene (DGKH).

In recent years, there has been an ongoing discussion about the value of laminar airflow (LAF=low turbulence displacement ventilation) in the operating room for prevention of surgical site infections (SSI). Some publications, e.g., from the WHO, issued the demand to no longer build LAF ceilings in operating rooms. The present statement deals critically with this position and justifies the use of LAF ceilings in different ways: Many of the papers cited by the WHO and others for the case against LAF do not provide reliable data.The remaining studies which might be used for answering the question give quite different results, also in favor of LAF.The size of the LAF ceiling in many studies is not given or mostly too small in comparison to actual technical requirements.LAF in different countries can mean quite different techniques (e.g., the US in comparison to Germany) so that the results of studies that do not take this into account may not be comparable.LAF has positive effects in terms of reducing particulate and bacterial load, associated with increased airflow in the surgical working area. A reduction of carcinogenic substances in the air may also be assumed, which would increase workers' safety. Thus, this paper recommends building LAF ceilings in the future as well, depending on the operations intended. Further, this paper gives an overview of possible reasons for surgical site infections and highlights the importance of discipline in the operating theatre.

Influence of air cooling units on air quality--a pilot project.

Air cooling units are said to pose a health risk to humans because of residual water and biological contamination. We measured particles 0.5 and 5 microm, ultrafine particles and bacterial counts near the outlet of 38 air cooling units and at the corresponding workplaces. Control measurements were performed in 17 rooms without air cooling units. There was no difference between bacterial counts measured near the outlet, at the typical workplaces and in control rooms. Measured bacterial counts near the outlet were between 15 and 950 cfu/m(3) (median 150), at the typical workplaces between 20 and 1685 cfu/m(3) (median 213) and in control rooms between 75 and 940 cfu/m(3) (median 240). Concentrations of particles and ultrafine particles were less in rooms with air cooling units than in control rooms. Thus, we could not find an impairment of air quality by air cooling units in our study. These results should be tested again in a greater study, primarily in another building than a hospital.

Monitoring of endoscope reprocessing with an adenosine triphosphate (ATP) bioluminescence method.

Background: The arising challenges over endoscope reprocessing quality proposes to look for possibilities to measure and control the process of endoscope reprocessing. Aim: The goal of this study was to evaluate the feasibility of monitoring endoscope reprocessing with an adenosine triphosphate (ATP) based bioluminescence system. Methods: 60 samples of eight gastroscopes have been assessed from routine clinical use in a major university hospital in Germany. Endoscopes have been assessed with an ATP system and microbial cultures at different timepoints during the reprocessing. Findings: After the bedside flush the mean ATP level in relative light units (RLU) was 19,437 RLU, after the manual cleaning 667 RLU and after the automated endoscope reprocessor (AER) 227 RLU. After the manual cleaning the mean total viable count (TVC) per endoscope was 15.3 CFU/10 ml, and after the AER 5.7 CFU/10 ml. Our results show that there are reprocessing cycles which are not able to clean a patient used endoscope. Conclusion: Our data suggest that monitoring of flexible endoscope with ATP can identify a number of different influence factors, like the endoscope condition and the endoscopic procedure, or especially the quality of the bedside flush and manual cleaning before the AER. More process control is one option to identify and improve influence factors to finally increase the overall reprocessing quality, best of all by different methods. ATP measurement seems to be a valid technique that allows an immediate repeat of the manual cleaning if the ATP results after manual cleaning exceed the established cutoff of 200 RLU.

Laminar air flow provides high air quality in the operating field even during real operating conditions, but personal protection seems to be necessary in operations with tissue combustion.

We measured bacterial and particle concentrations at the level of operative fields during 105 operation procedures under laminar air flow conditions. Measured concentrations were at least a factor of 20 lower than in comparable rooms without ultra-clean air and laminar air flow. Kind of operation (septic/aseptic), number of participating persons and quantity of talking seem to have less influence on air quality than presumed, single use cover improves the air quality. The number of ultra-fine and small particles was dramatically increased when tissue was coagulated during operation. This may pose health risks to surgeons and nurses, needs risk assessment and decisions about personal protection.

One-day point prevalence of emerging bacterial pathogens in four secondary and five tertiary care German hospitals - results from a pilot study of the German Society for Hospital Hygiene (Deutsche Gesellschaft für Krankenhaushygiene, DGKH).

OBJECTIVE: Data on the prevalence of emerging bacterial pathogens like extended-spectrum-lactamase-building (ESBL) Gram negative organisms, multiresistant Pseudomonas and Acinetobacter species or toxin-building Clostridium difficile in German hospitals are sparse. To provide data for different regions in Germany, a one-day point prevalence study with five tertiary care hospitals and four secondary care hospitals was conducted on the 10(th) of February 2010. METHOD: For participating hospitals, the level of care (primary/secondary/tertiary), staffing with infection prevention personnel, availability of a MRSA-screening, microbiological support and the prevalence of five emerging bacterial pathogens in intensive care, surgical and medical wards was assessed by questionnaire. RESULTS: Overall, 3411 patients were included. In tertiary hospitals, the following prevalences were given: MRSA 1.8%, ESBL E. coli 0.45%, ESBL Klebsiella spp. 0.41%, multiresistant Pseudomonas 0.53%, multiresistant Acinetobacter species 0.15%, VRE 0.49% und Clostridium difficile 1.01%. In secondary hospitals, as prevalences resulted for MRSA 3.48%, ESBL E. coli 0.4%, ESBL Klebsiella spp. 0.4%, multiresistant Pseudomonas 0%, multiresistant Acinetobacter species 0%, VRE 0.13% und Clostridium difficile 1.34%. DISCUSSION: The prevalence of MRSA found is comparable to other prevalence studies published in the last years, but remarkably higher than reported by the German National Surveillance System (KISS). As no prevalence data for other pathogens as MRSA could be found, only data from the ITS-KISS are available for comparison. Again, the prevalences found in the present study are much higher than reported by the KISS. Whether this is by chance or indicates a systematic underreporting in the KISS remains unclear. CONCLUSION: The results from this one day point prevalence study show that prevalences of emerging bacterial pathogens differ markedly between regions, departments and hospitals. This can be explained by regional, methodical and other difference associated with the level of care provided by these hospitals. Still, the prevalences found fit well to other prevalence studies from the last years but are remarkably higher than to be expected by the KISS. As questionnaire-based one-day prevalence studies have been shown to be inexpensive and feasible, such studies, using a fixed day and protocol, should be extendedly used in the future to collect representative data for Germany. By such initiatives, scientific societies as the DGKH can take part in collecting valuable epidemiological data of emerging bacterial pathogens.

Refurbishment works in a hospital during normal operation.

BACKGROUND: Construction and renovation work in hospitals pose risks of fungal airborne infections for immunosuppressed patients. If possible, reconstruction work will be postponed to periods without patient treatment. However, in many situations urgent damage demands immediate refurbishment works before the transferring of patients to other wards or closure of wards is possible. Reported here are infection control related measures and implemented procedures after two incidents of water damage which occurred on a surgical ward and an intensive care unit at the University hospital of Essen. METHODS: Between January and April 2009 and between September and October 2009, respectively, concentration of air-borne particles and number of viable fungi were measured at two surgical wards and one ICU. Preventive Infection Control Measures included erection of protective walls and HEPA filtration of air from the renovation area. RESULTS: During the renovation work on the surgical ward concentrations of moulds and particles ≥5 µm were significantly higher on the left side of the renovation area than on the right side (p=0.036 and p<0.001). Concentrations of particles ≥1 µm and particles ≥5 µm on both sides of the renovation area were significantly increased when compared with the control ward on the same floor but not when compared with the control ward on the other floor. Particles of all size were significantly elevated on the ICU during the renovation work. Aspergillus fumigatus could neither be cultured of the air of cardiac surgery intensive care unit nor of the intermediate care unit (control ward). During renovation works there was no nosocomial mould infection of patients treated on the two wards. CONCLUSION: Provided that the renovation area is tightly insulated from the areas of patient care on a ward, closure does not seem to be necessary during renovation works because variation of airborne fungi is similar to that of outdoor or control air. However a multidisciplinary team should be established. This team should perform risk assessment and determine necessary protective measures before starting any construction, renovation or maintenance work in health care settings.

What is the use? An international look at reuse of single-use medical devices.

Reuse of single-use devices is common in most countries worldwide. We provide an overview of the issue from an international perspective. In many developing and transitional countries reuse of cheap single-use devices (needles, syringes, surgical gloves) is common leading to large numbers of unsafe interventions, specifically injections and, as a consequence, infection with hepatitis B, C or HIV. There are various reasons for reuse: limited resources, insufficient knowledge of healthcare workers and the belief of patients that injection is more beneficial than oral medication. Reuse of cheap single-use devices should cease and both medical staff and the public should be informed about potential safety risks associated with injection. In developed countries, reuse of single-use items is less common but may include expensive technical products. Reuse is regulated in many countries (e.g. US, Canada, some European countries) demanding ethical and legal considerations, high standards of reprocessing and training of staff, risk assessment, management and validation of reprocessing. Well regulated reprocessing can decrease the number of single-use devices reprocessed. In developing as well as developed countries, a decision to reprocess single-use devices should only be made after a critical reflection of advantages and disadvantages.

ATP measurement as method to monitor the quality of reprocessing flexible endoscopes.

Insufficient performance of cleaning and disinfection of flexible endoscopes can pose an infection risk to patients. Actually quality of reprocessing is checked by performing microbiological cultures. Unfortunately, their results are not available on the same day so that more rapid methods are desirable. We compared the ATP (adenosine triphosphate) bioluminescence for hygiene checking of the reprocessing procedures of 108 flexible endoscopes with routine microbiological culture technics. Sensitivity and specifity of ATP bioluminescence was calculated. 28 endoscopes showed bacterial growth of at least one sample. Depending on the applied threshold of bioluminescence between 67 and 28 endoscopes were positive. Sensitivity varied between 0.46 and 0.75 and specifity between 0.43 and 0.81. ATP bioluminescence does not replace routine microbiologic methods but it can indicate the need of immediate check of reprocessing.