An outbreak of SARS-CoV-2 in a public-facing office in England.

BACKGROUND: An outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with an attack rate of 55% (22/40 workers) occurred at a public-facing office in England from August to September 2021. Published evidence regarding outbreaks in office workplaces remains limited. AIMS: To describe an investigation of workplace- and worker-related risk factors following an outbreak of SARS-CoV-2 in a public-facing office. METHODS: The COVID-19 (coronavirus disease 2019) Outbreak Investigation to Understand Transmission (COVID-OUT) study undertook an investigation of the outbreak. This included surface sampling, occupational environmental assessment, molecular and serological testing of workers, and detailed questionnaires. RESULTS: Despite existing COVID-19 control measures, surface sampling conducted during a self-imposed 2-week temporary office closure identified viral contamination (10/60 samples, 17% positive), particularly in a small, shared security office (6/9, 67% positive) and on a window handle in one open-plan office. Targeted enhanced cleaning was, therefore, undertaken before the office reopened. Repeat surface sampling after this identified only one positive (2%) sample. Ventilation was deemed adequate using carbon dioxide monitoring (typically ≤1000 ppm). Twelve workers (30%) responded to the COVID-OUT questionnaire, and all had been vaccinated with two doses. One-third of respondents (4/12) reported direct physical or close contact with members of the public; of these, 75% (3/4) reported a divider/screen between themselves and members of the public. CONCLUSIONS: The results highlight the potential utility of surface sampling to identify SARS-CoV-2 control deficiencies and the importance of evolving, site-specific risk assessments with layered COVID-19 mitigation strategies.

Probability of clinically significant hearing recovery following salvage intratympanic steroids for sudden sensorineural hearing loss in the 'real world'.

OBJECTIVE: This study aimed to determine the probability of hearing recovery in patients with idiopathic sudden sensorineural hearing loss following salvage intratympanic steroids. METHOD: A retrospective review of all patients receiving salvage intratympanic steroid injections for idiopathic sudden sensorineural hearing loss was performed (January 2014 to December 2019). Twenty-two patients were identified, of whom 15 met inclusion criteria. Pre- and post-treatment audiograms were compared with the unaffected ear. Hearing recovery was categorised based on American Academy of Otolaryngology Head and Neck Surgery criteria. RESULTS: Only 1 patient out of 15 (6.7 per cent) made a partial recovery, and the remainder were non-responders. The median duration of time between symptom onset and first salvage intratympanic steroid treatment was 52 days (range, 14-81 days). No adverse reactions were observed. CONCLUSION: 'Real world' patients with idiopathic sudden sensorineural hearing loss present differently to those in the literature. Sudden sensorineural hearing loss should be diagnosed with care and intratympanic steroid injections initiated early if considered appropriate. Patients should make an informed decision on treatment based on prognostic factors and local success rates.

Hazard Group 3 agent decontamination using hydrogen peroxide vapour in a class III microbiological safety cabinet.

AIMS: This study investigated the efficacy of hydrogen peroxide vapour (HPV) at inactivating hazard group 3 bacteria that have been presented dried from their growth medium to present a realistic challenge. METHODS AND RESULTS: Hydrogen peroxide vapour technology (Bioquell) was used to decontaminate a class III microbiological safety cabinet containing biological indicators (BIs) made by drying standard working suspensions of the following agents: Bacillus anthracis (Ames) spores, Brucella abortus (strain S99), Burkholderia pseudomallei (NCTC 12939), Escherichia coli O157 ST11 (NCTC 12079), Mycobacterium tuberculosis (strain H37Rv) and Yersinia pestis (strain CO92) on stainless steel coupons. Extended cycles were used to expose the agents for 90 min. The HPV cycle completely inactivated B. anthracis spores, B. abortus, B. pseudomallei, E. coli O157 and Y. pestis when BIs were processed using quantitative and qualitative methods. Whilst M. tuberculosis was not completely inactivated, it was reduced by 4 log10 from a starting concentration of 106 colony-forming units. CONCLUSIONS: This study demonstrates that HPV is able to inactivate a range of HG3 agents at high concentrations with associated organic matter, but M. tuberculosis showed increased resistance to the process. SIGNIFICANCE AND IMPACT OF THE STUDY: This publication demonstrates that HPV can inactivate HG3 agents that have an organic load associated with them. It also shows that M. tuberculosis has higher resistance to HPV than other agents. This shows that an appropriate BI to represent the agent of interest should be chosen to demonstrate a decontamination is successful.

Drumming-associated anthrax incidents: exposures to low levels of indoor environmental contamination.

Two fatal drumming-related inhalational anthrax incidents occurred in 2006 and 2008 in the UK. One individual was a drum maker and drummer from the Scottish Borders, most likely infected whilst playing a goat-skin drum contaminated with Bacillus anthracis spores; the second, a drummer and drum maker from East London, likely became infected whilst working with contaminated animal hides.We have collated epidemiological and environmental data from these incidents and reviewed them alongside three similar contemporaneous incidents in the USA. Sampling operations recovered the causative agent from drums and drum skins and from residences and communal buildings at low levels. From these data, we have considered the nature of the exposures and the number of other individuals likely to have been exposed, either to the primary infection events or to subsequent prolonged environmental contamination (or both).Despite many individual exposures to widespread low-level spore contamination in private residences and in work spaces for extended periods of time (at least 1 year in one instance), only one other individual acquired an infection (cutaneous). Whilst recognising the difficulty in making definitive inferences from these incidents to specific residual contamination levels, and by extending the risk to public health, we believe it may be useful to reflect on these findings when considering future incident management risk assessments and decisions in similar incidents that result in low-level indoor contamination.

Sampling and inactivation of wet disseminated spores from flooring materials, using commercially available robotic vacuum cleaners.

AIMS: Four commercially available robotic vacuum cleaners were assessed for sampling efficiency of wet disseminated Bacillus atrophaeus spores on carpet, polyvinyl chloride (PVC) and laminate flooring. Furthermore, their operability was evaluated and decontamination efficiency of one robot was assessed, using a sodium hypochlorite solution. METHODS AND RESULTS: In an environmental chamber, robots self-navigated around 4 m2 of flooring containing a single contaminated 0·25 m2 tile (c. 104 spores per cm2 ). Contamination levels at predetermined locations were assessed by macrofoam swabs (PVC and laminate) or water soluble tape (carpet), before and after sampling. Robots were dismantled postsampling and spore recoveries assessed. Aerosol contamination was also measured during sampling. Robot sampling efficiencies were variable, however, robots recovered most spores from laminate (up to 17·1%), then PVC and lastly the carpet. All robots spread contamination from the 'hotspot' (all robots spread <0·6% of the contamination to other areas) and became surface contaminated. Spores were detected at low levels during air sampling (<5·6 spores per litre). Liquid decontamination inactivated 99·1% of spores from PVC. CONCLUSIONS: Robotic vacuum cleaners show promise for both sampling and initial decontamination of indoor flooring. SIGNIFICANCE AND IMPACT OF THE STUDY: In the event of a bioterror incident, e.g. deliberate release of Bacillus anthracis spores, areas require sampling to determine the magnitude and extent of contamination, and to establish decontamination efficacy. In this study, we investigate robotic sampling methods against high concentrations of bacterial spores applied by wet deposition to different floorings, contamination spread to other areas, potential transfer of spores to the operators and assessment of a wet vacuum robot for spore inactivation. The robots' usability was evaluated and how they can be employed in real life scenarios. This will help to reduce the economic cost of sampling and the risk to sampling/decontamination teams.

Persistence of influenza on surfaces.

BACKGROUND: Close contact transmission (either direct or large droplet/droplet nuclei) is considered the main driver of influenza outbreaks but there is limited information regarding the role of fomites in transmission. AIM: To investigate the surface stability of influenza strains and thereby the role of fomites in transmission. METHODS: The viability and quantitative reverse transcription-polymerase chain reaction (qt-RT-PCR) signal of five influenza strains (A/PR/8/34/H1N1, A/Cal/7/09/H1N1, A/Cal/4/09/H1N1, A/Sol/54/06/H1N1, and A/Bris/59/07/H1N1) seeded on to three surfaces (cotton, microfibre, and stainless steel) were assessed over time. Coupons of material were seeded with 10µL of a 106-108pfu/mL suspension of cell culture-derived virus stock supplemented with 0.3% bovine serum albumin. Coupons were assayed by plaque assay and qt-RT-PCR at 1, 24h, and weekly for seven weeks using a vortex-mixing elution method. FINDINGS: Viable virus was detected from coupons for up to two weeks (stainless steel) and one week (cotton and microfibre), whereas detection of viruses by PCR was made for the entire seven-week study period. No strain differences were found. Ninety-nine percent reduction values (as a function of the seeding stock) were determined to be 17.7h for cotton (R2=0.86), 34.3h for microfibre (R2=0.80), and 174.9h for stainless steel (R2=0.98). CONCLUSION: Viable influenza was recovered from surfaces for up to two weeks. By contrast, influenza could be detected by PCR for more than seven weeks. These results have important implications for determining infection control protocols, cleaning regimes and sampling methods in healthcare settings.

Is there an infection risk when playing drums contaminated with Bacillus anthracis?

AIMS: This study aims to investigate the aerosol release of a Bacillus anthracis spore surrogate from two different types of drums while playing, by; (i) quantifying the number of spores aerosolized during playing; (ii) investigating spore recovery from drums over long time periods, and (iii) measuring differences between (i) and (ii) for two different drums types. METHODS AND RESULTS: Two African drums were contaminated with Bacillus atrophaeus spores then sampled and played by hand over a number of days. During playing three air samplers were used to collect any aerosols generated, the choice of air samplers (Casella slit sampler, all glass impinger and six-stage Andersen sampler) allowed for characterization of the aerosols produced. CONCLUSIONS: Spore contamination of drums was found to be long-lasting with a small percentage of the spores being detached and aerosolized during drumming. The results of these studies have been used for a quantitative risk assessment of playing drums contaminated with B. anthracis spores. SIGNIFICANCE AND IMPACT OF THE STUDY: This demonstrates that the risk of inhalational exposure while playing drums contaminated with the levels linked to the US and UK cases is very low and that the resulting cases of inhalational anthrax can be explained by being unusual events involving highly susceptible persons.

Responding to biological incidents--what are the current issues in remediation of the contaminated environment?

Since 2000 there have been a number of biological incidents resulting in environmental contamination with Bacillus anthracis, the causative agent of anthrax. These incidents include the US anthrax attacks in 2001, the US and UK drumming incidents in 2006-2008 and more recently, anthrax contamination of heroin in 2009/2010 and 2012/2013. Remediation techniques used to return environments to normal have varied between incidents, with different decontamination technologies being employed. Many factors need to be considered before a remediation strategy or recovery option can be implemented, including; cost, time (length of application), public perception of risk, and sampling strategies (and results) to name a few. These incidents have demonstrated that consolidated guidance for remediating biologically contaminated environments in the aftermath of a biological incident was required. The UK Recovery Handbook for Biological Incidents (UKRHBI) is a project led by Public Health England (PHE), formerly the Health Protection Agency (HPA) to provide guidance and advice on how to remediate the environment following a biological incident or outbreak of infection, and is expected to be published in 2015.

Investigation of healthcare-acquired infections associated with Pseudomonas aeruginosa biofilms in taps in neonatal units in Northern Ireland.

BACKGROUND: In December 2011 and early 2012 four neonates died from Pseudomonas aeruginosa bacteraemia in hospitals in Northern Ireland. AIM: To assess whether P. aeruginosa was associated with the neonatal unit taps and whether waterborne isolates were consistent with patient isolates. METHODS: Thirty taps and eight flow straighteners from the relevant hospitals were categorized and dismantled into 494 components and assessed for aerobic colony and P. aeruginosa counts using non-selective and selective agars. P. aeruginosa isolates were typed by variable number tandem repeat (VNTR) analysis. Selected tap components were subjected to epifluorescence and scanning electron microscopy to visualize biofilm. FINDINGS: The highest P. aeruginosa counts were from the flow straighteners, metal support collars and the tap bodies surrounding these two components. Complex flow straighteners had a significantly higher P. aeruginosa count than other types of flow straighteners (P < 0.05). Highest aerobic colony counts were associated with integrated mixers and solenoids (P < 0.05), but there was not a strong correlation (r = 0.33) between the aerobic colony counts and P. aeruginosa counts. Representative P. aeruginosa tap isolates from two hospital neonatal units had VNTR profiles consistent with strains from the tap water and infected neonates. CONCLUSION: P. aeruginosa was predominantly found in biofilms in flow straighteners and associated components in the tap outlets and was a possible source of the infections observed. Healthcare providers should be aware that water outlets can be a source of P. aeruginosa contamination and should take steps to reduce such contamination, monitor it and have strategies to minimize risk to susceptible patients.

Whispering gallery mode diamond resonator.

We demonstrate a nearly spherical diamond whispering gallery mode resonator with quality factor (Q factor) Q=2.4×10(7) limited by material loss approaching α=4×10(-3) cm(-1). The Q factor does not depend on the wavelength: it is approximately the same at 1319 and 1550 nm. Resonators with this range of Q (<10 MHz at 1550 nm wavelength) are attractive for laser locking and stabilization. Applications such as stable compact optical comb generators as well as Raman optical frequency shifters will be feasible with further improvement of the material.

Low-temperature decontamination with hydrogen peroxide or chlorine dioxide for space applications.

The currently used microbial decontamination method for spacecraft and components uses dry-heat microbial reduction at temperatures of >110°C for extended periods to prevent the contamination of extraplanetary destinations. This process is effective and reproducible, but it is also long and costly and precludes the use of heat-labile materials. The need for an alternative to dry-heat microbial reduction has been identified by space agencies. Investigations assessing the biological efficacy of two gaseous decontamination technologies, vapor hydrogen peroxide (Steris) and chlorine dioxide (ClorDiSys), were undertaken in a 20-m(3) exposure chamber. Five spore-forming Bacillus spp. were exposed on stainless steel coupons to vaporized hydrogen peroxide and chlorine dioxide gas. Exposure for 20 min to vapor hydrogen peroxide resulted in 6- and 5-log reductions in the recovery of Bacillus atrophaeus and Geobacillus stearothermophilus, respectively. However, in comparison, chlorine dioxide required an exposure period of 60 min to reduce both B. atrophaeus and G. stearothermophilus by 5 logs. Of the three other Bacillus spp. tested, Bacillus thuringiensis proved the most resistant to hydrogen peroxide and chlorine dioxide with D values of 175.4 s and 6.6 h, respectively. Both low-temperature decontamination technologies proved effective at reducing the Bacillus spp. tested within the exposure ranges by over 5 logs, with the exception of B. thuringiensis, which was more resistant to both technologies. These results indicate that a review of the indicator organism choice and loading could provide a more appropriate and realistic challenge for the sterilization procedures used in the space industry.

Meticillin-resistant Staphylococcus aureus is more resistant to vaporized hydrogen peroxide than commercial Geobacillus stearothermophilus biological indicators.

BACKGROUND: Vaporized hydrogen peroxide (VHP) is increasingly used in the decontamination of hospital isolation rooms. Commercially available bioindicators, most frequently Geobacillus stearothermophilus spores, are used to assess the efficacy of the decontamination phase. Staphylococcus aureus, including meticillin-resistant S. aureus (MRSA), produce catalase, which breaks down VHP, therefore potentially making it resistant to the decontamination phase. AIM: This investigation was designed to assess the resistance of meticillin-resistant S. aureus to VHP in comparison with commercially available biological indicators loaded with spores. METHODS: Stainless steel indicators were prepared with the same loading of MRSA (NCTC 13142) as commercially available indicators of G. stearothermophilus (ATCC 7953) (∼3.1×10(6) spores) and both indicators were exposed to a vapour hydrogen peroxide cycle (750 ppm). At set time-points during the exposure period, indicators containing both organisms were removed for processing and enumeration to compare survivability. FINDINGS: During the exposure period the recovery of MRSA from the coupons was between 1.5 and 3.5 log(10) higher than the recovery of G. stearothermophilus spores (P<0.05). This greater resistance may be due to the production of catalase which could break down the hydrogen peroxide, resulting in a reduction of the effectiveness of VHP. CONCLUSION: These findings highlight that the reduction achieved with a commercially available biological indicator cannot always be extrapolated to other micro-organisms. It must be recognized that although gaseous decontamination is the final step of the decontamination process, pre-cleaning of surfaces must be carried out to reduce the microbial loading being exposed.

Hydrogen peroxide vapour decontamination of surfaces artificially contaminated with norovirus surrogate feline calicivirus.

BACKGROUND: Noroviruses are a leading cause of gastrointestinal disease and are of particular concern in healthcare settings such as hospitals. As the virus is reported to be environmentally stable, effective decontamination following an outbreak is required to prevent recurrent outbreaks. AIM: To investigate the use of hydrogen peroxide vapour to decontaminate a number of surfaces that had been artificially contaminated with feline calicivirus (FCV), a surrogate for norovirus. The surfaces tested were representative of those found in hospital wards. METHODS: FCV was used to contaminate materials representative of a hospital setting (stainless steel, glass, vinyl flooring, ceramic tile and PVC plastic cornering). The carriers were exposed to 30% (w/w) hydrogen peroxide vapour at 5-min intervals over 20 min, after which postexposure viral titres were measured. FINDINGS: Hydrogen peroxide vapour reduced the viral titre by 4 log(10) on all surfaces tested within 20 min of exposure. The reduction in viral titre took longest to achieve on stainless steel (20 min), and the quickest effect was seen on vinyl flooring (10 min). For glass, plastic and ceramic tile surfaces, the desired reduction in viral titre was seen within 15 min of exposure. Hydrogen peroxide vapour allows for large-scale decontamination of areas following outbreaks of infectious organisms. CONCLUSION: Hydrogen peroxide vapour is effective against FCV and is active on a range of surfaces. Therefore, it may represent a suitable decontamination system for use following a hospital outbreak of norovirus.

Aerosol survival of Staphylococcus epidermidis.

Recent studies have suggested that aerosol dispersal might play a role in the dissemination of meticillin-resistant Staphylococcus aureus (MRSA). Relatively little has been published about the ability of staphylococci to survive in aerosols. This study measured the survival of Staphylococcus epidermidis, a surrogate for S. aureus, in aerosols and investigated the effect of relative humidity on survival. We used a Goldberg drum to assess survival at relative humidities of <20%, 40-60%, 70-80% and >90%. We controlled for the effects of aerosol dilution and physical decay by comparing the recovery of S. epidermidis with that of the aerosol-stable spores of Bacillus atrophaeus, using the ratio of their recovery rates to estimate biological degradation of S. epidermidis over time. At all relative humidities investigated 13% [95% confidence interval (CI): 10.1-16.2%] of the initial aerosol was recovered after 5h (300 min). The mean percentage survival ratio (% S. epidermidis:% B. atrophaeus) after 5h was 47% (95% CI: 33.5-60.5%). Overlapping 95% CIs of mean percentage survival ratios at each humidity level indicated that humidity did not have a significant effect on the survival in aerosol form of S. epidermidis. Additional experiments indicated that S. epidermidis was recoverable after five days at 76% humidity. The sizes of particles within the bacterial aerosol were well within the respirable range (<2.1 µm). The survival of aerosolised S. epidermidis demonstrated in this study suggests that staphylococci have the potential for aerosol dissemination in hospitals.

Evaluation of hydrogen peroxide gaseous disinfection systems to decontaminate viruses.

This study assessed the efficacy of two commonly used gaseous disinfection systems against high concentrations of a resistant viral surrogate in the presence and absence of soiling. MS2 bacteriophage suspensions were dried on to stainless steel carriers and exposed to hydrogen peroxide vapour (HPV) and vapour hydrogen peroxide (VHP) gaseous disinfection systems. The bacteriophages were also suspended and dried in 10% and 50% of horse blood to simulate the virus being present in a spill of blood/bodily fluids in a hospital ward environment. Carriers were removed from the gaseous disinfectant at regular intervals into phosphate-buffered saline, vortexed and assayed using a standard plaque assay. The effectiveness of both the HPV and VHP systems varied with the concentration of the bacteriophage with HPV resulting in a 6log(10) reduction in 10 min at the lowest viral concentration [10(7) plaque-forming units (pfu)/carrier] and requiring 45 min at the highest concentration (10(9) pfu/carrier). For the VHP system a 30 min exposure period was required to achieve a 6log(10) reduction at the lowest concentration and 60-90 min for the highest concentration. The addition of blood to the suspension greatly reduced the effectiveness of both disinfectants. This study demonstrates that the effectiveness of gaseous disinfectants against bacteriophage is a function of the viral concentration as well as the degree of soiling. It highlights the importance of effective cleaning prior to gaseous disinfection especially where high concentration agents are suspended in body fluids to ensure effective decontamination in hospitals.

Laboratory methods for assessing vaccine potency retained in aerosol outputs from nebulizers: application to World Health Organization measles aerosol project.

BACKGROUND: Laboratory methods for measuring vaccine potency of nebulized aerosol are required to support clinical trials of measles aerosol vaccination. METHODS: Measles vaccine containing the Edmonston Zagreb virus strain was reconstituted in sodium fluoride as tracer and nebulized from three devices. Emitted aerosol was collected using an impinger. Aliquots were removed from the impinger chamber for vaccine virus plaque assay and for fluoride measurement to determine aerosol output. RESULTS: Vaccine potency retention results were adjusted to take into account the effect of aerosol output on estimates. Adjusted potency of nebulized vaccine ranged from 88% to 102%. CONCLUSIONS: New laboratory methods to measure aerosol vaccine potency retention were reliable and accurate. The results demonstrated that Edmonston Zagreb vaccine remains robust during aerosolisation and imply that this is a viable candidate for further evaluation in the measles aerosol project.