Transvaginal ultrasound probe contamination by the human papillomavirus in the emergency department

Reprocessing semicritical items: An overview and an update on the shift from HLD to sterilization for endoscopes

BACKGROUND

Semicritical medical devices are defined as items that come into contact with mucous membranes or nonintact skin (e.g., gastrointestinal endoscopes, endocavitary probes). Such medical devices require minimally high-level disinfection.

METHODS

Analyze the methods used to reprocess semicritical medical devices and identify methods and new technologies to reduce the risk of infection.

RESULTS

The reprocessing methods for semicritical medical devices is described as well as a shift from high-level disinfection to sterilization for lumened endoscopes.

CONCLUSIONS

Strict adherence to current guidelines and transition to sterilization for endoscopes is required as more outbreaks have been linked to inadequately disinfected endoscopes and other semicritical items than any other reusable medical devices.

Presence of HPV in prostate tissue from patients submitted to prostate biopsy

PURPOSE

Prostate cancer (PCa) is the second most frequent cancer among men in the Western population. Infections, such as the one caused by the human papillomavirus (HPV), have been shown to promote inflammation that can lead to the appearance of neoplasms. This study aimed to verify the presence of HPV in neoplastic and non-neoplastic prostate tissue in patients undergoing prostate biopsy and its possible relationship with PCa.

METHODS

Prostate tissue fragments were collected by prostate biopsy and subjected to polymerase chain reaction with primers for the HPV L1 gene to identify the presence of the virus.

RESULTS

Among 162 patients, 10 (6.2%) had HPV and in 152 (93.8%) HPV was not identified in prostate biopsies. HPV was detected in 7/95 (7.4%) of patients with PCa, in 2/55 (3.6%) of patients without PCa, and in no patient with an inconclusive diagnosis of PCa. There was no significant difference (p = 0.487) of HPV presence in the tissue of patients with PCa.

CONCLUSIONS

There were no significant levels of HPV L1 protein in prostate tissue. The findings suggest the absence of HPV oncogenic activity in the prostate tissue of patients with PCa.

Time-effectiveness and convenience of transvaginal ultrasound probe disinfection using ultraviolet vs chlorine dioxide multistep wipe system: prospective survey study

OBJECTIVES

To compare the efficiency, ease of use and user satisfaction of two methods of transvaginal ultrasound probe high-level disinfection: ultraviolet-C radiation (UV-C) and a chlorine dioxide multistep wipe system.

METHODS

This was a prospective survey study. UV-C units were introduced into a busy early pregnancy assessment service and compared with a multiwipe system for disinfection. Before seeing each patient, healthcare professionals (HCPs) measured with a stopwatch the time taken to complete a cycle of disinfection using either UV-C or chlorine dioxide multistep wipes and responded to a quick-response (QR) code-linked survey. Additional essential tasks that could be completed before seeing the next patient during probe disinfection were also documented. Using another QR code-linked survey, data on ease of use, satisfaction with the system used and preferred system were collected. The ease of use and satisfaction with the system were rated on a 0 to 10 Likert scale (0 poor, 10 excellent). A free-text section for comments was then completed.

RESULTS

Disinfection using UV-C (n = 331) was 60% faster than the chlorine dioxide multiwipe system (n = 332) (101 vs 250 s; P < 0.0001). A greater number of tasks were completed during probe disinfection when using UV-C, saving a further 74 s per patient (P < 0.0001). The HCPs using UV-C (n = 71) reported greater ease of use (median Likert score, 10 vs 3; P < 0.0001) and satisfaction (median Likert score, 10 vs 2; P < 0.0001) compared with those using the multiwipe system (n = 43). HCPs reported that the chlorine dioxide system was time-consuming and environmentally unfriendly, while the UV-C system was efficient and easy to use. Overall, 98% of the HCPs preferred using the UV-C system.

CONCLUSIONS

UV-C technology is more time-efficient and allows more essential tasks to be completed during disinfection. For a 4-h ultrasound list of 15 patients, the use of UV-C would save 55 min 45 s. HCPs found UV-C preferable and easier to use. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Infection Transmission Associated With Contaminated Ultrasound Probes: A Systematic Review

A systematic review of seven studies on infections related to contaminated ultrasound probes showed that the infections were related to a failure in the decontamination process of ultrasound devices used on immature skin of neonates in an intensive care unit and transesophageal echocardiography probes. Six of the studies involved outbreaks in patients who underwent transesophageal echocardiography either during or after surgery or as a part of treatment for a nonsurgical cardiac condition. The evidence shows links between the infection outbreaks and environmental contamination, lack of standardized ultrasound probe disinfection processes, inadequate storage, and lack of monitoring of probe integrity. When personnel addressed the deficiencies (eg, improving the disinfection process, cleaning the probes immediately after use, inspecting the probes for defects), the infections ceased. Personnel involved with the reprocessing of ultrasound probes should clean, disinfect, inspect, and store ultrasound probes in a manner that maintains device integrity and prevents contamination.

Inactivation of Polyomavirus SV40 as Surrogate for Human Papillomaviruses by Chemical Disinfectants

Human papillomaviruses (HPV) are non-enveloped DNA viruses infecting cutaneous and mucosal squamous epithelia. Sexually transmitted HPV-types that are carcinogenic to humans such as HPV16 can induce cervical and other anogenital cancers. Virus transmission through fomites such as inadequately disinfected gynecological equipment is a further potential transmission route. Since HPV cannot be easily grown in cell culture, polyomavirus SV40 has been used as a surrogate virus when testing the virucidal activity of chemical disinfectants. So far, studies that have compared the virucidal activity of different disinfectants against HPV and SV40 are lacking. Here, we evaluated the susceptibility of HPV16 pseudovirus and SV40 to seven active biocidal substances using quantitative suspension tests. Ethanol, glutaraldehyde (GTA), dodecyldipropylentriamin (DPTA), and ortho-phthalaldehydes (OPA) were able to reduce the infectivity of HPV16 pseudovirus >99.99% after 5 min. In contrast, isopropanol, peracetic acid (PAA), and quaternary ammonium compounds with alkylamines (QAC) only led to a slight or no reduction in infectivity. Concerning SV40, only GTA (60 min contact time), PAA, and OPA had virus-inactivating effects. In conclusion, the virucidal activity of three out of seven disinfectants tested was different for HPV16 pseudovirus and SV40. In this study, SV40 was shown to be a reliable surrogate virus for HPV when testing isopropanol-, GTA-, QAC-, and OPA-based disinfectants.

[Disinfection of transvaginal ultrasound probes-A current overview of methods and recommendations]

Disinfection of ultrasound probes, especially of transvaginal probes, has been under discussion during recent years and there have been several new regulations and recommendations as well as trends in the field of disinfection methods. This article provides a review and summary of the current state of knowledge.

Infectious titres of human papillomaviruses (HPVs) in patient lesions, methodological considerations in evaluating HPV infectivity and implications for the efficacy of high-level disinfectants

BACKGROUND

Recent publications from a single research group have suggested that aldehyde-based high-level disinfectants (HLDs), such as ortho-phthalaldehyde (OPA), are not effective at inactivating HPVs and that therefore, patients may be at risk of HPV infection from medical devices. These results could have significant public health consequences and therefore necessitated evaluation of their reproducibility and clinical relevance.

METHODS

We developed methods and used standardised controls to: (1) quantify the infectious levels of clinically-sourced HPVs from patient lesions and compare them to laboratory-derived HPVs, (2) evaluate experimental factors that should be controlled to ensure consistent and reproducible infectivity measurements of different HPV genotypes, and (3) determine the efficacy of select HLDs.

FINDINGS

A novel focus forming unit (FFU) infectivity assay demonstrated that exfoliates from patient anogenital lesions and respiratory papillomas yielded infectious HPV burdens up to 2.7 × 103 FFU; therefore, using 2.2 × 102 to 1.0 × 104 FFU of laboratory-derived HPVs in disinfection assays provides a relevant range for clinical exposures. RNase and neutralising antibody sensitivities were used to ensure valid infectivity measures of tissue-derived and recombinant HPV preparations. HPV infectivity was demonstrated over a dynamic range of 4-5 log10; and disinfection with OPA and hypochlorite was achieved over 3 to >4 log10 with multiple genotypes of tissue-derived and recombinant HPV isolates.

INTERPRETATION

This work, along with a companion publication from an independent lab in this issue, address a major public health question by showing that HPVs are susceptible to HLDs.

FUNDING

Advanced Sterilization Products; US NIH (R01CA207368, U19AI084081, P30CA118100).

Non-sexual HPV transmission and role of vaccination for a better future (Review)

Human papilloma viruses (HPVs) belong to the Papillomaviridae family and are epitheliotropic infecting squamous epithelia (skin and mucosae). HPV is estimated to be the cause of 99% of cervical cancers (there is no evidence of significant genetic predisposition for cervical cancer), 90% of anal cancer, 65% vaginal cancers, 50% vulvar cancers, and 45-90% oropharyngeal cancers. The route of HPV transmission is primarily through skin-to-skin or skin-to-mucosa contact. Sexual transmission is the most documented, but there have been studies suggesting non-sexual courses. The horizontal transfer of HPV includes fomites, fingers, and mouth, skin contact (other than sexual). Self-inoculation is described in studies as a potential HPV transmission route, as it was certified in female virgins, and in children with genital warts (low-risk HPV) without a personal history of sexual abuse. Vertical transmission from mother to child is another HPV transfer course. Several studies have emphasized the possibility of infection through the amniotic fluid, or the placenta, or via contact with maternal genital mucosa during natural birth. Waterborne transmission of HPV has never been demonstrated; however, HPV DNA has been detected in water environments. Routine hygiene measures are proven to be inefficient in preventing HPV transmission, as the studies which have evaluated samples of HPV on contaminated medical equipment (after standard disinfection) have found them to be still positive. Annual costs associated with the morbidity and mortality of HPV-related diseases are estimated at approximately $4 billion. Once the HPV vaccine program in Australia was launched, many studies reported the initial effects: A decrease in the incidence of high-grade cervical abnormalities, no new genital warts cases in females under 21 years. Promoting greater understanding in the general public about the evident benefits of vaccination can create positive vaccine attitudes and scatter the myths of spurious side effects.

The ability of two chlorine dioxide chemistries to inactivate human papillomavirus-contaminated endocavitary ultrasound probes and nasendoscopes

Sexual transmission is the most common pathway for the spread of Human papillomavirus (HPV). However, the potential for iatrogenic HPV infections is also real. Even though cleared by the Food and Drug Administration and recommended by the World Federation for Ultrasound in Medicine and Biology, several disinfectants including glutaraldehyde and o-phthalaldehyde have shown a lack of efficacy for inactivating HPV. Other methods such as ultraviolet C and concentrated hydrogen peroxide have been shown highly effective at inactivating infectious HPV. In this study, two chlorine dioxide systems are also shown to be highly efficacious at inactivating HPV. An important difference in these present studies is that as opposed to testing in suspension or using a carrier, we dried the infectious virus directly onto endocavitary ultrasound probes and nasendoscopes, therefore, validating a more realistic system to demonstrate disinfectant efficacy.

Analysis of the integrity of ultrasound probe covers used for transvaginal examinations

BACKGROUND

Ultrasound probe covers should be used for any ultrasound procedure where there is contact with body fluids or mucous membranes. The type and quality of probe covers used in clinical practice differ widely and studies in the early 1990s showed that condoms were more superior for use with transvaginal examinations than commercial probe covers. Since then, although products have changed, there have been no further studies to assess the breakage rate of different probe covers. The objectives of this study were to assess the integrity of the most commonly used probe covers for transvaginal ultrasound examinations under clinical conditions and report the breakage rate.

METHODS

The study was conducted in public and private hospitals and private practices. A total of 500 covers for each of 10 brands of commercial covers and condoms (latex and latex free) were distributed to ultrasound practitioners. The transvaginal ultrasound examination practice was unchanged except that all covers were placed in a container for assessment instead of discarding post ultrasound examination. All covers were collected and subjected to a water leak test. Covers that broke upon deployment onto the ultrasound probe prior to the ultrasound examination were recorded. All covers that were broken or had microtears or leaks were recorded as well as photographed. Statistical analysis was performed along with Chi-squared analysis of the data and significance considered at P < 0.05.

RESULTS

None of the commercial covers broke upon deployment onto the ultrasound probe prior to ultrasound examination. A total of 5000 probe covers were examined post-transvaginal ultrasound examinations. The breakage rate for condoms ranged from 0.4% to 13% and for commercial covers 0-5%. Statistical analysis of the data by comparison of p-values revealed that the best performing group were the commercial non-latex probe covers and worst performing group were the non-latex condoms.

CONCLUSION

The breakage rates for commercial covers were not as high as previously reported and do not break upon deployment onto the ultrasound probe. This is the first comprehensive study that thoroughly evaluated the integrity of commercial covers and condoms used for transvaginal ultrasound examination in a clinical setting, with regards to brand, numbers and types of covers assessed.

Occupational exposure of oropharyngeal human papillomavirus amongst otolaryngologists

OBJECTIVES/HYPOTHESIS

Human papillomavirus (HPV) is a DNA virus that causes cancer in multiple sites. Although sexual activity is the primary means of oropharyngeal HPV acquisition, studies suggest HPV transmission through occupational exposure from medical instruments and surgical fumes. We assess if aerosolization of HPV16 DNA via electrocautery places otolaryngologists at risk for exposure.

STUDY DESIGN

Animal and human laboratory model.

METHODS

Plasmid (pLXSN16E6E7) expressing HPV p16 E6/E7 genes was transformed into DH5α Escherichia coli cells using the heat shock method. Miniprep and maxiprep purification of transformed DNA with subsequent restriction enzyme double digestion confirmed presence of E6E7 fragment. We injected 2 μg plasmid DNA in 20 μL TE (Tris and ethylenediaminetetraacetic acid) buffer intradermally into freshly severed mouse tail then cauterized for 5 to 10 seconds. Generated fumes were collected through a suction tube fitted with Whatman filter paper. Filter paper was placed in 100 μL TE buffer. Additionally, six patients undergoing transoral robotic surgery for resection of oropharyngeal cancer were identified, three with p16-negative tumors and three with p16-positive tumors. Intraoperatively, Whatman filter paper was exposed to electrocautery fumes, then placed in 100 uL TE buffer. Additional samples were collected from the suction tubing and filter, the surgical mask of the surgeon at head of the bed, and the robot arm.

RESULTS

Samples were analyzed via polymerase chain reaction with an assay sensitivity of 1.5 ng E6E7 DNA. None of the patient or mouse tail samples yielded detectable HPV16 DNA in the electrocautery fumes. We did not detect HPV16 DNA on the surgical masks, suction apparatus, or robot arm intraoperatively.

CONCLUSIONS

There is likely minimal risk of occupational exposure to HPV16 via electrocautery fumes.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:2366-2371, 2020.

Transvaginal ultrasound probes are human papillomavirus-free following low-level disinfection: cross-sectional multicenter survey

OBJECTIVES

To assess the frequency of detection of high-risk human papillomavirus (hrHPV) on transvaginal ultrasound (TVS) probes and keyboards and evaluate operator compliance with national recommendations for prevention of cross-infection during TVS.

METHODS

This was a multicenter observational survey involving 46 public and private centers, in the Paris region of France, in which at least five consecutive TVS examinations were performed per day. We audited 676 TVS procedures. We recorded preventive hygiene actions undertaken by the operator at three stages: (1) during TVS; (2) during probe disinfection; and (3) during preparation of the probe for the next TVS. After probe disinfection, we collected one sample from the bare probe and one from the ultrasound keyboard; following probe preparation for the next examination, an additional sample was obtained from the covered probe. The samples were tested for presence of hrHPV DNA using the Cobas® 4800 System.

RESULTS

We did not detect hrHPV DNA in samples collected from uncovered or covered probes (0%; 95% CI, 0.00-0.55%). Keyboard samples were positive for hrHPV in two cases (0.3%; 95% CI, 0.04-1.07%). During TVS, the operator avoided touching the keyboard with a hand that had touched the patient's vulva in 86% of cases and held the probe with a gloved hand in 68%. Before probe disinfection, the operator wore new gloves, or performed hand disinfection in 8% of cases. The probe disinfection technique used was adequate in 87% of cases, not performed at all in 12% and insufficient in 1%. Before preparing the probe for the next scan, the operators disinfected their hands or used new gloves in 81% of cases. The probe cover and the coupling gel used complied with recommendations in 98% and 46% of cases, respectively. Of the seven preventive hygiene actions recommended in national guidelines, all were performed in 2%, three to six in 95% and two in 3% of observations. In four (9%) centers, disinfection was not performed in over half the observations.

CONCLUSIONS

No evidence of hrHPV DNA was found on TVS probes and probe covers following low-level disinfection, despite suboptimal compliance with hygiene guidelines. Routine TVS practice could be made easier and safer with a global approach to probe disinfection and hand hygiene. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Decontamination of Intravaginal Probes Infected by Human Papillomavirus (HPV) Using UV-C Decontamination System

Background: This three-step study evaluated ultraviolet-C (UV-C) efficacy against human papillomavirus (HPV) found on vaginal ultrasound probes. Methods: The first two steps evaluated UV-C disinfection of vaginal ultrasound probes in routine condition. During the first phase, the probe (n = 100) was sampled after a complete cleaning and disinfection protocol, i.e., cleaning with chemically impregnated wipes, followed by UV-C. During the second phase, the probe (n = 47) was sampled after cleaning and UV-C. The final step consisted of applying mixes of HPV on a dedicated, covered probe (n = 15) then sampling the cover, the probe after removal of the cover, after cleaning, and after UV-C. HPV detection was performed using CLART^® HPV2 PCR (Genomica, Madrid, Spain). Results: In the first phase, no probes were found to be positive for both DNA after UV-C. In the second phase, eight probes were found to be positive after cleaning (seven with human DNA and one with HPV) and negative after UV-C. In the final phase, one probe was found to be positive for HPV for each sample except after UV-C. Conclusions: Covers followed by a chemically impregnated wipe are not sufficient to ensure patient safety during vaginal ultrasound examinations. UV-C is effective in routine conditions against contaminations found on vaginal ultrasound probes, especially HPV.

CLEAR: A Novel Approach to Ultrasound Equipment Homeostasis

Protocols for the sanitation and maintenance of point-of-care ultrasound (US) equipment are lacking. This study introduces the CLEAR protocol (clean, locate, energize, augment supplies, and remove patient identifiers) as a tool to improve the readiness of US equipment, termed US equipment homeostasis. The state of US equipment homeostasis in the emergency department of a single academic center was investigated before and after implementing this protocol, with an improvement in outcomes. These findings demonstrate that the CLEAR protocol can improve US homeostasis. CLEAR can function as a teaching tool to promote homeostasis as well as a checklist to assess compliance.

Medical Ultrasound Disinfection and Hygiene Practices: WFUMB Global Survey Results

As ultrasound technology rapidly evolves and is used more frequently in every area of medical diagnosis and treatment, it may be overlooked as a potential vector in the transmission of a health care-associated infection. A survey on disinfection and hygiene practice in medical ultrasound was disseminated via the World Federation for Ultrasound in Medicine and Biology (WFUMB) to its six member federations and associated ultrasound societies globally. One thousand twenty-nine responses were obtained across a broad range of ultrasound practitioners. A total of 76% of respondents used transducer covers every time to scan open wounds and 71% when blood and bodily fluids were present or for an interventional procedure. Approved high-level disinfectants are not always used, even when blood comes into contact with the transducer or after endocavity scans. Alcohol-based wipes were used by many respondents to clean both external transducers and endocavity transducers. Open-ended responses indicated that a large caseload hindered the time required for cleaning and that access to clear guidelines would be beneficial. Global survey results indicate that some users do not comply with disinfection practice, and there is a gap in knowledge on basic infection prevention and control education within the ultrasound unit. As the infectious status of a patient is not often disclosed prior to an ultrasound examination, training in suitable protocols for the cleaning and disinfection of ultrasound equipment is imperative to mitigate the risk of potential infection.

Guidance for the decontamination of intracavity medical devices: the report of a working group of the Healthcare Infection Society

BACKGROUND

Intracavity medical devices (ICMDs) are used in a wide variety of healthcare settings. The approach to their decontamination and the resources available also differ widely. Their potential for infection transmission is considerable.

AIM

To produce a comprehensive risk assessment-based approach to the decontamination of ICMDs, accompanied by an adaptable audit tool.

KEY RECOMMENDATIONS

Infection prevention and control in ultrasound - best practice recommendations from the European Society of Radiology Ultrasound Working Group

OBJECTIVES

The objective of these recommendations is to highlight the importance of infection prevention and control in ultrasound (US), including diagnostic and interventional settings.

METHODS

Review of available publications and discussion within a multidisciplinary group consistent of radiologists and microbiologists, in consultation with European patient and industry representatives.

RECOMMENDATIONS

Good basic hygiene standards are essential. All US equipment must be approved prior to first use, including hand held devices. Any equipment in direct patient contact must be cleaned and disinfected prior to first use and after every examination. Regular deep cleaning of the entire US machine and environment should be undertaken. Faulty transducers should not be used. As outlined in presented flowcharts, low level disinfection is sufficient for standard US on intact skin. For all other minor and major interventional procedures as well as all endo-cavity US, high level disinfection is mandatory. Dedicated transducer covers must be used when transducers are in contact with mucous membranes or body fluids and sterile gel should be used inside and outside covers.

CONCLUSIONS

Good standards of basic hygiene and thorough decontamination of all US equipment as well as appropriate use of US gel and transducer covers are essential to keep patients safe.

MAIN MESSAGES

• Transducers must be cleaned/disinfected before first use and after every examination. • Low level disinfection is sufficient for standard US on intact skin. • High level disinfection is mandatory for endo-cavity US and all interventions. • Dedicated transducer covers must be used for endo-cavity US and all interventions. • Sterile gel should be used for all endo-cavity US and all interventions.

UVC radiation as an effective disinfectant method to inactivate human papillomaviruses

Endocavitary ultrasound probes are part of a commonly used procedure in the clinical arena. The cavities examined, vaginal canal and cervix, anal canal, and oral cavity are all areas commonly infected with the human papillomavirus (HPV), thus making them susceptible to contamination by HPV. It has been demonstrated that these probes can remain contaminated with high-risk HPV even when approved disinfection protocols have been performed. we have previously shown that HPV is resistant to some high-level disinfectant (HLD). In our present study we analyzed efficacy of using high-level ultra-violet C (UVC) radiation against HPV16 and HPV18 using a hard-surface carrier test. Stocks of infectious authentic HPV16 and HPV18 virions were dried onto carriers with a 5% (v/v) protein soil or 4ppm hard water. Efficacy testing were performed with the automated device, Antigermix S1 device (UVC radiation at 253.7nm) and 0.55% OPA in quadruplicate with matched input, neutralization, and cytotoxicity controls. Hypochlorite was included as a positive control for viral deactivation. Infectivity was determined by the abundance (qRT-PCR) of the spliced E1^E4 transcript in infected recipient cells. The automated Antigermix S1 device showed excellent efficacy against HPV16 and HPV18 whereas OPA showed minimal efficacy. While HPV is highly resistant to OPA, high-level UVC radiation offers an effective disinfection practice for ultrasound probes. Our results suggest that healthcare facilities using endocavitary ultrasound probes need to strongly consider disinfection methods that are effective against HPV.

Guidelines for Cleaning Transvaginal Ultrasound Transducers Between Patients

The purpose of this article is to provide guidance regarding the cleaning and disinfection of transvaginal ultrasound probes. These recommendations are also applicable to transrectal probes.

Virucidal efficacy of a sonicated hydrogen peroxide system (trophon® EPR) following European and German test methods

Aim: The virucidal efficacy of an automated ultrasound probe disinfector (trophon^® EPR) was evaluated in a three step procedure according to European and German test methods. This system uses sonicated hydrogen peroxide mist (35%) at elevated temperature (50°C) in a closed chamber with control of all parameters within a 7 minute cycle. Methods: In the first step of examination, the peroxide solution was tested in a quantitative suspension assay according to the Guideline of Deutsche Vereinigung zur Bekämpfung der Viruskrankheiten (DVV) e.V. and Robert Koch-Institute (RKI) and in parallel with the European Norm EN 14476 with all test viruses creating a virucidal claim. In the second step, the virucidal efficacy of the hydrogen peroxide solution was evaluated in a hard surface carrier test according to the Guideline of DVV with adenovirus, murine norovirus and parvovirus simulating practical conditions. Finally, the efficacy was evaluated by the automated system using stainless steel carriers inoculated with test virus and positioned at different levels inside the chamber. Results: A ≥4 log₁₀ reduction of virus titre was demonstrated with all methods including carrier tests with murine norovirus, adenovirus, and parvovirus using the automated device. Conclusion: The automated device is able to inactivate test viruses of German and European norms and can therefore claim efficacy against human pathogenic enveloped and non-enveloped viruses. This includes human papillomaviruses which form part of the complete virucidal claim.

Advancing infection control in Australasian medical ultrasound practice

INTRODUCTION/AIMS

Australasia is witnessing a rapidly increasing use of diagnostic medical ultrasound in clinical practice with industry statistics giving a conservative estimate of ten million scans performed annually in Australia and New Zealand. Ultrasound practice has broadened from its traditional use in radiology, obstetrics and gynaecology, vascular and cardiology specialties to embrace emergency medicine, rheumatology, midwifery, physiotherapy, paramedics and other point of care practice. With this expansion of practice comes an increase in the potential risk for ultrasound transmitted bacterial or viral infection due to suboptimal cleaning habits of transducers, cords and keyboards.

RESULTS/CONCLUSION

This study describes results of an Australasian survey on the disinfection and hygiene practice in medical ultrasound. Results highlighted a significant need for updated guidelines and education on infection prevention and control in medical ultrasound.

Infection prevention and ultrasound probe decontamination practices in Europe: a survey of the European Society of Radiology

OBJECTIVES

Although ultrasound (US) is considered one of the safest imaging modalities, concerns have been raised regarding potential infection transmission risks through US procedures. A survey was undertaken by the European Society of Radiology (ESR) to establish infection prevention and control measures in US and to highlight the importance of good medical practice.

METHODS

An online survey was sent to all 22,000 full ESR members.

RESULTS

The response rate of completed surveys was 4.3 % (946 practitioners, 97 % of which were radiologists, mostly working in larger hospital settings). Among respondents, 29 %, 11 % and 6 % did not disinfect the US probe after every patient when performing standard surface US, endo-cavity US and interventional procedures, respectively. Eleven percent did not always use probe covers for endo-cavity US; for interventional procedures, the proportion was 23 %. A minority used sterile gel sachets in direct patient contact for endo-cavity scans (30 %), and 77.5 % used sterile gel for interventional procedures.

CONCLUSIONS

The survey results highlight a wide range of practices throughout Europe and the need to raise awareness amongst practitioners regarding the importance of infection prevention and control measures. The development of European recommendations encompassing all US examinations, together with education is a priority.

MAIN MESSAGES

• Transmission of infection through ultrasound procedures is possible. • There is a wide range of ultrasound probe decontamination practices in Europe. • Not all practitioners use probe covers for endo-cavity or interventional ultrasound. • Not all practitioners use sterile gel for internal and invasive procedures. • Currently there are no European recommendations encompassing all US examinations.

A randomised, single-blind comparison of high-level disinfectants for flexible nasendoscopes

OBJECTIVES

To compare the microbiological efficacy, turnaround time, cost, convenience, and patient and user tolerance of Tristel Trio Wipes, PeraSafe solution and Cidex OPA solution for the high-level disinfection of flexible nasendoscopes.

METHODS

Flexible nasendoscopes were used in routine clinical encounters. They were then disinfected with one of the three disinfectant methods. Surveillance cultures were taken before and after each disinfection process. Data relating to each of the study parameters were recorded.

RESULTS

Positive bacterial cultures were discovered on nasendoscopes disinfected with PeraSafe and Cidex OPA. Tristel Trio Wipes have no capital outlay cost, the lowest running cost, the greatest convenience and the fastest turnaround time. PeraSafe had a faster turnaround time than Cidex OPA, and lower running costs.

CONCLUSION

Tristel Trio Wipes are equal to PeraSafe and Cidex OPA in terms of microbiological efficacy. Turnaround time and cost are dramatically reduced when using Tristel Trio Wipes compared to the other disinfectant methods.

Outcome of one hundred consecutive ICSI attempts using patient operated home sonography for monitoring follicular growth

OBJECTIVE

cohort study describing clinical and laboratory outcomes in ICSI patients using self-operated endovaginal tele-monitoring (SOET).

SETTING

University department of reproductive medicine.

PATIENTS

78 patients undergoing 100 consecutive ICSI attempts.

INTERVENTIONS

patients' recorded vaginal sonograms and sent recordings using the cloud based Sonaura device to the care provider who procured responses, avoiding hospital visits.

MAIN OUTCOME MEASURES

Number of cycles without hospital visit, laboratory and clinical variables, transportation avoided.

RESULTS

In 100 attempts, only one patient missed her follicles, 9 hospital visits occurred for circumstantial reasons and 90 attempts were completed without any hospital visit between initiation and puncture. Mean number ± 2SD was for oocytes 11.7±6.6, metaphase-II oocytes 8.5±5.4, 2PN zygotes 5.5±3.7, good day-5 blastocysts 2.4±2.4, embryos transferred 1.0±0.7 and embryos frozen 1.3±2.2. Percentages of total (+HCG), clinical (cardiac activity) and on-going pregnancies (>20 weeks) were 40%, 35% and 29% per started cycle and 48.8%, 42.7% and 35.4% per embryo transfer.

CONCLUSIONS

Using SOET, 90% of ICSI (and IVF) patients can avoid visits to care providers for making sonograms. Results were similar as in patients with a similar profile using traditional monitoring. In appropriate patients, SOET is an efficient, safe and patient-friendly alternative for ovarian stimulation monitoring in IVF/ICSI programmes.

Mucosal alpha-papillomaviruses are not associated with esophageal squamous cell carcinomas: Lack of mechanistic evidence from South Africa, China and Iran and from a world-wide meta-analysis

Epidemiological and mechanistic evidence on the causative role of human papillomaviruses (HPV) in esophageal squamous cell carcinoma (ESCC) is unclear. We retrieved alcohol- and formalin-fixed paraffin-embedded ESCC tissues from 133 patients seropositive for antibodies against HPV early proteins, from high-incidence ESCC regions: South Africa, China and Iran. With rigorous care to prevent nucleic acid contamination, we analyzed these tissues for the presence of 51 mucosotropic human alpha-papillomaviruses by two sensitive, broad-spectrum genotyping methods, and for the markers of HPV-transformed phenotype: (i) HPV16/18 viral loads by quantitative real-time PCR, (ii) type-specific viral mRNA by E6*I/E6 full-length RT-PCR assays and (iii) expression of cellular protein p16(INK4a). Of 118 analyzable ESCC tissues, 10 (8%) were positive for DNA of HPV types: 16 (4 tumors); 33, 35, 45 (1 tumor each); 11 (2 tumors) and 16, 70 double infection (1 tumor). Inconsistent HPV DNA+ findings by two genotyping methods and negativity in qPCR indicated very low viral loads. A single HPV16 DNA+ tumor additionally harbored HPV16 E6*I mRNA but was p16(INK4a) negative (HPV16 E1 seropositive patient). Another HPV16 DNA+ tumor from an HPV16 E6 seropositive patient showed p16(INK4a) upregulation but no HPV16 mRNA. In the tumor tissues of these serologically preselected ESCC patients, we did not find consistent presence of HPV DNA, HPV mRNA or p16(INK4a) upregulation. These results were supported by a meta-analysis of 14 other similar studies regarding HPV-transformation of ESCC. Our study does not support the etiological role of the 51 analyzed mucosotropic HPV types in the ESCC carcinogenesis.

Incidence of human papillomavirus contamination of transvaginal probes in Japan and possible contamination prevention strategy

PURPOSE

To clarify the present status of human papillomavirus (HPV) contamination of transvaginal probes in Japan and propose a preventive method.

METHODS

This study was performed at three institutes: a tertiary center, secondary hospital, and primary facility. To identify contamination rates, probes were disinfected and covered with probe covers and condoms; the cover was changed for each patient. The probes were tested for HPV, and those with HPV detected were analyzed to identify the type of HPV. Next, nurses put on new gloves before covering the probe for each patient, and the probes were similarly tested for HPV.

RESULTS

A total of 120 probes were tested, and HPV was detected from a total of five probes, a contamination rate of 4.2 % (5/120). HPV was detected in all three institutes. Importantly, high-risk HPV, i.e., HPV-52, 56, and 59, was detected. After the "glove change strategy" was implemented, HPV was not detected on any of 150 probes tested at any of the three institutions.

CONCLUSIONS

In Japan, the HPV contamination rate of vaginal probes in routine practice was 4.2 %. There was no HPV contamination of probes after changing the gloves for cover exchange for each patient. This strategy may prevent HPV probe contamination.

Susceptibility of HPV16 and 18 to high level disinfectants indicated for semi-critical ultrasound probes

Ultrasound probes used in endocavitary procedures have been shown to be contaminated with high‐risk HPV after routine use and HPV is also known to be resistant to some high level disinfectants (HLDs). This study compared efficacy of two leading ultrasound probe HLD methods; liquid ortho‐phthalaldehyde (Cidex® OPA) and an automated device using sonicated hydrogen peroxide (trophon® EPR) against HPV16 and HPV18 in a hard‐surface carrier test. Native HPV16 and HPV18 virions were generated in organotypic epithelial raft cultures. Viral lysates were dried onto carriers with a 5% (v/v) protein soil. Efficacy tests were performed against the automated device at 35% and 31.5% H₂O₂ and 0.55% OPA in quadruplicate with matched input, neutralization, and cytotoxicity controls. Hypochlorite was included as a positive control. Infectivity was determined by the abundance (qRT‐PCR) of the spliced E1^E4 transcript in infected recipient cells. The automated HLD device showed excellent efficacy against HPV16 and HPV18 (>5 log₁₀ reductions in infectivity) whereas OPA showed minimal efficacy (<0.6 log₁₀ reductions). While HPV is highly resistant to OPA, sonicated hydrogen peroxide offers an effective disinfection solution for ultrasound probes. Disinfection methods that are effective against HPV should be adopted where possible. J. Med. Virol. 88:1076–1080, 2016. © 2015 The Authors. Journal of Medical Virology Published by Wiley Periodicals, Inc.

The importance of infection prevention and control in medical ultrasound

Infection control and prevention is critical to delivering safe and high-quality care to patients undergoing sonographic procedures. In Australia comprehensive standards for reprocessing of ultrasound probes are based on the AS/NZS, TGA and ASUM recommendations. These standards align with the US Centers for Disease Control and Prevention recommendations. However compliance to these guidelines is not ideal and there exists an unmet need for refinement of the guidelines relating to specific factors in clinical sonography. Significant microbiological evidence exists reflecting the increased risk of infection transmission specifically through inadequately reprocessed ultrasound probes. Studies have reported > 80% of transvaginal ultrasound probe handles are contaminated with disease causing pathogens since handle disinfection is omitted from standard reprocessing protocols. Significantly, it was recently discovered that widely-used high level disinfectants referred to in guidelines are unable to kill HPV while it is becoming increasingly apparent that attention must be paid to the clinical sonography environment as a potential source of nosocomial pathogens. Ultrasound probe reprocessing guidelines and standards are comprehensive however the challenge is in general awareness and effective implementation into practice. As future research in this area is performed, guidelines will need to be amenable to revision to provide patients with the best standard of care.

A risk for non-sexual transmission of human papillomavirus?

Human papillomaviruses (HPVs) are estimated to be the most common sexually transmitted virus in humans. The virus is of great interest as it is the etiological agent of cervical cancer. Sexual transmission of HPV is generally accepted, however, non-sexual transmission of the virus is often debated. Here, we review the evidence from basic research and clinical studies that show HPV can survive well outside of its host to potentially be transmitted by non-sexual means. In doing so, we hope to discover problems in current prevention practices and show a need for better disinfectants to combat the spread of HPV.

Emergency department ultrasound probe infection control: challenges and solutions

Point-of-care ultrasound (US) has become a cornerstone in the diagnosis and treatment of patients in the emergency department (ED). Despite the beneficial impact on patient care, concern exists over repeat use of probes and the role as a vector for pathogen transmission. US probes are used for various applications, with the level of infection risk, based on the Spaulding Classification, ranging from noncritical with common practice to semicritical with endocavitary probes. To date, the most closely studied organisms are Staphylococcus aureus and human papilloma virus. Current evidence does confirm probe colonization but has not established a causative role in human infection. Based on current literature, US use during invasive procedures remains an infection control concern, but routine use on intact skin does not appear to cause significant risk to patients. Various barrier methods are available, each with indications based on extent of procedure and likelihood of contact with mucosal surfaces. Additionally, chemical cleansing methods have been shown to be effective in limiting probe contamination after use. New technologies utilizing ultraviolet light are available and effective but not widely used in the ED setting. As our understanding of the critical factors in US probe cleaning and disinfection improves, it is important to assess the challenges found in our current practice and to identify potential solutions to improve practices and procedures in infection control across the spectrum of US probe use in various applications in the ED. This article serves as a summary of the current literature available on infection control topics with the utilization of point-of-care US, and discusses challenges and potential solutions to improve the current practice of probe-related infection control.

Infection prevention in the emergency department

Infection prevention remains a major challenge in emergency care. Acutely ill and injured patients seeking evaluation and treatment in the emergency department (ED) not only have the potential to spread communicable infectious diseases to health care personnel and other patients, but are vulnerable to acquiring new infections associated with the care they receive. This article will evaluate these risks and review the existing literature for infection prevention practices in the ED, ranging from hand hygiene, standard and transmission-based precautions, health care personnel vaccination, and environmental controls to strategies for preventing health care-associated infections. We will conclude by examining what can be done to optimize infection prevention in the ED and identify gaps in knowledge where further research is needed. Successful implementation of evidence-based practices coupled with innovation of novel approaches and technologies tailored specifically to the complex and dynamic environment of the ED are the keys to raising the standard for infection prevention and patient safety in emergency care.

[HPV contamination of endocavity vaginal ultrasound probes]

While the use of endovaginal ultrasound probes is increasing, the risk of contamination of women with endocavity vaginal probes was not assessed. In particular, the clinical significance of detection of human papillomavirus (HPV) infection, the most common sexually transmitted viral infection, on endovaginal ultrasound probes is uncertain. The recommendations of good practice for decontamination of these probes developed by the High Council for Public Health and the Academy of Medicine have not been evaluated. The objective of this article was to review recent publications concluding to the detection of HPV and human cellular DNA after gynecological examination and disinfection of vaginal ultrasound probes.

Persistence of microbial contamination on transvaginal ultrasound probes despite low-level disinfection procedure

AIM OF THE STUDY

In many countries, Low Level Disinfection (LLD) of covered transvaginal ultrasound probes is recommended between patients' examinations. The aim of this study was to evaluate the antimicrobial efficacy of LLD under routine conditions on a range of microorganisms.

MATERIALS AND METHODS

Samples were taken over a six month period in a private French Radiology Center. 300 specimens derived from endovaginal ultrasound probes were analyzed after disinfection of the probe with wipes impregnated with a quaternary ammonium compound and chlorhexidine. Human papillomavirus (HPV) was sought in the first set of s100 samples, Chlamydia trachomatis and mycoplasmas were searched in the second set of 100 samples, bacteria and fungi in the third 100 set samples. HPV, C. trachomatis and mycoplasmas were detected by PCR amplification. PCR positive samples were subjected to a nuclease treatment before an additional PCR assay to assess the likely viable microorganisms. Bacteria and fungi were investigated by conventional methods.

RESULTS

A substantial persistence of microorganisms was observed on the disinfected probes: HPV DNA was found on 13% of the samples and 7% in nuclease-resistant form. C. trachomatis DNA was detected on 20% of the probes by primary PCR but only 2% after nuclease treatment, while mycoplasma DNA was amplified in 8% and 4%, respectively. Commensal and/or environmental bacterial flora was present on 86% of the probes, occasionally in mixed culture, and at various levels (10->3000 CFU/probe); Staphylococcus aureus was cultured from 4% of the probes (10-560 CFU/probe). No fungi were isolated.

CONCLUSION

Our findings raise concerns about the efficacy of impregnated towels as a sole mean for disinfection of ultrasound probes. Although the ultrasound probes are used with disposable covers, our results highlight the potential risk of cross contamination between patients during ultrasound examination and emphasize the need for reviewing the disinfection procedure.

Counseling about the HPV vaccine: desexualize, educate, and advocate

Information is provided for clinicians who treat adolescents and adult women to use when counseling patients about human papillomavirus (HPV) vaccine. A literature search was done to determine: (1) reasons for refusal of the vaccine, including cost and concerns that immunization against HPV will lead to promiscuity; (2) potential for non-sexual transmission of HPV; (3) non-genital locations of HPV; (4) non-genital cancers associated with HPV. Vaccines for Children Program and the Affordable Care Act eliminate many costs.Neither biological nor behavioral evidence supports the idea that sexual behavior changes after immunization. HPV is transmitted from person to person by non-sexual routes including mother to child at birth and apparently by touch after birth. HPV is persistent in the environment, including medical environments. It has been found on apparently sterilized instruments used in vaginal exams. Pathogenic HPV has been recovered from breast tissue, sinonasal areas, and nipples as well as from hair follicles on arms, legs, scalps, eyebrows, and pubic hair. Pathogenic HPV was found in 6.5% of the oral cavities of a random sample of Americans. HPV is known to cause anal and oral cancers. It has also been associated with skin cancers, breast tumors, and prostate cancers. It is not known if the vaccine is protective against these cancers, but it is useful to educate about these other routes of transmission and non-genital HPV linked cancers so that patients/parents do not just focus on the sexual nature of the human papillomavirus.

High risk HPV contamination of endocavity vaginal ultrasound probes: an underestimated route of nosocomial infection?

BACKGROUND

Endocavity ultrasound is seen as a harmless procedure and has become a common gynaecological procedure. However without correct disinfection, it may result in nosocomial transmission of genito-urinary pathogens, such as high-risk Human Papillomavirus (HR-HPV). We aimed to evaluate the currently recommended disinfection procedure for covered endocavity ultrasound probes, which consists of "Low Level Disinfection" (LLD) with "quaternary ammonium compounds" containing wipes.

METHODS

From May to October 2011 swabs were taken from endovaginal ultrasound probes at the Gynecology Department of the Lyon University Hospital. During the first phase (May-June 2011) samples were taken after the ultrasound examination and after the LLD procedure. In a second phase (July-October 2011) swab samples were collected just before the probe was used. All samples were tested for the presence of human DNA (as a marker for a possible transmission of infectious pathogens from the genital tract) and HPV DNA with the Genomica DNA microarray (35 different HPV genotypes).

RESULTS

We collected 217 samples before and 200 samples after the ultrasound examination. The PCR was inhibited in two cases. Human DNA was detected in 36 (18%) post-examination samples and 61 (28%) pre-examination samples. After the ultrasound LLD procedure, 6 (3.0%) samples contained HR-HPV types (16, 31, 2×53 and 58). Similarly, HPV was detected in 6 pre-examination samples (2.7%). Amongst these 4 (1.9%) contained HR-HPV (types 53 and 70).

CONCLUSION

Our study reveals that a considerable number of ultrasound probes are contaminated with human and HR-HPV DNA, despite LLD disinfection and probe cover. In all hospitals, where LLD is performed, the endovaginal ultrasound procedure must therefore be considered a source for nosocomial HR-HPV infections. We recommend the stringent use of high-level disinfectants, such as glutaraldehyde or hydrogen peroxide solutions.