A novel human coronavirus that is now named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (formerly called HCoV-19) emerged in Wuhan, China, in late 2019 and is now causing a pandemic.1 We analyzed the aerosol and surface stability of SARS-CoV-2 and compared it with SARS-CoV-1, the most closely related human coronavirus.2
We evaluated the stability of SARS-CoV-2 and SARS-CoV-1 in aerosols and on various surfaces and estimated their decay rates using a Bayesian regression model (see the Methods section in the Supplementary Appendix, available with the full text of this letter at NEJM.org). SARS-CoV-2 nCoV-WA1-2020 (MN985325.1) and SARS-CoV-1 Tor2 (AY274119.3) were the strains used. Aerosols (<5 μm) containing SARS-CoV-2 (105.25 50% tissue-culture infectious dose [TCID50] per milliliter) or SARS-CoV-1 (106.75-7.00 TCID50 per milliliter) were generated with the use of a three-jet Collison nebulizer and fed into a Goldberg drum to create an aerosolized environment. The inoculum resulted in cycle-threshold values between 20 and 22, similar to those observed in samples obtained from the upper and lower respiratory tract in humans.
Our data consisted of 10 experimental conditions involving two viruses (SARS-CoV-2 and SARS-CoV-1) in five environmental conditions (aerosols, plastic, stainless steel, copper, and cardboard). All experimental measurements are reported as means across three replicates. Figure 1.
SARS-CoV-2 remained viable in aerosols throughout the duration of our experiment (3 hours), with a reduction in infectious titer from 103.5 to 102.7 TCID50 per liter of air. This reduction was similar to that observed with SARS-CoV-1, from 104.3 to 103.5 TCID50 per milliliter (Figure 1A).
SARS-CoV-2 was more stable on plastic and stainless steel than on copper and cardboard, and viable virus was detected up to 72 hours after application to these surfaces (Figure 1A), although the virus titer was greatly reduced (from 103.7 to 100.6 TCID50 per milliliter of medium after 72 hours on plastic and from 103.7 to 100.6 TCID50 per milliliter after 48 hours on stainless steel). The stability kinetics of SARS-CoV-1 were similar (from 103.4 to 100.7 TCID50 per milliliter after 72 hours on plastic and from 103.6 to 100.6 TCID50 per milliliter after 48 hours on stainless steel). On copper, no viable SARS-CoV-2 was measured after 4 hours and no viable SARS-CoV-1 was measured after 8 hours. On cardboard, no viable SARS-CoV-2 was measured after 24 hours and no viable SARS-CoV-1 was measured after 8 hours (Figure 1A).
Both viruses had an exponential decay in virus titer across all experimental conditions, as indicated by a linear decrease in the log10TCID50 per liter of air or milliliter of medium over time (Figure 1B). The half-lives of SARS-CoV-2 and SARS-CoV-1 were similar in aerosols, with median estimates of approximately 1.1 to 1.2 hours and 95% credible intervals of 0.64 to 2.64 for SARS-CoV-2 and 0.78 to 2.43 for SARS-CoV-1 (Figure 1C, and Table S1 in the Supplementary Appendix). The half-lives of the two viruses were also similar on copper. On cardboard, the half-life of SARS-CoV-2 was longer than that of SARS-CoV-1. The longest viability of both viruses was on stainless steel and plastic; the estimated median half-life of SARS-CoV-2 was approximately 5.6 hours on stainless steel and 6.8 hours on plastic (Figure 1C). Estimated differences in the half-lives of the two viruses were small except for those on cardboard (Figure 1C). Individual replicate data were noticeably “noisier” (i.e., there was more variation in the experiment, resulting in a larger standard error) for cardboard than for other surfaces (Fig. S1 through S5), so we advise caution in interpreting this result.
We found that the stability of SARS-CoV-2 was similar to that of SARS-CoV-1 under the experimental circumstances tested. This indicates that differences in the epidemiologic characteristics of these viruses probably arise from other factors, including high viral loads in the upper respiratory tract and the potential for persons infected with SARS-CoV-2 to shed and transmit the virus while asymptomatic.3,4 Our results indicate that aerosol and fomite transmission of SARS-CoV-2 is plausible, since the virus can remain viable and infectious in aerosols for hours and on surfaces up to days (depending on the inoculum shed). These findings echo those with SARS-CoV-1, in which these forms of transmission were associated with nosocomial spread and super-spreading events,5 and they provide information for pandemic mitigation efforts.
Neeltje van Doremalen, Ph.D. Trenton Bushmaker, B.Sc. National Institute of Allergy and Infectious Diseases, Hamilton, MT
Dylan H. Morris, M.Phil. Princeton University, Princeton, NJ
Myndi G. Holbrook, B.Sc. National Institute of Allergy and Infectious Diseases, Hamilton, MT
Amandine Gamble, Ph.D. University of California, Los Angeles, Los Angeles, CA
Brandi N. Williamson, M.P.H. National Institute of Allergy and Infectious Diseases, Hamilton, MT
Azaibi Tamin, Ph.D. Jennifer L. Harcourt, Ph.D. Natalie J. Thornburg, Ph.D. Susan I. Gerber, M.D. Centers for Disease Control and Prevention, Atlanta, GA
James O. Lloyd-Smith, Ph.D. University of California, Los Angeles, Los Angeles, CA, Bethesda, MD
Emmie de Wit, Ph.D. Vincent J. Munster, Ph.D. National Institute of Allergy and Infectious Diseases, Hamilton, MT firstname.lastname@example.org
Supported by the Intramural Research Program of the National Institute of Allergy and Infectious Diseases, National Institutes of Health, and by contracts from the Defense Advanced Research Projects Agency (DARPA PREEMPT No. D18AC00031, to Drs. Lloyd-Smith and Gamble), from the National Science Foundation (DEB-1557022, to Dr. Lloyd-Smith), and from the Strategic Environmental Research and Development Program of the Department of Defense (SERDP, RC-2635, to Dr. Lloyd-Smith).
Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.
The findings and conclusions in this letter are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention (CDC). Names of specific vendors, manufacturers, or products are included for public health and informational purposes; inclusion does not imply endorsement of the vendors, manufacturers, or products by the CDC or the Department of Health and Human Services.
This letter was published on March 17, 2020, at NEJM.org.
Dr. van Doremalen, Mr. Bushmaker, and Mr. Morris contributed equally to this letter.
Navigating the Roman circus of obstacles known as an international airport is likely the one thing travelers aren’t missing during the Covid-19 crisis. Now that forecasts predict tourism won’t fully recover until 2023, these transit centers are getting a rare, low-traffic chance to make many of the changes flyers have long wanted—along with upgrades they never imagined.
Among them: disinfection booths, biometric security scans, automated customs and border patrol screenings, and enhanced self-check-in stations. Together, they represent the most significant overhaul of the airport experience since Sept. 11.
“The traditional way we design airports has long been hamstrung in two directions,” says Matthew Johnson, who helped spearhead the ongoing $14 billion renovation of LAX in Los Angeles as an aviation principal for architecture firm Gensler. The de facto airport floor plan funnels traffic through an “X” shape, with passengers coming from various entries and converging at one congested portal—TSA—before dispersing to find their gate. This design was largely put into place after the 2001 terror attacks, when extensive security scans became emblems of personal safety.
If long lines were once the price of safety, they’re downright dangerous now. “Covid-19 is going to herald a complete reversal,” says Johnson, who proposes eliminating the X all together. Airports could become like casinos, he says, coupling eye-in-the-sky surveillance with state-of-the-art sensors—as in the “smart tunnel” at Dubai International that verifies your identity by scanning your iris as you walk through it. Add advanced X-ray technology, and airports may be able to identify threats without requiring anyone to line up, divest, or even put luggage in a tray.
The most radical changes have the potential to turn airports from hotbeds of frustration into beacons of innovation. Here’s a look at what’s being installed around the world, and a few ideas yet to come.
Without having to rush to get through a snaking TSA line, passengers will be able to enjoy their time anywhere in the airport—including presecurity areas. Free of human gridlock, these spaces will be landscaped and outfitted with seating, where it will be possible to get food dropped off from Uber Eats or Grubhub if traffic is light and you’re a little early. Such deliveries are being tested at Toronto Pearson.
Airline apps will also mitigate the need to touch screens; in May, United Airlines Inc. announced plans for touchless kiosks that print baggage tags when you scan your phone. Coupled with QR code boarding passes and self-drop luggage stations, the check-in process will be fully digitized. From here, walking to the gate is a choose-your-own-adventure, done on your own time.
Going Through Security
Some airports already provide security without requiring human interaction. At Hong Kong International, passengers tap passports to unlock security barriers, scan their boarding pass, and have their photo snapped for identity verification at an electronic terminal. Munich and Singapore Changi have similar systems. Then there’s new technology that’s being fast-tracked for deployment: Remotely operated X-ray machines can check carry-ons for explosives, and millimeter-wave imaging systems can examine your shoes for traces of contraband while they’re on your feet.
In response to the current pandemic, thermal cameras—common in Asian airports following the 2003 SARS outbreak—will become a ubiquitous way to detect feverish travelers. Trailblazing Hong Kong International is one-upping that, with full-body disinfecting stalls that look like walk-in tanning booths. They take your temperature and blast you with an antimicrobial spray, all in 40 seconds. Except for these stalls, all the technology operates in the background, without your even knowing it (though it may alarm those concerned about privacy).
Navigating the Terminal
In places such as Seoul Incheon and Guangzhou, a new type of employee can be spotted throughout terminals: robots. Some of them sterilize common high-touch surfaces such as bathrooms, hallways, bag trolleys, and elevator buttons with UV lights; others flag authorities when they detect an unmasked face.
At JFK an artificial intelligence platform called SafeDistance is using cameras to monitor for congestion, so employees can easily identify overcrowded areas and open up other avenues of access in response. A similar software tool called Zensor uses CCTV footage to bring real-time crowd estimates for places such as gate-side bathrooms, coffee shops, or retail outlets right to a traveler’s phone; Pittsburgh International is piloting it.
A touchless departure is the last step. Cathay Pacific Ltd. is working in collaboration with U.S. Customs and Border Protection to bring automated boarding gates to LAX and San Francisco International, joining a similar effort at JFK. They’ll scan your face and biometrically verify your identity, allowing you to get on the plane without handing over your ticket and passport.
James Groark, who handles landside innovations for the carrier as its vice president for airports, says that “eventually this will be mandatory for all airlines—the writing is on the wall.”
Air travel will never be the same after the advent of the COVID-19 outbreak. Just like how travellers would not have stepped on-board an airplane after 9/11 unless they were assured that there were no weapons on-board, they will not travel unless assurance is provided that there are no viruses on board.
SimpliFlying mapped out over 70 areas on the day of travel that would change due to new demands of the travellers. This PDF summarizes the key stages of travel and how each stage will change. Welcome to the age of post-corona travel. The age of sanitised travel.
Thought “babymoon” was bad? We decode 5 travel terms that you’ll be seeing more and more often in a world with COVID-19.
The travel industry has long been fond of portmanteaus, or blending multiple words into one. Motel (motor + hotel) has been in use since the 1920s, but travel-related frankenwords have proliferated over the past few decades as glamping, babymoons, staycations, and bleisure travel have all become commonplace—whether you like it or not.
It comes as no surprise that even though coronavirus has brought the travel industry to a screeching halt, people continue to innovate and create terms to describe the new processes and ideas that are being rolled out around the world in response to the pandemic. For example, the new suitcase sanitizing and tagging process that is being considered at airports to keep bag handlers and passengers safe has already been dubbed “sanitagging.”
We’ve put together a glossary of travel terms you’ll be seeing more often in a post-coronavirus world. While not all of them are catchy portmanteaus, it’ll help knowing them as we return to airports and hotels (hopefully) in the not so distant future.
In late April, aviation marketing firm SimpliFlying released a report titled, “The Rise of Sanitised Travel.” Among the 70 different elements of the passenger journey that the firm expects to change in air travel, the one that got the most attention was “sanitagging” at the airport—the process of sanitizing bags and giving them a tag once the process is complete.
SimpliFlying recommends three places that “sanitagging” should occur: upon checking in (to protect bag handlers), at security (for those with carry-on bags), and upon arrival at the destination (before they are placed on the conveyor belt).
Implementing such systems will take cooperation between airlines, airports, and governments. But given that 8 out of 10 passengers checked their luggage in 2018, and that COVID-19 can live on plastic and stainless steel for up to three days (hello, suitcases), sanitagging is not such a terrible idea. Already, Indira Gandhi International Airport in Delhi has made public its plans to disinfect luggage, and Hong Kong International Airport is testing the efficacy of applying an antimicrobial coating to surfaces around terminals, including baggage claim. —Katherine LaGrave
As some of the world’s countries ease up on their coronavirus restrictions, they’ve also floated the idea of a “travel bubble.” No, it’s not a transparent orb you roll around the world in à la Bubble Boy—rather, it’s an agreement between cooperating countries that allows for citizens to travel freely between the nations, in the hopes of kick-starting tourism and helping economies rebound.
On May 6, Estonian prime minister Jüri Ratas wrote on Twitter that he’d reached an agreement with the prime ministers of neighboring Latvia and Lithuania to open borders on May 15. “It’s a big step towards life as normal,” he wrote. (Anyone entering from outside these countries will still need to self-quarantine for 14 days.) With the move, the Baltic states would be the first to create such a bubble. The prime ministers of New Zealand and Australia—Jacinda Ardern and Scott Morrison, respectively—have also said they will enact a similar agreement when those countries loosen their restrictions.
Though several U.S. states have agreed to coordinate “reopenings” to protect their regions, travel bubbles have proved more polarizing. Primarily, this is due to the fact that enforcing exits and entries at national borders is one thing, but setting up rules over who can and can’t cross state lines is likely to be challenged, due to certain clauses in the U.S. Constitution that guarantee equal treatment. —K.L.
The term “mothballing” isn’t new, but the term has been used more often in recent months as flight demand took a nosedive and airplanes were taken out of service and put into storage—or mothballed. You may also hear the term “boneyard,” too, which is referring to the remote desert airports where mothballed planes are often stored. The desert locations are ideal since the low humidity means the planes are less likely to rust and there’s generally more room to accommodate all sizes of jets. —Lyndsey Matthews
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On April 24, the World Health Organization issued a brief denouncing the idea of immunity passports, writing: “At this point in the pandemic, there is not enough evidence about the effectiveness of antibody-mediated immunity to guarantee the accuracy of an ‘immunity passport’ or ‘risk-free certificate.’ People who assume that they are immune to a second infection because they have received a positive test result may ignore public health advice. The use of such certificates may therefore increase the risks of continued transmission.”
Still, countries around the world have continued the conversation: Both the U.S. and U.K. governments are currently in talks with tech companies to develop certificates people could use to show that they’ve had (and healed from) the virus.
How it would work: Using an app, you’d take a photo of your face and a government-approved I.D. This would then be matched with information about an antibody and antigen test. At checkpoints, the app would generate a QR code based on your data, showing the gate-keeper (a receptionist or border patrol agent, say) whether or not you are clear to proceed.
In Chile, the government is slated to start issuing immunity passports to those who have recovered from COVID-19. In Germany, government officials have asked the German Ethics Council to research how such a passport would affect its population, with health minister Jens Spahn noting, “The question of what it means for society when some people are hit by restrictions and others are not, that touches on the foundations of how society functions together.” Time, it seems, will tell. —K.L.
We included the definition of “nonessential travel” in our glossary of coronavirus terms like “lockdown” and “self-isolation,” but it’s worth revisiting this one again since we’ll be hearing it more as other countries and states begin to reopen in the coming weeks.
When Italy entered into Phase 2 of its lockdown on May 4, its citizens were allowed to travel more freely around their cities. But nonessential travel from abroad is still banned throughout the entire European Union through May 15—and could possibly be extended through June 15. That means, in order to travel to Italy and many other European countries, you’ll need to prove that you’re flying for an essential reason such as a medical worker responding to the crisis or another reason found to be necessary.
In the United States, nonessential travel hasn’t been defined as precisely, leaving it up to individual travelers to determine whether they have personal or business matters urgent enough that won’t allow them to stay at home. —L.M.
Fort Smith Public Schools is taking a rigorous approach to reducing the spread of germs in schools. With flu season bearing down on students and their teachers, FSPS Facilities staff are using Geneon foggers and a chemical called Hypochlorous acid (HOCl) to disinfect classrooms and offices throughout the district.
HOCI is a weak acid that forms when chlorine dissolves in water. HOCI is used in hospitals and several government facilities to help fight different viruses. The health department verifies that HOCI aids in the removal of influenza and certain bacteria, and that it is safe to use where children are present.
The district has one fogger in each of the secondary schools. These are used on a daily rotation from section to section of each school. At the elementary schools, there are two district teams that go out to fog 10 schools in one week and fog the remaining nine schools the very next week. These rotations began in late January and will continue until flu season is over. Facilities teams will increase their visits to elementary schools if there is a need.
In conjunction with the fogging there are a few things that each custodian is doing every day to help reduce the spread of germs. They are using HDQ which is a hospital grade disinfectant, virucide, and fungicide. Each door knob, paper towel dispenser, drinking fountain, and countertop is being wiped down with HDQ at different times throughout the day. All staff have been asked to help custodians ensure that all soap dispensers and hand sanitizer dispensers are full, and everyone is encouraged to promote good hygiene by washing hands often with soap or by using hand sanitizer.
Hypochlorous acid may be the disinfectant of choice for coronaviruses in an oral and maxillofacial surgery (OMS) office
Michael S. Block, DMD Brian G. Rowan, DMD MD
Abstract CoVID-19 virus structure and mechanism of infection
Coronavirus -19 (CoVID-19) is a novel virus. It causes Severe Acute Respiratory Syndrome. Coronavirus-2 (SARS-CoV-2) is the agent responsible for a surface to surface communicable disease which has infected approximately 4.7 million people as of May 17th, 2020 (1). Healthcare providers need options to limit and control the spread of the virus between each other and patients.
CoVID-19 is an enveloped, positive-sense, single-stranded RNA virus approximately 60 to 140 nm in diameter. The virus’s Spike glycoprotein S1 firmly binds to angiotensin converting enzyme 2 (ACE2) receptor which allows entry into the host cell (2, 3, 4). CoVID-19 infection creates a cytokine storm, severe pneumonia, multiple organ failure, and acute cardiac injury (5, 6).
Transmission of this virus occurs through touch or aerosol spreading of the virus. A common pathway of spreading this virus is through respiratory aerosols from the infected person (7). During speech, humans emit thousands of oral fluid droplets per second which can remain airborne for 8 to 14 minutes (8). CoVID-19 is detectable in surface aerosols for up to three hours, up to four hours on copper, up to 24 hours on cardboard, and up to two to three days on plastic and stainless steel (9, 10). There is a need to disinfect surfaces potentially exposed to CoVID-19 to prevent transmission.
Use of disinfectants
A disinfectant agent upon contact with the virus changes the protective protein coat, which loses its structure and aggregates, forming clumps of proteins with other viruses (9, 10).
Currently, the United States Environmental Protection Agency (USEPA) has recommended numerous disinfectants (11) against CoVID-19 which includes hypochlorous acid (11). The mechanism of disinfection involves
the destroying of the cell wall of microbes or viruses, allowing the disinfectant to destroy or inactivate them (12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27). This paper focuses on hypochlorous acid.
Hypochlorous Acid (HOCl)
An ideal disinfectant and sanitizer must be non-toxic to surface contact, non-corrosive, effective in various forms, and relatively inexpensive. Hypochlorous acid may be the disinfectant of choice for coronaviruses in an oral and maxillofacial surgery (OMS) office.
Hypochlorous acid (HOCl) is an endogenous substance in all mammals and it is effective against a broad range of microorganisms. Neutrophils, eosinophils, mononuclear phagocytes, and B lymphocytes produce HOCl in response to injury and infection through the mitochondrial-membrane–bound enzyme known as respiratory burst NADPH oxidase (28). HOCl selectively binds with the unsaturated lipid layer and subsequently disrupts cellular
integrity. Between pH levels of 3 and 6, the predominant species is HOCl which has maximal antimicrobial properties (29, 30).
Hypochlorous acid (HOCl) is a powerful oxidizing agent. In aqueous solution, it dissociates into H+ and OCl- , denaturing and aggregating proteins (30). HOCl also destroys viruses by chlorination by forming chloramines, and nitrogen-centered radicals resulting in single- as well as double-stranded DNA breaks rendering the nucleic acid useless and the virus harmless (31).
How is HOCl made? HOCl can be made on site combining non-iodinated salt, water and electrolysis. The system to make HOCl on site is a one-liter container which is filled with water. A gram of non-iodized salt and 1 teaspoon of vinegar is added to the water. The system has the ability to make 50 ppm (1 ppm = 1 mg/L) to 200 ppm concentrations depending on use which is chosen by pressing a button on the instrument. The electrolyzed solution is completed in 8 minutes, when it is ready for use.
The parameters that contribute to HOCl’s disinfectant’s efficacy include contact time and concentration (32, 33, 34). The method of application will also affect its efficacy to disinfect.
Stability of solution: Rossi-Fedele et al investigated the shelf-life of hypochlorous acid by being either exposed to or protected from sunlight. When the HOCl solution is exposed to sunlight, chlorine reduction starts at day 4. When sheltered from sunlight, the chlorine reduction started after day 14 (35). The half-life increases with decreasing pH due to the decreasing ratio of OCl−/HOCl (36). The parts per million (ppm) is the concentration of the –OCl which is the active ingredient and is also known as the available free chlorine (AFC) in the solution. HOCl solutions are less stable when exposed to UV radiation, sunlight, contact with air, or when the temperature of the solution was elevated greater than 25 degrees centigrade (C). HOCL solutions should be stored in cool, dark places, and contact with air should be minimized. The water for fabrication should be water that contains as small as concentration as possible of organic and inorganic ions (37, 38, 39, 40).
Concentration related to time needed for virucidal action: HOCl has been shown to inactivate a variety of viruses including coronaviruses in less than one minute (39). At a concentration of 200 ppm, HOCl is effective to decontaminate inert surfaces carrying noroviruses and other enteric viruses in a 1-minute contact time. When diluted 10-fold, HOCl solutions at 20 ppm were still effective in decontaminating environmental surfaces carrying viruses in a 10-minute contact time (40).
Recommendations for office use
The importance of aerosol size to disinfection and application: Those working in the dental and medical field using surgical and high-speed handpieces are at risk from aerosolization. Aerosols are defined as particles less than 50 micrometers in diameter. Particles of this size are small enough to stay airborne for an extended period before they settle on environmental surfaces or enter the respiratory tract (41, 42). Additionally, a true aerosol or droplet nuclei may be present in the air of the operatory for up to 30 minutes after a procedure (41).
Particles are classified based on size: coarse particles are 2.5–10 microns, fine particles are less than 2.5 microns, and ultrafine particles are less than 0.1 micron. The nose typically filters air particles above 10 microns. If a particle is less than 10 microns, it can enter the respiratory system. If it is less than 2.5 microns, it can enter the alveoli. A particle less than 0.1 micron, or an ultrafine particle like the COVID-19 virus, can enter the bloodstream or target the lungs.
Sotiriou et al. demonstrated that the amounts of small particles (<0.5 μm) generated during dental drilling procedures were much higher than the amounts of larger particles (>1 μm) (42). Ultrasonic and sonic transmission during nonsurgical procedures had the highest incidence of particle transmission, followed by air polishing, air/water syringe, and high-speed handpiece aerosolization (43). One study found that ultrasonic instrumentation can transmit 100,000 microbes per cubic foot with aerosolization of up to six feet, and, if improper air current is present, microbes can last anywhere from 35 minutes to 17 hours (44).
Mouthrinse: If used as a mouth rinse, one must assume that a portion of the rinse will be swallowed. The systemic and gastrointestinal effects of ingesting HOCl, from the perspective of its use in mouthwash, was evaluated in an animal study (45). Seventeen mice were used given free access to HOCl water as drinking water. No abnormal findings were observed in terms of visual inspections of the oral cavity, histopathological tests, or measurements of surface enamel roughness showing no systemic effect.
Other Clinical applications:
Ophthalmology: HOCl is used in the treatment of blepharitis by reducing the bacterial load on the surface of the periocular skin. Twenty minutes after application of a saline hygiene solution containing 100 ppm HOCl, a >99% reduction in the staphylococcal load was achieved (46).
Biofilms: HOCl may be effective for cleaning biofilm-contaminated implant surfaces. HOCl significantly lowered the lipopolysaccharide concentration of P. gingivalis when compared with NaOCl and chlorhexidine, and was well tolerated by the oral tissues (47). HOCl significantly reduced bacteria on toothbrushes. It was effective as a mouthwash and for toothbrush disinfection (48).
Wound care: In a clinical study on intraperitoneal wound care, patients had their peritoneal cavity lavaged with 100 ppm HOCl and their wound washed with 200 mL ppm. No adverse effects were observed (49).
Hypochlorous acid has been shown to be an effective agent in reducing wound bacterial counts in open wounds (50). In the irrigation solution in the ultrasonic system, HOCl lowered the bacterial counts by 4 to 6 logs. By the time of definitive closure, the saline-irrigated control wounds had bacterial counts back up to 105 whereas the HOCl irrigated wounds remained at 102 or fewer. More than 80% of patients in the saline group had postoperative closure failure compared with 25% of patients in the HOCl group.
Hand sanitizing: Hand antiseptics are alcohol-based or are non-alcohol based containing antibiotic compounds (51). Chlorine-based sanitizers, at a concentration of 50–100 ppm, are effective against bacteria and viruses (52). HOCl specifically used for hand sanitizers are effective with 100-200 pm strengths (53, 54).
Surface application: A study looked at disinfecting outpatient surgical centers using HOCl. After cleaning, the HOCl cleaning and disinfecting study arm had significantly lower bacterial counts compared to the standard cleaning and disinfecting rooms (55).
HOCl Applied by a spray or fogger
A fogger takes a solution and creates a small aerosol mist ideally less than 20 microns in size, to disinfect an area. HOCl fogs are highly effective in the microbial disinfection of surfaces. The fogging processing can alter the physical and chemical properties of the disinfectant. It was found that fogging reduced the available free chlorine (AFC) concentration by approximately 70% and increased the pH by approximately 1.3 making the solution slightly more basic. It is speculated that the loss of chlorine resulted from evaporation of chlorine gas (56, 57). Because the changes in the properties of hypochlorous fogs are predictable, pre-adjustment of the concentration and pH of the solution prior to fogging makes can control the concentration levels to the desirable range to inactivate pathogens after fogging (40). When used in the appropriate concentrations, a study found a 3
log10 reductions to 5 log10 reductions in both the infectivity and RNA titers of all tested viruses on both vertical and horizontal surfaces, suggesting that it is an effective approach to reduce viruses on surfaces (40, 58).
HOCl solutions appear to be virucidal based on concentrations above 50 ppm. HOCl was evaluated against a low pathogenic avian influenza virus (AIV), H7N1. HOCl solutions contained 50, 100 and 200 ppm chlorine at pH 6. Spraying with HOCl decreased the AIV titer to an undetectable level (< 2.5 log10TCID50/mL) within 5 sec, with the exception of the 50 ppm solution harvested after spraying at the distance of 30 cm. When HOCl solutions were sprayed directly on sheets containing the virus for 10 sec, the solutions of 100 and 200 ppm inactivated AIV immediately. The 50 ppm solution required at least 3 min of contact time. These data suggest that HOCl can be used in spray form to inactivate AIV (59, 60). When the aerosol was not sprayed directly onto an inoculated surface,
a lower amount of solution had a chance to come in contact with the AIV. It required at least 10 min of contact to be effective (61).
The ability of a sprayer to make smaller particles may help solution’s molecules to be suspended in the air for a longer period of time because of their low settling velocity rate. This may increase its chance to come in contact with pathogens and inactivate them. Thus, the fogger used should have an aerosol size less than 20 microns (62).
The Coronavirus Pandemic has caused both a massive healthcare and economic disruption all across the world. The current unavailability of an effective antiviral drug or approved vaccine means that the implementation of effective preventive measures are necessary to counteract CoVID-19. Oral-maxillofacial surgeons are high risk providers providing needed care to patients. As more OMS and surgical offices open during reopening in the United States and elsewhere in the world, the need to reduce risk of transmission of CoVID-19 between patients and providers is necessary. It is widely believed that with proper screening and discretion, along with adequate personal protective equipment (PPE), there is a low probability of becoming infected. The goal of this paper is to provide information regarding disinfection in the clinical office setting using hypochlorous acid, a relatively inexpensive, non-toxic, non-corrosive, and well-studied compound.
HOCl has uses in many industries from farming and restaurants regarding food, to healthcare applications including chronic wound care and disinfection (34, 36, 43, 45, 46, 63). In addition to being used as a liquid based disinfectant, fogging with hypochlorous vapor has shown viricidal activity to numerous types of viruses and bacteria (40, 56, 57). This is of potential benefit to disinfect large spaces such as medical and dental offices where aerosols can be airborne for extended periods of time (42, 44, 64). Oral-maxillofacial surgeons may be at a slightly lower risk to their dental counterparts in terms of particle size as ultrasonic scaling and high speed handpieces create smaller particles that remain airborne longer (42). However, aerosols are still created with surgical handpieces. Additionally, the CoVID-19 virus can be present upon some surfaces for days and the disinfection of all surfaces of an operatory is important to reduced transmission (9, 10).
Many properties of HCOl contribute to why it may be the disinfectant of choice in the OMS setting. While the shelf-life of HOCl is relatively short, it is effective for up to 2 weeks under ideal conditions (35). It can be made on site inexpensively. A gallon of hypochlorous acid can be purchased from manufacturers but it is far more economical for an oral-maxillofacial surgeon to produce the solution on site in the office (65). A variety of HOCl systems on the market are available costing less than $275 (66). By combining non iodinated salt, water, and electricity (33) a liter of HOCl can be made in 8 minutes and the process repeated many times throughout the day. By comparison a pack of common disinfecting wipes containing quaternary ammonium compounds containing 80 sheets cost between $4 and $15 for a pack. These wipes may only last a day or two depending the size of the office and area to clean. Shortages of these products can occur making sourcing them difficult as well (67).
In addition to using HOCl as wipes for disinfecting, using HOCl vapors through a fogging machine is an economical way to disinfect a large operating room or suite where aerosols were produced during surgery. Fogger or misting machines are handheld machines and can be purchased for a reasonable cost (68). The aerosol mists should be ideally less than 20 microns in size to maximally disinfect an area. It is important to note that fog processing can alter the physical and chemical properties of the disinfectant making it more dilute and basic. As mentioned before, the available free chlorine (AFC) concentration can be reduced by approximately 70% and the pH can increase by about 1.3 (40). To make a vapor as effective as a solution containing 100 ppm of HOCl, the solution would need to be concentrated. The fine mist can be left in the empty surgical room without thought regarding harmful chemical affects and then surfaces wipes clean and dry after a few minutes and ten minutes for a more dilute solution.
Hypochlorous acid is one disinfectant which combined with adequate PPE, screening/social distancing techniques, handwashing and high-volume evacuation suction that may help reduce the transmission of CoVID-19 in the outpatient OMFS surgical setting. It comprises many of the desired effects of the ideal disinfectant: it is easy to
use, inexpensive, has a good safety profile, can be used to disinfect large areas quickly and with a broad range of bactericidal and viricidal effects.
Disclosures: Dr. Block owns stocks with X-Nav, Inc. Dr. Rowan has no financial conflicts.
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New Technology Meets the New Normal: Solving Event Attendance During a Pandemic
Events, concerts, and any large gathering of people will never be the same, but Sani Pass is a mobile disinfection channel solution for the new normal in our post-coronavirus world.
June 16th 2020, Thunder Bay – While many businesses are reopening, the threat of COVID-19 is still preventing large gatherings from returning. Sani Pass, a mobile disinfection channel that can be setup at any event, building, or large gathering, can help expedite the opening of these businesses. Using a touch-free disinfection and temperature screening process, Sani Pass gives attendees and organizers added protection against infection.
Mark Zurevinski, CEO of Sani Pass, saw his entire business disappear with the emergence of COVID-19:
“Having been in the entertainment business for decades, we went from 100 to 0% overnight. We explored solutions to help us reopen our business, however there simply wasn’t any— so we built one: Sani Pass. The machine initially detects and verifies that you are wearing a face mask and that your body temperature is within acceptable limits. Hand sanitizer is then dispensed touch-free. Upon stepping into the unit, a natural, non-toxic disinfectant is emitted as a dry fog, leaving absolutely no residue. It’s truly an all-in-one solution for businesses looking to protect their staff and customers from cross-contamination.”
We strongly believe that the use of a Sani Pass disinfection channel, in combination with a proper face mask, helps in the prevention of contracting COVID-19 through cross-contamination when entering a populated space. The mobile disinfection channel is equipped with a proprietary system that disperses a very fine, dry fog of organic, non-toxic, non-irritant disinfection solution. This process assists in protecting individuals when entering a confined area by eliminating 99.9% of germs and viruses that may be present on their skin, clothes and handheld belongings. Sani Pass has also been designed to be handicap accessible.
The solution used within the Sani Pass unit is one of nature’s oldest disinfectants: HOCI. As Heidi Wilcox, Wilcox EVS microbiologist and infection control specialist, explains:
“Infection mitigation systems like Sani Pass that use HOCl are the holy grail of sanitizing and disinfecting. HOCl is, by far, the least toxic disinfectant for humans and the environment. Using HOCl, Sani Pass also cuts down on solid waste, like plastics or cardboard present in other cleaning operations. There are also no synthetic fragrances and dyes in the solution to avoid causing or exacerbating asthma or reducing indoor air quality.”
Sani Pass is touch-free, and the entire process is completed in approximately 8-10 seconds per person, depending on face mask detection, or if other advanced features are enabled.
While we can never expect to return to a world without COVID-19, we must do everything possible to protect people while still allowing them to live and enjoy their lives. Sani Pass is an all-in-one, mobile solution that comes in multiple models to fit a wide range of needs. More info on the different models available can be found on the Sani Pass website.
To learn more about Sani Pass, or to schedule an interview with Sani Pass CEO Mark Zurevinski, please call +1-603-306-3645 or e-mail email@example.com. You can also check out the Sani Pass website at http://sanipass.net.
All visitors to Russian president’s residence outside Moscow must go through device
Israel Times, by AFP 17 June 2020, 3:57 pm
A coronavirus disinfectant device installed June 16, 2020, at the entrance to the residence of Russian President Vladimir Putin, outside Moscow. (Screen Capture: Twitter)
MOSCOW, Russia — Visitors meeting Russian President Vladimir Putin at his country residence must first pass through a walk-through device that sprays them with disinfectant, to protect him from the coronavirus, officials said.
Putin has been self-isolating at his Novo-Ogaryovo residence outside Moscow under lockdown, although he made a public appearance without a mask at an outdoor event on the June 12 Russia Day holiday.
As part of precautions to protect the president, visitors walk through the device and get sprayed from above and the side, a video posted Tuesday evening on Twitter by Kremlin pool journalists from RIA Novosti state news agency showed.
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The authorities in Penza region east of Moscow where the device was made boasted that it “ensured the safety of the head of government and all those who visit him.”
The Penza regional government said the president’s staff got in touch with the Russian manufacturing company, which until the virus outbreak specialized in automatic cleaning equipment for industrial use.
The device includes facial recognition technology and can take people’s temperatures, according to the manufacturers.
The Kremlin has imposed a range of measures to protect Putin including regular virus testing of the leader and all those who come into contact with him.
Visitors have to take a virus test before meeting Putin, his spokesman said.
The president began holding video conference calls with officials in April, although there have been a few exceptions. For example he was shown meeting in person with the chief of oil giant Rosneft, Igor Sechin, on May 12.
Despite these measures, some in Putin’s circle have caught the virus, including his spokesman Dmitry Peskov, who said, however, that he had not met the president recently enough to have infected him.
In an apparent close brush with the virus in March, Putin was shown on television shaking hands with the chief doctor at a Moscow virus hospital while neither was wearing a mask. The doctor, Denis Protsenko, soon afterwards tested positive.
The elaborate precautions protecting Putin sparked anger from some as the Kremlin has ruled it is safe to hold a national vote on July 1 on constitutional changes that would allow him to serve another consecutive Kremlin term.
“Let them install this know-how at every polling station and then hold a vote,” wrote a commentator, Aleks, on the website of Komsomolskaya Pravda tabloid.
“While an N95 mask (or KN95) is probably our best personal protection, ultra-low volume fogging with a hypochlorous acid solution is our best option at this point to ‘clean’ the air.”
Congratulations to the dental profession. We won the lottery. According to data from the Occupational Information Network, dental hygienists are the most likely of all health care workers to contract SARS-CoV-2 in the workplace and dentists and assistants are right behind them!
This is primarily because of the aerosols we create when using ultrasonic scalers and highspeed handpieces. According to The New England Journal of Medicine, viral particles stay contagious in the air for 3 hours or more. While an N95 mask (or KN95) is probably our best personal protection, ultra-low volume fogging with a hypochlorous acid solution is our best option at this point to “clean” the air.
Understanding Cold Fogging
I’ve received a lot of questions from dentists about cold fogging and will answer some of the most common here. As information continuously changes, I’ve also started a blog to address fogging concerns and will send out a newsletter with updates and new information every week. If you send me a question, I will answer it on the blog; if you are confused about something, chances are others are as well.
There is still so much we need to understand about this virus. We are currently bombarded with information, often contradictory, and certainly very confusing. So, the intent of my blog is to give us a place to ask and answer questions, cooperate, collaborate and share our best practices. I like to think SARS-CoV-2 is Goliath and we are, collectively, David. And we all know how that story turned out! To receive the newsletter and join the discussion on THE COLD FOG BLOG, please register on the homepage of my website, lisagermain.com.
Now, on to the questions.
Why is Hypochlorous Acid the Best Solution to Use for Cold Fogging?
Hypochlorous acid (HOCl), also known as electrolyzed water, is considered by the FDA to be “the form of free available chlorine that has the highest bactericidal activity against a broad range of microorganisms” (US FDA, 2015). HOCl has no toxic material disposal requirements and, according to the OSHA Hazard Communication Standard, is not considered to be hazardous waste, adding yet another advantageous element to HOCl use .
The additional protein denaturing activity of HOCl and, in particular, its inactivation of prion
proteins, also suggests new opportunities for the design and execution of disease control
2 measures in health care institutions .
The reason hypochlorous acid is such an effective oxidant is because it carries no electrical charge. In contrast, the hypochlorite ion (bleach) carries a negative charge. Because germ surfaces also carry a negative charge, they initially repel each other. It takes up to half an hour for bleach to do the job, whereas hypochlorous acid’s lack of electrical charge allows it to penetrate the protective lipid barrier surrounding the viral particles quickly and to destroy the proteins in a matter of seconds.
How safe is it?
Hypochlorous acid, unlike chlorine bleach, is 100% safe, non-irritating and not corrosive. Various concentrations of hypochlorous acid are used in the food industry, for eye and wound care and as a surface disinfectant. So, if it gets on your skin or in your eyes, it will not burn. Even if it were accidentally ingested, it is non-toxic. However, there are currently no studies that discuss inhalation safety, so if you do decide to use it, wearing a mask during application is advised.
How do I obtain HOCl?
Various formulations and strengths of HOCl are registered with the EPA, and it is used for disinfection and sterilization worldwide. It is available pre-made, or you can make your own with a home electrolysis machine using water, non-iodized salt and vinegar.
How much should I use?
Current recommendations for cold fogging to deviralize (is that a word?*) aerosols created in the dental office are in a concentration of 200 ppm. The solution is a weak acid with a pH between 5 to 7. There are test strips available to test the ppm, as well as to test the pH.
How does fogging work?
The solution is placed into the reservoir of an ultra-low volume fogging machine that will create a mist (not a spray) of the solution. The machine must be able to disperse the HOCl in a particle size of 20 microns or less, so check the specs of your device before use. Surfaces must be clean and dry prior to cold fogging. So, wipe down your chairs, counters, lights, etc. with whatever you normally use to disinfect them first.
Now comes the fun part. Point the fogger at one corner of the ceiling of your operatory and begin spraying a fine mist all the way around the perimeter. Then distribute it evenly in “stripes” across the rest of the ceiling. You can then give an extra mist over the chair area where aerosol creation is the heaviest. Now, don’t go all “Rambo” with it or you will create puddles. If done correctly, it should dry in a minute or so. You can then seat your patient. Cold fogging can be done between every patient if you choose.
Can I Cold Fog PPE?
While the intent is to clear the viral particles in the air, isolation gowns and shoes can safely be cold fogged with HOCl, although efficacy has not been tested. It is very important to note that N95 masks become ineffective if they get wet. Moisture will destroy the electrostatic charge in the filter that creates the true protective barrier between the virus and your respiratory system. It is safe to cold fog your street clothing and scrubs; however, it is not a substitute for laundering them.
How Can Cold Fogging Be Used With Other Methods?
Cold fogging with electrolyzed water is often confused with electrostatic spraying, a method for surface disinfection and not for aerosols. HVAC filters and room filters with HEPA technology and UVC light are all great adjuncts for cleaning and recirculating the air and can
be used as additional protection along with cold fogging. Heat fogging uses different machinery and is not appropriate for indoor use.
And now for the $64 million question:
If I do ‘X’, ‘Y’ and ‘Z’, (fill in your protocol), Is It Still Necessary To Cold Fog With Hypochlorous Acid?
The bottom line is we don’t know the answer. It is, however, a logical way to deal with the microbes created by dental aerosols. Every clinician needs to do their own due diligence to establish a protocol they feel creates a safe environment for themselves, their team and their patients.
*I cannot find “deviralize” in any reference or dictionary…so if it becomes part of our language, remember where you heard it first!
OSHA Hazard Communication Standard: 29 CFR 1910.1200
Hughson, A. G., Race, B., Kraus, A., Sangaré, L. R., Robins, L., Groveman, B. R., … Caughey, B. (2016). Inactivation of Prions and Amyloid Seeds with Hypochlorous Acid. PLoS Pathogens, 12(9), e1005914. http://doi.org/10.1371/journal.ppat.1005914