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3 New Facts About SARS-CoV-2 on Surfaces and Fomite Transmission

Uncategorized May 31, 2020

Hello, my name's Dr. Cameron Jones, and welcome to this week's live stream.

Now, I guess all of you are getting used to using some type of hand sanitizer when you go out? This is to protect us from coming into contact with other people or environments and to reduce the chance of the coronavirus replicating onto our hands and persisting on our hands, and then transferring them onto our face or onto our mucus membrane, or to other objects within our homes or workplaces where other people could come into contact with them. And so, today I wanted to talk to you about three new facts about fomites that you really need to know, and I've titled it COVID Fomites. Realistically it is coming into contact with the SARS-CoV-2 virus, which causes COVID-19.

In any case, what I want to talk about today is these three new facts. And essentially I want to talk about a paper which really talked about and put this into perspective very, very clearly. And this is talking about the transmission of the virus in a South African hospital, and it makes it incredibly clear how people actually do get sick with this particular virus from touching objects in their local environment. And this is a really fundamental paper, and we need to be very mindful and aware of this.

I also want to talk about another really interesting paper that came out in the literature this week, and it was talking about whether or not sunlight can be used, or specifically UVB, which is a particular range of wavelengths in the light spectrum, and their ability to deactivate the virus. And I also want to talk about the aerosol distribution of disinfectants, because many of you who live in urban environments have probably seen individuals who are paid to disinfect high touch surface areas in the city and in the towns, to potentially deactivate the coronavirus. I want to talk about this aerosol distribution or how you spray disinfectants in the environment. I also want to talk about hand sanitizers, and I want to talk about the alcohol-based hand sanitizers because we're all being encouraged to use alcohol-based hand sanitizers when we can't use soap and water. And I want to point out some of the issues and problems with this as well.

Now, I'm going to go full screen now. Now, Derek who works with me here in one of my labs, sent me this because he noted that some people who were paid to disinfect things like benches in the street, these are essentially the set of high touch surfaces. Someone is actually being paid to spray disinfectant, and as you can see, this individual did a really bad job. Now, in a sense, if you're using a sprayer or some way of actually distributing the disinfectant, you need to make sure that you've got sufficient dwell time, the concentration of the disinfected is correct, and that it is actually coming into contact with the high touch surfaces. So I would argue that whoever is being paid for this, the city is wasting their money. There needs to be a lot more education going into those individuals who are being paid to disinfect public spaces because this issue of fomite contamination is very real. And that is the topic of today's live stream.

Now, a couple of days ago in the New York Times, there was this very contentious title and article which came out and the CDC in the United States made the point that surfaces are not the main ways that coronavirus spreads. Well, we already know that. We know it's person-to-person and it is the droplet spread, but it is not just the droplets that end up settling out onto horizontal surfaces and on things like mice and keyboards in the workplace, but there's also this issue of fecal shedding in bathrooms and getting into contact with other surfaces. And the fact that you know, even the disinfectant pumps, research has shown in the literature that the top part, that your hand comes into contact with, is highly contaminated.

So we need to be very mindful of this issue of spray disinfectants being properly applied in urban environments and in our workplaces, and especially as we reopen and everyone is looking towards making a COVID safe workplace. So, the CDC said, Guess what? It may not be as important to disinfect all of your external objects like packages, grocery bags, and that sort of thing. Now, is this true or false? Well, I'm going to answer that, and that's one of the key messages in this live stream. And to do that, I want to highlight a tweet because the Twitter-sphere went off when this article appeared in the US media.

A scientist by the name of Eric Topol, who has over 1,200 peer-reviewed papers, and in fact was given a $200 million grant by the National Institute of Health for his work in precision medicine and consider that the state of the art for bringing health care to the population. And so he stated that the CDC was in infect somewhat negligent in the sense that they should not be promoting this message that surfaces are not dangerous, because they very much are. And he makes this point in his tweet and in other writings, which you can access.

Now, I want to talk about what the CDC did because they very quickly changed their website and they changed the headings around to reflect the scientific thinking about surface contamination. And I've put the URL up here so you can quickly review this yourself. And essentially what the CDC says now is that obviously person-to-person spread is the number one way that people become contaminated with the SARS-CoV-2 virus. They also state on this page that there is low risk from animal transmission to people, but the other way around, infected people to animals, is very much real and is a real possibility.

They also say that touching a surface or an object that has the virus on it is going to allow it to be transmitted, and this is something that we all need to be aware of. Certainly the research literature, the pre-print literature, there is so much information coming out online that we are continually learning about how this virus behaves in the real world. But it is very important to be very aware that surface contamination is very real and the CDC definitely supports this claim.

Now, I want to back this up with some other reports that have come out this week. And one is from a hospital in South Africa, in Durban, South Africa. And this is a tragedy in itself, but it is a wonderful piece of detective work that the medical personnel and scientists at this particular hospital have been able to provide and write up and produce, and it's available for us to read online. And what happens is is that this particular hospital had a lot of COVID cases. Unfortunately, 15 patients died. Now that's terrible in itself. However, they do have a very good and detailed timeline along with all the DNA or molecular evidence about the infections that occurred within this environment, the built environment, and they track this through from the beginning to the end. And that was from the 9th of March to the 30th of April. And there were 119 COVID cases.

And guess what? 80 of those were the staff. That is, the staff actually became sick with the SARS-CoV-2 virus and 39 patients within the hospital ended up getting this virus disease. Now, the evidence suggests that a single person entered the hospital and they entered on the 9th of March, and this whole disaster stemmed from this one person. But do you think it was person-to-person transfer? Well, I think not. And this is what this review of the evidence and the epidemiological evidence shows and confirms.

So, the first patient entered the emergency room with COVID symptoms and he is thought to have transmitted this directly to a stroke patient who was in the cardiac ward at the same time. Now, the detective work, as I said, went further, and they found that the infection then spread within five different wards of the hospital. And the conclusion in the publication stated that indirect contact and fomite transmission, which is the surface transmission, were likely to be the dominant modes of patient-to-patient transmission. And remember, you have 39 COVID patients from one, but 80 staff who became sick with symptoms of COVID, from this one introduction into the hospital. So there was no way due to the isolation that these individuals transmitted this via droplet spread. So it was picked up and distributed around the hospital on surfaces.

Now, there were also, unfortunately, other outbreaks into the adjoining region. And that affected a dialysis center and also an aged care facility that was affiliated with the primary hospital and 135 infections were acquired nosocomially, in a sense that is hospital-based acquisition of the virus. Now, molecular screening showed that every single one of the COVID patients had the same genetic composition of this RNA virus.

So, what are the conclusions from this publication and what should you do? Well, they make it very clear. Management and staff within this hospital, and consider this transferable to what needs to be occurring in cities all over the world as everyone begins the task of reopening and making their businesses COVID safe. Management must promote a culture whereby infection control is important. And so this whole concept of microbiological literacy needs to be focused on as well because people need to be aware of the role of microbes and viruses and what their potential is. So I think, unfortunately, this pandemic is certainly shining a light on microbiological literacy, and it's something that everyone is self-educating about, but it's something that needs to be more fully covered as part of specialized and ongoing training. You can see, certainly, with that photograph I put up earlier in this presentation, that people who are currently being paid to disinfect city streets are doing a pretty bad job.

Now, the next point I want to make is that hand hygiene needs to be continually emphasized, but not just emphasized, it needs to be practiced as well. And where you can't use soap and water you need to be using alcohol-based hand sanitizers. Now, environmental cleaning practices must be improved. And over the last couple of weeks, I have looked at how fluorescent brighteners, how ultraviolet lights, how you can make your own ultraviolet camera with your smartphone, and sticky tape and some blue and purple texters/markers, can quickly turn your smartphone into a device that you can use with a fluorescent pen/marker to determine whether or not the cleaners have done a good job. Because at the end of the day, cleaning has become the number one method apart from social distancing and masks, whereby we can proactively help ourselves to reduce the risk of getting the dreaded COVID-19.

So cleaning must be monitored closely, and the use of fluorescence markers and other ways of testing in the environment cannot be overlooked. Now, the importance of regular cleaning of surfaces, especially medical equipment and in healthcare settings, obviously is fundamental, but I would argue that certainly in fast-food restaurants and places of entertainment and gymnasiums and sporting environments, obviously workplace cleaning is going to become fundamental under tables, under seats, high touch surfaces, computer keyboards, press plates indoors, all of that. Everything that is probably currently being managed in small businesses when this occurs at scale, the probability of things going wrong is a big issue. And you can see from that photograph that Derek sent me to use for today's live stream, that people are just spraying the disinfectant on and moving on to the next item. That's not good enough if you want to implement effective infection control.

Anyway, without digressing any further, physical distancing is obviously important. And the authors conclude from the South African study, that consideration needs to be given to weekly PCR testing. And I would argue further that certainly in Australia and countries that show a low level of transmission, in order to reduce the potential of further outbreaks and significant upticks, we need to be very mindful of testing in the environment, and this needs to probably include something better than fluorescent markers. And in some high-risk environments, it's definitely going to be necessary to test for the actual presence of the virus remaining on surfaces.

And to do that, we would be using a molecular testing kit to test this out, using PCR. We're going to get into this in-depth in the coming days and weeks. Now, a wonderful blog post appeared, which also then went into the mainstream media, and again, into the Twitter-sphere and other avenues. And a scientist by the name of Dr. Erin Bromage made this very easy to remember formula. And it is: successful infection, that is whether you and I get the virus, depends on your exposure to the virus and the time that you've been exposed. So, the first part of the equation, the exposure to the virus, you need to add up all of the opportunities that you might have in your day-to-day work or leisure, to come into contact with either symptomatic or asymptomatic people, and then how much time you spend with them. So there's a very easy to remember equation. So, the more times you're in high-risk environments and the longer you spend in those high-risk environments, the greater the probability of a successful infection event. And that is another key takeaway of today's presentation.

Another colleague of mine sent me an SMS with an attached paper very early in the morning, earlier this week. And in it, the attachment was, Sunlight Kills Coronavirus. Obviously I instantly woke up, read the PDF word for word, and was intrigued by the graphs that appeared in figures four and five towards the end of this document. And I'm going to put up the early, you can get this off the Journal of Infectious Diseases and in the Journal of Infectious Diseases, they are demonstrating how sunlight can be used to kill SARS-CoV-2 between seven and 14 minutes, which is just fantastic, especially for us in Australia, whereby we have a lot of sunlight.

Now, again, I have just taken one of the graphs with the aim of simplifying these presentations I do each week. Rather than overloading you with data, I wanted to show you what happens to the viability of the SARS COVID 2 virus in darkness. That is, when we have the lights off. And you can see that it's pretty much a very slowly decreasing line. So over time, we know that the replication capacity of the virus reduces, and what the scientists did is that they used live virus, sprayed it onto coupons of stainless steel like my lab benches, and then they have been measuring the ability of the virus to be recovered using swab testing of those surfaces. And you can see in the dark that it very slowly reduces over time.

Now, if we move on to the next example, this is the key point of the experiment. What they did is they used UVB light to irradiate onto the virus, and you can quickly see a wonderful decrease in the recovery rate of the virus. So, this is UVB light at 1.6 watts per square meter of coverage. And if that doesn't make any sense to you, I'm going to explain this and tell you what UVB light is. But again, I've put the reference up and it will be in the show notes as well. So, what is the role of the sun and why did these people focus on UVB? We've talked about UVC before, which is ultraviolet germicidal irradiation, and those wavelengths at often 254 nanometers are just fantastic for killing a whole range of microbes, including bacteria, yeast, fungi and deactivating viruses as well.

But these signs in this paper have moved up the light spectrum towards the UVB range and the UVB range is a really interesting section of the light spectrum. And many of you may be aware of several famous models that have a skin condition called vitiligo, and UVB has been known since 1904 to be very beneficial in the treatment of patients with this skin condition called vitiligo. And this is closely related to something called photodynamic therapy, which I'm also going to be discussing in future live streams is well. But I want to get back to why UVB is effective in deactivating viruses and where else is UVB lights used?

Well, herpetologists not to be confused with hepatology, which is a branch of medicine, herpetologists are focused on the zoology of lizards in a sense, and a range of different animals like that. And these particular lizards require exposure to sunlight. How do you do that if you have them as a pet? Well, you can purchase UVB lights and you can jump online and you can find a whole range of vendors selling UVB lights, LED's, fluorescent fittings, all different types of lights, which emit UVB. And this publication does demonstrate that you can deactivate the virus in the environment.

Now, should you do this? I'm definitely not advocating you doing this because even though UVB light is very beneficial for treating this skin condition called vitiligo, UVB is the dominant wavelength which contributes to melanoma. It causes skin cancer. It will make you sunburned, and that is the light frequency that does it, the UVB. So in a sense, we can't just install UVB lights and wander around. We can't put them into Grand Central Station or the train station of Bondi Junction, or any other public environment. Trams and trains? Well, maybe, but what are you going to do? You can't give everyone sunburn, but there are opportunities to use these lights, just like we use ultraviolet germicidal irradiation with the UVC to install these and have them come on when there are no persons present. And that's no persons or pets present at all.

So, there are tantalizing opportunities for using light to deactivate viruses, at least on surfaces, but they too will run into the same problems of only being able to get to the top side of high touch services. So the underside of chairs, for example, which is one of the dominant problems. If you can imagine walking into a fast-food restaurant or any restaurant, we all pull our chair towards us, it's a high touch area. Light is not going to be effective in deactivating, or any microorganisms, if it is from the top down. But you can see that there are opportunities of using light effectively.

Now, next week, I'm going to be talking about deactivation with light, because this is the first of many publications I suspect that are going to be emerging in the peer review and open source literatures in the coming weeks, months and years. Because this issue of deactivation of various different agents has been on the radar of scientists certainly for a long period of time and there is an outstanding publication that came out in 2013 entitled Can Biowarfare Agents Be Defeated With Light? And anyone who's interested in using light for deactivation of anything, not just viruses, but bacteria, yeast, and fungi, and all sorts of other encapsulated plasmids and things like that, should be looking at this particular paper because it does an excellent review of this whole area.

Now, conclusions. Well, how do we go about protecting yourself? Well, we still don't know lots about this virus. So there is, as I said, emerging literature every day and what we think we know one-month changes to some extent, as new information is introduced. So, originally people thought that the infected period was really about two weeks, but some papers and media stories have come out in the last 48 hours suggesting that the period at which people can have virus recovered could be potentially up to 80 days. So this is very concerning from a public health messaging viewpoint, because how do you know what is most relevant to provide to people at what point in time, and when do you change information and modify it to make it more meaningful and accurate as new information appears in the research literature?

So, I just want to make the point that a lot of what we're learning is changing, that obviously we do need to maintain social distancing. In Australia, the suggestion is 1.5 meters. The research literature says really it's a lot longer than that, a lot longer distance. So maintain significant distance, especially if you're in a susceptible population or group or spending time as we move into more populated areas like shopping centers. Wash your hands with soap and water and if none available, well then use these alcohol-based hand sanitizers. And obviously, routinely clean and disinfect high touch surfaces. And that is where I want to go.

Now, I am going to come back now to this because I want to give you a little demonstration about why soap and water is better than these hand sanitizers. Now, I do use hand sanitizer all the time, but there's something which we can get, which is a fluorescent containing hand gel. And it is to demonstrate what the process of washing your hands with alcohol-based hand wash actually does. What I'm going to, I'm just going to turn the lights off in here so that you can see this a little bit better. I'm going to apply this exactly as if I was using my alcohol-based hand sanitizer, but this one is fluorescent. And try not to drop this on my computer. So, you can see that.

Now, I'm going to wash my hands in front of you, just like I would if I was using hand sanitizer, getting back into my car or after going to the supermarket, or before I do something such as that, which is very common to all of us. Now, if I use my UV light now, you can see what areas of my hands I've actually managed to disinfect. And look, it's not particularly perfect, is it? So some areas of my hands have got a good amount of hand sanitizer on it and other areas don't have very much at all. So, the point of this little exercise is to show you that even if you use hand sanitizer, it's not a perfect solution. And so I think we need to be very mindful that the best way, this is only a harm minimization approach, it's fundamental and very important, but the same goes for disinfecting surfaces in buildings as we move towards COVID safe workplaces. If the product doesn't come in contact, the disinfecting product, with all of the surfaces and maintain this dwell time, it's not going to sanitize the surface. And at the end of the day, that is the real take-home message from this live stream.

In any case, I'm going to go and wash my hands and I'll talk to you next week and see you then. Have a great week. Bye for now. 

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