Outbreaks on Cruise Liners Offer Lessons for Hospitals

We asked readers the question, “Are You Concerned about Coffee Cup Contamination?” This was in response to a query by a visitor to this website who worried about catching a cold or the flu because the coffee barista touched the top of her cup and lid with bare hands. By the way, research published in the journal Clinical Microbiology and Infection (Jan., 2014) suggests that flu viruses can linger on finger tips for at least half an hour. Are there lessons for hospitals from this research?

People Hate To Think About Microbial Contamination:

Many of the comments that came in implied that worrying about coffee cup lid contamination is ridiculous and the whole “germ thing” has been blown way out of proportion.

Jennifer said:

“No, I don’t want a worker sticking his contaminated finger on my cup, but it’s more of a psychological ick factor than an physiological one. I’m in the ‘challenge your immune system’ camp.”

R.M. stated:

“I have no concern about this whatsoever. Stop being so paranoid.”

Just adds:

“I understand the ‘barista and the lid’ anxiety, but it’s based on psychology and appearances, not science or medicine. If you SEE it, it becomes a worry, like the roach on the wall of the restaurant. Disgusting, and you may walk out. But if you never saw it, no big deal.”

Norovirus IS a Big Deal!

We wonder if the “no worries” camp would be so cavalier if they came down with the extreme vomiting and diarrhea that affected over 600 passengers and crew on the Royal Caribbean cruise ship that made headlines. Investigators suspect norovirus, which is easily spread from person to person by hand contact.

People often assume that this infection only affects those in close quarters, such as on cruise ships. But the CDC estimates that there are as many as 21 million cases of gastroenteritis linked to norovirus annually. Many occur in the community and are mislabeled as “stomach flu” or food poisoning. When you “catch” this infection, projectile vomiting and horrific diarrhea will make you think twice about the barista who takes your money and then handles your coffee cup lid with the same unprotected hands.

Norovirus is especially contagious, but it is not the only “germ” that can be transmitted from one person to the next by dirty hands. Besides the obvious viruses that cause colds and flu, there are lots of other nasties out there including Clostridium difficile (C. diff), rotavirus and hepatitis A, to name just a few.

What About Doctors & Nurses?

For years, infection control experts have been calling for improved hand hygiene. Gradually, health care workers are complying, but there is a long way to go.

An article in the Wall Street Journal (Sept. 30, 2013) by Laura Landro puts the situation into perspective:

“Yet despite years of efforts to educate both clinicians and patients, studies show hospital staff on average comply with hand-washing protocols, including cleansing with soap and water or alcohol-based gels, only about 50% of the time. Two new studies show patients aren’t much more comfortable today than a decade ago with the idea of asking doctors and medical staff to lather up.”

It turns out that most of us are afraid we might alienate our doctor or nurse if we ask about hand washing, even when there are signs in hospitals encouraging us to do so.

Other Sources of Contamination: White Coats & Stethoscopes?

As hard as it has been to get health professionals to wash their hands between patients, it has been far harder to get doctors to give up their white coats, ties, rings and watches. American male physicians are quite attached to their white coats, ties and the stethoscopes draped around their necks. All these items are potential sources of infection. To be blunt, they are frequently filthy, loaded with really bad bacteria, viruses and fungi.

The British Ban:

Several years ago the National Health Service in the United Kingdom banned long-sleeved white coats and required physicians, nurses and other healthcare workers to get “bare below the elbows.” That’s because study after study has found that white coats are frequently contaminated with a range of unpleasant bacteria. Ditto for ties and jewelry. In the UK doctors have to leave their uniforms at the hospital or clinic, where they are washed regularly.

American hospital administrators have scoffed at the UK initiative, claiming there is inadequate evidence to support these safety measures. In the U.S. it is not uncommon to see doctors and other workers going home or stopping in the grocery store wearing their white coats or scrubs. Many hospitals do not even have a policy for when and how these uniforms need to be washed.

All that might change if administrators follow new recommendations from the Society for Healthcare Epidemiology of America (SHEA). In essence, this prestigious organization is encouraging American health professionals to adopt the UK standards, ie, “bare below the elbows.” Ditch the jewelry! If white coats are worn at all, they should be hung up before interacting with patients. Regular laundering of white coats with hot water and bleach is encouraged.

A Paucity of Research:

You might imagine that physicians would be very interested to know whether contaminated white coats, neckties, stethoscopes or mobile phones pose a risk for patients. An article in Infection Control and Hospital Epidemiology (Nov. 2016) reveals that there has been a surprising lack of research into that important question:

“Transmission of pathogens within the hospital environment remains a hazard for hospitalized patients. Healthcare personnel clothing and devices carried by them may harbor pathogens and contribute to the risk of pathogen transmission.

“OBJECTIVE To examine bacterial contamination of healthcare personnel attire and commonly used devices.

“METHODS Systematic review.

“RESULTS Of 1,175 studies screened, 72 individual studies assessed contamination of a variety of items, including white coats, neckties, stethoscopes, and mobile electronic devices, with varied pathogens including Staphylococcus aureus, including methicillin-resistant S. aureus, gram-negative rods, and enterococci. Contamination rates varied significantly across studies and by device but in general ranged from 0 to 32% for methicillin-resistant S. aureus and gram-negative rods. Four studies evaluated for possible connection between healthcare personnel contaminants and clinical isolates with no unequivocally direct link identified.

“CONCLUSIONS Further studies to explore the relationship between healthcare personnel attire and devices and clinical infection are needed.”

We interpret this to mean that more research is necessary to answer the question of whether white coats or cell phones transmit nasty germs to patients. Until such studies are completed, are there lessons for hospitals?

We think hospital personnel need to err on the side of caution. That is especially true for white coats. A study published in the American Journal of Infection Control (Jan. 2017) revealed that nurses’ white coats were commonly contaminated with bacteria:

“After the second shift, bacterial colonies on polyester and blend fabrics increased by ~98% and ~70%, respectively. Among the isolates detected on polyester after the second shift, Escherichia coli was the most abundant (47.8%), followed by staphylococci (19.1%).”

Ask Your Doctor to Clean Her Stethoscope!

One other thing: the experts at SHEA say that stethoscopes “should be cleaned between patients.” When is the last time you saw your doctor really clean her stethoscope with alcohol before putting it on your chest or back? Stethoscopes are another source of contamination, but many health professionals rarely clean their stethoscopes between patients.

We suspect that implementation of these voluntary recommendations will take years. There is often resistance to change. And patients often feel powerless to speak up. They may believe that asking a doctor to take off a white coat, wash his hands or clean a stethoscope is tantamount to waving a red flag in front of a bull.

What do you think? Could you ever bring yourself to ask your doctor to:

Wash her hands? Remove his white coat? Clean the stethoscope? Share your thoughts below.

Revised: 10/12/17