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418 Dairy, Food and Environmental Sanitation — JUNE 2000
Dairy, Food and Environmental Sanitation, Vol. 20, No. 6, Pages 418-425
Copyright© International Association for Food Protection, 6200 Aurora Ave., Suite 200W, Des Moines, IA 50322
Reducing Transmission
of Infectious Agents
in the Home
Part II: Control Points
Michael P. Doyle,1 Kathryn L. Ruoff,2 Merle Pierson,3 Winkler Weinberg,4
Barbara Soule,5 and Barry S. Michaels6
(This is the last of a two-part series. Part I ran in the May 2000 issue of DFES.)
CONTROL POINTS IN THE
HOME
In any given household, certain
areas are more likely than others to
harbor disease-causing microorgan-
isms. Implementing effective strate-
gies to control pathogens in these
areas provides the best opportunity
for protecting household members
from illness.
Many pathogens can survive for
extended periods of time on fabrics
and household surfaces, increasing
the risk of pathogen transmission.
For example:
•Staphylococcus spp. can
survive on clothing and
handkerchiefs for up to a
month (66).
• Inf luenza A and B viruses
can remain viable for about
eight hours on cloth, and at
low relative humidity can
survive for days (7, 59).
• Adenovirus can survive at
least eight weeks on com-
mon environmental sur-
faces (62).
Some household features are
particularly conducive to bacterial
survival and transmission, regardless
of where in the home they are lo-
cated.
SUMMARY
Americans spend an estimated 90% of their lives
indoors, and during this time they are continually exposed
to a variety of substances, ranging from viruses to chemical
byproducts, that can cause illness. According to the
Centers for Disease Control and Prevention (CDC), at
least 250 disease-causing organisms can be transmitted by
food or drink, and several hundred more are transmitted
via the respiratory tract through sneezes, coughs, etc.
The actual likelihood of illness after exposure to
household pathogens varies considerably. Exposure to
even a small dose of some disease-causing organisms can
initiate serious infection, whereas massive exposure to
others is required to overcome the body’s natural defenses.
In some individuals, however, even comparatively benign
organisms can lead to serious illness. These vulnerable,
high-risk groups are believed to comprise approximately
25% of the population in the United States, and their
numbers will increase in the coming years.
The prevalence of potential disease-causing
microorganisms in the home environment, coupled with
the rapid rise of antibiotic-resistant microbes and the
growing numbers of at-risk individuals, make effective
household hygiene critical to the maintenance of a healthy
family.
JUNE 2000 — Dairy, Food and Environmental Sanitation 419
• Research on dispersal of mi-
crobial contaminants within
households revealed that
24% of door handles were
contaminated with E. coli
after meals were prepared
(27).
• Dust can harbor infectious
particles and allergenic ma-
terial, potentially contribut-
ing to cross-contamination
(6).
• Air can contain a variety of
respiratory irritants and
pathogens, including bacte-
ria, molds, lead dust, and
pollens (60, 79). Improved
insulation and increased
use of air conditioning,
with a resulting decline in
air exchange in many
homes, have increased the
level of airborne pollutants
in the home environment
(75).
• Carpets and dust can harbor
large numbers of microor-
ganisms, compared with
hard-surface f looring (73);
even hard flooring, how-
ever, can become a reser-
voir for infectious material
if not cleaned thoroughly
following family illness (4,
74).
THE KITCHEN
As a center of household activ-
ity, the kitchen is arguably one of the
most important areas for hazard con-
trol in the home. As the site of food
preparation and storage, it is an ideal
area for microbial pathogen trans-
mission. Inadequate hygiene or im-
proper food handling procedures by
the primary food preparer can lead
to widespread illness among house-
hold members. The food handler is
considered the main cause of cross-
contamination of surfaces, equip-
ment, and utensils in kitchens (78,
82, 87).
Contaminants in the kitchen en-
vironment can be remarkably resil-
ient. In one study, investigators us-
ing Salmonella-contaminated eggs
found that everything contacting
these eggs could easily become con-
taminated. When spread onto a
Formica work surface, the Salmo-
nella-laden eggs dried quickly into
a thin, invisible film, with the bacte-
ria surviving on the surface for at
least 24 hours. Utensils used to mix
these eggs were contaminated even
after washing (44).
Sponges, dishcloths, and dish
towels
Kitchen sponges and dishcloths
are ideal environments for bacterial
survival and growth, because these
objects are continually moist and
supplied with nutrients in the form
of food drippings and scraps (27,
64). In one study, 28 different types
of bacteria, Enterobacteriaceae,
Pseudomonas spp., and Burkhold-
eria spp., were isolated from cellu-
lose sponges and dishcloths. Sal-
monella spp. were detected in 14%
to 15% of sponges and dishcloths,
and Staphylococcus aureus was
present in about 20% (80). More
recently, a two-year study of “nor-
mal” US kitchens revealed that 67%
of tested sponges were contami-
nated with fecal coliforms (46).
Hand contact with such contami-
nated sponges or dishcloths can eas-
ily lead to cross-contamination, as
liquid wrung from sponges and dish-
cloths sometimes has extremely
high microbial counts (27, 30, 80).
The use of contaminated dish
towels to dry recently washed dishes
can lead to significant re-contamina-
tion of previously clean dishes. Stud-
ies have revealed increased bacterial
levels on dishes wiped with con-
taminated dish towels (10, 25).
The sink
The kitchen sink, much like the
cloths and sponges used in it, can
be an important reservoir of micro-
bial contamination. Bacteria isolated
from kitchen sinks include E. coli,
Klebsiella pneumoniae, Salmon-
ella spp., Enterobacter cloacae, and
Citrobacter freundii (46, 84). The
use of dishcloths to wipe sink sur-
faces can lead to the spread of mi-
croorganisms to other kitchen sur-
faces, when contaminated rags are
used to wipe counters, stoves, and
other surfaces (30, 80, 97).
The area in and around the sink
is easily contaminated during food
preparation and is often recontami-
nated during attempts at cleaning.
Bacterial contamination is parti-
cularly common — and preventable
— in the following areas:
• An estimated 82% of sink
faucet handles are contami-
nated during food prepara-
tion (27).
• Epidemiologic investiga-
tions revealed that drain
boards and sink drain areas
are frequently contaminated
with E. coli and other coli-
forms and can pose a health
hazard to consumers (12,
65, 84).
The refrigerator
Perhaps nowhere in the home is
there a greater challenge to cleaning
than in the refrigerator. The average
household refrigerator is the perfect
environment for the formation of
biofilms, which are invisible protec-
tive layers (composed of bacteria
and their byproducts) that can shield
bacterial cells from the destructive
effects of physical or chemical agents
(109). For example, microorganisms
in biofilms have been found to be
150 to 3,000 times more resistant to
free chlorine than are unprotected
cells (54).
The pantry
A 1991 study of 30 pantries in
the northeastern United States re-
vealed that many foods were stored
beyond the recommended “best use
by” date. Many insects, including
cockroaches, were found, product
rotation was poor, cleaning was ir-
regular, and many purchases were
not dated (22).
Canned foods generally remain
safe because they are sealed and are
almost totally free of bacteria, with
pathogens having been killed by the
canning process (31). Only a few
thermophilic and thermoduric
sporeformers may remain (77). If
420 Dairy, Food and Environmental Sanitation — JUNE 2000
these few survivors are anaerobic,
however, the spores can grow when
temperatures are sufficiently warm,
causing spoilage within the can (77).
Improper storage (>40°F) or too-long
storage can lead to this form of spoil-
age. In the United States, approxi-
mately two dozen cases of foodborne
botulism, usually due to contami-
nated home-canned foods that were
improperly processed, are reported
to the CDC each year (88).
Cutting boards
Cutting boards are a significant
source of cross-contamination in the
home, partly because of practices
such as cutting salad ingredients on
a board previously used to cut raw
meat (52, 108). Several surveys have
revealed that a high percentage of
consumers are unaware of the basics
of cutting-board safety (106, 107),
as seen from the following survey
results as examples:
• Up to 60% of people do not
wash the cutting board af-
ter cutting raw meat or
poultry and before cutting
fresh vegetables for a salad.
• 37% rinse, but do not wash,
the cutting board after cut-
ting raw meat or poultry
and before cutting fresh
vegetables for a salad.
• 9% do not wash the work
surface at all after cutting
raw chicken and removing
meat from bones.
Hazard reduction methods
The kitchen is one of the most
significant hazard zones in the home
for the growth and transmission of
a variety of microbial pathogens.
Fortunately, the likelihood of con-
tamination can be substantially re-
duced with proper handwashing
techniques and other appropriate
hygiene procedures.
When working with food in the
kitchen, all surfaces and utensils
should be cleaned frequently with
hot, soapy water to prevent cross-
contamination. Contamination of
cutting boards can be prevented by
cutting animal products on dispos-
able waxed paper or parchment
paper, or by using separate cutting
boards for meat and produce
(boards can be labeled or color-
coded to avoid mix-ups). To ensure
removal of disease-causing micro-
organisms, cutting boards should
be cleaned regularly with hot water
and detergent (88). Plastic cutting
boards may be washed in the dish-
washer.
Because dishcloths and cloth
towels provide a highly favorable en-
vironment for survival and growth
of disease-causing microbes, many
experts recommend the use of
paper towels along with disinfectant
chemicals to effectively reduce mi-
crobial counts on kitchen surfaces
(45, 57, 85, 87). Indeed, the simple
act of drying a wet surface can help
reduce hazards, as microorganisms
thrive on wet surfaces such as
countertops, sponges, and towels.
Wiping surfaces to dr yness reduces
microorganisms on laminate sur-
faces and minimizes the likelihood
of microbial growth (32, 86). This
is due in part to physical removal of
microorganisms, as well as the elimi-
nation of moisture that would oth-
erwise enhance the growth of bac-
teria (18). If cloth towels must be
used, they should be washed fre-
quently. Sponges should not be used
in the kitchen.
To prevent microbial growth, all
surfaces in the refrigerator should be
thoroughly cleaned on a regular ba-
sis. Results of recent studies indicate
that efficient cleaning, sanitizing,
and dry-wiping is an effective com-
bination for removing microbial con-
taminants from biofilms (32).
Regarding the pantry, consum-
ers should never taste food from
cans in which the contents appear
questionable. Leaky, corroded, rusty,
bulging, or spurting cans are signs of
problems. If the contents of a can
appear bubbly, slimy, moldy, pu-
trid, sulfurous, or decomposed, the
entire can with contents should be
discarded (9, 99).
THE LAUNDRY ROOM
Many studies have revealed the
long-term persistence of various bac-
teria and viruses on certain textile
materials (26, 61, 89, 90, 92, 104,
105). For example, staphylococci
can survive on clothing and hand-
kerchiefs for at least one month (66),
and laboratory studies have revealed
that Salmonella Typhimurium can
persist for up to 24 weeks on wool
and cotton sheeting, even at low
humidity (28, 105).
Dissemination of bacteria and
other microorganisms from cloth
surfaces can occur without great
difficulty (61, 63, 66), and damp
cloth surfaces can support the
growth of microorganisms (86,
105). The persistence of micro-
organisms on damp cloth surfaces
increases the potential for cross-
contamination when laundry is
handled (55, 63, 91).
Workers handling laundry with-
out the advantage of protective bar-
riers have become infected after in-
cidental exposure to infectious ma-
terials present in laundry (63, 71,
94, 96, 98). Exacerbating this prob-
lem is the fact that microorganisms
can survive on inner surfaces of wash-
ing machines and are capable of be-
ing transferred into later loads (3,
16, 100).
Hazard reduction methods
Hot water (165°F) greatly re-
duces the microbial load of laun-
dered fabric, particularly when com-
bined with the use of 1% bleach (3,
93). Drying in an automatic dryer
also greatly reduces the number of
viable microorganisms in laundry,
as does ironing (3, 93, 103, 104).
Finally, the laundry of sick family
members always should be done
separately, at the highest possible
water temperature and the longest,
most vigorous wash cycle, prefer-
ably with bleach.
THE DINING ROOM
In homes in the United States,
dining room tables, eating utensils,
and dishes are potential areas that
can become contaminated, particu-
larly by sick family members or those
who are asymptomatic carriers of
infection (12, 58). Cloth napkins,
still featured in many homes, are
sometimes subject to repeated
uses prior to laundering (1, 40).
Although cloth napkins traditionally
are considered more formal than
single-use paper napkins, they can
JUNE 2000 — Dairy, Food and Environmental Sanitation 421
serve as a reservoir for many poten-
tially pathogenic organisms (74). In
the European Community, napkins
are seen as such a formidable source
of potential infection that even dis-
posable paper mealtime napkins and
paper handkerchiefs are considered
“non-recyclable biowaste” (34, 83).
Even laundered napkins may be
of doubtful sanitary state. The laun-
dering process frequently is inad-
equate at removing microbial con-
taminants from napkins, particularly
when napkins are used to wipe in-
fective material from the area of the
mouth and nose. In both a recent
study (70) and an earlier study (69),
it was shown that laundering did not
significantly reduce bacterial counts
in colored fabric napkins. In the ear-
lier study, the average bacterial count
of 10 laundered fabric napkins was
600,000 bacterial colony-forming
units per square inch (69).
Hazard reduction methods
To prevent the spread of infec-
tious material in the dining room,
sharing of utensils and improper food
handling should be avoided as much
as possible. When using cloth nap-
kins, limit use to a single meal, and
wash napkins in hot water (165°F)
with bleach following each use. The
use of paper napkins at the dinner
table is one of the most effective
ways to interrupt the transmission of
the potential pathogens that can oc-
cur with the reuse of cloth napkins.
THE BATHROOM
It is natural to assume that the
bathroom would be one of the more
high-risk zones in the home. Yet the
well-recognized risks of fecal-oral
contamination have sensitized most
adults to the importance of at least
some attempt at proper hygiene,
making the bathroom a relatively
sanitary region — possibly even more
sanitary than the kitchen, in some
cases. However, many objects and
surfaces in the bathroom can serve
as reservoirs for disease-causing mi-
croorganisms. For example, the bac-
terial content of bar soaps increases
dramatically after use, and remains
high as long as the soaps are wet (15,
47).
The toilet
Proper use of toilet paper is the
first barrier against contamination of
the hands and bathroom surfaces.
Yet as a public-health advance, toi-
let paper has long been underesti-
mated. In several studies of diarrheal
disease, improved toilet hygiene re-
duced morbidity by 33% (21, 49).
Indeed, there have been reported
instances in which outbreaks of dis-
eases such as hepatitis A have been
associated with the lack of toilet
paper (76).
Despite the barrier protection
afforded by toilet paper, the toilet
and its immediate environs are usu-
ally contaminated. Aerosols laden
with microorganisms have been
shown to emanate from toilets after
normal f lushing (13, 24, 35, 68),
and bacteria, viruses, and protozoa
capable of causing disease have been
found in these aerosols. While f lush-
ing seems to reduce by a thousand-
fold the bacteria remaining in a toi-
let, the fresh aerosol remains in the
air for up to 12 minutes if the toilet
is flushed with the lid open (35).
Hepatitis, rotavirus, E. coli, and
Salmonella may be transmitted via
the airborne route (23, 48), and the
flushing of an open household toi-
let could cause infectious particles
from feces to be deposited in the
nose, mouth, or eyes, or on bath-
room surfaces (11). If hands touch
these surfaces, self-inoculation can
occur by touching the eyes, nose,
mouth, or other areas of the body
that are susceptible to infectious
agents (43). Aerosols settle close to
the toilet bowl, on the bathroom
floor and on nearby objects, with
objects at toilet height being the
most prone to contamination. Chil-
dren are most at risk of picking up
infectious material because of their
close proximity to contaminated
sites and because of their lack of
understanding of and training in
hygiene practices. Frequent clean-
ing of the toilet area with disinfec-
tant and paper towels will reduce
potential exposure to fecal contami-
nants. Cleaning the toilet bowl regu-
larly is also important (11).
Toilet tanks are frequently con-
taminated with coliforms, which
could become a problem for the
immunocompromised (11, 36, 84).
The flushing of the toilet reduces
the microbial load substantially (3
logs) every time it is flushed (35);
however, residual bacteria are usu-
ally present. In addition, if the tank
remains contaminated, every flush
fills the bowl and air with contami-
nated material. In communities with
chlorinated water, the residual chlo-
rine level of 0.1 to 0.5 ppm will kill
bacteria in the water, given time.
Towels
Communal cloth hand towels
have been identified as sources of
infective pathogens in restaurants
(26, 41), hospitals (26, 41, 50), gen-
eral medical practices (37), dental
laboratories (67), day-care centers
(18), schools (20), laundry facilities
(71), and family households (38).
To reduce the risk of cross-contami-
nation, communal towels have been
replaced by disposable paper tow-
els or sterile cloths in some hospi-
tals (39).
Bathroom towels can be a sig-
nificant source of microbial patho-
gens, due to the presence of body
secretions that are inevitably present
on communal towels (26, 38, 42).
Staphylococcus aureus, Pseudomo-
nas aeruginosa, P. maltophilia,
P. coppice, P. putrifaciens, P. putida,
P. fluorescens, alpha- and beta-
hemolytic Streptococcus, Coryne-
bacterium spp., and Acinetobacter
lwoffi, as well as E. coli, Salmonella
spp., Enterobacter agglomerans,
and various other Enterobacteriaceae
have been isolated from bathroom
towels (33, 51, 81, 95, 103). While
many of these bacteria do not cause
disease in healthy people, the pres-
ence of these organisms is an indica-
tion of skin, nasopharyngeal, or fe-
cal contamination. Thus, bathroom
towels may play a role in the dissemi-
nation of microorganisms and the
spread of infection in the home (11).
Hazard reduction methods
It is advisable to flush toilets
with the seat down, to prevent the
spread of potentially infective micro-
organisms. In addition, periodic
cleaning of the bowl and outside of
the tank, as well as the use of toilet
tank cleaners, can reduce bacterial
contaminants and help prevent
droplet contamination (11).
422 Dairy, Food and Environmental Sanitation — JUNE 2000
All exposed surfaces in the bath-
room should be cleaned regularly
with a disinfectant, with particular
care taken when a member of the
household is ill. The toilet flush
handle carries risk of fecal contami-
nation; hence it should be cleaned
frequently to prevent cross-contami-
nation (11, 65, 84).
Paper towels can be substituted
for communal hand towels in the
bathroom to reduce the risk of patho-
gen transmission. While this is al-
ways a good practice for everyday
use, it can be especially effective
when someone in the household is
ill.
THE BEDROOM
The bedroom is the primary re-
treat of ill family members and as
such represents a significant hazard
zone during times of illness. Soiled
bedding can be a source of patho-
genic organisms. Although only a
few instances of cross-contamina-
tion associated with soiled linen have
been reported, the hazard clearly
exists (102). Bed stripping has
been reported to increase microbial
release into the immediate environ-
ment of the bedroom (19, 56). Even
individuals with no outward signs
of illness may be asymptomatic
excretors of pathogens such as
Salmonella (29, 56).
Hazard reduction methods
When handling bedclothes or
bedding of sick family members, it is
advisable to sort laundry and wash
the infected person’s linens sepa-
rately, to prevent the spread of dis-
ease (102). Sheets should not be
shaken, as this can further disperse
infectious particles into the air.
Hands should be washed after han-
dling potentially contaminated bed-
ding or bedclothes.
THE NURSERY
The average preschool child of-
ten has six to eight colds and other
infections annually, each of which
can spread to other members of the
household (101). Attendance at day-
care facilities can increase this ill-
ness rate substantially (2, 5, 101).
Conscientious toy cleaning and gen-
eral environmental sanitation in the
preschool setting, however, can re-
duce the rate of respiratory illness,
physician visits, and missed school
days by nearly 50% (53).
Contamination of baby lotions
can occur if microorganisms are in-
troduced into the lotion bottle, and
several illness outbreaks have been
associated with contaminated lotion
(8, 72). Use of small bottles can help
reduce the risk of contamination, as
well as use of bottles with pump-top
closures (14).
Hazard reduction methods
To prevent transmission of
pathogens among children, the CDC
recommends that infants and tod-
dlers not be encouraged to share
toys, and that their toys be washable
(17). Weekly dishwasher cleaning
or disinfectant treatment with
bleach solution is advised for hard
plastic toys, and stuffed toys should
be washed in the washing machine
weekly (or at more frequent inter-
vals if heavily soiled) (17). It is rec-
ommended that even toys used by
older children be washed on a
weekly basis.
Because changing tables are eas-
ily contaminated by infant fecal mat-
ter, changing areas should be as far
as possible from the kitchen and
food-preparation areas. Changing
tables should be covered with
a waterproof, disposable barrier
cloth or should be disinfected after
every use. Alcohol gel products are
ideal for this purpose because of
the rapid microorganism kill rate
(15-30 seconds). In addition, wiping
with a paper towel can help remove
heavy soil, as well as removing
excess alcohol gel, to prevent
inhalation of alcohol fumes by the
infant.
CONCLUSIONS
Not even the most scrupulous
hygiene will completely eliminate
infectious disease hazards from the
home or guarantee the health of all
family members. But the use of ba-
sic prevention techniques in areas
known to contain the most infective
hazards — such as the kitchen, bath-
room and bedroom/sickroom — can
do much to prevent infection and
limit the spread of illness in the
home.
Handwashing and the other haz-
ard-reduction techniques discussed
in this report are especially impor-
tant when one or more members of
the household are ill or are in a high-
risk group. Whenever an ill person
is in the home, it is advisable to con-
sider not only his or her body but
also the entire surrounding environ-
ment as contaminated — including
clothing, bedclothes, furniture, and
common surfaces such as door-
knobs. Fabrics that come in contact
with ill family members should al-
ways be washed separately, prefer-
ably in hot water with bleach, and
all surfaces should be regularly
cleaned with disinfectant and single-
use paper towels, to prevent cross-
contamination.
Household sanitation involves
every aspect of family life and every
room and every member of the
household. Use of effective measures
can, in many instances, prevent dis-
ease transmission among family
members. Thus, through preventive
sanitation and other good hygiene
practices, chains of contagion can
be broken.
ABOUT THE AUTHORS
1Center for Food Safety and Qual-
ity Enhancement, University of Geor-
gia, 1109 Experiment Street, Griffin,
GA 30223-1797; Phone: 770.228.
7284; Fax: 770.229.3216; E-mail:
mdoyle@cfsqe.griffin.peachnet.edu;
2Microbiology Laboratories, Massa-
chusetts General Hospital; 3Depart-
ment of Food Science and Technol-
ogy, Virginia Polytechnic Institute
and State University; 4Infectious Dis-
ease Service, The Southeast Perm-
anente Medical Group, Atlanta;
5Quality Management, Education, &
Epidemiology Resources, Provi-
dence St. Peter Hospital; 6Georgia-
Pacific Corporation.
JUNE 2000 — Dairy, Food and Environmental Sanitation 423
ACKNOWLEDGMENTS
The authors wish to acknowl-
edge and thank Georgia-Pacific Cor-
poration for their continued sup-
port of the HealthSmart Advisory
Board and its initiatives.
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