ArticlePDF Available

Bacterial Contamination of Computer Keyboards and Mice in University and Hospital Settings

Authors:

Abstract and Figures

Use of computers in health care setting in Libya has increased in the recent years. The role of hands in the transmission of bacterial infections is well documented. This study analyses pathogenic microorganisms on the external surface of two routinely utilized items, Personal Computer (PC) keyboards and mouse devices. A total of 35 samples were collected from different computer labs of Abuslim higher institute of health sciences and Abuslim trauma hospital, Tripoli, Libya. The samples collected were cultured with blood agar, nutrient agar, and MacConkey agar for further identification. All pure isolated colonies were differentiated by Gram staining and then biochemically identified using catalase, oxidase, indole, citrate, urease, coagulase, sugar fermentation tests. Our results have demonstrated that all 35 samples were contaminated with five pathogenic bacteria (E.coli spp, Salmonella spp., Klebsiella spp., Pseudomonas spp., and Staphylococcus spp.). Coagulase negative E.coli prevailed in the segregated sample. The next bacteria sullying in all samples was gram-positive Staphylococcus epidermidis. There was 100% contamination rate in this study, with the computer mice showing higher contamination rate than keyboards while, the 35 control samples showed no bacterial growth. The presence of bacterial sullying on these tested objects shows that they may serve as ecological vehicles for the transmission of conceivably pathogenic microscopic organisms. Customary cleaning and purification of PCs is prescribed to diminish the bacterial level.
Content may be subject to copyright.
DJ International Journal of Medical Research, Vol. 2(1) 2017, pp. 1-7
*Corresponding author. Tel.: +218921132362
Email address: elabdri83@yahoo.com (A.Atia)
Double blind peer review under responsibility of DJ Publications
http://dx.doi.org/10.18831/djmed.org/2017011001
2456-5709 © 2017 DJ Publications by Dedicated Juncture Researcher’s Association. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 1
RESEARCH ARTICLE
Bacterial Contamination of Computer Keyboards and Mice in University and
Hospital Settings
Hamida Amer1, *Ahmed Atia2, Khaled Tawil3
1Department of Medical Laboratory, Abuslim Higher Institute of Health Sciences, Tripoli, Libya.
2Department of Anesthesia and Intensive Care, Faculty of Medical Technology, Tripoli University,
Tripoli, Libya.
3Department of Microbiology and Immunology, Faculty of Medicine, Tripoli University, Tripoli, Libya.
Received- 24 January 2017, Revised- 1 April 2017, Accepted- 29 April 2017, Published- 26 May 2017
ABSTRACT
Use of computers in health care setting in Libya has increased in the recent years. The role of
hands in the transmission of bacterial infections is well documented. This study analyses pathogenic
microorganisms on the external surface of two routinely utilized items, Personal Computer (PC)
keyboards and mouse devices. A total of 35 samples were collected from different computer labs of
Abuslim higher institute of health sciences and Abuslim trauma hospital, Tripoli, Libya. The samples
collected were cultured with blood agar, nutrient agar, and MacConkey agar for further identification. All
pure isolated colonies were differentiated by Gram staining and then biochemically identified using
catalase, oxidase, indole, citrate, urease, coagulase, sugar fermentation tests. Our results have
demonstrated that all 35 samples were contaminated with five pathogenic bacteria (E.coli spp, Salmonella
spp., Klebsiella spp., Pseudomonas spp., and Staphylococcus spp.). Coagulase negative E.coli prevailed in
the segregated sample. The next bacteria sullying in all samples was gram-positive Staphylococcus
epidermidis. There was 100% contamination rate in this study, with the computer mice showing higher
contamination rate than keyboards while, the 35 control samples showed no bacterial growth. The
presence of bacterial sullying on these tested objects shows that they may serve as ecological vehicles for
the transmission of conceivably pathogenic microscopic organisms. Customary cleaning and purification
of PCs is prescribed to diminish the bacterial level.
Keywords: Personal computer, Keyboards, Mice, Bacteria, E.coli.
1. INTRODUCTION
Many individuals do not generally
understand the amount to which microorganisms
are found on numerous regular objects outside
their living spaces, in their workplaces, and even
in their living places. Such items include; tables,
PCs, cell phones, entryway handles, fitness
centre gear and different objects which appear to
be tainted with conceivably genuine pathogens
[1, 2]. Computer keyboard and mouse devices
are the most open surface parts of a computer
which show 100% contamination rate [3, 4].
Every type of these devices and exteriors can be
the conceivable hotspot for diseases, which
could influence the health of individuals [5].
PCs keep on having an expanded
presence in numerous areas of our work
including recreational and private perspectives.
The significances of PC had been recognized in
different fields, for example in the wellbeing,
back training and research settings [6]. People
consider that microorganisms are just found in
research laboratories or in clinics and hospitals
and hence they have a deceptive sentiment of
security in different spots. Absence of
knowledge about where microorganisms could
H.Amer et al./DJ International Journal of Medical Research, Vol. 2(1), 2017 pp. 1-7
2
be present is the potential reason for medical
issues. Information uncovered that right around
80% of diseases are transmitted through direct
contact by hands to different objects [1].
Past research has brought up the notion
that the normal number of microorganisms
existing on various client PCs was altogether
higher than that of a single client PC [7].
Additionally, sharing of open PCs by different
clients may encourage expanded transmission
and pervasiveness of pathogenic microorganisms
all over the group [8]. In a study it was
demonstrated that the bacterial defilement rate in
PC keyboards were 99.9% and in mice it was
100% in the case of general skin ordinary
vegetation [4]. In addition, [9] reported the
presence of bacterial contamination in all tested
computers that were inactivated by disinfectants.
Similarly, a moderate to severe contamination in
79% of computers in the clinical department had
also been reported in [10].
In this present study, the degree of
bacterial defilement in some PC keyboards and
mouse devices in Abuslim higher institute of
health sciences and Abuslim trauma hospital had
been examined.
2. MATERIALS AND METHODS
This study was conducted in Abuslim
Higher Institute of Health Sciences (AHIHS) and
Abuslim Trauma Hospital (ATH), where
adequate microbiological labs and staff rooms
were provided. Test specimens were gathered
from 35 PC keyboards and mice gadgets (16
samples were from AHIHS and 19 samples were
from ATH, obtained from October 2015 to
December 2015). A sum of 35 control tests from
shiny new untouched PC consoles and PC mice
were likewise included.
Separation of different bacterial sullying
from the specimens was performed utilizing a
solitary sterile swab saturated with clean saline
solution [11, 12]. After the gathering, swabs
were crushed in 1ml clean saline solution. An
aggregate sum of 100µl was spread on every
blood agar, nutrient agar, and MacConkey agar.
All specimens were plated for three hours of
gathering. At that point the immunized media
were incubated vigorously at 37°C for 48 hours.
All clean separated settlements were
separated by Gram staining and afterwards
biochemically recognized by utilizing catalase,
oxidase, indole, citrate, urease, coagulase, sugar
aging tests. All research facility works were
done in the labs of bureau of restorative lab,
AHIHS, Tripoli, Libya.
3. RESULTS
Morphological and biochemical tests
were carried out and the after effect of bacteria
secluded from PC keyboards and mouse is
shown in table A1. Five microscopic organisms
were separated in this study and were alleged to
pollute PC keyboard and mouse. All 35 isolated
samples from computer keyboards and mouse
were found contaminated with bacteria. Out of 9
Staphylococcus spp.; 7 of them were detached
from keyboard and 2 were from mouse. A total
of 7 bacteria were Klebsiella spp.; of which 2
were detached from keyboards and 5 were from
mouse. A total of 15 were Escherichia spp.; of
which 5 were detached from keyboards and 10
were detached from mouse. Another 3 were
Pseudomonas spp. detached from mouse. Only
one Salmonella spp. was detached from mouse. 9
bacterial segregates were got from keyboard and
26 bacteria were detached from mouse as shown
in table A2 while, the 35 control samples showed
no bacterial growth.
4. DISCUSSION
The principle goal of the present
bacterial study was to detach and recognize the
pathogenic and non-pathogenic microorganisms
on the external surface of computers (keyboards
and mice) for creating public awareness about
the health hazards resulting from these
microorganisms. An aggregate of 35 PC
keyboard and mice were tried for microbial
pollution. Our results confirmed the presence of
different microorganisms on the external surface
of computer keyboards and mouse devices of all
tested samples, with normal flora being
predominant.
In this study, the contamination rate was
100%. The inspected conceivably pathogenic
bacteria contained 34.5% of Klebsiella
pneumoniae, Pseudomonas putida and
Staphylococcus aureus on PC mouse gadgets
when contrasted on keyboard (22.2%) as shown
in figure B1. It was reported by [13] that the
most noteworthy rate of defilement in patient
H.Amer et al./DJ International Journal of Medical Research, Vol. 2(1), 2017 pp. 1-7
3
rooms was present on keyboards (with 5.4%
Enterococcus spp.) and mice (with 5.9%
Staphylococcus aureus) while, the non-
pathogenic bacteria present on keyboards and
mice of our isolates comprised of
Staphylococcus epidermidis, Salmonella
enterica, and E. coli being part of the normal
flora as shown in table A3. These results were
in agreement with that of the segregated
Staphylococcus epidermidis obtained from
keyboards in hospital setting [13].
Various studies have demonstrated that
PC keyboard and mouse gadgets can end up
polluted with pathogenic microscopic organisms
[14-18]. [1] was a study intended to explore the
incidence of bacterial pollution and the kind of
defiling living beings on 400 trial specimens of
PC keyboard, PC mice, shopping baskets and
elevator buttons. They found that the normal rate
of bacterial sullying of the four items were
95.5% with the highest rate seen in elevator
buttons (97%), while the lowest was computer
keyboards (88%) [1]. Another study done by
[14] on 250 computer keyboards and mouse
found that a sum of 148 microscopic organism
isolates were acquired, with Staphylococcus spp.
being the most contaminated for about 42.6%.
[15] Another study also found bacterial
contamination in all tested keyboards in 14
faculty computers and 16 in a hospital setting,
with nosocomial pathogens such as Methicillin-
resistant Staphylococcus Aureus (MRSA),
Vancomycin-Resistant Enterococci (VRE), and
P. aeruginosa. More recently, 300 samples were
collected from different computer labs of
LCWU, Pakistan, and they found that all the
samples were contaminated with pathogenic
bacteria (E.coli, Salmonella, Shigella, and
Staphylococcus) [11, 12]. Similarly, [16]
examined the bacterial defilement of PC
keyboard and mice in the workplace and
reported the existence of Staphylococcus aureus,
Escherichia coli and Salmonella spp.. Further,
another investigator reported the presence of
contamination on multi users of computer
keyboards and mouse devices [17-19]. In our
current study, we confirmed the presence of
bacterial contamination in all our tested samples,
which further confirm the previous presented
works.
5. CONCLUSION
In this current study, we demonstrated a
high rate of bacterial contamination in keyboard
and mouse devices of all our sample isolates.
Moreover, the sullying rates of non-pathogenic
microbes were more than pathogenic
microscopic organisms, suggesting a poor
environmental hygiene in our environment
settings. Our results also provide clear evidence
that E.coli, Salmonella spp., Klebsiella spp.,
Pseudomonas spp. and Staphylococcus spp. are
the frequently occurring bacteria in our
environment, which not only make our
environment unhealthy but also spread a number
of diseases. However accentuation must be kept,
being set on consistently with a great amount of
cleanliness by all staff members before and after
treating the patients.
ACKNOWLEDGMENTS
We thank Abuslim higher institute of
health sciences for funding this study.
REFERENCES
[1] A.K.Al-Ghamdi, S.M.A.Abdelmalek and
A.M.Ashshi, Bacterial Contamination of
Computer Keyboards and Mice, Elevator
Buttons and Shopping Carts, African
Journal of Microbiology Research, Vol.
5, No. 23, 2011, pp. 3998-4003.
[2] C.R.Shalinimol, Identification and
Evaluation of Bacillus Species Bacteria
from Sago Industrial Waste, DJ
International Journal of Advances in
Microbiology & Microbiological
Research, Vol. 1, No. 1, 2016, pp. 1-6,
http://dx.doi.org/10.18831/djmicro.org/2
016011001.
[3] K.Sarah, C.Gillian and Y.M.Derek, The
Importance of Computer Science for
Public Health Training: An Opportunity
and Call to Action, JMIR Public Health
Surveillance, Vol. 2, No. 1, 2016, pp. 10,
http://dx.doi.org/10.2196/publichealth.5
018.
[4] S.Y.Eltablawy and H.N.Elhifnawi,
Microbial Contamination of some
Computer Keyboards and Mice in
National Center for Radiation Research
and Technology, World Applied
H.Amer et al./DJ International Journal of Medical Research, Vol. 2(1), 2017 pp. 1-7
4
Sciences Journal, Vol. 6, No. 2, 2009,
pp. 162-167.
[5] R.Vincenzo, C.Andrea, M.Santi, and
G.Antonino. Bacterial Contamination of
Inanimate Surfaces and Equipment in
the Intensive Care Unit, Journal of
Intensive Care, Vol. 3, 2015, pp.
54, http://dx.doi.org/10.1186/s40560-
015-0120-5.
[6] S.A.Onasanya, The Impact of Computer
in a Developing Country like Nigeria,
Nigerian Journal of Research and
Production, Vol. 1, 2002, pp. 92-102.
[7] G.Anderson and E.A.Palombo, Microbial
Contamination of Computer Keyboards
in a University Setting, American
Journal of Infection Control, Vol. 37,
No. 6, 2009, pp. 507-509,
http://dx.doi.org/10.1016/j.ajic.2008.10.
032.
[8] Y.Longtin, H.Sax, B.Allegranzi,
F.Schneider and D.Pitte, Hand Hygiene,
New England Journal of Medicine, Vol.
13, 2011, pp. 24,
http://dx.doi.org/10.1056/NEJMvcm090
3599.
[9] W.A.Rutala, M.S.White, M.F.Gergen,
and D.J.Weber, Bacterial Contamination
of Keyboards: Effect and Functional
Impact of Disinfectants, Infection
Control and Hospital Epidemiology,
Vol. 27, 2006, pp. 372-377,
http://dx.doi.org/10.1086/503340.
[10] D.J.Waghorn, W.Y.Wan, C.Greaves,
N.Whittame, H.C.Bosely, and
S.Cantirrlls, Contamination of Computer
Keyboards in Clinical Areas: Potential
Reservoir for Nosocomial Spread of
Organism, British Journal of Infection
Control, Vol. 6, No. 3, 2005, pp. 22-4.
[11] P.M Diaz, Impact of Biofilm Infection
and its Treatment, DJ International
Journal of Advances in Microbiology &
Microbiological Research, Vol. 1, No. 1,
2016, pp. 7-13,
http://dx.doi.org/10.18831/djmicro.org/2
016011002.
[12] K.Malik and N.Naeem, Study of
Bacteria on Computer Mice and
Keyboards, International Journal of
Current Microbiolgy and Applied
Science, Vol. 3, No. 4, 2014, pp. 813-
823.
[13] M.Hartmann, A.Benson and L.Junger,
Computer Keyboard and Mouse as a
Reservoir of Pathogens in an Intensive
Care Unit, Journal of Clinical
Monitoring and Computing, Vol. 18, No.
1, 2014, pp. 7-12.
[14] O.C.Chimezie, A.Chukwudi,
A.Nnaemeka, O.Collins, O.E.Chinyere
and A.F.Ngozi, Bacteriological
Examination of Computer Keyboards
and Mouse Devices and their
Susceptibility Patterns to Disinfectants,
American Journal of Microbiology, Vol.
4, No. 1, 2013, pp. 9-19,
http://dx.doi.org/ 10.3844/ajmsp.2013.9.
19.
[15] B.H.Elizabeth, R.R.Brian,
W.J.Lancaster, R.L. Mann and
S.N.Leonard, Surface Microbiology of
the iPad Tablet Computer and the
Potential to serve as a Fomite in both
Inpatient Practice Settings as well as
Outside of the Hospital Environment,
PLOS, Vol. 13, 2014, pp. 1371,
https://doi.org/10.1371/journal.pone.011
1250.
[16] X.Shen, Investigation of the Bacterial
Contamination of Computer Keyboard
and Mouse in the Office, Journal of
Environmental and Occupational
Medicine, Vol. 3, 2010, pp. 17.
[17] A.Agersew, M.Degisew and
W.Yitayih, Bacterial Profile and their
Antimicrobial Susceptibility Patterns of
Computer Keyboards and Mice at
Gondar University Hospital, Northwest
Ethiopia, Biomedicine and
Biotechnology, Vol. 3, No. 1, 2015, pp.
1-7, http://dx.doi.org/ 10.12691/bb-3-1-
1.
[18] N.Tagoe and F.Kumi-Ansah, Computer
Keyboard and Mice: Potential Sources
of Disease Transmission and Infections,
The Internet Journal of Public Health,
Vol. 1, No. 2, 2010, pp. 1-6.
[19] C.R.Shalinimol, A Study on
Optimization of Microbial Alpha-
Amylase Production, DJ International
H.Amer et al./DJ International Journal of Medical Research, Vol. 2(1), 2017 pp. 1-7
5
Journal of Advances in Microbiology &
Microbiological Research, Vol. 1, No. 1,
2016, pp. 22-27,
http://dx.doi.org/10.18831/djmicro.org/2
016011004.
H.Amer et al./DJ International Journal of Medical Research, Vol. 2(1), 2017 pp. 1-7
6
APPENDIX A
Table A1.Morphological and biochemical tests result of bacteria detached from PC keyboards and mouse
Morphological
characterization
Biochemical tests
Colour
Consistency
Catalase
test
Oxidase
test
Indole
test
Urease
test
Coagulase
test
Mannitol
Suspected
organisms
White
Smooth
edge
+
-
-
-
-
Staphylococcus
spp.
Bluish
Bubble
shape
+
-
-
-
-
-
Klebsiella spp.
Greenish
Rough
surface
+
-
+
-
-
Escherichia
spp.
Light
yellow
Raised
+
+
-
-
-
Pseudomonas
spp.
Reddish
Rod shaped
+
-
-
-
-
-
Salmonella spp.
Table A2.Frequency of bacterial occurrence in PC keyboards and mouse
Isolates
Keyboard (%)
Mouse (%)
Total (%)
Staphylococcus spp.
2 (22.2%)
7 (26.9%)
9 (25.7%)
Klebsiella spp.
2 (22.2%)
5 (19.2%)
7 (20.0%)
Escherichia spp.
5 (55.6%)
10 (38.5%)
15 (42.9%)
Pseudomonas spp.
0 (0%)
3 (11.5%)
3 (8.6%)
Salmonella spp.
0 (0%)
1 (3.8%)
1 (2.8%)
Total
9
26
35
Table A3.Pathogenic and non-pathogenic microbial sullying of PC (keyboards and mice)
Isolates
No. (%) of keyboards positive for
contamination (n=9)
No. (%) of mice positive for
contamination (n=26)
Non-pathogenic bacteria
Escherichia coli
5 (55.6%)
10 (38.5%)
Staphylococcus epidermidis
2 (22.2%)
6 (23.1%)
Salmonella enterica
0 (0%)
1 (3.8%)
Pathogenic bacteria
Klebsiella pneumoniae
2 (22.2%)
5 (19.2%)
Staphylococcus aureus
0 (0%)
1 (3.8%)
Pseudomonas putida
0 (0%)
3 (11.5%)
H.Amer et al./DJ International Journal of Medical Research, Vol. 2(1), 2017 pp. 1-7
7
APPENDIX B
Figure B1.Total percentage of microbial contamination of computers (keyboards and mice)
... Surgeons always view X-ray images though the computer during surgery, enabling them to perform precise operations. Unfortunately, keyboards and computer mice are found to be sources of bacterial contamination [10,11]. In practice, to keep surgeons' hands sterilized, the surgeons will communicate with nurses or assistants to control the keyboard and computer mouse. ...
Article
Full-text available
Surgeons must intraoperatively view cross-section images under sterilization conditions. Keyboard and computer mouse are sources of contamination. A computer vision algorithm and a hand movement pattern analysis technique have been applied to solve the problem based on surgeon’s behaviors. This paper proposed a new method to control the radiological image viewer in an operating room. A pattern code of hand movement and a grid square guideline are used. Our proposed algorithm comprises three steps: hand tracking, pattern code area identification, and hand movement pattern recognition. First, the system is fed with a sequence of three-dimensional data. A 3D camera captures the whole target body. A skeleton tracking algorithm is used to detect the human body. The left-hand joint in the skeleton data set is tracked. Second, as this algorithm supports one hand movement, a grid square guideline is defined. Hand movements are interpreted from the hand path moving in the grid square area. Finally, the pattern code is defined as a feature vector. By using the feature vector and closest point classifier, the hand movements are recognized by the K-Nearest Neighbors algorithm. To test the performance of the proposed algorithm, data from twenty subjects were used. Seven commands were used to interface with the computer workstation to control the radiological image viewer. The accuracy rate was 95.72%. The repeatability was 1.88. The advantage of this method is that one hand can control the image viewer software from a distance of 1.5 m satisfactorily without contacting computer devices. Our method also does not need big data set to train the system.
... This is in consonance with the work of Kannan et al. (2017), who reported 100% contamination in all of the sampled computer keyboards and mice. Also, Amer et al. (2017) Muhammad et al. (2016), and also confirms their normal flora status on human body. However, S. aureus has been implicated to cause a number of infections in humans (Hartman et al., 2004;Kanayama et al., 2017). ...
... The present finding is comparatively lower than the previously conducted different studies across the globe including a study (n = 24 swabs) from Egypt [52] that was conducted to investigate microbial contamination Shiferaw 13 BioMed Research International of computer keyboards (99.9%) and mice (100%). Likewise, higher results than the current finding such as research findings from Brazil [14] done to assess bacterial contamination of inert hospital surfaces and equipment in critical and noncritical care units with the prevalence of 94.1%; Libya [53,54] with a contamination rate of 99% and 100%, respectively; Morocco [55] with a contamination rate of 88%; the bacteriological study of electronic devices used by HCW in Rwanda [56] with contamination of 98.53%; a study in Slovakia [57] that was done to assess bacterial contamination of mobile phone and computer keyboard (92%); and the study in the United Kingdom [58] that reported a 95.7% of bacterial contamination of hospital bed-control handsets in a surgical setting were reported. The substantially higher reports of the previous studies as compared to the present findings may be explained due to the difference in the study design [14,58,59]; the frequency of cleaning, disinfecting, and sterilizing (use of irradiations) of surfaces and equipment used directly or indirectly for the patient diagnosis and treatment [5,52]; time of swabbing [60]; awareness of the HCW about microbial contamination of inanimate surfaces and devices [2]; the capability of the pathogen to form biofilm on inanimate surfaces and electronic devices which enables them to survive longer [61]; and variation in the type of microbial reservoir [53]. ...
Article
Full-text available
Background. Hospital-acquired infections have remained a serious cause of mortality, morbidity, and extended hospitalization. Bacterial contamination of inanimate surfaces of the hospital environment and equipment is considered a major contributing factor to the development of several nosocomial infections worldwide. The hospital environment and many devices are an important reservoir of many clinically important bacterial agents including multidrug-resistant pathogens. Therefore, this systematic review and meta-analysis are aimed at investigating bacterial pathogens and their antimicrobial resistance patterns of inanimate surfaces and equipment in Ethiopia. Methods. An exhaustive literature search was carried out using the major electronic databases including PubMed, Web of Science, MEDLINE, EMBASE, CINAHL, Google Scholar, Cochrane Library, Scopus, and Wiley online library to identify potentially relevant studies without date restriction. Original articles which address the research question were identified, screened, and included using the PRISMA flow diagram. Data extraction was prepared in Microsoft Excel, and data quality was assessed by using 9-point Joanna Briggs Institute critical appraisal tools. Then, data were exported to STATA 16.0 software for analyses of pooled estimation of outcome measures. Estimation of outcome measures at a 95% confidence interval was performed using DerSimonian-Laird’s random-effects model. Finally, results were presented via text, figures, and tables. Results. A total of 18 studies with 3058 bacterial isolates recovered from 3423 swab specimens were included for systematic review and meta-analysis. The pooled prevalence of bacterial contamination of inanimate surfaces and equipment was found 70% (95% CI: 59, 82). Among the Gram-negative bacterial species, the prevalence of ampicillin-resistant K. pneumoniae was the highest 80% (95% CI: 78, 92) followed by Citrobacter species 78% (95% CI: 57, 83). Conclusion. This study has shown a high prevalence of bacterial contamination of inanimate surfaces and equipment in Ethiopia. 1. Introduction Hospital-acquired infections (HAIs) are causing the major cause of mortality, morbidity, increased medical costs for treatment, and extended hospitalization. A hospital environment is a major contributing factor to the development of several HAIs worldwide [1]. Contamination of the inert hospital environment, healthcare workers (HCWs), and medical equipment facilitates the rapid spreading of hospital microorganisms from patient to patient, HCW to the patients, and inanimate surfaces to all bodies [2, 3]. Improper equipment sterilization, inadequate decontamination of surfaces, and poor hand hygiene practices of healthcare providers contribute to the cross-transmission of several pathogens including the multidrug-resistant (MDR) strains of bacteria which are responsible for many nosocomial admissions [4, 5]. Bacterial contamination of high-contact communal surfaces (medical charts, bed rails, white coats/scrubs, telephone/cell phones, computer keyboards/mice, and handwashing sink) and medical equipment (blood pressure cuffs, mechanical ventilator, portable radiograph equipment, ultrasound machine, and stethoscopes) is a worrisome healthcare problem to the management and treatments of a critically ill patient [5–7]. Bacterial contamination of inanimate surfaces and equipment is problematic to overcome as it can serve as a reservoir for an unlimited period through a gradual cross-transmission of pathogens and subsequent contact with patients and HCWs at a time of disease management [8]. It can be caused by a range of bacterial (both Gram-positive and Gram-negative isolates) and fungal species [9–12]. A highly virulent pathogen such as Staphylococcus aureus (Methicillin-resistant Staphylococcus aureus or MRSA), Coagulase-negative Staphylococci (CoNS), Enterococcus species (vancomycin-resistant Enterococci), Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Clostridium difficile, and Acinetobacter baumannii are capable of harbouring on contaminated inanimate surfaces and medical apparatus [5]. Contributing factors for the transfer of microorganisms from one surface to another may depend on the type of organisms, source of surfaces, surface humidity level, size of inoculum, medical personnel hand hygiene compliance, ward design (overbending), number of colonized patients, and antibiotic stewardship practices [13, 14]. Nosocomial infections can be either emerged from endogenous microflora of the patient during antibiotic therapy or acquired from the exogenous inert environment that plays an important role in the potential reservoir to the microorganism of horizontal infection transmission [5, 15, 16]. In the hospital setting, inanimate surfaces such as mattresses, bed frames, doorknobs, mobile phones, and ophthalmic solutions/eye drops [12] from various wards or units and several medical types of equipment such as stethoscopes, portable radiograph, and ultrasound instruments are the key reservoir for medically important pathogens. Various equipment in the healthcare setting can be utilized in a patient zone for both monitoring and therapeutic purposes. Based on this, it should be decontaminated before and after the patient contact as well as exposure to the environment to mitigate the horizontal transfer of microorganisms from infected patients [14, 17, 18]. The importance of nosocomial infections has grown into the epidemiology and determinants of healthcare-related microbial contamination to implement measures against the rapidly evolving colonization and dissemination of MDR pathogens [3, 14, 19]. This is mainly due to microbial contamination being common among ICU, operating room (OR), adult medical wards, pediatric wards, neonatal intensive care unit, and gynecologic wards [14]. Lack of regular cleaning and disinfection practices is believed as the main factor for the spread of HAIs. Besides monitoring the microbial quality of medical equipment, the regulation of indoor air bacterial load of the healthcare rooms has a significant role in the health of occupants [20–22]. This is because the bacterial pathogens can survive and remain viable on inert surfaces and/or equipment due to their ability to form biofilms which allow withstanding against jeopardy environmental conditions around their niche. Otherwise, factors such as surface porosity and humidity shall exist. Besides, it enhances the pathogens to adapt to environmental stress and selected pressures at its vicinity [2, 3, 23]. Decontamination with the use of physical or chemical means to remove and inactivate the contaminant pathogens from the surfaces of the hospital environment in order to provide a safe environment for handling of the patient is essential [12, 24, 25]. Not only decontamination processes but also disinfection, cleaning, and sterilization are very important steps to be done for a reusable item safe for further medical use. Failure to properly adhere to these techniques toward the inanimate surfaces and equipment not only is a risk linked with a break of host barriers but also is a risk for person-to-person transmissions and transmission of environmental pathogens [26, 27]. In general, understanding the epidemiology and determinants of microbial contamination at a country level is fundamental to reinforce effective decontamination, disinfection, cleaning, and sterilization methods to mitigate microbial dissemination and systematic surveillance of MDR pathogens in Ethiopia. Although there are some individual studies concerning bacterial contamination of inanimate surfaces and equipment in Ethiopia, a systematic review and meta-analysis study regarding bacterial pathogens and their antimicrobial resistance patterns of inanimate surfaces and equipment in Ethiopia is unavailable as far as our knowledge goes. Therefore, this study is aimed at performing a systematic review and meta-analysis to estimate the overall prevalence of bacterial contamination of inanimate surfaces and equipment in Ethiopia. 2. Methods 2.1. Study Design, Setting, and Period This systematic review and meta-analysis study was conducted in Ethiopia. It is the second-most populous country next to Nigeria in the Africa continent with a current total population greater than 115 million (https://worldpopulationreview.com/countries/ethiopia-population). Any laboratory-based studies that address the outcome of interest in light of the concept of bacterial contamination of inanimate surfaces and equipment conducted using the standard microbiological protocols from the Ethiopian population were systematically studied. Laboratory-based studies conducted in different public and private health intuitions (hospitals, health centres), as well as wards or units including medical wards (MW), pediatric wards (PW), orthopaedic wards (OPW), surgical wards (SW), gynecologic wards (GW), emergency wards (EW), intensive care unit (ICU), and neonatal intensive care unit (NICU), were studied. Consequently, a systematic review and meta-analysis study was conducted to sum up the pooled prevalence of bacterial contaminants isolated from different contaminant reservoirs and their drug resistance patterns reported from the various regions of Ethiopia. Any relevant studies addressing the research objective were considered for screening regardless of the study period provided that any updates till the date of the manuscript submission for publication were considered. 2.2. Literature Search Strategy An exhaustive literature search strategy toward studies reporting the prevalence of bacterial contamination of inanimate surfaces and equipment was conducted for grey and peer review literature with no date restrictions. Electronic database search engines such as MEDLINE, PubMed, Cochrane Library, Scopus, Google Scholar, EMBASE, CINAHL, Wiley online library, Index Medicus, Africa Journals Online, Clarivate, medRxiv, bioRxiv, and Web of Science were exhaustively searched to identify potentially published relevant studies. Besides, expert consultation, reference tracing of potential full-text articles, preprints, and conference proceedings were carefully assessed to complete the search strategy. Additional data was sought even from the authors to complete the information through email contact, especially for inaccessible/full of charge original research articles. Further, regular alerts were established to few selected databases like PubMed and Google Scholar to update the search strategy before the publication of the article. Moreover, Google and other internet search engines were used to search for additional web-based or electronic materials. Hence, the searches were rerun just before the final data analyses. Keywords and controlled vocabularies are used for the search; the relevant materials used for the review were selected by the authors. As a result, keywords were developed following the medical subject heading (MeSH) search strategy. The Boolean operators (AND, OR, and NOT) and wild cards (“”) were customized by the authors based on the research questions of the outcome measures. Accordingly, filters like language, year, subject, and article type as well as helpful search tags were used. The literature search strategy was based on the following keywords and phrases: “microbial contamination”, “bacterial contamination”, bacterial contamination of inanimate surfaces OR “bacterial contamination of equipment”, “microbial contamination of inert hospital environment” OR “prevalence of bacterial contamination of equipment, inanimate surfaces” AND “Ethiopia”, “indoor air bacterial load determination”, “ward bacterial contamination”, OR “equipment contamination” AND “Ethiopia”. Besides, searching using specific bacterial species like “Staphylococcus aureus” OR “E. coli” OR “Acinetobacter baumannii” AND “ICU ward contamination” AND “Ethiopia” was made. 2.3. Operational Definition 2.3.1. Medical Equipment Medical equipment is any device including a sphygmomanometer, stethoscope, and thermometer used for the diagnosis and therapeutic purposes for hospitalized patients in pediatrics, ICU, neonatal intensive care unit (NICU), and surgical, medical, gynecology, and orthopaedic wards/units [5, 14]. Nonmedical devices that harbour microbes also include computers and HCW’s cell phones as well as other equipment found in the hospital environment that has contact with HCW. 2.3.2. Inanimate Surfaces These are a surface of the inert hospital environment and the surface of the material used during patient treatment and management such as bedside tables, mattress, computers, computer standing tables, ophthalmic solutions or multidose eye drops, white coats/scrubs, telephone/cell phones, and handwashing sink [5, 12, 28]. 2.3.3. Indoor Air This is the air inside the rooms, wards, and units during laboratory investigation [3]. 2.3.4. Settle Plate or Passive Air Sampling Petri dishes containing blood agar plates are left open to air for a given period; then, microbes carried by inert particles fall onto the surface of the nutrient with an average deposition rate of 0.46 cm/s being reported [17, 29]. 2.4. Inclusion and Exclusion Criteria Before identifying appropriately published relevant full-text articles either in local or international journals, a selection criteria checklist for study eligibility was developed by the authors. 2.4.1. Inclusion Criteria All studies which met the following criteria were included in the review process: [1] studies that reported the prevalence of bacterial contamination from inanimate surfaces and/or equipment, [2] studies published in English language but conducted only in Ethiopia at any date, [3] studies conducted using the standard bacteriological techniques (i.e., using swab method or settle plate sampling method following a 1/1/1 schedule. That means sterile Petri dishes containing 5% sheep’s blood agar were left on the air for 1 hour and 1 meter above the floor as well as 1 meter away from the wall [17, 29].), [4] studies accurately reporting the swab culture growth rate for bacterial isolates and their drug susceptibility/resistance tested against selected commercially available drugs used for the treatment of HAI based on the clinical laboratory standard institute (CLSI) document [30] [5], all relevant free-of-charge full-text original research articles, and [6] studies reporting the prevalence from nonmedical equipment like the mobile phone of HCWs, Ethiopian currency notes or coins, computers, and bus surfaces. In addition, any online freely available (preprint and not peer-reviewed) materials like dissertations (MSc, PhD) were also included. At the same time, records retrieved from instructional repository digital libraries (private and public institutions) were included. 2.4.2. Exclusion Criteria The study was excluded for the following reasons: [1] inaccessible or irretrievable full-text articles after requesting from the corresponding authors via email or research gate account; [2] review, commentaries, letters to the editor, conference proceeding, and abstracts; [3] studies that report bacterial contamination from environmental entities (soil, lake, river, and hospital effluent water); [4] reports from food items (dairy products, meat, coffee, fruits, vegetables, and cereals); [5] studies done on microbiological assessment of safety, quality of drinking water, and nonalcoholic beverages; [6] studies on animal microbial colonization; [7] studies having mixed sample sources and results (swab, water, and food); and [8] microbial contamination of the inert environment and/or devices due to microbial toxins such as aflatoxins and mycotoxins. Besides, studies were excluded if there is incomplete information to address the primary goal of the research question. For example, studies with insufficient/vague outcome measures after review by peer reviewers independently were discarded. Not surprisingly, fungal contamination of inanimate surfaces and equipment was automatically excluded from the entire review process. 2.5. Data Screening, Extraction, and Management To enhance screening, online records from various databases and directories were exported appropriately to ENDNOTE reference software version 8.2 (Thomson Reuters, Stamford, CT, USA). Then, the records were merged into one folder to identify and remove duplicate articles with the help of ENDNOTE or manual tracing as there are several possibilities of citation styles per article. Thereafter, a couple of authors Teklehaimanot Kiros (TK) and Tegenaw Tiruneh (TT) independently screened the title and abstracts of each article based on the predefined eligibility criteria as mentioned above (inclusion/exclusion criteria). Records that passed the screening phase were further subjected to eligibility assessment of full-text articles according to the critical appraisal checklist for systematic reviews and research syntheses [31]. For this, three authors, TK, Tahir Eyayu (TE), and Shewaneh Damtie (SD) independently collected full-text articles and evaluated their eligibility for meta-analysis. In case of discrepancy among authors, Wasihun Hailemichael (WH) and Lemma Workineh (LW) were assigned to facilitate rechecking the review process (primarily for accuracy and consistency) until mutual or anonymous consensus was reached to any arisen disagreement between or among the authors. The data extraction was performed by peer reviewers (TK with TE and TT with SD) who independently extracted all relevant articles using a standardized and pretested format prepared in Microsoft Excel. The authors designed a data extraction form adopted from Cochrane collaboration and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA, 2009 Checklists) as shown (Supplementary file 1: Table S1: PRISMA checklists). Lastly, a checklist is customized into our study protocol to address all research questions and outcome measures. The data extraction format included principally study ID, first author and reference, study design, study setting, publication year, study site in the country, sample size, sampling technique, specimen collection method along with a source of contamination (inanimate surfaces and equipment), the prevalence of outcome of interest, types of bacterial isolates, and antimicrobial resistance patterns. In cases of insufficient/incomplete data, the authors independently reviewed the full text of the article for further information and clarification. Any inconsistencies were resolved through discussion until a consensus is reached among the authors assigned for data retrieval. Thereafter, extracted data from each article were summarized into Microsoft Excel and spreadsheet. The list of references and laboratory data for each study were carefully cross-checked to ensure no redundancies coexisted. Duplicate studies were excluded; otherwise, they provide additional outcome measurements based on the review objective. Finally, the study selection process was presented using the PRISMA flow diagram for all studies reviewed, screened, and included in the quantitative synthesis or meta-analysis as described previously [32]. Finally, a total of 18 eligible original articles were included in this meta-analysis. 2.6. Outcome Measurements This systematic review and meta-analysis study from Ethiopia has three major outcomes. The first outcome of interest was to determine the overall pooled prevalence of bacterial isolates (culture positive) recovered from inanimate surfaces and devices summarized from the different regions in Ethiopia. The second outcome was to identify and estimate the pooled proportion of the etiologic agents causing inanimate surface and equipment contamination. The third outcome measure of the study was to summarize the drug resistance patterns of the pathogens recovered from the various sources of contaminants across the regions of Ethiopia. 2.7. Quality Assessment Critical appraisal of the studies was made by assigned reviewers to ensure the accuracy and consistency of data. The quality of studies was assessed using standard critical appraisal tools prepared by the Joanna Briggs Institute (JBI), at the University of Adelaide, Australia [33]. The main objective of the appraisal was to carefully assess the methodological quality of studies, the possibility of bias in its design, and the extent to which the statistical analysis and data synthesis are addressed. The JBI appraisal checklist for prevalence studies has nine important questions. The questions (Q1-Q9) primarily focus on the appropriateness of the sampling frame to address the target population, appropriateness of sampling techniques, adequacy of the sample size, the details of study subjects and setting, the depth of statistical analysis, the presence of valid methods to identify the condition, the extent it is measured as per the standard, the appropriateness of the methods, and adequacy of the response management. The critical appraisal was also conducted to evaluate the internal (systematic error) and external validity of studies thereby reducing the risk of biases among individual studies. In all cases, scores of the two authors (TK and TT) in consultation with a third author (TE) in case of discrepancy (between the two authors’ appraisal result) were taken for a final decision. Total scores ranged between 0 and 9. Finally, studies with the number of positive responses (yes) greater than half of the number of checklists (i.e., a score of five and above) were included in the systematic review and meta-analysis. 2.8. Assessment of Publication Bias Publication bias assessment was conducted using a funnel plot. For this study, the presence of publication bias was examined using a funnel plot and Egger’s test. Upon the visual inspection of the funnel plot, the asymmetrical distribution of studies on the funnel plot might suggest the presence of publication bias due to the small study effect [34, 35]. 2.9. Data Synthesis, Analysis, and Reporting The extracted data were imported from Microsoft Excel to STATA software for the pooled estimation of outcome measures. Data manipulation and statistical analyses were performed using STATA software version 16 (College Station, Texas, USA) [36]. DerSimonian-Laird’s random-effects model was applied to estimate the overall pooled prevalence of bacterial contamination at a 95% confidence level. The model is recommended to adjust for variability in the presence of heterogeneity among studies [37]. Sensitivity analysis and subgroup analyses were also conducted to minimize the degree of heterogeneity across studies. Meanwhile, heterogeneity was checked using test statistics. test statistics is the preferable and more reliable test to measure the variability across the studies. It ranges between 0 and 100%. suggested more homogeneity, suggested moderate heterogeneity, and suggested high heterogeneity [38]. The subgroup analysis was carried out based on the study region and methods of sample collection. This reduces the random inconsistency between the point estimates of the primary study. Finally, all statistical tests with values less than 0.05 and corresponding 95% CI were considered statistically significant. The results of the findings were presented by texts, summary tables, and figures (forest plots). 3. Results 3.1. Literature Search A comprehensive literature search was made in major electronic database engines including Google Scholar, PubMed, MEDLINE, Web of Science, EMBASE, and CINAHL and yielded a total of 1825 publications. Among the total, 1647 records were discarded due to duplications assessed by ENDNOTE and/or manual tracing, unrelation to the objective of the review question, and being simply a qualitative study. The remaining articles that were subjected to a detailed screening process () were further thoroughly assessed to sufficiently meet the primary outcome measures satisfactorily and unambiguously. Among these, were screened for the eligibility of the full-text articles. Based on the predetermined inclusion and exclusion criteria, the removal of articles with reasons such as reports from veterinary specimens, food, and food products and environmental entities (soil and water), as well as incomplete results concerning the research objective, was made (Figure 1). In this regard, 8 studies were removed due to failure to meet the inclusion criteria for our study. Consequently, only a total of 18 original full-text articles addressing the primary outcome measures sufficiently and unambiguously were included in this systematic review and meta-analysis study.
Article
Full-text available
This paper proposes a novel computer vision based system that allows doctors, surgeons and other physicians to control X-Ray images just by using simple gestures thus eliminating the need of traditional devices like mouse and keyboard. This will help reduce the risk of contamination in sterile environments like those found in the hospitals and it will also help in preventing the spread of covid by not allowing contact with contaminated surfaces. It is implemented using CNN model. CNN is specially used for image recognition as well as processing. The system detects gestures through in-built webcam and converts it into corresponding computer commands to perform its associated tasks.
Article
Full-text available
here has been a dramatic increase in the use of computers in healthcare settings in recent years. Staff move from computer to patient and back as part of their daily routine. To ascertain whether computer keyboards may harbour organisms and act as potential reservoirs for nosocomial spread, swabs were taken from the keyboards and mice of 48 computers situated in a variety of clinical areas. All 48 keyboards were contaminated; 4% were colonised with recognised bacterial pathogens and 96% harboured organisms that in certain clinical circumstances could cause nosocomial infections. Computer keyboards and mice should be cleaned regularly and the use of plastic covers may facilitate this. Cleaning requirements should take a higher priority when both purchasing and designing new healthcare equipment. However, all such improvements remain secondary to the need for strict hand hygiene practice in clinical areas.
Article
Full-text available
Objective: User interfaces of patient data management systems (PDMS) in intensive care units (ICU), like computer keyboard and mouse, may serve as reservoirs for the transmission of microorganisms. Pathogens may be transferred via the hands of personnel to the patient causing nosocomial infections. The purpose of this study was to examine the microbial contamination of computer user interfaces with potentially pathogenic microorganisms, compared with other fomites in a surgical intensive care unit of a tertiary teaching hospital. Methods: Sterile swab samples were received from patient's bedside computer keyboard and mouse, and three other sites (infusion pumps, ventilator, ward round trolley) in the patient's room in a 14 bed surgical intensive care unit at a university hospital. At the central ward samples from keyboard and mouse of the physician's workstation, and control buttons of the ward's intercom and telephone receiver were obtained. Quantitative and qualitative bacteriological sampling occurred during two periods of three months each on eight nonconsecutive days. Results: In all 14 patients' rooms we collected a total of 1118 samples: 222 samples from keyboards and mice, 214 from infusion pumps and 174 from the ward's trolley. From the central ward 16 samples per formites were obtained (computer keyboard and mouse at the physician's workstation and the ward's intercom and telephone receiver). Microbacterial analysis from samples in patients' rooms yielded 26 contaminated samples from keyboard and mouse (5.9%) compared with 18 positive results from other fomites within patients' rooms (3.0%; p < 0.02). At the physician's computer terminal two samples obtained from the mouse (6.3%) showed positive microbial testing whereas the ward's intercom and telephone receiver were not contaminated (p = 0.15). Conclusions: The colonization rate for computer keyboard and mouse of a PDMS with potentially pathogenic microorganisms is greater than that of other user interfaces in a surgical ICU. These fomites may be additional reservoirs for the transmision of microorganisms and become vectors for cross-transmission of nosocomial infections in the ICU setting.
Article
Computers are ubiquitous in the healthcare setting and have been shown to be contaminated with potentially pathogenic microorganisms. This study was performed to determine the degree of microbial contamination, the efficacy of different disinfectants, and the cosmetic and functional effects of the disinfectants on the computer keyboards. We assessed the effectiveness of 6 different disinfectants (1 each containing chlorine, alcohol, or phenol and 3 containing quaternary ammonium) against 3 test organisms (oxacillin-resistant Staphylococcus aureus [ORSA], Pseudomonas aeruginosa, and vancomycin-resistant Enterococcus species) inoculated onto study computer keyboards. We also assessed the computer keyboards for functional and cosmetic damage after disinfectant use. Potential pathogens cultured from more than 50% of the computers included coagulase-negative staphylococci (100% of keyboards), diphtheroids (80%), Micrococcus species (72%), and Bacillus species (64%). Other pathogens cultured included ORSA (4% of keyboards), OSSA (4%), vancomycin-susceptible Enterococcus species (12%), and nonfermentative gram-negative rods (36%). All disinfectants, as well as the sterile water control, were effective at removing or inactivating more than 95% of the test bacteria. No functional or cosmetic damage to the computer keyboards was observed after 300 disinfection cycles. Our data suggest that microbial contamination of keyboards is prevalent and that keyboards may be successfully decontaminated with disinfectants. Keyboards should be disinfected daily or when visibly soiled or if they become contaminated with blood.
Bacterial Contamination of Inanimate Surfaces and Equipment in the Intensive Care Unit
  • R Vincenzo
  • C Andrea
  • M Santi
  • G Antonino
R.Vincenzo, C.Andrea, M.Santi, and G.Antonino. Bacterial Contamination of Inanimate Surfaces and Equipment in the Intensive Care Unit, Journal of Intensive Care, Vol. 3, 2015, pp. 54, http://dx.doi.org/10.1186/s40560015-0120-5.
The Impact of Computer in a Developing Country like Nigeria
  • S A Onasanya
S.A.Onasanya, The Impact of Computer in a Developing Country like Nigeria, Nigerian Journal of Research and Production, Vol. 1, 2002, pp. 92-102.
  • G Anderson
  • E A Palombo
G.Anderson and E.A.Palombo, Microbial Contamination of Computer Keyboards in a University Setting, American Journal of Infection Control, Vol. 37, No. 6, 2009, pp. 507-509, http://dx.doi.org/10.1016/j.ajic.2008.10. 032. [8] Y.Longtin, H.Sax, B.Allegranzi, F.Schneider and D.Pitte, Hand Hygiene, New England Journal of Medicine, Vol. 13, 2011, pp. 24, http://dx.doi.org/10.1056/NEJMvcm090 3599.
Impact of Biofilm Infection and its Treatment
  • P Diaz
P.M Diaz, Impact of Biofilm Infection and its Treatment, DJ International Journal of Advances in Microbiology & Microbiological Research, Vol. 1, No. 1, 2016, pp. 7-13, http://dx.doi.org/10.18831/djmicro.org/2 016011002.
Study of Bacteria on Computer Mice and Keyboards
  • K Malik
  • N Naeem
K.Malik and N.Naeem, Study of Bacteria on Computer Mice and Keyboards, International Journal of Current Microbiolgy and Applied Science, Vol. 3, No. 4, 2014, pp. 813823.
Bacteriological Examination of Computer Keyboards and Mouse Devices and their Susceptibility Patterns to Disinfectants Surface Microbiology of the iPad Tablet Computer and the Potential to serve as a Fomite in both Inpatient Practice Settings as well as Outside of the
  • O C Chimezie
  • A Chukwudi
  • A Nnaemeka
  • O Collins
  • O E Chinyere
  • A F Ngozi
  • B H Elizabeth
  • R R Brian
  • W J Lancaster
  • R L Mann
  • S N Leonard
[14] O.C.Chimezie, A.Chukwudi, A.Nnaemeka, O.Collins, O.E.Chinyere and A.F.Ngozi, Bacteriological Examination of Computer Keyboards and Mouse Devices and their Susceptibility Patterns to Disinfectants, American Journal of Microbiology, Vol. 4, No. 1, 2013, pp. 9-19, http://dx.doi.org/ 10.3844/ajmsp.2013.9. 19. [15] B.H.Elizabeth, R.R.Brian, W.J.Lancaster, R.L. Mann and S.N.Leonard, Surface Microbiology of the iPad Tablet Computer and the Potential to serve as a Fomite in both Inpatient Practice Settings as well as Outside of the Hospital Environment, PLOS, Vol. 13, 2014, pp. 1371, https://doi.org/10.1371/journal.pone.011 1250.