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ANTIMI CRobial COPPER TOUCH surfaces REDUCE INFECTIONS, LIBERATE RESOURCES AND CUT COSTS

he role of the environment in - Measurement of antibacterial activity on on the stainless steel control (Michels the transmission of healthcare- plastics and other non-porous surfaces et al. 2008). Tassociated infections (HCAIs) is (ISO 2011) tests, conducted at >90 Laboratory research on the antimi- increasingly recognised, requiring a new percent humidity, 35oC and over 24 crobial efficacy of copper and copper approach to the selection of materials for hours under a plastic film. These basic alloys has been carried out and verified objects frequently touched by healthcare tests are described as a proof of principle at institutions around the world, with workers, patients and visitors that can and do not indicate how a material will results peer-reviewed and published in serve as reservoirs of infection. perform in the field. respected journals. They exhibit efficacy There are many technologies and mate- To better represent actual in-use condi- under typical indoor conditions, unlike rials on the market, but none are as effec- tions when testing copper, researchers silver-containing materials and triclosan, Angela Vessey tive under typical indoor conditions as developed new protocols to reflect typical which showed no antimicrobial efficacy copper, and its hygienic properties are far room temperature and humidity and used under these conditions, as shown in Figure Director Copper Development from new to us. The Ancient Egyptians, representative contaminants. 2 (Michels et al. 2009). Association G reeks and Romans used copper-based Hemel Hempstead, UK preparations to treat ailments and prevent wound infections, and in India drinking "THE ANCIENT EGYPTIANS, GREEKS angela.vessey@ copperalliance.org.uk water is traditionally stored in pots made AND ROMANS USED COPPER-BASED antimicrobialcopper.org of brass — an alloy of copper and zinc. Evidence shows that upgrading the @copperchat PREPARATIONS TO TREAT AILMENTS AND most frequently-touched surfaces in a healthcare environment to antimicro- PREVENT WOUND INFECTIONS AND IN bial copper can reduce the spread of costly infections and improve patient INDIA DRINKING WATER IS TRADITIONALLY care. This article explores the growing body of research — from laboratory tests STORED IN POTS MADE OF BRASS" and clinical trials — and considers the practicalities and economics of upgrading The U.S. Environmental Protection Simulations of ‘dry’ touch contamination key surfaces to copper. Agency (EPA) approved one such test events have also been developed, and method and developed further protocols these tests show an even more rapid kill, Effective Under Typical Indoor — including a challenging recontami- with 106 vancomycin-resistant entero- Conditions nation test — leading to the registra- cocci (VRE) killed in less than 10 minutes Copper’s antimicrobial properties have tion of hundreds of copper alloys to be on 1cm2 copper (Warnes et al. 2011). been documented in scientific literature marketed in the U.S. with public health A leading researcher in this field is for more than a century, but it was not claims. These were the first solid materials Professor Bill Keevil, Chair in Environmental until 2000 that its efficacy against the to achieve such recognition. As a general Healthcare at the University of pathogens responsible for HCAIs began rule, alloys should have a minimum 60 Southampton, and his work includes to be assessed. percent copper content, and the higher investigation of the mechanisms by which Fifteen years on, more than 60 papers the copper content, the faster the kill (in copper exerts its antimicrobial effect. report copper’s broad-spectrum, rapid laboratory tests). For bacteria, the current consensus efficacy against bacteria, viruses and Figure 1 shows the results of an EPA among researchers is that there are fungi — including MRSA, E. coli, Influenza recontamination test simulating a splash several probably interacting mecha- and norovirus. No pathogen tested has or sneeze — a ‘wet’ contamination event nisms, including: been able to survive on copper. — with MRSA applied every three hours • Causing leakage of potassium Claims of antimicrobial efficacy made over a 24-hour period at room tempera- or glutamate through the outer for many antimicrobial products are ture and humidity. The number of MRSA membrane of bacteria; based on Japanese Industrial Standard used (1 million colony forming units per • Disturbing osmotic balance; (JIS) Z 2801, Antibacterial products - square inch) is far higher than would be • Binding to proteins that do not require Test for antibacterial activity and effi- found in a typical contamination event. On copper; cacy (Japanese Standards Association copper, the MRSA are totally eliminated • Causing oxidative stress by gener- 2012) and International Organization before the next recontamination, while ating hydrogen peroxide; for Standardization (ISO) 22196: 2011 there is survival and significant growth • Degradation of bacterial DNA.

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The Bostonian Sleep Clinic - UK Isku Medical Centre - Finland Ralph H. Johnson VA Medical Center Image credit: Brass Age Image credit: Copper Development Association 1- US - Clinical Trial Site

There is also agreement that bacteria infection that pose a risk to patients, Numerous trials have since been will not develop resistaance to copper. staff and visitors, for days, weeks or even conducted in different healthcare systems Professor Keevil explains: “Copper works months. The first clinical trial – under- — including the U.S., Germany and Finland in completely different ways to antibiotics taken at Selly Oak Hospital in Birmingham, — and different clinical environments such or common biocides. It punches a hole in UK – found that antimicrobial copper as nephrology, geriatric and ICU wards. the cell membrane, like a balloon, and the taps, toilet seats and door handles on They have similarly reported significant bacteria collapse. It stops them respiring, a general medical ward had 90 to 100 and continuous bioburden reduction, with goes into the cell and destroys their DNA. percent fewer bacteria on them than trial leaders concluding that antimicrobial Mutation happens because you get small the same items made from standard copper surfaces can provide an additional changes in DNA in cells. The beauty of materials (Casey et al. 2009). measure to reduce the spread of HCAIs. copper is it destroys the DNA; there is nothing left. We’ve shown this for bacteria, fungi and viruses. They can't mutate. They have no time.” Most recently, the Southampton team has investigated the contribution antimicrobial copper surfaces can make to combating the rise of antibiotic resistance, assessing the ability of two different strains of bacteria to pass genetic material conveying antibiotic resistance between them on copper and stainless steel. While this took place on stainless steel, it did not happen on copper (Warnes et al. 2012). Copper can therefore contribute to the Figure 1. EPA Recontamination Test to Simulate a Busy Ward: 1 million CFUs of MRSA every 3 fight against antibiotic resistance in two Hours on Copper (C110) and Stainless Steel ways: by reducing the spread of infec- Source: Grass et al. (2010) tions and thus the need for antibiotics and by preventing the transfer of resistance between bacteria on surfaces.

Proven Under Challenging Clinical Conditions Having established the inherent ability of copper to eliminate bacteria and viruses in the laboratory, the next logical step was to discover how this would trans- late into real clinical environments. It is important to note that trials have used solid materials, as the effective surface will not wear away or be susceptible to reduced efficacy over time, as with coat- ings and composites. Figure 2. MRSA Viability on copper, silver- and triclosan-coated materials and stainless steel Pathogens persist on standard clinical at room temperature and humidity touch surfaces, creating reservoirs of Source: Michels et al. (2009)

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between burden and HCAI risk, with 89 percent of HCAIs occurring among patients in rooms with a burden of more than 500 colony-forming units (CFU) per 100 cm2 (Salgado et al. 2013). Key healthcare watchdogs and horizon scanning bodies around the world, including ECRI Institute (2014) and the Canadian Network for Environmental Scanning in Health (Ndegwa 2015) have recognised the growing body of evidence for copper’s potential to boost infection control. It has also been acknowledged in the evidence- Figure 3. Sustained Reduction of Microbial Burden on Hospital Surfaces Through Introduction of Copper based epic3 guidelines, which included Source: Schmidt et al. (2012) copper as an emerging technology in 2014 (Loveday et al. 2014). With this proven efficacy in mind, the next question arising will naturally concern the cost of installing antimicrobial copper touch surfaces.

C ost Benefits of Upgrading to Copper HCAIs are very common and very costly, both financially and in terms of human life. Approximately 20 percent of ICU patients in European hospitals get HCAIS, and in 2011 they affected 4.1 million patients, necessitating 16 million extra days in hospital. Thirty-seven thousand deaths were recorded as being caused by HCAIs, plus 110,000 deaths where they were a Figure 4. Quartile Distribution of HCAIs Stratified by Microbial Burden Source: Salgado et al. (2013) contributing factor, and they had a direct clinical cost in excess of 7 billion euros A multicentre clinical trial in ICUs, funded the six surfaces (Schmidt et al. 2012). (World Health Organization 2011). by the U.S. Department of Defense, took Just 10 percent of touch surfaces were York Health Economics Consortium (YHEC), the research one step further and asked upgraded to antimicrobial copper, yet the a group of leading global health economists the question "Will the bioburden reduc- impact was significant. This study is the based at the University of York in the UK, tion associated with the installation of first to report a correlation between envi- developed a fully-referenced cost benefit copper surfaces reduce the number of ronmental bioburden (whether in copper model for hospital managers to illustrate infections?" Led by Dr. Michael Schmidt, or control rooms) and the risk of acquiring the economic rationale of an antimicrobial Professor and Vice Chair of Microbiology an infection, and to show a reduction in copper installation (Taylor et al. 2013). The and Immunology at the Medical University that risk due to a minimal intervention model is based on the cost of installing of South Carolina, the trial team found with an effective antimicrobial material. antimicrobial copper touch surfaces and that replacing just six key, near-patient Figure 4 demonstrates this correla- the balancing cost savings resulting from touch surfaces reduced the incidence tion, with quartile distribution of HCAIs reduced infection rates. The model allows of infections by 58 percent (Salgado et stratified by microbial burden measured local data to be entered for site-specific al. 2013). Figure 3 shows the accompa- in the ICU room during the patient’s stay. evaluations, but is populated with default nying reduction in microbial burden on There was a significant burden association data for the UK as an illustration.

Table 1

Source: Copper Development Association (2014)

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Using UK data for cost of infection, how does one get started with selecting hospital equipment, furniture and fittings industry data for cost of antimicrobial the priority touch surfaces to upgrade in to indicate their products are made from copper and standard components, and a given healthcare environment? solid antimicrobial copper, and that the a conservative infection rate reduc- A number of studies have identified organisation adheres to strict usage rules tion of 20 percent (where the U.S. trial frequently-touched surfaces as being guiding their understanding of the under- reported a 58 percent reduction), the contamination hotspots that present an lying technology and its deployment. model considers a planned refurbishment infection risk and are therefore targets for An online directory of approved products or new build. It predicts that the cost of upgrade. Based on a review of international is available to browse on antimicrobi- replacing the six key touch surfaces in research, the United States Centers for alcopper.org. a 20-bed ICU with antimicrobial copper Disease Control and Prevention (CDC) Copper alloys offer a wide palette of equivalents will be recouped in less than published a checklist of key surfaces colours from the gold of brasses to the two months, based on fewer infections based upon the likelihood of touch and rich brown of bronzes right through to and the resulting shorter lengths of stay. contamination (Guh et al. 2015). the silver/white shades of copper-nickels. It also calculates a positive impact on In the many copper clinical trials, Copper alloys will naturally darken over bed days and quality-adjusted life years conducted around the world, multi- time, but this does not impact their anti- offered by antimicrobial copper. disciplinary teams have prioritised high microbial efficacy. More colour-stable Dr. Matthew Taylor, YHEC’s director and frequency touch surfaces to upgrade to alloys traditionally used in naval appli- one of the model’s authors, concludes: copper. The factors considered include cations are available. “After the initial two months, ongoing known hotspots from microbiological cost savings will accrue from the reduc- testing and likely hotspots based on Wide Installation tion in blocked beds and better directed experience and understanding of staff/ Antimicrobial copper surfaces are an staff resources.” patient/visitor dynamics. adjunct to and not a replacement for Table 1 represents a summary of these existing infection control measures. Specifying Copper surfaces with CDC surfaces indicated Alongside good hand hygiene and regular There is an ever-expanding range of by an asterisk, to differentiate from surface cleaning and disinfection, they will products on the market as the supply those identified in clinical trials, and is continuously reduce surface contamina- chain responds to growing demand, so the starting point for selecting items to tion and consequently the risk of infec- upgrade for any new build or refurbish- tions being passed between people via ment project. these surfaces. Key points Input should also be sought from the Installations have already taken place infection control team and ward staff to around the world in more than 25 coun- • Copper is a powerful antimicrobial with rapid, broad- ensure that all high-risk touch surfaces tries. In these hospitals, the importance spectrum efficacy against bacteria and viruses, includ- specific to a particular area are included. of taking a multidisciplinary approach to ing MRSA, E. coli and norovirus. • ‘Antimicrobial Copper’ is an umbrella term for pure The regular environmental swabbing infection control has been clear. copper and a family of copper alloys that benefit from carried out by infection control teams the metal’s inherent antimicrobial efficacy. to assess the state of cleanliness will Further Reading • Touch surfaces – such as bed rails, overbed tables, taps also indicate contamination. You can download a simple, four-page and light switches – made from antimicrobial copper harbour >80 percent less microbial contamination than Support with identifying efficacious guide Antimicrobial Copper: A Hospital non-copper equivalents. products is available in the form of Manager's Guide (CDA Publication 219) • This reduction in contamination has been shown to an industry stewardship scheme. The (2014) from News and Downloads/ reduce infections by 58 percent. + Antimicrobial Copper brand and Cu mark Brochures on antimicrobialcopper.org. are used by leading manufacturers of

References

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