HENRICO COUNTY HEALTH DEPARTMENT 8600 DIXON POWERS DRIVE

P. O. BOX 90775 HENRICO, VIRGINIA 23273-0775

In cooperation with the State Department of Health

November 15, 2016 Lynne Deane, M.D. and Tom Roberts University of Richmond, Student Health and Weinstein Center 29 Westhampton Way Richmond, Virginia 23173 Dear Dr. Deane and Mr. Roberts: Laura Young, District Epidemiologist, and Angela West, Regional Epidemiologist, performed an environmental assessment of the University of Richmond Weinstein Center for Recreation and Wellness on November 10, 2016 as part of an ongoing investigation of increased cases of skin and soft tissue infections (SSTI) and MRSA among students at the university. An environmental assessment was pursued because interviews with the affected students revealed that the majority of them utilized the cardio area (elliptical machines) and strength training areas (dumbbells) at the recreation center. Laura and Angela met briefly with Tom Roberts, Assistant Vice President, Recreation and Wellness and Marti Tomlin, Associate Director of Facilities, as well as with Dr. Lynn Deane to discuss the areas that would be assessed at the facility. Since our meeting last week, PFGE results were received from our state laboratory on the three MRSA isolates submitted, and all 3 were indistinguishable and were not patterns seen by our lab previously (the state lab only performs PFGE on MRSA isolates from outbreaks). In addition, the antimicrobial resistance on these isolates was interesting with resistance not only to Penicillins but also to Ciprofloxacin (intermediate to Levofloxacin) and Erythromycin. A Clean Trace NG Luminometer was used during the assessment to determine baseline levels of contamination of various equipment and surfaces and to assess the effectiveness of the available cleaning products in the facility. Even a perfectly clean sample will not give a zero result, so resulting values should be used as general indicators. Equipment and areas focused on were determined by interviews with students diagnosed by the Student Health Clinic. Ideally, multiple surfaces on the same piece of equipment would be swabbed and a cleaning challenge would be performed on each item, however, the swabs for these detectors are expensive and we are limited in the number of swabs that we have available. The readings below are meant as an example and for educational purposes to assist with establishing cleaning schedules/routines and for training staff. Ranges with this device indicate acceptable levels are those below 500 relative light units (RLU). Levels of 501-999 RLU indicate that “caution” is needed and the area needs to be cleaned; and levels above 1000 RLU represent a “fail” and the area should be thoroughly cleaned and then re-tested. Typically, a smooth surface will have a lower reading than a textured surface and a metal surface will have a lower reading than a rubber or vinyl surface. The following levels were detected:

Recreation Area

Recreation Equipment

Item tested Relative Light Units (RLU)

Cleaning challenge

RLU post cleaning

% decrease in microbial burden

Entrance n/a Hand Scanner 839 Cardio Theater 11 Elliptical 1

R heart rate handle R handle hold keypad

Cardio Theater 11 Elliptical 2

R heart rate handle n/a Yes, wipe 297 unknown R heart rate handle 297 Yes, spray 27 91% keypad 521

Cardio Theater 11 Elliptical 3

R heart rate handle 153 Yes, wipe 79 48% L heart rate handle 195 Yes, spray 39 80%

Cardio Corner Upstairs

Elliptical L heart rate handle 22

Strength training, downstairs

Dumbbells 5lb orange with ridged handle

1414

Dumbbells 8lb black with smooth handle

223

Strength training, upstairs

Dumbbells, near free-weight equipment

5lb black with metal handle

456

Dumbbells, near Studio

7.5lb yellow with ridged handle

3083 Yes, wipe 72 98%

Mat Black Mat 2423 Yes, wipe 1019 58% Studio Yoga Mat 1

Yoga Mat 2 885 845

Upstairs Exercise Ball Red Ball 784 The results above indicate that the highest RLU readings were found in the strength training areas. It is likely that dumbbells are not cleaned routinely by staff or users. Among the dumbbells tested, those with a ridged grip handle had higher readings than those with a metal or smooth handle. It is important when cleaning these items to thoroughly clean the hand grips. Furthermore, it also seems that mats and exercise balls are not cleaned frequently enough by staff or users. Cardio equipment had RLU readings that were more within an acceptable range, and it is likely that the high touch areas on these items are cleaned more routinely by staff and users. With regards to the cleaning challenges, in general, the spray cleaner performed better than the wipes in cleaning a surface (decreasing the microbial burden by 80% and 91%). The wipe performed well in cleaning the grip of the dumbbell; however, there is limited surface area to clean on a dumbbell so the performance of the wipe was optimized when compared to cleaning a larger surface area such as the entire keypad or the hand-holds on an elliptical. In addition, studies have shown that MRSA can survive for months (>90 days) on some items and it tends to survive the longest on items made of plastic and vinyl, particularly when there is sufficient skin cells and microbial load present (such as the dumbbells). It is important when using a wipe that the appropriate kill time is adhered to and that multiple wipes are used for larger surfaces (for example, you may need to use three wipes total to clean the keypad and both hand holds on an elliptical machine, one wipe would not suffice to clean all three areas).

Anecdotally, we observed that the majority of the elliptical machines had a very narrow grip area compared with other elliptical machines on the market. This could lead to greater friction when a user is holding onto the heart rate pads during exercise which could increase chaffing in the underarm area. Chaffing, especially repeated chaffing in an area thereby increases the likelihood of cellulitis or other SSTIs in the underarm area. Most women were wearing tank tops during our site visit which increases skin exposure to microbes present in the gym environment. Based on the results above and on additional observations, we would like to provide the Wellness Center with the following recommendations for environmental cleaning and infection control: Cleaning Supplies:

• Ensure that cleaning supplies are available in all areas of the gym. Both Spartan Hard Surface Disinfecting Wipes and Sani-T-10 Disinfectant Spray were noted to be easily accessible in many areas of the gym, particularly in the Cardio Theater. In the upstairs multipurpose room, only Purell hand-wipes were noted to be available. It is recommended that a sanitizing option for the equipment be placed in this room as well because Purell wipes are not meant to clean equipment. As sanitizing wipes/sprays should not be used on skin, it is recommended that the Purell wipes remain in the room.

• While the available disinfection wipes and the spray were both effective, the spray appeared to be more effective at cleaning larger surfaces and it is recommended that staff members use the spray at least once daily when cleaning equipment and general use areas. We recommend continuing to have the wipes in the facility as patrons may prefer them, and we want to encourage the use of disinfection supplies.

• When cleaning equipment with a wipe or spray, it is important to ensure that the surface being cleaned appears wet so that the cleaner can work effectively. For instance, one wipe should effectively clean a single handle of an elliptical machine, but it would take multiple wipes to clean all high-touch surfaces on that machine. Ensure that staff who perform environmental cleaning are using products appropriately and using them for the correct “kill-time” of the product.

• Since the lids on the wipe containers remain open most of the day, staff should ensure that the wipes are still adequately wet when using them on equipment. If the wipes are drying out, they will not be as effective.

Cleaning Schedules:

• Establish a routine daily and weekly cleaning schedule and review that schedule with staff. Teach staff with environmental cleaning duties how to clean items effectively and ensure that they understand the manufacturer’s instructions on the cleaning products that are used. Observe staff cleaning to ensure that all items are being cleaned and that the cleaning is effective.

• Facility staff indicated that the monitors will clean equipment weekly and that fitness staff perform some cleaning on a daily basis. However, it was noted that some items, such as the dumbbells are rarely cleaned even though they are high-touch areas. Given

the recent increase in SSTIs, as well as respiratory illness at the university, high-touch areas on equipment (handles, heart rate monitors, keypads, etc) should be thoroughly cleaned by staff at least twice daily. A thorough cleaning of all equipment surfaces, including mats and dumbbells should be done weekly. With the upcoming holiday vacation, we encourage the recreation center to aggressively clean while the facility is not busy. Items that had high RLU readings, and those which are rarely cleaned by staff or users, will likely need to be cleaned several times by staff members in the course of one day before the microbial burden falls to acceptable levels.

• Reinforce the importance of cleaning equipment both before and after use to students and faculty who utilize the recreation areas.

• Ensure that the hand scanner at the entrance is cleaned hourly by staff that monitor the entrance. Ensure that hand sanitizer is available directly next to scanner.

Education:

• Ensure that staff members understand their cleaning responsibilities and schedules. • Ensure that staff members understand the cleaning products that are utilized by the

facility and how to most effectively clean with these products. • Educate students and staff about how to recognize an SSTI and to keep this area

covered with a bandage when using the recreational facilities. If the area cannot be covered, or if it is draining so profusely that it drains through the covering, they should not use the facility until the area has healed.

I would like to thank you and your staff for the cooperation shown thus far as we all work together to keep your students and staff healthy. If you have any questions or concerns, please contact the Henrico Health Department at 804-501-5216. Sincerely,

Laura R. Young, MPH, CIC Susan Fischer Davis, MD Epidemiologist Director Henrico Health District Henrico Health District 804-501-5216 laura.r.young@vdh.virginia.gov