1. Introduction

Healthcare-associated infections (HAI) are a significant burden globally, with millions of patients affected each year. [Reference 1] These infections affect both high- and limited-resource healthcare settings, but in limited-resource settings, rates are approximately twice as high (15 out of every 100 patients versus 7 out of every 100 patients). Furthermore, infection rates within certain patient populations, including surgical patients, patients in intensive-care units (ICU) and neonatal units, are significantly higher in limited-resource settings.

It is well documented that environmental contamination in healthcare settings plays a role in the transmission of HAIs. [References 2, 3] Therefore, environmental cleaning is a fundamental intervention for infection prevention and control (IPC). It is a multifaceted intervention that involves cleaning and disinfection (when indicated) of the environment alongside other key program elements (e.g., leadership support, training, monitoring, and feedback mechanisms).

To be effective, environmental cleaning activities must be implemented within the framework of the facility IPC program, and not as a standalone intervention. It is also essential that IPC programs advocate for and work with facility administration and government officials to budget, and operate and maintain adequate water, sanitation, and hygiene (WASH) infrastructure to ensure that environmental cleaning can be performed according to best practices.

1.1 Environmental transmission of HAIs

In a variety of healthcare settings, environmental contamination has been significantly associated with transmission of pathogens in major outbreaks of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), Clostridioides difficile (C. diff), and more recently in protracted outbreaks of Acinetobacter baumannii. Outbreak investigations have determined that the risk of patient colonization and infection increased significantly if the patient occupied a room that had been previously occupied by an infected or colonized patient. Therefore, the role of immediate patient care environment—particularly, environmental surfaces within the patient zone that are frequently touched by or in direct physical contact with the patient such as bed rails, bedside tables and chairs—in facilitating survival and subsequent transfer of microorganisms was established. [References 4–10] However, it is important to note that environmental transmission of HAIs can occur by different pathways.

It has also been documented that some healthcare-associated pathogens can survive on environmental surfaces for months.[Reference 3]  In 2006, a laboratory-based study documented the survival times of a range of significant healthcare-associated pathogens, including gram-negative bacilli, and found that they could persist much longer in the environment than was previously understood. For example, Acinetobacter spp. survived up to 5 months and Klebsiella spp. up to 30 months. [References 11–12] The actual survival times in healthcare settings vary considerably based on factors such as temperature, humidity, and surface type.

Figure 1 illustrates the environmental transmission pathway in general terms. Microorganisms are transferred from the environment to a susceptible host through:

• contact with contaminated environmental surfaces and noncritical equipment
• contact with contaminated hands or gloves of healthcare workers during the provision of care, as well as by caretakers and visitors

Contaminated hands or gloves will also continue to spread microorganisms around the environment. Figure 1 also shows how these pathways can be broken and highlights that environmental cleaning and hand hygiene (preceded by glove removal, as applicable) can break this chain of transmission.

Evidence is increasing but remains limited that effective environmental cleaning strategies reduce the risk of transmission and contribute to outbreak control.[References 7, 13–22] Consequently, the use of multiple (i.e., a bundle) interventions as well as an overall multi-modal approach to IPC activities and programs is recommended, for both the outbreak and routine setting.

1.2 Environmental cleaning and IPC

Environmental cleaning is part of Standard Precautions, which should be applied to all patients in all healthcare facilities. It is important to implement environmental cleaning programs within the framework of facility level IPC programs. Where possible—during staff training and education, for example—consider generating synergies and highlighting the relationship between environmental cleaning and hand hygiene activities in preventing environmental transmission of HAIs.

Facility level IPC programs include multiple elements, ranging from surveillance for HAIs to training and education for all healthcare workers on IPC. The World Health Organization (WHO) has defined core components of IPC programs in Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level.

Environmental cleaning is addressed explicitly within Core Component 8: Built environment, materials and equipment for IPC at the facility level.

But other components include important aspects for the implementation of environmental cleaning as well, such as:

• Core Component 2: IPC guidelines
• Core Component 3: IPC education and training
• Core Component 6: Monitoring/audit of IPC practices and feedback

At the national level, it is important that these Core Components (2, 3 and 6) include frameworks and guidance to inform facility level approaches to environmental cleaning.

Given the wide range of IPC responsibilities at acute healthcare facilities, implementation of robust IPC programs requires a dedicated, trained IPC team (or at least a focal person). The IPC team should consult and be involved in the technical aspects of environmental cleaning program (e.g., training, policy development). A separate team is recommended for the overall management and implementation of the environmental cleaning program. In small primary care facilities with limited inpatient services, the IPC team or focal person might be directly responsible for managing environmental cleaning activities.

1.3 Environmental cleaning and WASH infrastructure

Healthcare facilities must have adequate water supply and sanitation infrastructure (e.g., safe wastewater disposal) to perform environmental cleaning according to best practices. A recent global report summarized the critical lack of access to basic water, sanitation, and hygiene (WASH) services in healthcare facilities in resource-limited settings, which hinders the ability of facilities to implement effective environmental cleaning programs. [Reference 23]

In response to the identified need to improve WASH in Healthcare facilities, WHO and UNICEF have engaged partners and proposed practical steps to improve WASH services. Notably, this includes using and reporting on:

• harmonized monitoring indicators for the Sustainable Development Goals: Healthcare Facilities, Joint Monitoring Programme (JMP)
• a facility improvement tool to assist incremental improvements to WASH services: Water and Sanitation for Health Facility Improvement Tool ((WASH FIT)): a practical guide for improving quality of care through water, sanitation and hygiene in healthcare facilities
• eight recommended practical steps that provide a roadmap for country improvement in the long term and align with the 2019 World Health Assembly Resolution on WASH in healthcare facilities: WHO | WASH in health care facilities

1.4 Basis and evidence for proposed best practices

The following best practices for environmental cleaning in resource-limited settings are proposed as a standard reference and a resource to:

• supplement existing guidelines
• inform the development of guidelines where needed
• elevate the attention to this critical and under-resourced aspect of healthcare and patient safety

These best practices are derived directly from a variety of best practices and cleaning standard documents from several English-speaking high-resource settings, most notably, the United States of America, Canada, the United Kingdom, and Australia. These documents have been generated by a combination of expert opinion and ranking of the current evidence. See Further reading for a list of the documents that have been used extensively in the development of these best practices.

These best practices were developed by a committee of experts in environmental cleaning in resource-limited settings. Using a consensus-driven process, we have included the best practices most relevant and achievable for the target context.

For example, the best practices in ICUs in this document include more frequent environmental cleaning that recommended in several of the referenced documents because of the increased HAI risk and burden in ICUs in resource-limited settings. Alternatively, the use of no-touch and novel disinfection devices, which are increasingly common in high-resource settings, were excluded from this document because of their prohibitive cost and limited evidence on their effectiveness in reducing HAIs in resource-limited settings.

This is a living document that will be updated and improved as new evidence becomes available.

1.5 Purpose and scope of the document

The purpose of these best practices is to improve and standardize the implementation of environmental cleaning in patient care areas in all healthcare facilities in resource-limited settings.

1.6 Intended audience of the document

This document is intended for healthcare facility staff who have a role in the development, management, or oversight of environmental cleaning services (internal or contracted) for the healthcare facility.

1.7 Overview of the document

The best practices are divided into three chapters, described below and relationally in Figure 2.

Chapter 2: Environmental Cleaning Programs

• An environmental cleaning program is a structured set of elements or interventions which facilitate implementation of environmental cleaning at a healthcare facility.
• Environmental cleaning programs require a standardized and multi-modal approach and strong management and engagement from multiple stakeholders and departments of the healthcare facility, such as administration, IPC, WASH or facilities management.
• This chapter provides the best practices for implementing environmental cleaning programs for all program mechanisms (managed in-house or contracted), including the key program elements of:
  • organization/administration
  • staffing and training
  • infrastructure and supplies
  • policies and procedures
  • monitoring, feedback and audit

Chapter 3: Environmental Cleaning Supplies and Equipment

• The selection and appropriate use of supplies and equipment is critical for effective environmental cleaning in patient care areas.
• This chapter provides overall best practices for selection, preparation, and care of environmental cleaning supplies and equipment, including:
  • cleaning and disinfectant products
  • reusable and disposable supplies
  • cleaning equipment
  • personal protective equipment (PPE) for the cleaning staff

Chapter 4: Environmental Cleaning Procedures

• It is critical to develop and implement standard operating procedures (SOP) for patient care areas.
• This chapter provides:
  • the overall strategies and techniques for conducting environmental cleaning according to best practice based on risk assessment
• Best practices for the frequency, method, and process for every major area in healthcare settings to help users develop tailored SOPs for all patient care areas in their facility, including:
  • outpatient areas
  • general inpatient areas
  • specialized patient areas