We have entered a new journey through an unprecedented time. The coronavirus (COVID-19) is ravaging the world and especially my home state of New York. I am humbled to be working every day alongside my colleagues — dedicated doctors, nurse practitioners, nurses, and ancillary staff — who are fighting, as the President of the United States puts it, “an invisible enemy.” But the enemy’s effects are profoundly visible: hospitals floors are full with patients who are intubated, critical, and in respiratory distress. Supplies of respiratory equipment are critically low. Personal protective equipment and disinfecting products have become commodities. A No Visitors’ policy is in effect; social distancing is paramount. Personal hygiene and clean surfaces have become more essential today than they have ever been.
Clinicians are appropriately focusing attention on the respiratory status of our virus-affected patients, because pneumonia-induced cytokine surge and acute respiratory distress syndrome overwhelm the presentation. But what about our skin, our biggest barrier to harmful entry and our protector against microbes and outside forces? We face tremendous challenges in caring for our great protector. Respiratory equipment already is known to be the number 1 cause of pressure injuries; as more patients are infected with coronavirus, more cutaneous pressure injuries will occur. Epidermal stripping is to be expected as numerous adhesive devices are attached to patients. More irritant dermatitis will occur among hospital workers, because frequent hand washing/sanitizing is breaking down the outer stratum corneum, not to mention the wounds associated with face masks. More than ever, as barriers between skin and equipment become critical, adhesive releasers, creams and acrylate films, and emollients are needed for worker protection.
In pediatrics and especially neonatology, we have to concentrate on prevention. My patients cannot afford serious illnesses; their bodies are often too immature to be exposed to microbes without catastrophic outcomes. Examples are prolific and include Staphylococcus aureus skin colonization, central line infections, systemic infections, community-acquired S aureus via contact and surface colonization; congenital fungal and bacterial infections related to the maternal microbiome and neonatal exposure; Clostridium difficile infections in the hospitals via fomite/surface1 transmission; and, of course, viral infections, including COVID-19 via droplets. Whether we are providers, patients in the hospital, or citizens in the community, our skin defends us daily, and every surface it touches presents a risk.1
The infection spread due to the COVID-19 pandemic is not unique. The skin microbiome, skin, and environmental surfaces are colonized with microbes; whether commensal or pathogenic, these microbes have been the subject of many studies. In hospitals, the patient environment includes patient-care equipment, environmental surfaces, visitors touching the patient, and (in the case of a neonate) the mother/baby skin interaction during labor. We know that infants are highly susceptible to microbiome changes based on the mode of delivery. Vaginal delivery will induce colonization by diverse commensal bacteria, such as Lactobacillus species,2 whereas a Caesarian section will introduce maternal skin and mouth flora including Staphylococcus and Streptococcus species.2 In addition, maternal diabetes, breast infection, or poor diet will promote pathogenic skin colonization; neonatal feeding with breast milk will promote Lactobacillus species colonization of the skin and gut.2 Studies involving vernix retention in newborns demonstrated superior skin condition as well acid mantle development and commensal bacterial colonization; therefore, removing the vernix by bathing is to be avoided. Early bathing is not recommended in newborns in general for variety of reasons, except after delivery associated with certain maternal viral conditions, such as hepatitis C, human immunodeficiency virus, human lymphotropic virus, and now COVID-19. Transmission to caretakers and surfaces is highly probable and represents significant risk to personnel and patients. In the neonatal world, patient colonization with methicillin-resistant S aureus is another example of surface transmission, demonstrating the need for decontamination (skin with chlorhexidine and surfaces with strong antiseptics) and skin decolonization.
As noted in a previous Children with Wounds column,3 infected patients are recognized as a source of pathogens, and the use of transmission-based precautions is central to preventing dissemination of pathogens; colonized patients and surfaces also represent a risk of pathogen dissemination. Consistent and correct use of standard and transmission-based precautions is generally relied on to protect health care workers and help control pathogen cross transmission. However, it is far from certain whether the typical compliance levels with hand hygiene, environmental surface cleaning, and use of barriers are adequate to manage this risk. Colonization is referred to as the presence of microorganisms in or on a host, with growth and multiplication but without tissue invasion or cellular injury.1 A colonized person shows no obvious signs of disease yet can spread microorganisms into the environment through normal day-to-day activities. Although most of the microorganisms shed are nonpathogenic to the colonized host, bacteria or viruses may be pathogenic to other people, depending on the portal of entry or the immune system strength of the susceptible host. The potential for pathogen dissemination from an asymptomatic person is high as the average human body contains ~0.3 percent bacteria by weight.4
Three (3) common sources of microorganisms shed by people include, feces, saliva, and skin cells.1 As much as it provides a barrier, skin is a landing ground for these microorganisms. As skin sheds, so do the microbes inhabiting the outer layer. The American Academy of Dermatology5 estimates that out of 19 million skin cells, 30 000 to 40 000 are shed daily. Meadow et al6 reported that humans shed 1x 106 particles of >0.5 micrometer/hour. Many of these particles contain bacteria (there are 1x1011 bacteria/m2 on skin), viruses, and fungal debris in addition to human debris. Viral particles are even smaller and tend to be disseminated even more.
A few months before COVID-19 came our way, I spoke with Mary Brennan, WOCN, Assistant Director for Wound and Ostomy Care at North Shore University Hospital, Northwell Health, New York state. We discussed a study on the safety of our pillows and surfaces and contamination potential even after thorough outside cleaning that she was working on with our colleagues from the Northwell Feinstein Institute Skin Research group. She shared her experiences to inform readers.
Ms. Brennan: While bacteria have been the primary culprit in most hospital-acquired infections, viruses now have emerged as a major heath issue. Research has shown that limiting use of indwelling urinary catheters and cleansing high risk patients in intensive care units with chlorhexidine can be successful in limiting bacteria spread; however, viruses remain an uncharted territory. Identifying standards of care to contain and treat viruses, along with potential processes to identify and eliminate viruses in our health care settings, will emerge as a focus as more about virus pathology is identified and understood.
Within our health system, efforts have been ongoing to ensure all measures aimed at minimizing risks to our patients are provided. We have examined and evaluated potential issues of colonization and contamination of equipment. Use of reusable equipment, such as typical hospital mattress, positioning aids, and pillows, is an aspect of care that affects every patient. Pillows were not considered a potential source of infection until testing began to emerge in Europe. In a study funded by Gabriel Scientific Limited,7 100 standard pillows with sewn edges and fluid-resistant covers were opened and tested; results indicated that bacteria and fluids were contained within the inner material.
Subsequently, 100 “new" blue pillows incorporating welded seams and an engineered hydrophobic microporous membrane (filter) that would act as a breathable barrier were tested. Study results indicated the blue pillows did not harbor bacteria or fluid; it was surmised that the filter had an extremely high fractional efficiency that prevented even the tiniest liquid- and airborne pathogens from passing through to the interior of the product. Türk et al8 tested the outer and inner core of the standard white pillows and the filtered blue pillows in a maternity ward in Finland and found the filtered pillows were more culture-negative than standard pillows. Results out of Europe9,10 indicated that the average pillow has 1 million spores and as many as 16 types of fungus, are used 3000 hours each year, and involve 20 gallons of sweat.
After reviewing the results of these studies, our facility embarked on an initial testing of our currently used laminated standard hospital pillows that were thought to be fluid-resistant and hypoallergenic. A total of 20 pillows were collected from random units in our 800-bed facility and brought to a bench scientist for testing. Initial study analysis included testing the sewn seams of each pillow and then cutting open the pillows. The results revealed human and bacterial DNA were present in the inner core of the pillows. When we learned our pillows were not resistant to fluids, we began a study to evaluate the new blue pillows. We replaced our white pillows with the new blue study pillows in every unit and then randomly sampled pillows at 2-month intervals for analysis. So far, none of the blue pillows has shown any evidence of bacteria, and the few that were cut open do not reveal any human or bacterial DNA. This study is ongoing and will be fully discussed in future publications.
The work of Mary and her colleagues was intriguing. We decided to work with the manufacturer, Spry Therapeutics, to replace all existing neonatal mattresses with their PneumaPure technology to minimize colonization, risk of dandruff, and viral particle exposure. They pursued the ideas that the traditional method of stitching pillows enables pathogens to enter and accumulate within the pillow’s interior, contaminating pillow users and those in close proximity7-10 and that small surface perforations may create additional entry points for pathogens. A pressure strikethrough test revealed extensive particle release in the air every time person laid down or squeezed a regular hospital-grade pillow, with significant inhalation of released matter. Medical pillows and mattresses from Spry Therapeutics PheumaPure feature a new, soft-surface filter with Nano-Barrier technology; independent testing showed this new filter technology blocks even the smallest superbugs (as small as 0.02 microns) from entering or exiting any soft surface, including viruses such as COVID-19. The company’s Pureshield fabric protection provides a waterproof, breathable barrier, while seams are hermetically sealed via Safeweld technology. We have 6 different mattresses in our neonatal intensive care units; all are being replaced (see Figure 1 and Figure 2). We plan to study the colonization pattern of our original, sewn-seam mattresses versus the new mattresses after at least a few months of use.
When COVID-19 came our way, our children’s hospital made a decision to change all our pillows to the blue medical pillows. We hope this will be one of many necessary steps that help prevent viral spread. I urge all hospitals to share new technologies, innovations, successes and failures, now and in the future. We have to figure how to fight this virus along with all other pathogens to help our skin perform its toughest job — keeping us safe!