REBECCA LEACH, RN, BSN, MPH, CIC, has been an infection preventionist since 2010, with a background in nursing and epidemiology. Leach, a member of Infection Control Today®’s Editorial Advisory Board, currently works at a healthcare system in Phoenix, Arizona, that includes 5 hospitals and more than 100 outpatient treatment centers.

Rebecca Leach, MPH, BSN, RN, CIC

Dental and oral surgery clinics have historically been underrepresented in the scope of practice of infection preventionists (IPs). Infection prevention and control (IPC) lapses in dental clinics can have a significant impact on patients. The CDC has published recommendations since 2003, with the most recent updated edition of summary recommendations in 2016.

Basic IPC practices have a universal application. For example, standard precautions apply in dental clinics as they do in acute care facilities. Hand hygiene is a cornerstone of IPC practices, as well as the use of personal protective equipment, environmental disinfection, and safe injection practices. Instrument cleaning and sterilization are key topics for ensuring safe dental care. Mechanical cleaning is preferred over manual cleaning.

Oral surgery can also impact patient outcomes, as microorganisms from the oral cavity may potentially spread to normally sterile sites and cause secondary infections. Risk factors for surgical site infections (SSIs) after oral and dental procedures can be classified as patient-related or procedure-related. Patient-related risk factors include variables such as age, diabetes status, smoking status, and other comorbidities. Procedure-related risk factors include instrument sterilization, preparation of the surgical site, prophylactic antimicrobial use, and duration of the procedure.

In acute care facilities, patients may have oral and maxillofacial procedures for various admitting diagnoses, such as trauma (eg, motor vehicle crash, assault, falls), cleft lip and palate, impacted teeth, or other skeletal malformations. Dental surgery and procedures in outpatient settings are typically performed for less complicated issues, such as tooth extractions or dental implants.

In the US, limited data exist to understand the rate of SSIs following oral surgery. Literature has reported rates that can range from 2.15% to 30.8%, depending on the type of procedure.

 A study recently published from Saudi Arabia found a rate of 10.3% of SSIs after oral or maxillofacial surgery.

The study by AlKhamis et al reviewed patient- and procedure-related risk factors for SSIs. They found that increased age, male gender, and diabetes status were strongly associated with increased risk for SSIs.

 Interestingly, the use of a chlorhexidine mouthwash was not found to be a statistically significant variable in the prevention of SSIs. However, the group that used the mouthwash before surgery was small, so there might not have been a large enough sample size to establish significance. Oral care and hygiene are key patient-level factors that contribute to the risk of poor outcomes and have been shown to be significant in other studies.

As far as procedure-related risk factors, when comparing procedure types, cases classified as head and neck lesions had the highest prevalence of SSIs, followed by maxillofacial trauma and then dentoalveolar surgeries.

 However, the analysis showed no statistically significant difference in risk according to the type of surgery. The variables associated with an increased risk of oral surgery are consistent with those for other procedures, including multiple trips to the operating room, a higher American Society of Anesthesiologists score, and a higher wound classification.

The use of prophylactic antimicrobials in dental surgery to prevent SSIs showed variation in practice in this study. Typically, dentists in the outpatient setting are more likely to prescribe an antimicrobial for patients with a history of joint replacement or other risk factors. This is to prevent the seeding of a secondary site rather than to prevent a primary SSI. In an acute care setting, preoperative antimicrobials may be used more often as part of standard procedures and processes to prevent postoperative complications.

Dental SSIs are not required to be reported as infections for acute care facilities in federal or state health care–associated infection reporting. Therefore, surveillance is largely limited to focused published research. Outpatient clinics and surgery centers would have even less structured surveillance approaches. Because of these limitations, it is challenging to understand the scope of the problem and identify trends to address opportunities for improvement.

Several key factors should be included in a dental SSI prevention program. First, patient-related factors need to be managed as much as possible preoperatively. Diabetes management is a key factor to consider in preoperative counseling. Maintaining blood glucose levels within a normal range can decrease the risk of postoperative infection. Patient oral hygiene practices can be reviewed and improved. The use of a chlorhexidine mouthwash preoperatively should be considered, along with regular good oral care. If patients are hospitalized, tooth brushing and oral care should be continued as part of standard patient care.

The use of prophylactic antimicrobials is a key step in surgical procedures, but the growing concern about antimicrobial resistance poses a challenge. To decrease the risk of resistance, some guidelines recommend reserving the use of prophylactic antibiotics for patients and procedures at the highest risk.

 It would be essential to review data to validate this practice, understand how infection rates may be impacted, and weigh the risk of infection vs potential resistance when making such recommendations.

Environmental cleaning and disinfection must be performed with products registered with the Environmental Protection Agency. Between patient cleaning and end-of-day cleaning, there should be standard processes. High-touch surfaces would be a focus for between-case cleaning, with a terminal clean performed at the end of the operative day. Checklists and standard operating procedures can assist with staff training and consistency. It’s essential that any manufacturer’s instructions for use (IFUs) related to proper cleaning and disinfection are followed for both surfaces and any instruments or reusable medical equipment.

IPs should discuss the processes for instrument cleaning, disinfection, and sterilization with staff to ensure that all IFUs are being followed and that staff have documented competencies. Single-use instruments are another option, especially in outpatient settings where volume is high and there may not be large enough autoclaves to handle the turnover needed to meet schedule needs.

Sterilization of instruments is a high-risk process in any setting, including dental clinics. Tabletop autoclaves are the typical device for sterilization. Autoclaves require monitoring with indicators to ensure sterilization is achieved. Additionally, routine maintenance is necessary to ensure the proper functioning of the autoclave.

In acute care settings, IPs are required to have water management programs. If a hospital licenses a dental clinic, then that clinic would also need to be included in the program. Water management is equally important in an outpatient dental setting. IPs must have a basic understanding of all the risk factors that contribute to water quality issues in dental care.

Dental waterlines are a potential source of contamination during procedures in clinics. There are published guidelines for managing dental waterlines, including cleaning, disinfecting, and testing the lines. At a minimum, the water must meet the exact requirements for drinking water, with fewer than 500 colony-forming units per milliliter.

 For surgical procedures, sterile saline, irrigating solutions, and/or water must be used. These sterile solutions cannot flow through the main dental unit waterlines; therefore, they must be delivered via alternative methods, such as single-sterile, prefilled syringes or utilizing a sterile bulb or syringe from a multidose container.

Practitioners should be aware of several areas of innovation in oral surgery. Research into advanced antiseptic products is ongoing, as dual-action antimicrobials are being explored for increased effectiveness in reducing infection and inflammation.4 Use of laser-assisted surgery is also becoming more common, which decreases the risk of SSIs. Finally, the use of nanomaterials, such as silver-impregnated implants or sutures, has shown promising results in reducing the risk of infection.

IPs may have limited experience working in dental clinics or reviewing safe practices for oral surgery. There are several resources available to assist IPs as they educate themselves on best practices, such as the “Infection Prevention Checklist for Dental Settings” published by the CDC in 2016.

 Bringing forward the basic knowledge of disinfection, sterilization, standard precautions, and patient safety practices, IPs can be a valuable resource for dental health professionals to collaborate and develop strong IPC programs for dental health providers. 

Standard precautions. CDC. May 15, 2024. Accessed May 16, 2025. https://www.cdc.gov/dental-infection-control/hcp/summary/standard-precautions.html

Bromberg N, Brizuela M. Preventing cross infection in the dental office. In: StatPearls. StatPearls Publishing; 2023. Accessed May 16, 2025. https://www.ncbi.nlm.nih.gov/books/NBK589669/

AlKhamis M, Abedalqader T, Ouban A, et al. Surgical site infections in oral and maxillofacial surgeries: prevalence and associated risk factors. World Journal of Surgery and Surgical Research. August 12, 2024. Accessed May 7, 2025. https://www.surgeryresearchjournal.com/open-access/surgical-site-infections-in-oral-and-maxillofacial-surgeries-prevalence-and-9748.pdf

Bouguezzi A, Abdellatif C, Hentati H, Selmi J. Infection control in oral surgery: innovations and protocols. Journal of Pharmaceutical Research and Reports. January 30, 2025. Accessed May 13, 2025. https://www.onlinescientificresearch.com/articles/infection-control-in-oral-surgery--innovations-and-protocols.pdf

Healthcare-associated infections: infection prevention in oral health settings. Wisconsin Department of Health Services. Revised February 14, 2025. Accessed May 14, 2025. https://www.dhs.wisconsin.gov/hai/oral-health.htm

Infection prevention checklist for dental settings: basic expectations for safe care. CDC. Accessed May 16, 2025. 

https://www.cdc.gov/dental-infection-control/media/pdfs/Infection-Prevention-Checklist-for-Dental-Settings-fillable-form.pdf

Articles

Dental and oral surgery clinics are often overlooked in infection prevention programs, yet lapses can have serious consequences. Strengthening surveillance, sterilization, and patient safety practices is critical to reducing surgical site infections.

Elevating Infection Prevention in Dental Clinics: Addressing Surgical Site Infection Risks

(Adobe Stock 1668486842 by Nonthakorn with AI)

 was first identified and became an organism of public health concern in 2016. Since that time, surveillance has been initiated nationally, and states require the reporting of positive cases to health departments for tracking. Since the identification of 

, the CDC has published recommendations for infection control and surveillance.

Infection control guidance includes hand hygiene, environmental cleaning with an approved agent that has a kill claim for C 

, isolation precautions based on the patient care setting, and communication between patient care settings when transfers occur.

 Additionally, screening guidelines were later added to assist with active surveillance and early identification of colonized patients. C 

 is transmitted efficiently in the environment as it can persist on surfaces for an extended period, and many common disinfectants are not effective at eliminating it.

Current screening recommendations by CDC focus on those who are considered high risk for colonization, including: those with an epidemiological link to an outbreak or positive case; those who come from a high risk facility, such as ventilator equipped skilled nursing facility (SNF) or long term acute care (LTAC); and those with patient-level factors such as mechanical ventilation and colonization with other multi-drug resistant organisms (MDROs).

 by Cheng et al. presented a review of an updated screening process for 

 The facility had an existing protocol, and due to a recent exposure event, the local team updated the protocol to expand screening criteria for admitted patients with the intent of preventing future exposures or outbreaks.

The facility screening criteria initially focused on admitted patients who had been in an SNF within the past month and had been on a mechanical ventilator and/or had a tracheostomy. In the second phase of the screening protocol, patients admitted from any SNF, not just ventilator-capable, were included. Also, all patients from an SNF were screened, not just those with mechanical ventilation and/or tracheostomies.

Choosing screening criteria is dependent on several factors. The CDC guidelines serve as a starting point; however, local epidemiology and transmission patterns must also be considered when identifying risk groups. Additionally, time frames are often challenging in 

 screening criteria, as there is no consistent recommendation of how far back to review a patient’s history. Some facilities screen for a year prior, while others screen for 3 months to a month, as mentioned in this article. Things to consider when getting a history are how well your patients can remember prior admissions and whether staff are aware of which SNFs are ventilator-compatible in their area.

A key point made in the article is that screening alone will not result in the appropriate disruption of transmission. Facilities also need a comprehensive infection prevention strategy and process for patient management. Once patients are identified, a follow-through process is necessary to test, initiate isolation, notify relevant stakeholders, and perform environmental disinfection.

Anyone who has been involved in an exposure or outbreak investigation will understand the level of resources involved and the significant time and energy required in that process. To decrease the risk of exposure, the goal is to initiate screening as early in the admission process as possible, ie, in the emergency department (ED). And based on the experience documented in the article, expanding screening populations and risk criteria to capture a broader range of patients could also identify cases that would not have been identified previously.

The article described that a lab culture completed the testing for patients. The ability of facilities to perform culture or molecular testing for 

 varies across the country. Smaller facilities or those in areas with low levels of cases will likely have to send out tests to reference labs or public health labs. The turnaround time for results can be several days, which limits the potential for actionable responses. If your facility must conduct testing, one key consideration is which patients will be placed in presumptive isolation while awaiting test results. Lengthy isolation while awaiting results may impact patient care and result in additional expense to the facility.

In the article, the team determined to initiate Isolation for patients on a ventilator or those with a tracheostomy, as these patients were deemed to be at higher risk based on their analysis of data and prior experiences. All other screened patients were not placed in presumptive isolation. Each facility will need to consider what will work best locally and can utilize a similar risk assessment process to determine which patients to isolate, if it is not feasible to place all patients in presumptive isolation.

Screening test results found an overall positivity rate of 

for all patients was 2.4%. Fifty-one patients met the criteria as high risk (ventilated or tracheostomy), and of those, 17.7% were positive. When examining the patient location in the prior month, 454 patients were screened from non-ventilated capable facilities, and of those, 2 were considered high risk due to the presence of tracheostomies (but were not ventilator-dependent). Neither of those patients was positive. The overall positivity rate for the lower risk facilities was 1.1% (5 patients). Comparing overall vent-dependent and/or tracheostomy patients (high-risk) to all others, the odds ratio for having a positive 

These results indicate that patients with tracheostomies and/or mechanical ventilation are at a higher risk of colonization with 

. Facilities planning to begin screening for 

, starting with a focus on patients with those risk factors, would be a reasonable approach to capture most colonized patients. Following the trends of local epidemiology and known outbreaks would also be critical to ensure that updates to screening criteria can be made to reflect the ever-changing transmission of 

. Collaboration with the lab, environmental services, frontline clinical providers (including ED and nursing), and clinical informaticists to update electronic surveillance questions and order sets is a necessary step for a successful program.

https://www.cdCgov/candida-auris/hcp/infection-control/index.html

Screening recommendations for healthcare facilities. CDC Updated April 24, 2024. 

https://www.cdCgov/candida-auris/hcp/screening-hcp/index.html

A Cheng, K Brody, J Ehni, A Gallate, S Lorin, B Camins, A Javaid. Analysis of an expanded admission screening protocol for 

Candida auris continues to challenge infection preventionists with its persistence, resistance, and potential for outbreaks. New evidence shows that early, expanded screening—beginning in the emergency department—may be the key to stopping transmission before it starts.

Candida auris: Why Expanded Screening Must Start at the Front Door

Cleaning systems for medical instruments. Ultrasonic cleaner

The cleaning and disinfecting of reusable medical instruments and devices is a crucial process in patient safety for health care facilities. Sterile processing departments are often overlooked in their importance to the entire facility, but infection preventionists need to have a working understanding of all the steps, various types of equipment involved, and potential points of risk for disease transmission that can occur.

Ultrasonic cleaners are utilized in sterile processing departments (SPD) to automate instrument cleaning. They are critical for instruments that may be challenging to manually clean effectively, such as devices with jagged edges, hinges, or serrations. The manufacturer’s instructions for use (IFU) always indicate if ultrasonic cleaning is required or appropriate for devices.

The instrument-cleaning process starts at the point of use, with the appropriate enzyme or pretreatment applied immediately after the procedure. Instruments must remain wet and transported in a rigid, closed container with appropriate biohazard labeling. Transportation to the SPD should occur immediately after the point-of-use treatment has been applied to prevent the instruments from drying. If bioburden is allowed to dry on the instruments, the cleaning becomes more challenging, potentially impacting the disinfection and sterilization steps in the process.

Once instruments are received in SPD, the decontamination process continues with rinsing, flushing, soaking, inspection, and any manual cleaning indicated by the IFUs. Then, the instruments are ready for ultrasonic cleaning. During manual cleaning, the technician must follow the care instructions for each instrument, ensuring the appropriate brushes are used, any instruments with hinges or moveable parts are opened and cleaned, and visible bioburden is removed.

Ultrasonic cleaners create ultrasonic sound waves to cause cavitation and remove bioburden.

 Cavitation is the process by which microscopic bubbles in the detergent grow and implode, causing the release of tissue and contaminants from the instrument surface.

This process allows the effective cleaning of instruments with details such as small openings and hinges that are challenging to clean manually. The microscopic bubbles can penetrate these areas and remove any remaining tissue or contamination.

For lumened instruments, ultrasonic cleaners can connect to the instruments and provide the same cavitation process for both the interior and exterior. Additionally, the flushing and rinsing steps are incorporated into the machine’s process, ensuring full cleaning of those lumened devices that are so challenging to clean manually.

The appropriate cleaning agent must be used based on the ultrasonic cleaner and instrument IFUs. The type of cleaning agent used must meet several key considerations. It must be compatible with the cavitation process, work in different types of water quality, and be nontoxic, low-foaming, and free-rinsing.

 Water temperature also impacts the cleaning agent’s effectiveness.

Personnel should receive appropriate training and competencies for the use of ultrasonic cleaners. Sterile processing staff must clearly understand their role and its importance to patient safety. All steps of the decontamination process must be completed with accuracy and attention to detail. This can be challenging when the work is repetitive and there is pressure to quickly turn over instruments for a busy operating room schedule.

Some key points that need to be covered in training include how to properly load instruments in the cleaner to ensure as much surface area is exposed, for example, with hinges open. Instruments should not be overcrowded or overweight for the cleaner. Additionally, the visual inspection of instruments for signs of damage, bioburden, staining, or pitting during the manual cleaning is important to ensure any worn or damaged instruments are removed from use.

Another consideration for the IP when thinking about ultrasonic cleaning, or any process in SPD, is the facility water management program. Water quality for reprocessing medical devices. Water quality can directly impact the ability of sterile processing to perform adequate cleaning and disinfection of instruments. The water management program must be managed by a multidisciplinary team, which includes facilities management, infection prevention, and sterile processing. Recent water quality standards have identified key areas where the water management programs need to focus and where to implement routine water quality testing.

Poor water quality can contribute to many factors that can negatively affect the patient. For ultrasonic cleaners, in particular, water hardness, temperature, bacterial and endotoxin levels, ion levels, and sedimentation would all impact the machine's effectiveness.

For example, corrosion caused by water hardness or sedimentation can contribute to the device's malfunction. If an instrument is not cleaned and disinfected, a patient could be exposed to endotoxins or microorganisms that can contribute to infection. Hardness can impact the washer device itself and leave residue on instruments.

When discussing water management, 3 types of water are important to understand: utility water, critical water, and steam.

 Utility water, which comes from the facility’s connected water supply, is typically used for initial steps in reprocessing, except for a final rinse with critical water. Critical water has been treated to remove bacteria and endotoxins, has the approved pH levels, and meets other specifications. Some ultrasonic washers may perform the final rinse automatically, and critical water would be used for that rinse. The post-wash rinse is essential to remove any residual cleaning agent and contaminants. The manufacturer’s IFUs must be reviewed for the device to ensure the appropriate water is used for each cycle.

SPD staff must maintain logs of ultrasonic cleaners’ required maintenance and quality testing. The specific machine IFUs will indicate the type of maintenance and schedules. This may include device calibration, test strips for detergent levels, or testing for protein levels. The IP should review those logs when performing rounds in SPD to ensure completeness.

Studies have compared the effectiveness of manual cleaning to ultrasonic cleaning. Most studies have found that compared to manual cleaning, ultrasonic cleaning is more effective at removing residue from instruments, particularly those that are harder to clean.

 As medical instruments become more complex, manual cleaning becomes more difficult. However, manual cleaning is still considered best practice in the first step of the decontamination process and should not be skipped over instead of ultrasonic or automated cleaning alone. Manual cleaning of larger debris is critical for the ability of the ultrasonic cavitation process to be effective.

Are there any cons to ultrasonic cleaning? The first consideration is the cost of the equipment. However, given the benefits over manual cleaning alone, that can easily be countered with a risk-benefit analysis. Second, it is important to review the IFUs for any instruments that will be placed in the cleaner. Some materials are incompatible with ultrasonic cleaning and could damage the machine or the instruments. While not a barrier, SPD staff must have the proper training and competencies on the equipment to ensure all aspects of the IFUs are adhered to.

For many IPs, sterile processing is an intimidating and challenging area to develop expertise in, especially as a novice IP who has not worked in a perioperative field. It is important for the IP to collaborate with SPD leadership, make frequent rounds in the department, talk with staff about their processes, and reach out to fellow IPs to ask questions.

Guide to ultrasonic cleaning of medical devices: how ultrasonics work and more. Steris. May 31, 2024. Accessed February 14, 2025. 

https://www.steris.com/healthcare/knowledge-center/sterile-processing/guide-to-ultrasonic-cleaning

Ultrasonic cleaning vs. manual cleaning. February 28, 2024. Ultra Clean Systems, Inc. Accessed February 15, 2025. 

https://ultracleansystems.com/ultrasonic-cleaning-vs-manual-cleaning/#:~:text=Ultrasonic%20cleaning%2C%20however%2C%20has%20proven,placed%20in%20an%20ultrasonic%20cleaner

What hospitals need to know: Using water during processing of medical instruments. ECRI. April 26, 2024. Accessed February 19, 2025. 

https://home.ecri.org/blogs/ecri-blog/what-hospitals-need-to-know-using-water-during-processing-of-medical-devices

Ultrasonic cleaners enhance sterile processing by removing microscopic bioburden, ensuring safer medical instruments, reducing infection risks, and improving efficiency compared to manual cleaning alone.


How Ultrasonic Cleaning Enhances Patient Safety

February is Rare Disease Month, a time to raise awareness of uncommon but serious illnesses. In this article, 

’s editorial advisory board member, explores the Nipah virus—a rare, highly virulent zoonotic disease with significant public health concerns. Understanding its transmission, impact, and prevention strategies is crucial in combating emerging infectious threats.

Zoonotic diseases are diseases that spread from animals to humans. Emerging infectious diseases and novel viruses often result from zoonotic spillover. Rare infectious diseases are classified as such because they have a low prevalence in the general population. Nipah virus is an infectious disease that falls into both categories.

Nipah virus is a zoonotic disease that has high mortality and morbidity for humans. First identified in 1999, the virus was discovered in Malaysia and Singapore, where an outbreak occurred in swine that spread to humans who had close contact with the sick animals.

 The natural reservoirs of the Nipah virus are fruit bats and flying foxes.

There is no disease associated with Nipah virus in the fruit bats, which makes an ideal host for the virus. The natural habitats of the fruit bats include Malaysia, Bangladesh, India, Cambodia, and Indonesia.


Nipah virus is a single strand RNA based virus of the Paramyxoviridae family.

 The virus is highly virulent and, like other RNA viruses, has the potential for a high level of mutations.

Transmission occurs with direct contact with infected animals, ingesting raw food contaminated by infected animals, or contact with bodily fluids of an infected person. The incubation period is typically 4 to 14 days. Signs and symptoms of an infected person include fever, headache, cough, sore throat, and difficulty breathing. The illness typically lasts 3 to 14 days; however, if severe disease develops, a person can have encephalitis, coma, and possible death. Based on studied outbreaks, the mortality rate for humans infected with Nipah virus range from 30% to 70%.

Since the early symptoms are nonspecific, early identification of cases can be challenging without accompanying epidemiological evidence. Lab tests are available to detect the Nipah virus, including polymerase chain reaction (PCR) and live culture assay.

 No treatments are available for Nipah virus infection; supportive care is the current recommendation. 

Once a positive case is identified, strict infection control practices must be implemented to prevent spread to close contacts and health care providers. Isolation precautions, including contact and droplet precautions, are recommended, with airborne precautions as an option depending on transmission circumstances.

The best way to prevent future outbreaks is to limit exposure to the reservoir, fruit bats. Humans are at increased risk of acquiring the infection due to the virus spillover from the bats to domestic stock. Human impact on the environment also increases the possibility of exposure. Deforestation and over-farming encroach on the natural habitats of the fruit bats, bringing potential host animals into contact with infected reservoirs. 

One of the most recent outbreaks of Nipah virus was also one of the largest, with over 30 individuals infected. This was related to infections of domestic pigs and then resulted in human-to-human spread.

 Other outbreaks have resulted from eating date palm sap or fruits that infected fruit bats had contaminated.

As with other rare infectious diseases, there is limited attention to not only developing treatment or vaccination options but also limited diagnostics and early detection. Animal health surveillance would give an early clue of potential outbreaks in farm animals or livestock. Having rapid testing available in the areas of high occurrence is also necessary, but due to limited public health resources, it proves a challenge. Vaccination research has started for the Nipah virus; however, there have not been any promising human trials yet. 

As with any zoonotic disease, the changes in reservoir habitats combined with viral mutations could expand the host bats to other areas of the globe and increase human-to-human spread. If either occurs, or both simultaneously, then the risk of a large-scale outbreak is high. In the meantime, local populations at risk for encountering infected bats or livestock need to have the knowledge and resources available to prevent transmission, such as keeping bats away from the fruit and date palm juice, having appropriate protective equipment when handling sick animals, and resources for appropriate hand hygiene when caring for ill patients.

References

1.	CDC. About Nipah virus. Updated February 23, 2024. Accessed February 24, 2025. 

https://www.cdc.gov/nipah-virus/about/index.html


2.	The Lancet. Nipah virus: A reemerging public health concern. Z Cui, J Li, L Meng, Z Zhang. Volume 5(3), E212. Published online December 20, 2023. Accessed February 24, 2025. 

https://www.thelancet.com/journals/lanmic/article/PIIS2666-5247(23)00361-0/fulltext


3.	P Devnath, HMAA Musad. Nipah virus: a potential pandemic agent in the context of severe acute respiratory syndrome coronavirus 2 pandemic. New Microbes New Infections. Volume 41. March 19, 2021.
4.	World Health Organization. Nipah Virus. Published May 30, 2018. Accessed February 25, 2025. 

https://www.who.int/news-room/fact-sheets/detail/nipah-virus

For Rare Disease Month, Rebecca Leach, MPH, BSN, RN, CIC, writes on Nipah virus, a rare but deadly zoonotic disease that poses a significant public health threat. With high mutation potential and no cure, prevention and awareness are critical.

Rare Disease Month: Nipah Virus—It Is From Bats!

Vector-borne diseases are medical conditions in humans caused by pathogens transmitted by host organisms, which facilitate the transmission of diseases between individuals, from animals to humans, or through vectors. Vectors are often insects or other parasites that feed on the blood of animals and spread pathogens through that blood contact. Vector-borne illnesses account for more than 17% of all infectious diseases.

Some of the most common vector-borne diseases include malaria, dengue virus, Zika virus, West Nile fever, and Lyme disease. However, numerous other illnesses are transmitted by vectors worldwide. Some common vectors include mosquitoes, fleas, ticks, and select species of flies.

Vector-borne pathogen hosts can be divided into 3 main types: reservoir, incompetent, and dead-end hosts. Reservoirs are animals or environments where the pathogen can survive and reproduce without causing illness or symptoms. Incompetent hosts are organisms that provide nutrition for the vector but do not develop disease. Dead-end hosts are the final link in the chain of infection, where the pathogen causes illness but is not directly transmitted to other susceptible hosts. Humans are often the dead-end hosts for many vector-borne diseases.

According to World Health Organization (WHO) data, up to 80% of the world’s population is at risk for 1 or more vector-borne diseases.

 However, the most significant burden of vector-borne diseases is currently in tropical and subtropical areas.

Climate change is having a direct impact on the epidemiology of vector-borne illnesses. Travel-associated cases of vector-borne diseases do occur. However, there had been no local spread because the vector could not survive in the new environment. We now see favorable climate changes for the expansion of vector habitats. An example of how climate-impacted vector conditions is the Zika virus outbreak in South America in 2015. The weather patterns associated with El Niño in that same time frame were very conducive to the mosquito species

resulting in an expanded vector population and a regional outbreak of Zika virus in the human population.

Human interactions with the environment also impact vector-borne diseases. Building dams, crop irrigation, deforestation, farming and livestock practices, and urban expansion impact the vector habitats that transmit pathogens to newly susceptible hosts. For example, the expansion of irrigation for farming purposes has been shown to significantly impact the spread of emerging infectious and zoonotic diseases in the local population.

Dengue virus is the most widespread vector-borne illness. A study of cities in India found that increased green spaces with open water and densely populated areas with poor waste management practices had increased the

 Traditional approaches to removing the vectors in these urban areas are no longer effective, as the vectors’ breeding grounds evolve with changes in city design.

Travel from endemic areas often introduces vector-borne diseases to nonendemic regions. For example, mosquitoes transmitted on flights have been known to spread malaria, dengue virus, and chikungunya to France.

 Typically, the vector would not have been available in France to continue the transmission cycle, but with adaptation, the local mosquito population is now capable of transmitting these pathogens, and numerous local cases are identified annually.

Additionally, antimicrobial use in livestock and humans can cause mutations in the pathogen’s genetic code, leading to drug-resistant variants. Like other multidrug-resistant organisms, antimicrobial stewardship is essential for vector-borne diseases.

Prevention practices for vector-borne diseases have a hierarchical level of effectiveness. The most effective control types are elimination, engineering, and behavioral controls. Active surveillance and understanding a disease’s epidemiology are the foundations of prevention efforts. As with many prevention programs, a combination of all types is necessary to reduce the transmission risk effectively.

Elimination controls in these cases include the removal of the vector. Chemical insecticides are used widely in this instance. Insecticides have proven effectiveness; however, there are concerns with resistance and adverse effects of the chemicals, which limit their use.

Removal of the breeding ground for the vectors is another approach to elimination controls. Water and sanitation programs are crucial public health practices that can reduce risk. Zoonotic transmission and reservoirs must also be included in control efforts. Trends over the past decades have shown that most emerging infectious diseases have a zoonotic transmission origin. For example, the West Nile virus emergence in the US was seen as one of the most significant zoonotic diseases transmitted via vectors to humans.

Engineering controls help to isolate people from a hazard. Some examples of engineering controls include mosquito nets, screens in windows and doors, and, more recently, genetic modification of vectors to limit their ability to spread pathogens. Research on arboviruses can lead to possible genetic solutions to disease transmission. For example, a 2022 study examined why yellow fever is not endemic in Asia, even though the vector is prevalent. Researchers found that the mosquitoes infected with Japanese encephalitis could not transmit yellow fever.

 Understanding these natural occurrences could lead to further research on potential genetic modification to mimic the same controls.

Vaccination is available for some vector-borne diseases, such as yellow fever and dengue virus. However, further research and development are needed to increase vaccine availability and effectiveness. Additionally, trust in national public health and vaccine programs has decreased over time, so much education and culture-specific dialogue are needed to regain the acceptance of vaccines internationally.

Behavioral modification is often the least effective intervention, as human factors cannot be controlled in a standard way to ensure compliance. However, education and personal practices are still essential in prevention practices. Examples include using bug sprays or lotions, wearing long sleeves and pants, emptying standing water around one’s home, and engaging in behaviors to minimize vector exposure. The use of prophylactic medication is another example of behavioral control.

With all this information, what does a typical infection preventionist need to know about vector-borne diseases? As stated above, the prevention aspects are typically in public health, which aligns with infection prevention but has a slightly different lens to how disease prevention is approached. Infection preventionists must collaborate with local public health agencies. Knowing your local epidemiology of vector-borne diseases, concerns, and whether we have known vectors in our area should be shared with your frontline staff, including emergency room providers and infectious disease clinicians. I worked with local public health staff members when the first locally transmitted case of dengue virus was identified in an assisted living community under our health care organization’s umbrella. Infection prevention acted as the liaison between public health and the administrators of the subacute facility to help with case identification, implementation of mitigation efforts, and staff and resident education. As vector-borne diseases spread into novel areas, infection preventionists can be at the forefront of preparedness efforts to ensure their facilities and communities are proactively engaged.

One last thing to consider, as many of these diseases are preventable with basic public health strategies, is why they still have such an impact. Understanding the impacts of climate change, focusing efforts on vaccine development, and ensuring access to prophylactic medications are needed from international perspectives to reverse the trend of increasing spread and suitable reservoirs for vectors. Support of legislation and regional and national public health efforts that address sanitation, urban development, and mitigation factors is essential to decrease the global impact of vector-borne diseases.

1. Vector-borne diseases. World Health Organization. September 26, 2024. Accessed November 17, 2024. 

https://www.who.int/news-room/fact-sheets/detail/vector-borne-diseases

2. Updated WHO guidance for controlling vector-borne diseases through indoor residual spraying. World Health Organization. February 15, 2024. Accessed November 5, 2024. 

https://www.who.int/news/item/15-02-2024-updated-who-guidance-for-controlling-vector-borne-diseases-through-indoor-residual-spraying

3. Rocklöv J, Dubrow R. Climate change: an enduring challenge for vector-borne disease prevention and control. 

. 2020;21:479-483. doi:10.1038/s41590-020-0648-y

4. Chala B, Hamde F. Emerging and re-emerging vector-borne infectious diseases and the challenges for control: a review. 

5. Vector-borne diseases: mosquitoes, ticks, biting flies… how far will they go? 

. June 17, 2024. Accessed November 18, 2024. 

https://www.pasteur.fr/en/research-journal/reports/vector-borne-diseases-mosquitoes-ticks-biting-flies-how-far-will-they-go

Videos

"Climate change is having a direct impact on the epidemiology of vector-borne illnesses. Travel-associated cases of vector-borne diseases do occur."

Vector-Borne Diseases: Understanding Their Transmission and Prevention, and the Role of Infection Preventionists

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Transplants are a scientific breakthrough that has helped thousands of patients. They are a complex and critical part of acute care for infection prevention programs. Many infection preventionists (IPs) may never encounter a transplant program in their career, as it is specialized and limited to facilities with robust surgical, critical care, and postacute resources to support successful programs. There are 2 types of transplants: solid organ and hematopoietic cell transplants. Additionally, donors can be live or deceased, depending on the organ or tissue donated.

The most common organ transplants in the US are the heart, lungs, kidneys, and liver.

The most common tissues transplanted include bone, ligaments, tendons, corneas, skin, heart valves, and blood vessels.

 Numerous agencies are involved in transplant safety, including the Centers for Medicare and Medicaid Services, the US Food and Drug Administration, and the CDC. Each agency offers regulatory standards, best practices, education, and advocacy programs.

Screening transplant donors and recipients is essential to prevent disease transmission. The Association of Organ Procurement Organizations (AOPO) has specific guidelines for what types of infections will be tested on deceased donors. Resting and voluntary testing guidelines are required. The required testing includes cytomegalovirus (CMV), Epstein-Barr virus (EBV), syphilis, HIV, hepatitis B virus, hepatitis C virus, and

While OPOs require testing for select infections or pathogens, the manner of testing, which type of test to use, and the donor population they test may vary. For example, guidelines recommend the use of nucleic acid testing for hepatitis. However, not all OPOs may be able to receive the results before transplantation because a third-party lab performs the testing. Similarly, the types of testing for syphilis vary depending on the OPO, and it would be necessary for the receiving transplant providers to understand the interpretation of the varying tests and, again, how long the turnaround time or secondary tests may be before transplantation.

Testing for seasonal and locally endemic diseases is also inconsistent across the country. These infections are voluntary to test; however, in some areas, many OPOs already perform testing for some of the most common infections resulting in posttransplant transmission. The Organ Procurement and Transplantation Network recently published a proposal to expand the required testing of deceased donors to include Strongyloides and 

 The intent is to identify early, before transplant, if the donor has antibodies. However, this proposal has potential negative impacts, namely that many OPO labs do not have the capabilities to test for these parasites, the requirement to test before transplant may not be feasible as turnaround time could be several days, and there is potential for false positives.

 All these considerations balance the broad screening to prevent disease transmission, the practicalities of what the OPOs can perform, and the varying resources available across the transplant programs.

The testing time frame for donors depends on whether the donor is deceased or living. Living donors will have more time for thorough interviews, risk assessments, and testing. Deceased donors typically only have several hours before procurement and transplantation, and interviews are based on next of kin or medical history. Living donors may receive more extensive testing based on risk assessment and the ability to complete confirmatory tests.

In addition to testing donors, there are recommendations for screening transplant recipients. Pretransplant candidates are often immunosuppressed due to long-term steroids or immunosuppression therapies and, while awaiting transplant, are at high risk for exposure and infections. Additionally, depending on the measures needed to treat the patient in organ failure, they could be at risk for other health care–associated infections, such as bloodstream infections, surgical site infections, and pneumonia.

Pretransplant infections need to be treated as quickly and thoroughly as possible. If the infection is related to a device, the recommendation is to treat and remove the device. The transplant is recommended to be delayed; however, there is no clear recommendation on how long to delay, and it is left to the clinical teams’ judgment.

Transplant recipients should be screened for latent or active tuberculosis, histoplasmosis, syphilis, and coccidiomycosis (where endemic) in addition to the previously discussed infections.

 Patients with cystic fibrosis awaiting lung transplants should be screened for Burkholderia. Cases have shown that posttransplant patients colonized with Burkholderia had higher posttransplant morbidity and mortality compared with patients who were not colonized.4 Viral infections, such as CMV and EBV, have been found to increase adverse outcomes in transplant patients.

 If the recipient screens positive, transplantation should be delayed as long as possible until the infection resolves.

Another consideration for screening potential recipients is multidrug-resistant organisms (MDROs). There are no current guidelines requiring screening for specific MDROs, and there are limited studies that have looked at the outcomes for patients who are colonized pre- and posttransplant. For deceased donors, urine and blood cultures are collected, looking for any active infection but not specifically screening for MDROs of concern. If a transplant candidate has a medical device or implant, the risk of infection or colonization with an MDRO is increased. There is variation across transplant programs on the active screening of such MDROs as vancomycin-resistant 

 (CRE), and methicillin-resistant Staphylococcus aureus. It is generally recommended that colonization or active infection be treated before transplantation; however, for some patients with active CRE infections, there is some controversy about the ability of the host (patient) to survive, requiring a case-by-case review for each patient.

Pretransplant patients should also receive certain vaccinations. The reemergence of vaccine-preventable diseases, such as measles, mumps, and polio, poses a threat to transplant patients. For example, varicella infection posttransplant has a high risk for severe morbidity and mortality.

 Pretransplant vaccination administration should be a routine part of a transplant program. Additionally, household contacts of transplant patients, especially for pediatric transplants, should be evaluated for vaccine status.

Another consideration for IPs is the testing protocols for organ donors for blood and urine cultures. The CDC surveillance definitions have specific guidelines and exemptions that require evidence that the OPO representative has consulted on the case and submitted documentation that the patient is accepted for donation. Until those specific items are documented in the patient chart, any positive cultures need to be reviewed as potential health care–associated infections.

For the IPs who support transplant programs, outbreak detection, and investigation skills must be at the forefront of the IP program. With a high-risk patient population, unusual organisms such as fungal or seasonal respiratory viruses can occur. Basic infection prevention strategies must be applied to help decrease the risk of health care transmission, including screening staff and visitors, enhanced hand hygiene practices, environmental cleaning and disinfection, and appropriate use of personal protective equipment.

Transplant programs will have implications for isolation precautions. Often, immunosuppressed patients require extended isolation precautions for certain infections due to prolonged shedding. Additionally, hematopoietic stem cell transplant patients may be in protected environments. The IP must understand the requirements for a protected environment in their facility. Patient rooms must be under positive pressure, a minimum of 12 air exchanges are required, handwashing sinks should be available at the unit entrance, and antimicrobial scrubs and soaps should be available.

Construction and renovation activity in or near transplant units can be high risk. Performing a strong construction risk assessment with the team,
developing plans for air filtration and airflow to decrease the spread of dust and mold, and ensuring all construction staff who enter understand the importance of following the infection prevention recommendations are key to maintaining a safe unit. Similarly, live plants and fresh produce have been identified as potential sources of molds and are typically avoided in transplant units. Water quality may be another area where special filtration may be necessary to decrease the risk of waterborne pathogens in sinks and showers.

Infections are one of the common causes of morbidity and mortality post-transplant.

Transplant programs are complex and require extensive additional knowledge and skills for an IP to provide appropriate surveillance, recommendations, and support. The many aspects of infection prevention needed to ensure a safe program require collaboration with a multidisciplinary team.

About transplant safety. Centers for Disease Control and Prevention. Updated February 26, 2024. Accessed June 14, 2024. https://www.cdc.gov/transplant-safety/ about/index.html

Theodoropoulis NM, Greenwald MA, Chin-Hong P, Ison MG. Testing deceased organ donors for infections: an organ procurement organization survey. 

2021;21(5):1924-1930. doi:10.1111/ajt.16552

Improve deceased donor evaluation for endemic diseases. Organ Procurement & Transplantation Network. Health Resources & Services Administration. January 19, 2023. Accessed June 17, 2024. https://optn.transplant. hrsa.gov/policies-bylaws/public-comment/improve-deceased-donor-evaluation-for-endemic-diseases

Avery RK. Recipient screening prior to solid-organ transplantation. 

2002;35(12):1513-1519. doi:10.1086/344777

Malinis M, Boucher HW; AST Infectious Diseases Community of Practice. Screening of donor and candidate prior to solid organ transplantation: guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. 

Pergam SA. Infection prevention in transplantation. 

2016;18(2):7. doi:10.1007/s11908-015- 0513-6

Transplants are a crucial yet complex part of acute care. They involve various organs and tissues, necessitating robust infection prevention programs and compliance with strict regulatory standards.