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Norovirus and Chlorine Bleach: The Perfect Pathogen Meets its Match

Colorized transmission electron micrograph of norovirus particles

Colorized transmission electron micrograph of norovirus particles

Courtesy of CDC/ Charles D. Humphrey


Is there such a thing as a “perfect” human pathogen? If by perfect we mean a disease-causing microorganism that is highly contagious; quickly and profusely shed in the environment by its hosts; and able to evolve rapidly to both avoid widespread human immunity and ensure a large pool of susceptible hosts, then norovirus comes very close. Norovirus expert Dr. Aron Hall of the Centers for Disease Control and Prevention’s (CDC’s) Division of Viral Diseases cleverly entertained the notion that noroviruses could be the perfect human pathogens in a 2012 editorial commentary.1

Notorious Norovirus

Sometimes referred to as “the stomach bug,” and infamous for spreading through cruise ships, norovirus is responsible for some 19-21 million cases of gastrointestinal illness in the US annually.2 The very young, the very old and the immunocompromised are especially vulnerable to norovirus. It is the most common cause of foodborne illness in the US—responsible for at least 50,000 hospitalizations and between 570 and 800 deaths annually.3 But norovirus respects no borders. It is a global player. Found in both developed and developing countries, it is the main cause of half of all gastroenteritis outbreaks worldwide. A 2016 analysis4 estimated the virus’ global economic burden at $60 billion, the largest share of which ($56 billion) is lost productivity.

Means of Transmission

Norovirus is spread in three main ways: (1) close personal contact with an infected individual; (2) ingesting contaminated food or water; and (3) contact with contaminated surfaces. Norovirus can be transmitted by ingesting food contaminated at the source (e.g., fruits and vegetables) or by infected food handlers. (Food handlers who return to work sooner than 48 hours after they no longer have symptoms can still spread norovirus.5 ) Norovirus has remarkable staying power on environmental surfaces where it can persist for up to two weeks. It can survive freezing and withstand heating to 140 degrees. To destroy norovirus in drinking water, CDC recommends6 bringing water to a rolling boil (212 degrees Fahrenheit) for one minute. Astonishingly, only 18 norovirus particles are required to infect a human host. For perspective, there are billions of particles in the stool and vomit of infected individuals.

Outsmarting Norovirus

Efforts to develop a vaccine for norovirus are still in their infancy,7 so proper hygiene and surface disinfection practices must be employed to control the spread of the perfect pathogen. People infected with norovirus are advised to limit their contact with others for at least two days after symptoms have ended. Disinfecting surfaces contaminated with the persistent norovirus can go a long way to curtailing outbreaks. Properly prepared chlorine bleach solutions (see below) destroy norovirus on surfaces. Simply cleaning surfaces with soap and water or other cleaning product can actually spread virus particles. In the City of Albuquerque, for example, restaurant staff are encouraged to switch from quaternary ammonium disinfectants to chlorine bleach disinfectants when a norovirus outbreak occurs.8

Communicating a Disinfection Strategy

In 2012, the Water Quality and Health Council participated in a partnership with public health experts, including the New Jersey Somerset County Department of Health, the CDC, the National Environmental Health Association and others, to develop a series of downloadable posters featuring directions for preparing bleach solutions to destroy noroviruses on surfaces. For example, the posters include detailed directions on how to clean and disinfect an area affected by a vomiting or diarrhea incident. Posters are available in English, Spanish and French and can be found at http://www.disinfect-for-health.org/tools-reduce-spread-norovirus.

So when it comes to combatting the nearly perfect pathogen norovirus, remember:

  • the right way to wash your hands;
  • do not prepare food or care for others when you are sick;
  • wash fruits and vegetables and cook seafood thoroughly;
  • clean and disinfect contaminated surfaces using chlorine bleach or other disinfectant registered as effective against norovirus by the EPA; and
  • launder clothes thoroughly.

Linda F. Golodner is President Emeritus of the National Consumers League and Vice Chair of the Water Quality and Health Council.

Click here to download this article.

1 Hall, A.J. (2012). Noroviruses: The Perfect Human Pathogens? Journal of Infectious Diseases, 205: 1622-1624. http://jid.oxfordjournals.org/content/205/11/1622.full.

2 CDC (2015). Norovirus: U.S. Trends and Outbreaks, http://www.cdc.gov/norovirus/trends-outbreaks.html.

3 CDC (2015). Prevent the Spread of Norovirus, http://www.cdc.gov/features/norovirus/.

4 Bartsch, S.M., Lopman, B.A., Ozawa, S., Hall, A.J., and Lee, B.Y. (2016). Global Economic Burden of Norovirus Gastroenteritis, PLOS ONE, DOI:10.1371/journal.pone.0151219. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0151219.

5 CDC (2014). Norovirus and Working with Food, http://www.cdc.gov/norovirus/food-handlers/work-with-food.html.

6 CDC (2015). Noroviruses and Drinking Water from Private Wells, http://www.cdc.gov/healthywater/drinking/private/wells/disease/norovirus.html.

7 CDC (205). Making a Norovirus Vaccine a Reality, https://blogs.cdc.gov/publichealthmatters/2015/03/making-a-norovirus-vaccine-a-reality/.

8 “Norovirus Kitchen/Dining Room Response Procedures, City of Albuquerque Environmental Health Department handout at 4th Annual Norovirus Conference, August 4, 2016.



The Right Way to Wash Your Hands
Written by Barbara Soule, RN, MPA, CIC, FSAHEA

Wash your hands! The parental command echoes in my memory. It is also the public health message we hear most often when the subject is preventing the spread of infectious illness. Hand washing may be one of the easiest things we can do to ward off sickness, but the casual observer in any public restroom can attest to the slap-dash ritual practiced by many. Running water over the hands for a few seconds may be better than nothing, but consciously washing hands correctly is a learned behavior that can pay dividends.

The “Why” of Handwashing

The simple fact is that washing hands removes germs that can make you and others sick. Human hands, which perform countless useful activities, are also the prime vehicles for moving germs from person to person.  As the Centers for Disease Control and Prevention (CDC) website notes, people can infect themselves by touching their eyes, nose and mouth.  Germ-laden hands can make others sick when they prepare food or drinks. And frequently touched surfaces, such as hand rails and publicly used electronic touch pads, are essentially “drop-off” and “pick-up” points for the germ du jour.

According to CDC, teaching people about handwashing benefits the community in which they live. Studies cited by CDC1 show handwashing reduces:

  • The number of people who get sick with diarrhea by 31%
  • Diarrheal illness in people with weakened immune systems by 58%
  • Respiratory illnesses in the general population by 16-21%

The “How” of Handwashing

A downloadable World Health Organization poster recommends following the steps below to wash your hands correctly.  Practice (and review the chart) until the steps become routine.  You will know you have washed long enough if you can hum the “Happy Birthday” song twice.  By the way, “handrub” is another way of denoting “hand sanitizer.”

At a recent public health conference I attended, a presenter guided the audience through a lively “dry run” handwashing exercise from their seats in the auditorium. Shortly afterwards, during a scheduled break in the agenda, the restrooms filled with people who had been through the exercise. It was obvious that attendees at the sinks were self-consciously attempting to replicate the handwashing steps properly. No one wanted to be that slap-dash hand washer, and a few commented that they were trying hard to get it right. I like to think that those conference attendees are now modeling great handwashing for others, spreading a good habit, and—most importantly—not spreading germs!

You might want to try it yourself and teach it to your children to instill good habits early.

Barbara M. Soule, R.N. MPA, CIC, FSHEA, FAPIC is an Infection Preventionist and a member of the Water Quality & Health Council.

Click here to download this article.

Studies cited by CDC on its Handwashing:  Clean Hands Save Lives website include:

  1.  Ejemot RI, Ehiri JE, Meremikwu MM, Critchley JA. Hand washing for preventing diarrhoea. Cochrane Database Syst Rev. 2008;1:CD004265.
  2. Aiello AE, Coulborn RM, Perez V, Larson EL. Effect of hand hygiene on infectious disease risk in the community setting: a meta-analysis.Am J Public Health. 2008;98(8):1372-81.
  3. Huang DB, Zhou J. Effect of intensive handwashing in the prevention of diarrhoeal illness among patients with AIDS: a randomized controlled study. J Med Microbiol. 2007;56(5):659-63.
  4. Rabie T and Curtis V. Handwashing and risk of respiratory infections: a quantitative systematic review.Trop Med Int Health. 2006 Mar;11(3):258-67.

Are You Ready for an Emergency?

Earthquakes, hurricanes, tornadoes, floods, wildfires, pandemics1 , disease outbreaks, terrorist attacks… We may not like to think about the disasters that can befall us, but these potential events warrant our preparedness. September is National Preparedness Month, and a new infographic—The Power of Preparedness—from the Centers for Disease Control and Prevention (CDC) indicates that over 60 percent of Americans do not have an emergency plan that they have discussed with their household. Are you in that camp? According to the 2014 Federal Emergency Management Agency report, “Preparedness in America”, the percentage of people taking recommended preparedness actions in 2011 remains largely unchanged since 2007.

Taking the First Steps

Where you live determines the type of emergency you may be most at risk of experiencing. If you live in a coastal area, your greatest risk could be hurricanes. Flooding may be a serious risk if you live near water, in a flood zone, for example. You may live in a tectonically active area, in which case earthquakes are a concern. Residents in or near forested areas subject to drought may count wildfires among their greatest risks. Do you live in a metropolitan area and have close contact with many people on a daily basis in your commute to work or as part of your job? Diseases can spread quickly among people in close contact. Unfortunately, by their nature, terrorist attacks are random and unpredictable.

Once you have determined your greatest risk factors, preparedness activities become clearer. That said, every household could benefit by storing and regularly updating:

  • Water and food to last each person at least 3 days (more is likely appropriate for many emergencies; for example, a pandemic may require 6-8 weeks of supplies).
  • Fuel for cooking, e.g., propane or charcoal.
  • Medications and first aid supplies for each person to last at least 3 days (include prescription medications and over-the-counter medications for treating fever, flu, colds, etc.).
  • Unscented chlorine bleach or appropriate water treatment tablets for preparing safe drinking water after stored water supplies have been depleted.
  • Flashlights and radios (and the appropriate batteries to power them unless they are solar-powered or operated by a hand-crank).
  • Candles and matches.
  • Emergency cash (Think: What if ATMs were inoperable?).
  • A family plan previously discussed with family members including routes to take/not take to get home and meeting sites in case getting home is not possible.
  • A pet plan which includes identification tags, food, water, and a safe place for them in the event of an emergency.

Customizing Your Emergency Plan

Build on the basic recommendations above with your unique circumstances in mind.

  • If you take life-sustaining prescription medication, discuss with your doctor the possibility of storing an emergency supply of medication in your home.
  • If you anticipate that a forest fire or earthquake could force you to leave your home, have an emergency “go bag” ready that contains at least one change of clothing, medicines, personal hygiene and other items you will likely need to survive away from home, such as your cell phone charger.
  • A face mask can help protect you during dust storms and from volcanic ash or ash from wildfires.
  • Is your only means of transportation from your community by personal vehicle? Keep your vehicle in good repair and its gas tank at least 50 percent full. On the other hand, if it is unlikely that you will have to evacuate, but you know that losing power is a real risk, you might want to invest in a portable generator and plan how you will safely store propane or gasoline.
  • Long, insulated underwear is essential in extremely cold weather disasters when gas and electricity go out for extended periods of time.
  • How do elderly and incapacitated neighbors and relatives fit into your emergency plans?
  • How about a bad flu season? The Water Quality & Health Council developed “Dr. Ralph’s Flu Preparedness Closet” to list the items needed to stay healthy and secure during a pandemic flu outbreak.
Emergency Water

Water is one of the “non-negotiables” of our daily survival. According to www.ready.gov/water, each person in a household requires one gallon of safe water per day for drinking and sanitation.

Either purchase commercially bottled water to store, or prepare your own containers of water using food grade water storage containers (visit surplus or camping supply stores or their websites). Alternatively, use 2-liter plastic drink bottles that are thoroughly cleaned.

Sanitize plastic drink bottles with a solution made by adding 1 teaspoon of unscented chlorine bleach to one quart of water. Rinse well and fill each 2- liter bottle with tap water. If your tap water is treated by a water utility, nothing else is required. If the tap water comes from a well or other untreated source, add 2 drops of non-scented chlorine bleach to the water. Let the water stand for at least 30 minutes before using. Tightly close each bottle (don’t touch the inside of the cap), write the date on a label and store in a cool, dark place. Water that has not been commercially bottled should be replaced every 6 months.

One easy way to get started on the path to preparedness is to download the FEMA App to your smart phone. You will receive weather alerts and be able to access critical information in the event of an emergency, including the locations of emergency shelters. Our hope this National Preparedness Month is that more Americans will see preparedness as a worthwhile and potentially life-saving activity.

Ralph Morris, MD, MPH, is a Physician and Preventive Medicine and Public Health official living in Bemidji, MN.

Click here to download this article.

1 A pandemic is a widespread disease outbreak, affecting large areas, such as an entire country, continent, or even the entire world.



What Are Zoonotic Diseases?
Written by Water Quality & Health Council

If you guessed that ZOOnotic diseases have something to do with animals, you are right.  According to the Centers for Disease Control and Prevention (CDC), a zoonotic disease is one that can spread between animals and humans under natural conditions—such as in homes, on farms, and at county fairs and petting zoos—and can be caused by viruses, bacteria, parasites and fungi.  Ironically, animals that can transmit zoonotic pathogens (disease-causing germs) to people often have no symptoms of disease and simply act as carriers.

Zoonotic, Emerging, and Waterborne Diseases

Zoonotic diseases are also very common:  At least six out of every 10 infectious diseases in humans are thought to be spread from animals.  Wildlife serves as a “reservoir” for many diseases common to domestic animals and humans.  Moreover, zoonotic pathogens are closely tied to so-called emerging (or reemerging) infectious diseases, and up to 75% of emerging pathogens are thought to be of zoonotic origin, including Ebola virus disease and Lassa fever.

Of course, people all over the world enjoy and work with animals on a daily basis.  But we also encounter very small animals unintentionally, such as ticks, fleas and mosquitoes (called disease “vectors”), which can transmit a wide variety of zoonotic diseases of tremendous global health importance.  In addition to Zika virus, mosquitoes can transmit West Nile virus, Dengue, malaria and chikungunya, and thrive in urban neighborhoods with standing, untreated water such as neglected or abandoned swimming pools.

Not surprisingly, many waterborne diseases, including outbreaks, result from ingesting zoonotic pathogens—whether of human or animal origin.  Well-known zoonotic diseases include cryptosporidiosis and giardiasis, particularly because both are caused by enteric protozoan parasites that are resistant to chlorination.  Cryptosporidium was responsible for the largest documented waterborne disease outbreak in US history, affecting over 400,000 people in Milwaukee in 1993! Bacterial zoonotic pathogens include Campylobacter from chickens, pathogenic E. coli from cattle (especially calves) and Salmonella from pet turtles and frogs.  Rotavirus and hepatitis E virus from swine can also be transmitted to persons through inadequately or untreated waters.  CDC maintains a list of diseases that can be spread from pets to people, many of which can be waterborne or rely on water-based vectors such as mosquitoes.

Preventing Zoonotic Diseases

It’s important to be aware of the different ways zoonotic diseases are transmitted to people, including:

  • Contact with the feces, saliva (such as when your dog licks your face or hands), blood and urine of an infected animal
  • Being bitten by an infected tick or mosquito
  • Consuming something unsafe, such as untreated water from a stream, undercooked meat or unwashed fruits and vegetables that are contaminated with feces from an infected person or animal

Source: https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5805a3.htm

It’s also important to consider that some people are more at risk from developing serious or even life-threatening infections from zoonotic pathogens than others, including children, pregnant women, elderly and immunocompromised persons, such as someone with HIV or a chemotherapy patient.

 Fortunately, there are many over-lapping ways you can protect yourself from zoonotic diseases:

  • Wash hands frequently and follow proper hygiene
  • Always wash hands after being around animals, including pets
  • Take measures to prevent mosquito and tick bites

So remember, all creatures great and small can carry and transmit disease-causing germs, but an ounce of prevention (and disinfectant or bug spray) and frequent hand-washing can go a long way.

Additional information on healthy pets and people is available from CDC:


Click here to download this article.


Stepping up Our Game against Zika Virus

“Ground zero” for the first likely cases of locally transmitted Zika virus in the US has been identified as a one-mile square patch in the Wynwood neighborhood north of downtown Miami.  The virus has not yet been found in local mosquitoes, but Florida Department of Health officials are aggressively implementing disease and environmental surveillance while city and county agencies conduct mosquito control measures.   These include ground level spraying of the “ground hugging,” mosquitoes (aerial spraying is less efficient and effective), treating storm drains and removing standing water in affected neighborhoods.  Blood donations from the affected region are being screened for the virus. In short, it’s “game on” for Zika virus prevention in Florida where I work as an environmental administrator.

CDC poster illustrates measures to protect against mosquito bites

Health Officials Working Together

The Florida Department of Health and the US Centers for Disease Control and Prevention (CDC) are partnering to keep the public advised on strategies to avoid the mosquito borne illness that might result in devastating health effects in newborns of infected mothers and other less well documented health effects in adults, such as Guillain-Barre Syndrome (see CDC webpage).

According to the World Health Organization, the female (biting) Aedes aegypti mosquito flies an average of only 400 meters in her lifetime, meaning that it is people, not mosquitoes that move the virus among widely spaced communities.

Until a vaccine is available, the essential measures to avoid contracting the Zika virus are to prevent mosquito bites and to ensure protection during sex in the event that a partner may be a Zika virus carrier.  Because 80 percent of people infected with Zika virus have no symptoms, condom use during sexual intercourse is especially critical for pregnant women or women who may become pregnant.  CDC also recommends that women who are pregnant or who are planning to become pregnant postpone travel to areas with widespread Zika infection (see CDC webpage on Zika and Sexual Transmission).  That now includes the impacted area of Florida’s Wynwood neighborhood.

Drain and Cover

The Florida Department of Health’s “Drain and Cover” program provides the following tips to control the risk of mosquito borne illness:

  • Drain water from garbage cans, house gutters, pool covers, coolers, toys, flower pots, or any other containers where sprinkler or rain water has collected.
  • Discard old tires, drums, bottles, cans, pots and pans, broken appliances and other items that aren’t being used.
  • Empty and clean birdbaths and pets’ water bowls at least once or twice per week.
  • Protect boats and vehicles from rain with tarps that do not accumulate water.
  • Maintain appropriate pool chemistry of swimming pools. Empty plastic swimming pools when not in use.
  • Repair broken screens on windows, doors, porches and patios.
  • If you must be outside when Aedes mosquitoes are active (daytime), cover up. Wear shoes, socks, long pants and long sleeves.
  • Apply mosquito repellent to bare skin and clothing. Follow label directions. Repellents with DEET, picaridin, oil of lemon eucalyptus, para-menthane-diol, and IR3535 are effective and safe for pregnant and breast-feeding women, when used as directed. Use netting instead of repellents to protect children younger than two months.

Looking Ahead

If the recent outbreaks of dengue and chikungunya— which are also spread by the Aedes mosquito — are any indication, then it is expected that Florida will experience only small and geographically limited outbreaks of Zika.  That said, CDC notes regions once affected by dengue and chikungunya are considered to be a higher risk for Zika virus outbreaks.  The Florida Department of Health is committed to employ every available resource in order to reduce the spread of Zika virus.  Yes, it’s “game on” for Zika virus prevention in Florida.

The Florida Department of Health issues frequent Zika virus updates at:


Bob G. Vincent is an Environmental Administrator in the Florida Department of Health (and a helava nice guy). He manages Department of Health programs for Healthy Marine Beaches, Safe Drinking Water, Water Well Surveillance and Public Pools and Bathing Places.

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Unusual Uses for Chlorine Bleach
Written by A guest article by Dominique M. Williams

I have had the privilege of spending the last four years of my life on one of the most beautiful college campuses in Maryland. Everything I ever needed was within a short walking distance of my dorm room—the dining hall, library, mailroom, and student center, you name it! Yet even with all of these nearby resources, I spent most of my time in my room doing homework. This is the classic scenario for any undergraduate science major. Living in a building with more than 100 fellow students, the laundry room instantly became the most in-demand place in the entire residence hall. Keeping that in mind, I always ensured that I stocked up on two items each semester: detergent and bleach.

Bleach, chemically referred to as an aqueous solution of sodium hypochlorite (NaOCl), is one of the most common household chemicals used across the United States. Bleach is primarily used to whiten and brighten clothes, but there are other surprising uses! For starters, bleach is also used to remove certain stains and disinfect surfaces contaminated with pathogens. But what are some of the really unusual uses of bleach?

Cleaning Seashells

One of the most beautiful and memorable souvenirs you can take away from any sandy beach is a seashell. Most beachgoers will simply take the seashells home and place them on a dresser or into storage without completing one fundamental task—cleaning them! One pungent reminder is the awful odor they often carry.

While in the sea, mollusks absorb and process the minerals surrounding them, secreting calcium carbonate (CaCO3). The calcium carbonate forms an outer shell on the outside of their bodies, which continues to expand as the mollusk grows. When mollusks die, their shells are abandoned to the sea, many of which eventually appear on the beaches we frequent throughout the year. Knowing that sea creatures formerly lived in these shells should serve as a reminder to clean them promptly, and bleach is up to the task. According to Seashells.org, empty shells should be soaked in a 50-50 solution of water and bleach until the periostracum, the thin outer layer of skin, has disintegrated.

Flower Power

My family has a flower garden that sits next to the front door. When the garden is vacant, I enter the house through the garage. When the garden is in full bloom, I enter through the front door just so I can see the flowers.

Flowers possess everything they need in their natural habitat.  They collect nutrients from the soil through their roots. They absorb water through the roots, pushing the water up to the leaves via a specialized plant cell system called the xylem. The leaves are also responsible for providing the major source of food. Through photosynthesis and chlorophyll (the green pigment found in the leaves), plants use energy from sunlight to convert carbon dioxide (CO2) from the atmosphere and water into carbohydrates and oxygen.

When transferring flowers from soil to a vase, they are separated from their source of sustenance. While filling a vase with water and food additives serves as an effective substitute, cut flowers are still limited in their ability to receive essential nutrients, and are even more susceptible to wilting. But, the disinfecting power of bleach proves to be a suitable solution for this issue. Joan Rose, PhD, of the Water Quality & Health Council, suggests adding ¼ teaspoon of chlorine bleach to each quart of water in the vase. The addition of bleach preserves the clarity of the water and protects the flowers by destroying the bacteria that cause wilting. Although too much bleach will kill the flowers, a small amount is just enough to keep them in bloom for a long time!

Light The Way!

Bleach is not only used to lighten clothing, but homes as well! One fateful day in 2002, Brazilian mechanic Alfred Moser and his wife suffered through a citywide blackout. Although they experienced blackouts regularly, this time Moser decided to combat this power outage with his own man-made light, inspired by some advice from his boss. Mr. Moser successfully illuminated his home using only a plastic water bottle filled with water, a small amount of bleach, and sunlight! After the bottle was mostly filled with water, Moser added two capfuls of bleach and sealed it with a black cap. Next, Mr. Moser drilled a hole in one of his roof tiles, pushed the filled water bottle through, and applied polyester resin to prevent leakage.

When the sunlight strikes the bottle, it immediately illuminates the room below due to refraction of light. The addition of bleach prevents the water from turning green with algae when exposed to sunlight. It also prevents the water from clouding by destroying the microorganisms that could potentially reproduce inside of the bottle. Both the bleach and water must be replaced every five years in order to maintain its continuous use. Owners and renters of unlit homes across Brazil and other developing countries never have to worry about living in the dark again—at least during the daytime.

For a common household item, bleach sure has some interesting and peculiar uses, yet all three have proven to be extremely useful! Now, I wonder if detergent is good for anything else too….

Dominique Williams is a 2016 summer intern for the American Chemistry Council Chlorine Chemistry Division. Dominique is a senior chemistry major at Stevenson University in Owings Mills, Maryland.

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Sepsis Explained

Sepsis is the body’s overwhelming and life-threatening response to infection. Sepsis causes inflammation throughout the body, which can lead to tissue damage, organ failure, and even death, according to the Centers for Disease Control and Prevention (CDC). Sepsis is a serious complication of septicemia, also known as bacteremia or blood poisoning. Septicemia occurs when a bacterial infection somewhere in the body (e.g., the skin, kidneys, urinary tract, abdominal area or lungs) spreads into the bloodstream.

We recently wrote about human Vibrio infections from contaminated shellfish and coastal and especially brackish waters. Some Vibrio infections progress to sepsis, which is why we highlighted the Louisiana Department of Wildlife and Fisheries advisory that fishermen in saltwater carry with them “basic disinfectant (chlorine bleach mixed one part bleach to four parts fresh water1 or tincture of iodine, or antibiotic ointment) and use if skin is punctured while handling fishing tackle, bait or fish.”

According to the Mayo Clinic website, sepsis is diagnosed when at least two of the following signs accompany a probable or confirmed infection:

  • Elevated body temperature of 101 degrees F (or greater) or a below normal body temperature of 8 degrees F (or less)
  • Heart rate higher than 90 beats per minute
  • Respiratory rate higher than 20 breaths per minute.

Severe sepsis is diagnosed with at least one more of the following, which indicate an organ may be failing:

  • Significantly decreased urine output
  • Abrupt change in mental status
  • Decrease in platelet count
  • Difficulty breathing
  • Abnormal heart pumping function
  • Abdominal pain

Toxins released into the bloodstream by some bacteria can cause extremely low blood pressure. Septic shock results when the patient does not respond to simple fluid replacement. Septic shock can lead to death. Whereas most people recover from mild sepsis, the Mayo Clinic website indicates a 50 percent mortality rate for septic shock. The image above, from the CDC Sepsis Fact Sheet, lists major strategies for preventing sepsis.

Who is Vulnerable to Sepsis?

Anyone can develop septicemia and sepsis, but according to the Mayo Clinic the most vulnerable include the very young and very old; patients taking immunosuppressive medications; cancer patients; long-term steroid users; people with long-standing diabetes, AIDS or cirrhosis; people with large burns or severe injuries; and people with infections, such as pneumonia, meningitis, cellulitis and urinary tract infections.

Sepsis Requires Treatment!

Sepsis is a medical emergency that requires treatment. There are more than one million cases of sepsis each year in the US. Sepsis can lead to septic shock and death; survivors of sepsis may suffer permanent organ damage and have to deal with life-changing health effects.

The CDC recommends calling your doctor or going to the emergency room immediately if you have any signs or symptoms of an infection or sepsis. CDC urges that you state, “I AM CONCERNED ABOUT SEPSIS” to ensure timely evaluation and treatment, which may include antibiotics, oxygen and intravenous fluids. The image below from the CDC Sepsis Fact Sheet may be helpful in determining when to seek medical attention. Forewarned is forearmed!


For more information on sepsis, please see www.cdc.gov/sepsis.

Barbara M. Soule, R.N. MPA, CIC, FSHEA is an Infection Preventionist and a member of the Water Quality & Health Council. Ralph Morris, MD, MPH, is a Physician and Preventive Medicine and Public Health official.

Click here to download this article.

1 Fishermen should prepare this solution daily, as bleach solutions weaken over time.


Vibrio Infection: Rare, but Worth Knowing About

Planning a beach vacation this summer? You should know about a group of naturally-occurring bacteria found in the warm coastal, especially brackish waters of the US that pose a rare but potentially serious risk to raw seafood consumers, anglers, commercial fishermen and others engaged in salt water-based activities. The culprits are several species of Vibrio bacteria. According to the Centers for Disease Control and Prevention (CDC), Vibrio are responsible for an estimated 80,000 cases of infection—known as vibriosis—in the US every year. When Vibrio invades the bloodstream, the result can be fatal. There are approximately 100 US deaths per year from vibriosis.

Vibrio bacteria are most prevalent in estuarine waters between May and October when water temperatures are elevated1 . CDC data indicate more than half of all reported vibriosis cases (65 percent) are caused by eating contaminated food. Thirty-five percent of cases are the result of people with open wounds and scrapes contacting Vibrio-affected waters.

Vibrio vulnificus

With a hospitalization rate of over 90 percent and with nearly 40 percent of cases leading to death,2 one of the Vibrio species in particular—Vibrio vulnificus—has been called the “most virulent foodborne pathogen in the United States.” Vibrio vulnificus also has been called a “flesh-eating bacteria” because of the toxins it releases that destroy human flesh. News reports chronicle rare but tragic instances of unsuspecting individuals who become infected with Vibrio vulnificus, resulting in progressive flesh destruction and limb amputation, a measure that may or may not save their life. Wound infections may start as redness and swelling at the site of the wound and progress throughout the body, according to CDC. The severe illness is characterized by “fever and chills, decreased blood pressure (septic shock), and blood-tinged blistering skin lesions.”

Louisiana’s Department of Wildlife and Fisheries warns fishermen to be aware that exposing open wounds to seawater containing Vibrio vulnificus “may lead to skin breakdown and ulceration.” A July 2014 advisory recommends fishermen in saltwater carry with them “basic disinfectant (chlorine bleach mixed one part bleach to four parts fresh water3 or tincture of iodine, or antibiotic ointment) and use if skin is punctured while handling fishing tackle, bait or fish.” The sooner one of these antiseptics is applied to a wound, the lower the risk of infection.

Are You Vibrio-vulnerable?

According to CDC, the most “Vibrio-vulnerable” are those with compromised immune systems, especially those with chronic liver disease. Although vibriosis is rare in healthy individuals, to reduce your risk of infection, avoid the following:

  • Consuming raw or undercooked shellfish
    • Consumers who want to eat raw bivalve shellfish should ask where the shellfish were harvested. Consumers should not eat raw Gulf Coast oysters, clams, or mussels from May to October unless they have been processed to kill the Vibrio vulnificus
  • Swallowing seawater
  • Contacting seawater when you have an open wound or scrape
  • Handling raw shellfish
    • Wear gloves and replace immediately if torn.

If you suspect Vibrio infection, seek medical attention quickly for potentially life-saving treatment.

Planning a beach vacation? Put your risk of Vibrio infection in perspective, exercise any relevant precautions, and enjoy!

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1 According to CDC, Vibrio species are most prevalent in saline waters of temperatures between 68 and 95 degrees Fahrenheit.

2 Oliver, J.D. (2005). “Wound infections caused by Vibrio vulnificus and other marine bacteria,” Epidemiol. Infect. Jun;133(3):383-91.

3 Fishermen should prepare this solution daily, as bleach solutions weaken over time.


Cleanup in the Aftermath of Flooding

With record flooding in areas of Texas and the 2016 hurricane season just beginning, we think a word to the wise on cleanup in the aftermath of flooding is in order. First, assume that all flood waters are contaminated and that exposure to these waters may raise the risk of diarrhea, dysentery, and even hepatitis, skin and eye infections and respiratory disorders.

The first step in the cleanup operation is to remove flood water and sewage and dry the affected area. Powerful fans and enhanced ventilation are helpful for drying damp structural surfaces. Meanwhile, it is important to evaluate items contacted by flood waters, deciding what to discard and what to keep. Whenever possible, a disinfecting solution of water and chlorine bleach should be applied to affected surfaces of saved items.

To help prevent disease transmission associated with flood cleanup, the Water Quality and Health Council offers the following tips:

  • When using a disinfecting solution to clean up after a flood, remember to:
    • Wear gloves and protective clothing. Do not touch your face or eyes.
    • Change the disinfecting solution often and whenever it is cloudy.
    • Be thorough. Wash and dry everything well.
    • When finished, wash your hands thoroughly with soap and water for at least 20 seconds, even if you have worn gloves.
  • If an item got wet, assume it is contaminated.
  • Disinfecting works best when all loose dirt and debris are removed first. That’s why the Centers for Disease Control and Prevention recommends first washing surfaces with soap and warm, clean water. Next, use a household bleach solution to disinfect.
  • Prepare a bleach solution (3/4 cup regular strength chlorine bleach or 1/2 cup concentrated bleach to one gallon of water) to disinfect walls, floors and other surfaces touched by floodwaters. Keep the area wet for at least two minutes.
  • When addressing exterior surfaces, such as outdoor furniture, patios, decks and play equipment, keep surfaces wet with disinfecting solution for 10 minutes after removing loose dirt and debris with soap and warm, clear water. This may mean wetting the surface with disinfecting solution more than once.
  • Carpets and rugs that have been soaked for more than 24 hours should be discarded. If carpets and rugs were soaked for less than 24 hours, evaluate as follows: Carpets that contacted sewage-contaminated floodwater should be discarded. Carpets contacted only clean basement seepage or lawn runoff into a sub-basement, for example, may be dried and cleaned. Washable throw rugs usually can be cleaned adequately in a washing machine. For more information on cleaning flood-damaged carpets and rugs, see this North Dakota State University website.
  • Chlorine bleach solutions degrade quickly- be sure to make a fresh solution daily as needed. Unused solution may be discharged into toilet or sink.

Contaminated clothing should be washed in the hottest possible water with detergent and chlorine bleach if fabric instructions permit.

Disinfecting Private Wells

If the wellhead has been submerged by floodwaters, the well has most likely been contaminated.

If microbial contamination is suspected (if well was flooded or if water is unusually cloudy, odorous or tastes different), immediate disinfection is recommended. If contamination is discovered through water sampling, disinfection is required. Private well water consumers may choose to have their water sampled again immediately after disinfecting to be certain water is safe to drink. Thereafter, periodic sampling can help provide assurance of good drinking water quality.

Consumers of private well water may contact the local health department for advice on well disinfection. This task can be carried out either by ground water professionals or by the homeowner using an array of information resources available from state and local health departments and government agencies. See, for example, the US Environmental Protection Agency’s website, “What to Do With Your Private Well After the Flood” at: https://www.epa.gov/privatewells/what-do-your-private-well-after-flood.

Note: Depending on the local geology, it is possible for an aquifer (underground water-bearing formation) to become contaminated by floodwater. In such cases, disinfecting the well may not ensure safe water. Aquifer contamination by floodwaters usually clears up after a period of time, but until water sampling confirms good water quality, the household served by a private well should disinfect all water used for drinking and food preparation.

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The Terms of Germ Inactivation
Written by Water Quality & Health Council

Reducing disease-causing microorganisms—aka “pathogens” or “germs”—on environmental surfaces is a matter of using the right agent for the task at hand.  You would no sooner wash your hands in a bleach solution after gardening than expect surgical instruments to be prepared by washing them in soapy water.

Terms that apply to germ reduction on surfaces—cleaning, sanitizing, disinfecting and sterilizing—have distinct definitions, but they are often misused.  To help you navigate these terms, please see the table below:

Vocabulary of Germ Inactivation on Environmental Surfaces1







Removes visible dirt, impurities and pathogens using chemical or physical means.

Cleaning is appropriate when surfaces are visibly dirty.
When a surface is both visibly dirty and contaminated, and requires sanitizing or disinfecting, cleaning is the first step.

Water, detergent, enzymatic products

Cleaning does not remove all pathogens and does not necessarily kill them.  If cleaning tools are used on multiple surfaces before being sanitized, cross-contamination can occur.


Lowers the number of pathogens on surfaces using chemical or physical means.  Pathogen numbers are lowered to a safe level, which is determined by a given public health standard or set of requirements.

Food-contact surfaces such as commercial deli slicers must be cleaned and sanitized on a regular basis. Other examples are the diaper-changing tables in day care centers and shared toys.

Water, detergent, enzymatic products, also liquid chemicals (e.g., alcohols, glutaraldehyde, formaldehyde, hydrogen peroxide, iodophors, ortho-phthalaldehyde, peracetic acid, phenolics, quaternary ammonium compounds, and sodium hypochlorite bleach solutions), wet pasteurization

Sanitizing works by cleaning and/or disinfecting to lower the risk of spreading infection. Sanitizing is often thought to be synonymous with disinfecting, but there is a subtle difference in that sanitizing lowers pathogen numbers to a particular standard.


Kills many or all pathogens on surfaces (except bacterial spores) using chemical or physical means.
There are different degrees of disinfection depending on the purpose or use of the item being disinfected.

Low level disinfection is used for example for common items, such as toilets that do not pose significant risk while high level disinfection is used in healthcare for items that enter the body, such as endoscopes.

Liquid chemicals (e.g., alcohols, glutaraldehyde, formaldehyde, hydrogen peroxide, iodophors, ortho-phthalaldehyde, peracetic acid, phenolics, quaternary ammonium compounds, and sodium hypochlorite bleach solutions), wet pasteurization

For soiled surfaces, disinfecting should follow cleaning to ensure the disinfectant is not “used up” in reacting with dirt and other impurities.


Destroys all forms of microbial life, including bacterial spores, using chemical or physical means.

Surgical instruments must be sterile.

Gamma and x-ray radiation
Ethylene oxide gas, steam under pressure, dry heat, hydrogen peroxide gas plasma, liquid peracetic acid

Sterilizing is preceded by cleaning.
There is no validity to the term “partially sterile.”

A Word about Antiseptics

Agents that kill germs on living tissue and skin are known as antiseptics.  Examples of antiseptics include alcohol in mouthwashes and chlorhexidine, and other anti-microbial agents in products designed to prepare skin surfaces for surgery or administering intravenous fluid.  CDC notes that antiseptics generally are not used on environmental surfaces.  By the same token, sanitizers, disinfectants and sterilants are not used as antiseptics because they can injure the skin and other tissues.

We hope this short article is a helpful resource in clarifying the terms of germ inactivation.

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1CDC sources include: Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 and
How to Clean and Disinfect Schools to Help Slow the Spread of Flu


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