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Survival of Bacterial Pathogens on Paper and Bacterial Retrieval from Paper to Hands | American Journal of Nursing | December 2011

Survival of Bacterial Pathogens on Paper and Bacterial Retrieval from Paper to Hands | American Journal of Nursing | December 2011

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Survival of Bacterial Pathogens onPaper and Bacterial Retrieval fromPaper to Hands:
Preliminary Results
Continuing Education
By Nils-Olaf Hübner, MD, Claudia Hübner, PhD, Axel Kramer, MD, PhD, and Ojan Assadian, MD, DTMH
hile electronic medical records andinformation systems are increasinglyfound in hospitals and other clinical set-tings, paper may still be one of the mostcommon materials on any hospital unit.Paper isused as a recording medium in medicalandnursing charts, patient files, notes, and reports, andmay be introduced into the clinical setting by patientsand visitors in the form of books, newspapers, maga-zines, and other items. Paper documents are used everyday and in every way, not only by nurses and physicians,butby many other people involved in patient care.Disinfection of paper, unlike most other equipment,is not an easy task because of its porous surface andincompatibility with liquid disinfectants. Evidence isabundant from studies of paper money that paper cantransmit pathogens in nonclinical settings.
Much research has been conducted on the trans-mission of pathogens from hands to inanimate sur-faces. However, it remains unclear how long bacteriacan survive on paper and how many organisms maybe transferred in a full hand-to-paper-to-hand trans-mission cycle.
1, 4-10
Paper documents could be an im-portant vehicle for cross-contamination and infectionin clinical settings, but data are scarce. The aim of ourstudy was to investigate how long bacterial pathogenscan survive on regular office paper and to quantify theproportion of pathogens transferred from hand topaper and back to another hand.
We performed a two-step experimental studyof bacterial survivability and transmissionunder labo-ratory conditions simulating a “worst-case scenario” (ahigh number ofcolony-forming units [CFU] per cm
,and optimal transmission by wet finger and pressureagainst paper) for the spread of pathogens.
Preparation of paper swatches.
One-centimeter-square swatches were cut from white all-purpose print-ing paper (80 g/m
, Future multitech, UPM, Helsinki,Finland) and steam sterilized. The paper was shownto be free of antibacterial properties in an agar diffu-sion assay in accordance with standard DIN 58940-2-3 of the German Institute for Standardization.
11, 12
Test of organism survivability on paper.
To testthe survival of bacterial organisms on paper, we usedstandard procedures for preparing bacterial cultures.Four organisms—
Escherichia coli
Pseudomonas aeruginosa
—were cultured overnight in tryptic soy broth(TSB, a growth medium commonly used in the cultiva-tion of aerobic bacteria) and prepared to 10
CFU/mL.For each strain, 18 swatches were inoculated with0.25 mL of test suspension and air-dried at room tem-perature. Immediately after drying, each sample wasplaced in a vortexer (a device used to agitate microbial
samples in solution) with 10 mL of 0.9% saline solution.
Volumes of 0.1 mL of undiluted sampling solution and
0.1 mL from 1:10 and 1:100 dilutions in TSB were plated
December 2011
Vol. 111, No. 12
onto Columbia blood agar plates (Becton Dickinson,
Heidelberg, Germany), incubated at 36
1°C for 24 hours,
and plate counted. Samples were stored, while protectedfrom direct sunlight and contamination, under standard
room conditions (23
2°C, 55
5% relative air humidity).
They were then sampled and plate counted after 48, 72,96, 144, and 168 hours, to test for bacterial growth.Tests for bacterial growthwere repeated three times.
Test of bacterial transmissibility.
To test the trans-missibility of bacteria from one hand to paper and backto another hand, we adapted the classic finger-padmethod developed by Ansari and Sattar and specified inthe American Society for Testing and Materials (ASTM)Standards E-1838-96 and E-1838-02 for testing viru-cidal activity of hand antiseptics.
5, 13-15
The nonpatho-genic
E. coli
strain NCTC 10538 (from the NationalCollection of Type Cultures [NCTC], a part of theHealth Protection Agency of the United Kingdom)was used as the test organism. Volunteers washed theirhands in tap water without soap, dried them with single-use papertowels, and waited 10 minutes to ensure thatthey were dry.
The tip of each volunteer’s index fingerwas inoculated with 25 microliters of test suspension(10
CFU/mL) and air-dried.After drying, volunteers pressed the inoculated finger-tips on paper swatches for 30 seconds. The index finger-tips of another group of volunteers were then irrigatedwith sterile 0.9% saline (to simulate the common badhabit of licking the finger before turning pages or goingthrough files) and pressed on the contaminated swatchesfor 30 seconds to simulate cross-contamination. A ster-ile Eppendorf tube filled with 1 mL of saline solutionwas then pressed to the fingertip of each of the second
volunteers and shaken for one minute; volumes of 0.1 mL
of this undiluted sampling solution were plated ontoColumbia blood agar and incubated as described above.Tests were repeated six times.
Survival of test organisms on paper over time.
Alltest strains survived on the inoculated paper. Figure 1shows the changes in recoverable organisms for eachindividual organism. There were notable differences inthe survival of different pathogens over time.
E. coli
was reduced by almost 5 log
in 24 hours (a reduction
 Paper is omnipresent on hospital units, butfewstudies have examined the possible role of paper in thespread of nosocomial pathogens.
To determine by laboratory investigationhow long bacterial pathogens can survive on office paperand whether bacteria can be transferred from hands to pa-per and back to hands in a “worst-case scenario.”
Samples of four bacterial pathogens (
Esch- erichia coli 
Staphylococcus aureus 
Pseudomonas aeruginosa 
Enterococcus hirae 
) were prepared according to stan-dard laboratory procedures. Sterile swatches of office paperwere inoculated with the pathogens and bacterial survivalwas tested over seven days. To test the transmission of bac-teria from one person’s hands to paper and back to anotherperson’s hands, the fingertips of volunteers were inoculatedwith a nonpathogenic strain of
E. coli 
; these volunteers thenpressed the inoculum onto sterile paper swatches. Anothergroup of volunteers whose hands had been moistened pressedtheir fingertips onto the contaminated paper swatches. Bac-teria transferred to the moistened fingertips were cultivatedaccording to standard laboratory procedures.
The four tested organisms showed differencesin length of survival depending on environmental room con-ditions, but were stable on paper for up to 72 hours and stillcultivable after seven days. Test organisms were transferredto paper, survived on it, and were retransferred back tohands.
Paper can serve as a vehicle for cross-contamination of bacterial pathogens in medical settings ifcurrent recommendations on hand hygiene aren’t meticu-lously followed.
cross-contamination, disinfection, finger padmethod, hand antisepsis, hand hygiene, hospital-acquiredinfection, infection control, nosocomial infection, spread ofpathogens, survival on inanimate surfaces
December 2011
Vol. 111, No. 12
Bacteria can be transferred to paper,survive on it, and subsequentlycontaminate hands.
of 5 log
is equivalent to a 99.999% reduction in re-coverable organisms, the minimum reduction re-quired for a surface in a clinical setting to be considereddisinfected). Other organisms, including
P. aerugi-nosa
E. hirae
, were quite resistant to room condi-tions and were reduced by 3 log
(99.9%) only afterseven days; therefore the paper wasn’t disinfectedwithin thetest period, and was still a potential sourceof infection.
Transmissibility of bacteria from hand to paperand back.
We demonstrated that test organisms weretransferred from hands to paper and back to hands(see Table 1). A transmission was detected in all six ex-periments. Although the mean bacterial transfer rate(from one volunteer’s finger to the next volunteer’s fin-ger)was relatively low (0.009%), quantities of bacteriasufficient to cause infection or disease were resampledfrom the second volunteer’s fingertip.(An inoculumof 5 log
organisms—that is, an inoculum containing100,000 organisms—would still
be enough for cross-contamination. The initial quantity of bacteria in theinoculum was 2.75 ×10
CFU/mL, corresponding toa total of 7.44 log
or 74,400,000,000 bacteria in thesample solution.)
Because of paper’s omnipresence on hospital units,thequestion if and to what extent it can play a roleas a vehicle for bacterial pathogens and promote cross-infection is of great importance. It has been repeatedlyshown that medical records can be heavily contami-nated with pathogens, including multidrug-resistantbacteria like methicillin-resistant
S. aureus
-lactamase (ESBL)–producingenterobacteria, or vancomycin-resistant
17, 18
However, data on the survival of bacteriaon paper and other porous surfaces are scarce.We demonstrated that bacteria not only survive onpaper but can also be transferred from one person’shands to paper and back to another person’s hands.This is congruent with the results of studies of bacte-rial growth and survival onother inanimate surfacesand observational evidence.
10, 19-21
Interestingly, the trans-mission rate found in a full hand-to-paper-to-hand cy-clefits well with published data on transmission ratesto and from other inanimate surfaces.
Organisms show differences in resistance to roomconditions, but most of the tested pathogens were quitestable on paper for up to 72 hours and still cultivable
December 2011
Vol. 111, No. 12
   R  e   d  u  c   t   i  o  n   i  n   C   F   U   /  m   L   (   l  o  g
   1   0
   /  m   L   )
E. coli
(NCTC 10538)
S. aureus
(ATCC 6538)
P. aeruginosa
(ATCC 15442)
Inoculum24 hours Afterdrying168 hours144 hours72 hours48 hours
E. hirae
(ATCC 10541)
CFU = colony-forming units.
Initial quantity of bacteria in the inoculum was 2.75 × 10
CFU/mL, corresponding to a total of 7.44 log
Specic bacterial strains are identied by the alphanumeric designations in parentheses. The American Type Culture Collection(ATCC) and the National Collection of Type Cultures (NCTC) are repositories and distributors of standard reference microorganisms,cell lines, and other biological materials.
Survival of Test Organisms on Paper Over Time

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