American Journal of Infection Control 42 (2014) 1138-40
Contents lists available at ScienceDirect
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Letters to the Editor
Use of adenosine
50 -triphosphate
bioluminescence assays to
measure cleaning: The role
of spores and Clostridium
difficile infection rates
To the Editor:
We read with great interest the article by Haas et al1 on the imple-
mentation of ultraviolet (UV) environmental disinfection in a large
hospital setting. Many institutions use either fluorescent markers or
adenosine 50 -triphosphate (ATP) bioluminescence assays to determine
adequacy of hospital room cleaning, including with UV or hydrogen
peroxide supplemental cleaning. Intracellular ATP content can vary
depending on conditions in the environment and the organism.2
Additionally the ATP content of spores is markedly lower than that of
vegetative cells of the same organism.3 Therefore measuring ATP may
underestimate the burden of spores, especially with Clostridium difficile.
The reductions in hospital-acquired multidrug-resistant organisms
and C difficile rates observed by Haas et al1 may have been independent
of the implementation of UV disinfection and resulted from increased
cleaning efficacy (the authors note a new environmental services
contractor was placed in 2011) or the other interventions noted. Did
the authors find an improvement in room cleaning using either the ATP
bioluminescence assay in 2010 or using the fluorescent marker from
2011-2013? Decreases in this intermediate outcome would strengthen
the contention that UV cleaning was a major cause of the observed
results, although a differential effect may have been observed. It is
possible that removal of fluorescent marker may be a more effective
surrogate for mechanical removal of C difficile spores than a lower
relative light unit reading from an ATP bioluminescence assay.
References
1. Haas JP, Menz J, Dusz S, Montecalvo MA. Implementation and impact of ultraviolet
environment disinfection in an acute care setting. Am J Infect Control 2014;42:586-90.
2. Shama G, Malik DJ. The uses and abuses of rapid bioluminescence-based ATP
assays. Int J Hyg Environ Health 2013;216:115-25.
3. Setlow P, Kornberg A. Biochemical Studies of Bacterial Sporulation and Germi-
nation XXIII. Nucleotide Metabolism during spore Germination. J Biol Chem
1970;245:3645-52.
DOI of original article: http://dx.doi.org/10.1016/j.ajic.2014.07.007
Conflicts of interest: None to report.
Jesse T. Jacob, MD*
Division of Infectious Diseases
Department of Medicine
Emory University School of Medicine
Atlanta, GA
0196-6553/$36.00 - Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
American Journal of
Infection Control
Kristin N. Hake, RN, MPH
Emory Healthcare
Atlanta, GA
*
Address correspondence to Jesse T. Jacob, MD,
Division of Infectious Diseases, Department of Medicine,
Emory University School of Medicine, Orr Bldg #1020,
550 Peachtree St, NE, Atlanta, GA 30308.
E-mail address: jtjacob@emory.edu (J.T. Jacob).
http://dx.doi.org/10.1016/j.ajic.2014.05.037
Reply to “Use of
adenosine triphosphate
bioluminescence assays to
measure cleaning: The role
of spores and Clostridium
difficile infection rates”
Thank you for your interest in our study of the implementation
and outcome of ultraviolet environmental disinfection (UVD).1
Although we cannot say with certainty that UVD is responsible
for our decrease in Clostridium difficile and multidrug-resistant or-
ganisms, we saw a decrease in these rates soon after imple-
mentation of UVD. This change did not occur in the first 6 months
after the change to a new environmental services contractor, nor
was it correlated with any other intervention.
With regard to assessment of cleaning using adenosine
triphosphate versus a fluorescent indicator, our contractors each
chose the method that their company endorsed, and used this to
validate cleaning and give feedback to their staff. We did note some
discrepancies between visual inspection and reported cleanliness
during the fluorescent indicator phase. Upon investigation we
found that when discharge cleaning was targeted for assessment, a
different person placed the fluorescent marks than the person who
assessed for their removal. This led to a potential for false negatives
based on the assessor not knowing exactly where the marks were
placed. We did not attempt to correlate contractor-reported
cleaning results with patient outcome because both contractors
consistently reported very high rates of cleaning efficacy.
Reference
1. Haas JP, Menz J, Dusz S, Montecalvo MA. Implementation and impact of ultraviolet
environment disinfection in an acute care setting. Am J Infect Control 2014;42:
586-90.
 Letters to the Editor / American Journal of Infection Control 42 (2014) 1138-40
DOI of original article: http://dx.doi.org/10.1016/j.ajic.2014.05.037
Conflicts of interest: None to report.
Janet P. Haas, PhD, RN, CIC*
Westchester Medical Center
Department of Infection Prevention and Control
Valhalla, NY
Department of Medicine
New York Medical College
Valhalla, NY
* Address correspondence to Janet P. Haas, PhD, RN, CIC,
Infection Prevention and Control, Westchester Medical Center,
100 Woods Rd, Valhalla, NY 10595.
E-mail address: Haasj@wcmc.com (J.P. Haas).
http://dx.doi.org/10.1016/j.ajic.2014.07.007
Practice of cupping (Hijama)
and the risk of bloodborne
infections
To the Editor:
Hijama is a type of wet cupping that is frequently practiced in
many Muslim countries. This technique involves using a cup to pull
the skin into traction, which results in a laceration of the skin with
drawing of blood into the cup. Similar forms of cupping and
bloodletting are also sometimes employed in traditional Chinese
medicine and other systems of alternative medicine. However, very
little evidence is available to justify the use of this technique as a
method of treatment. A systematic review evaluating the efficacy of
cupping as a method of treatment concluded that no high-quality
evidence exists regarding the use of cupping as a method of
treatment, except for treating pain.1 Even for the treatment of pain,
most randomized trials conducted to date are of poor quality and
possess severe methodologic flaws.2
At the other end of the spectrum, a growing body of evidence
suggests that the practice of Hijama carries a significant risk of
bloodborne infections, including HIV, hepatitis B, and hepatitis C
infections. A meta-analysis of 357 clinical studies concluded that
Hijama was a definitive risk factor for transmission of hepatitis C
infection (pooled odds ratio, 1.5).3 Another study based on 24,948
cases of hepatitis C infection reported in Saudi Arabiada country
where Hijama is routinely practiceddrevealed that Hijama was the
mode of transmission in a substantial proportion of patients.4 A
growing body of evidence has also implicated Hijama in the
transmission of HIV and hepatitis B infections.
Despite the lack of evidence supporting the efficacy of Hijama
and the demonstrated risk of transmission of bloodborne patho-
gens, this technique continues to be practiced widely in several
parts of the world.5 Even worse is the fact that the risks posed by
this technique have received virtually no attention by the general
public or mass media. This may be attributable to complex reli-
gious, cultural, and social influences in regions where Hijama is
routinely practiced. Health care professionals in such regions can
play a key role in raising awareness regarding the risks posed by
Hijama. At the same time, it is imperative for public health au-
thorities to enforce regulations to ensure that people choosing
1139
Hijama as a method of treatment are fully aware of the health
hazards posed by it.
References
1. Lee MS, Kim J, Ernst E. Is cupping an effective treatment? An overview of sys-
tematic reviews. J Acupunct Meridian Stud 2011;4:1-4.
2. Kim J, Lee MS, Lee D, Boddy K, Ernst E. Cupping for treating pain: a systematic
review. Evid Based Complement Alternat Med 2011;2011:467014.
3. El-Ghitany EM, Wahab MA, Wahab EWA, Hassouna S, Farghaly AG.
A comprehensive hepatitis C virus risk factors meta-analysis (1989-2013); Do
they differ in Egypt? Liver Int; 2014. Article in Press.
4. Madani TA. Hepatitis C virus infections reported in Saudi Arabia over 11 years of
surveillance. Ann Saudi Med 2007;27:191-4.
5. Jan MM, Basamh MS, Bahassan OM, Jamal-Allail AA. The use of complementary
and alternative therapies in Western Saudi Arabia. Saudi Med J 2009;30:682-6.
Conflicts of interests: None to report.
Abdul Rehman, MBBS*
Noor Ul-Ain Baloch, MBBS
Department of Biological & Biomedical Sciences
Aga Khan University
Karachi, Sindh, Pakistan
Muhammad Awais, MBBS
Department of Radiology
Aga Khan University Hospital
Karachi, Sindh, Pakistan
*
Address correspondence to Abdul Rehman, MBBS, Department of
Biological & Biomedical Sciences, The Aga Khan University,
Stadium Rd, Karachi, Sindh, Pakistan.
E-mail address: jsmawais@yahoo.com (A. Rehman).
http://dx.doi.org/10.1016/j.ajic.2014.06.031
Clinical implications of
dual-positive rapid influenza
diagnostic tests during
influenza season:
Co-colonization, coinfection,
or false positive test?
To the Editor:
Rapid influenza diagnostic tests (RIDTs) are the initial tests per-
formed at many health care practices due to their ease of use, quick
turnaround, and relatively low cost to identify influenza viruses A
and B. If an RIDT result is positive, the high specificity confirms the
diagnosis of influenza, whereas a negative result should be
followed-up with polymerase chain reaction (PCR) testing.1,2 Rarely,
clinicians may encounter a problem with interpretation when RIDT
results show dual positivity for influenza A and B. Although coin-
fection has been reporteddit is not uncommon with influenza A
virusesdcoinfection with influenza A and B viruses is rare. Because
coinfection with influenza A and B in adults is so unusual, coinfec-
tion should not be assumed without additional PCR testing.3-9
During the 2013-2014 influenza season, an adult patient in our
hospital presented with an influenza-like illness with a dual positive
QuickVue Influenza A þ B Test (Quidel Corp, San Diego, Calif) result
that warranted further investigation.