Dental periodontal procedures: a systematic review of contamination (splatter, droplets and aerosol) in relation to COVID-19

Introduction The emergence of the SARS-CoV-2 virus and subsequent COVID-19 pandemic has had a significant effect on the delivery of routine dentistry; and in particular, periodontal care across the world. This systematic review examines the literature relating to splatter, droplet settle and aerosol for periodontal procedures and forms part of a wider body of research to understand the risk of contamination in relation to periodontal care procedures relevant to COVID-19. Methods A search of the literature was carried out using key terms and MeSH words relating to the review questions. Sources included Medline (OVID), Embase (OVID), Cochrane Central Register of Controlled Trials, Scopus, Web of Science and LILACS, ClinicalTrials.Gov. Studies meeting inclusion criteria were screened in duplicate and data extraction was carried out using a template. All studies were assessed for methodological quality and sensitivity. Narrative synthesis was undertaken. Results Fifty studies were included in the review with procedures including ultrasonic scaling (n = 44), air polishing (n = 4), prophylaxis (n = 2) and hand scaling (n = 3). Outcomes included bacterial (colony-forming units e.g. on settle plates) or blood contamination (e.g. visible splatter) and non bacterial, non blood (e.g. chemiluminescence or coloured dyes) contamination. All studies found contamination at all sites although the contamination associated with hand scaling was very low. Contamination was identified in all of the studies even where suction was used at baseline. Higher power settings created greater contamination. Distribution of contamination varied in relation to operator position and was found on the operator, patient and assistant with higher levels around the head of the operator and the mouth and chest of the patient. Settle was identified 30 min after treatments had finished but returned to background levels when measured at or after an hour. The evidence was generally low to medium quality and likely to underestimate contamination. Conclusion Ultrasonic scaling, air polishing and prophylaxis procedures produce contamination (splatter, droplets and aerosol) in the presence of suction, with a small amount of evidence showing droplets taking between 30 min and 1 h to settle. Consideration should be given to infection control, areas of cleaning particularly around the patient and appropriate personal protective equipment, with particular attention to respiratory, facial and body protection for these procedures. In addition, the use of lower power settings should be considered to reduce the amount and spread of contamination.

Splatters and Aerosols Contamination in Dental Aerosol Generating Procedures

Dental aerosol-generating procedures produce a large amount of splatters and aerosols that create a major concern for airborne disease transmission, such as COVID-19. This study established a method to visualise splatter and aerosol contamination by common dental instrumentation, namely ultrasonic scaling, air-water spray, high-speed and low-speed handpieces. Mock dental procedures were performed on a mannequin model, containing teeth in a typodont and a phantom head, using irrigation water containing fluorescein dye as a tracer. Filter papers were placed in 10 different locations to collect splatters and aerosols, at distances ranging from 20 to 120 cm from the source. All four types of dental equipment produced contamination from splatters and aerosols. At 120 cm away from the source, the high-speed handpiece generated the greatest amount and size (656 ± 551 μm) of splatter particles, while the triplex syringe generated the largest amount of aerosols (particle size: 1.73 ± 2.23 μm). Of note, the low-speed handpiece produced the least amount and size (260 ± 142 μm) of splatter particles and the least amount of aerosols (particle size: 4.47 ± 5.92 μm) at 120 cm. All four dental AGPs produce contamination from droplets and aerosols, with different patterns of distribution. This simple model provides a method to test various preventive strategies to reduce risks from splatter and aerosols.

Correlation of Salmonella enterica and Listeria monocytogenes in Irrigation Water to Environmental Factors, Fecal Indicators, and Bacterial Communities

Outbreaks of foodborne illnesses linked to fresh fruits and vegetables have been key drivers behind a wide breadth of research aiming to fill data gaps in our understanding of the total ecology of agricultural water sources such as ponds and wells and the relationship of this ecology to foodborne pathogens such as Salmonella enterica and Listeria monocytogenes. Both S. enterica and L. monocytogenes can persist in irrigation water and have been linked to produce contamination events. Data describing the abundance of these organisms in specific agricultural water sources are valuable to guide water treatment measures. Here, we profiled the culture independent water microbiota of four farm ponds and wells correlated with microbiological recovery of S. enterica (prevalence: pond, 19.4%; well, 3.3%), L. monocytogenes (pond, 27.1%; well, 4.2%) and fecal indicator testing. Correlation between abiotic factors, including water parameters (temperature, pH, conductivity, dissolved oxygen percentage, oxidation reduction potential, and turbidity) and weather (temperature and rainfall), and foodborne pathogens were also evaluated. Although abiotic factors did not correlate with recovery of S. enterica or L. monocytogenes (p > 0.05), fecal indicators were positively correlated with incidence of S. enterica in well water. Bacterial taxa such as Sphingomonadaceae and Hymenobacter were positively correlated with the prevalence and population of S. enterica, and recovery of L. monocytogenes was positively correlated with the abundance of Rhizobacter and Comamonadaceae (p < 0.03). These data will support evolving mitigation strategies to reduce the risk of produce contamination by foodborne pathogens through irrigation.

Planar Interdigitated Aptasensor for Flow-Through Detection of Listeria spp. in Hydroponic Lettuce Growth Media

Irrigation water is a primary source of fresh produce contamination by bacteria during the preharvest, particularly in hydroponic systems where the control of pests and pathogens is a major challenge. In this work, we demonstrate the development of a Listeria biosensor using platinum interdigitated microelectrodes (Pt-IME). The sensor is incorporated into a particle/sediment trap for the real-time analysis of irrigation water in a hydroponic lettuce system. We demonstrate the application of this system using a smartphone-based potentiostat for rapid on-site analysis of water quality. A detailed characterization of the electrochemical behavior was conducted in the presence/absence of DNA and Listeria spp., which was followed by calibration in various solutions with and without flow. In flow conditions (100 mL samples), the aptasensor had a sensitivity of 3.37 ± 0.21 kΩ log-CFU−1 mL, and the LOD was 48 ± 12 CFU mL−1 with a linear range of 102 to 104 CFU mL−1. In stagnant solution with no flow, the aptasensor performance was significantly improved in buffer, vegetable broth, and hydroponic media. Sensor hysteresis ranged from 2 to 16% after rinsing in a strong basic solution (direct reuse) and was insignificant after removing the aptamer via washing in Piranha solution (reuse after adsorption with fresh aptamer). This is the first demonstration of an aptasensor used to monitor microbial water quality for hydroponic lettuce in real time using a smartphone-based acquisition system for volumes that conform with the regulatory standards. The aptasensor demonstrated a recovery of 90% and may be reused a limited number of times with minor washing steps.

Small produce farm environments can harbor diverse Listeria monocytogenes and Listeria spp. populations

A comprehensive understanding of foodborne pathogen diversity in pre-harvest environments is necessary to effectively track pathogens on farms and identify sources of produce contamination. As such, this study aimed to characterize Listeria diversity in wildlife feces and agricultural water collected from a New York State produce farm over a growing season. Water samples were collected from a pond (N=80) and stream (N=52). Fecal samples (N=77) were opportunistically collected from areas <5m from the water sources; all samples were collected from a <0.5km2 area. Overall, 41% (86/209) and 24% (50/209) of samples were positive for Listeria monocytogenes and Listeria spp. (excluding L. monocytogenes), respectively. For each positive sample, one L. monocytogenes or Listeria spp. isolate was speciated by sequencing the sigB gene, which allowed for additional characterization based on the sigB allelic type (AT). The 86 L. monocytogenes and 50 Listeria spp. isolates represented 8 and 23 different ATs, respectively. A subset of L. monocytogenes isolates (N=44) from pond water and pond-adjacent feces (representing a ~5,000m2 area) were further characterized by PFGE; these 44 isolates represented 22 PFGE types, which is indicative of considerable diversity at a small spatial scale. Ten PFGE types were isolated more than once, suggesting persistence or re-introduction of PFGE types in this area. Given the small spatial scale, the prevalence of L. monocytogenes and Listeria spp., as well as the considerable diversity amongst isolates, suggests traceback investigations may be challenging. For example, traceback of finished product or processing facility contamination with specific subtypes to pre-harvest sources may require collection of large sample sets, and characterization of a considerable number of isolates. Our data also support the adage, “absence of evidence does not equal evidence of absence” applies to L. monocytogenes traceback efforts at the pre-harvest level.

Factors Impacting the Prevalence of Foodborne Pathogens in Agricultural Water Sources in the Southeastern United States

Surface water poses a great risk to fruit and vegetable crops when contaminated by foodborne pathogens. Several factors impact the microbial quality of surface waters and increase the risk of produce contamination. Therefore, evaluating the factors associated with the prevalence of pathogenic microorganisms in agricultural water sources is critical to determine and establish preventive actions that may minimize the incidence of foodborne outbreaks associated with contaminated production water. In the Southeastern U.S. environmental factors such as rainfall, temperature, and seasonal variations have been associated with the prevalence of pathogens or microbial indicators of fecal contamination in water. Also, the geographical location of the irrigation sources as well as surrounding activities and land use play an important role on the survival and prevalence of pathogenic bacteria. Therefore, these factors may be determinants useful in the evaluation of production water quality and may help to preemptively identify scenarios or hazards associated with the incidence of foodborne pathogenic microorganisms.

Salmonella Survival in Soil and Transfer Onto Produce via Splash Events

ABSTRACT Nearly one-half of foodborne illnesses in the United States can be attributed to fresh produce consumption. The preharvest stage of production presents a critical opportunity to prevent produce contamination in the field from contaminating postharvest operations and exposing consumers to foodborne pathogens. One produce-contamination route that is not often explored is the transfer of pathogens in the soil to edible portions of crops via splash water. We report here on the results from multiple field and microcosm experiments examining the potential for Salmonella contamination of produce crops via splash water, and the effect of soil moisture content on Salmonella survival in soil and concentration in splash water. In field and microcosm experiments, we detected Salmonella for up to 8 to 10 days after inoculation in soil and on produce. Salmonella and suspended solids were detected in splash water at heights of up to 80 cm from the soil surface. Soil-moisture conditions before the splash event influenced the detection of Salmonella on crops after the splash events—Salmonella concentrations on produce after rainfall were significantly higher in wet plots than in dry plots (geometric mean difference = 0.43 CFU/g; P = 0.03). Similarly, concentrations of Salmonella in splash water in wet plots trended higher than concentrations from dry plots (geometric mean difference = 0.67 CFU/100 mL; P = 0.04). These results indicate that splash transfer of Salmonella from soil onto crops can occur and that antecedent soil-moisture content may mediate the efficiency of microbial transfer. Splash transfer of Salmonella may, therefore, pose a hazard to produce safety. The potential for the risk of splash should be further explored in agricultural regions in which Salmonella and other pathogens are present in soil. These results will help inform the assessment of produce safety risk and the development of management practices for the mitigation of produce contamination. HIGHLIGHTS

Quantitative Shedding of Multiple Genotypes of Cryptosporidium and Giardia by Deer Mice (Peromyscus maniculatus) in a Major Agricultural Region on the California Central Coast

ABSTRACT Deer mice (Peromyscus maniculatus) are abundant and widely distributed rodents in North America that occupy diverse habitats, including agricultural landscapes. Giardia and Cryptosporidium are common parasites in wildlife including deer mice, which may play a role in on-farm contamination of produce. An important step in assessing the risk of produce contamination by Cryptosporidium and Giardia shed by deer mice is to determine the prevalence, levels, and genotypes of (oo)cysts in mouse feces. A total of 63 (30.3%) and 53 (25.5%) of 208 deer mice trapped on 12 farms on the California Central Coast were positive for Cryptosporidium and Giardia, respectively. Of these mice, 41 (19.7%) contained both parasites. The odds of Cryptosporidium shedding were 2.5 to 5 times higher for mice trapped in autumn than for mice trapped in summer or spring. Female mice had a higher prevalence and two- to threefold higher levels of Cryptosporidium and Giardia compared with male mice. Female adults and female juveniles had the highest rates of contamination of the environment with Cryptosporidium and Giardia, respectively. We estimated that 20 infected deer mice inhabiting 1 ha of a typical leafy green produce farm in the study region could shed approximately 5.3 × 108 Cryptosporidium and 10.5 × 108 Giardia, respectively, per day into the environment. The small-subunit rRNA gene loci from a subset of protozoan isolates were sequenced and compared with existing sequences in GenBank. Multiple genotypes of Cryptosporidium and Giardia were found, and BLAST analyses suggest that Giardia and the majority of Cryptosporidium genotypes in deer mice circulate within various rodent populations, but some Cryptosporidium isolates possess zoonotic potential.

Multistate outbreak of Listeria monocytogenes infections linked to whole apples used in commercially produced, prepackaged caramel apples: United States, 2014–2015

SUMMARYWhole apples have not been previously implicated in outbreaks of foodborne bacterial illness. We investigated a nationwide listeriosis outbreak associated with caramel apples. We defined an outbreak-associated case as an infection with one or both of two outbreak strains of Listeria monocytogenes highly related by whole-genome multilocus sequence typing (wgMLST) from 1 October 2014 to 1 February 2015. Single-interviewer open-ended interviews identified the source. Outbreak-associated cases were compared with non-outbreak-associated cases and traceback and environmental investigations were performed. We identified 35 outbreak-associated cases in 12 states; 34 (97%) were hospitalized and seven (20%) died. Outbreak-associated ill persons were more likely to have eaten commercially produced, prepackaged caramel apples (odds ratio 326·7, 95% confidence interval 32·2–3314). Environmental samples from the grower's packing facility and distribution-chain whole apples yielded isolates highly related to outbreak isolates by wgMLST. This outbreak highlights the importance of minimizing produce contamination with L. monocytogenes. Investigators should perform single-interviewer open-ended interviews when a food is not readily identified.