Occupational Health & Safety

Health professionals should be aware of the health risks posed by unclean cellphones.

Mobile Phones in Hospital Settings: A Serious Threat to Infection Control Practices

Health professionals need to help raise awareness about the health risks of using an unclean cell phone.

The global system for mobile telecommunication was established in 1982 in Europe with a view of providing an improved communications network. The first use of mobile phones in India was in 1995; today there are 287 million mobile phone users in India, which accounts for 85 percent of all telecommunication users.1 Today, mobile phones have become one of the most indispensable accessories of professional and social life. Although they are usually stored in bags or pockets, mobile phones are handled frequently and held close to the face.2

Hospital-acquired infections affect more than 25 percent of admitted patients in developing countries. In U.S. hospitals, they cause 1.7 million infections per year and are associated with approximately 100,000 deaths. It is estimated that one third of these infections could be prevented by adhering to standard infection control guidelines.3

Germ Prone
Increasing functionality and affordable prices for cellphones and smart phones have resulted in a global reliance on staying connected. Cell phones are now commonplace, whether it be the dinner table, the kitchen, a restaurant, the gym, or even the bathroom. These factors and the heat generated by cellphones contribute to harboring bacteria on the device at alarming levels. When we consider a cellphone's daily contact with the face, mouth, ears, and hands, the dire health risks of using germ-infested mobile devices are obvious.

Unlike our hands, which are easily sterilized using hand sanitizers made available readily across all hospitals and medical facilities, our mobile phones are cumbersome to clean. Even we rarely make an effort to sanitize them. As a result, these devices carry a variety of bacteria. Cellphones are used often in hospitals by patients, visitors, and health care workers. Also, travelers who go to low-income countries where potable water and good sanitation are limited are exposed to the risk of contracting infections because these individuals carry phones, and the potential of such accessories to spread bacterial infection is not yet clear.4

Bacterial Infections in Health Care Workers and Corporate Users
A study was conducted in Southern India to determine whether mobile phones of health care workers (HCWs) and corporate users harbor micro-organisms. Swabs collected from mobile phones were inoculated in solid and liquid media and incubated aerobically. Growth was identified as per standard microbiological procedures.

Antibiotic susceptibility was determined for Staphylococcus aureus. A questionnaire was used for data collection on awareness of mobile phone use. Of 51 HCWs and 36 corporate mobile phones sampled, only five (6 percent) showed no growth. Pathogens isolated from HCW samples included S. aureus (methicillin-sensitive S. aureus, methicillin-resistant S. aureus), Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa. Coagulase-negative Staphylococci also were isolated. Among corporate isolates, 29 percent were pathogenic. Polymicrobial growth was detected in 71 percent of HCW mobile phones and 78 percent of corporate mobile phones. Only 12 percent of HCWs used disinfectants to wipe their mobile phones.

Therefore, it was concluded that mobile phones serve as a ready surface for colonization of nosocomial agents, indicating the importance of hand hygiene to prevent cross-transmission.5

The first study of bacterial contamination of mobile phones was conducted in a teaching hospital in Turkey with a bed capacity of 200 and one intensive care unit.6 One-fifth of the cellular telephones examined in a study conducted in New York were found to harbor pathogenic microorganisms.7 Health care workers' mobile phones provide a reservoir of bacteria known to cause nosocomial infections. UK National Health Service restrictions on the utilization of mobile phones within hospitals have been relaxed; however, utilization of these devices by inpatients and the risk of cross-contamination are currently unknown.

Demographics and characteristics of mobile phone utilization by inpatients and phone surface microbial contamination were examined by Brady, et al. One hundred and two out of 145 (70.3 percent) inpatients who completed a questionnaire detailing their opinions and utilization of mobile phones also provided their mobile phones for bacteriological analysis and comparative bacteriological swabs from their nasal cavities; 92.4 percent of patients supported utilization of mobile phones by inpatients; indeed, 24.5 percent of patients stated that mobile phones were vital to their inpatient stay.

Patients in younger age categories were more likely to possess a mobile phone both inside and outside hospital (p <0.01), but="" there="" was="" no="" gender="" association.="" eighty-six="" out="" of="" 102="" (84.3="" percent)="" patients'="" mobile="" phone="" swabs="" were="" positive="" for="" microbial="" contamination.="" twelve="" phones="" (11.8="" percent)="" grew="" bacteria="" known="" to="" cause="" nosocomial="" infection.="" seven="" phone="" (6.9="" percent)="" and="" 32="" nasal="" swabs="" (31.4="" percent)="" demonstrated="">Staphylococcus aureus contamination. MSSA/MRSA contamination of phones was associated with concomitant nasal colonization. Patient utilization of mobile phones in the clinical setting was popular and common.8

A cross-sectional study was conducted in Turkey to determine bacterial colonization on the mobile phones used by patients, patients' companions, visitors, and health care workers. Significantly higher rates of pathogens (39.6 percent versus 20.6 percent, respectively; P = .02) were found in mobile phones of patients' (n = 48) versus the health care workers (n = 12). There also were more multidrug pathogens in the patients' mobile phones, including methicillin-resistant Staphylococcus aureus, extended-spectrum ß-lactamase-producing Escherichia coli, Klebsiella spp, high-level aminoglycoside-resistant Enterococcus spp, and carabepenem-resistant Acinetobacter baumanii. Findings suggest that mobile phones of patients, patients' companions, and visitors represent higher risk for nosocomial pathogen colonization than those of HCWs. Specific infection control measures may be required for this threat.9

In Nigeria, there has been an increase in the use of mobile phones among the general population, and the use of phones is common in certain areas of the environment where the percentage presence of bacteria is likely high, such as in hospitals, in animal slaughter areas, and in toilets. A study was conducted to determine whether mobile phones could play a role in the spread of bacterial pathogens and to proffer possible control or preventive measures that could be instituted to avoid this likely vehicle of infection. In this study, 62 percent of 400 mobile phones from all of the study groups were found to be contaminated by bacterial agents.

Isolation of bacterial agents from electronic devices such as hand-held computers and personal digital assistants has shown these devices to be possible modes of transmission of nosocomial pathogens.10 In a study conducted in Queen Elizabeth Hospital in Barbados, West Indies, more than 40 percent of mobile phones of 266 medical staff and students were culture positive.11 Ulger, et al. reported that 94.5 percent of 200 health care workers and their mobile phones were contaminated with various microorganisms, including nosocomial pathogens, in a study conducted in New York and Israel.12

Nosocomial infection is an important problem in all modern hospitals. As early as 1861, Semmelweis demonstrated that bacteria were transmitted to patients by the contaminated hands of health care workers. Hospital operating rooms and intensive care units are the workplaces that need the highest hygiene standards, both for the personnel working there and the equipment used by them.13 Rusin, et al. had documented both gram-positive and gram-negative bacteria in hand-to-mouth transfer during casual activities. This implies that mobile phones may serve as vehicles of transmission of diseases such as diarrhoea, pneumonia, boils, and abscesses.14 A study was conducted in Turkey to determine the contamination rate of health care workers' mobile phones and hands in operating rooms and ICUs. These results showed that HCWs' hands and their mobile phones were contaminated with various types of microorganisms.15

Dental Clinics
A cross-sectional study was conducted in India to determine the level and type of bacterial contamination of the mobile phones of dental personnel involved in direct patient care and to determine the usefulness of cleaning with 70 percent isopropyl alcohol for decontamination. Dental faculty and trainees in an Indian dental school were asked to participate in a study in which a questionnaire was administered concerning patterns of mobile phone use and disinfection. Swabs from mobile phones of the participants were taken using moist sterile swabs and plated on blood agar plates. The bacteria isolated were identified by biochemical tests.

Eighteen percent of the participants (n=9) reported using their phones while attending patients. Nearly 64 percent (n=32) used their mobiles for checking time, and 64 percent (n=42) reported never cleaning their phones. In total, 50 mobile phones were cultured for microorganisms: 98 percent (n=49) were culture-positive, and 34 percent (n=17) grew potentially pathogenic bacteria. There was significant reduction in the mean number of colony-forming units after decontamination with alcohol (p less than 0.001). The bacterial load was reduced by around 87 percent. The results of this study show that mobile phones may act as an important source of nosocomial pathogens in the dental setting. Therefore, it is important for dental school administrators to encourage higher compliance with hand-washing practices and routine surface disinfection through framing of strict protocols to reduce the chances of occurrence of nosocomial infections.16

Researchers conducted a pilot study to estimate the prevalence and type of microorganisms isolated from the mobile phones of 80 health care workers at a Thai hospital before and after alcohol cleansing. The surface of the phone’s keypad, mouthpiece, and earpiece was swabbed, and the phone was cleaned with a 70 percent alcohol pad. A second culture swab of the keypad, mouthpiece, and earpiece was obtained one minute later. The researchers reported that 38 participants (47.5 percent) had exposure to multidrug-resistant bacteria at enrollment in the study, and there was an average of two cases per house staff with multidrug-resistant bacteria. Three mobile phones (3.8 percent) had cultures positive for Acinetobacter spp. before alcohol cleaning. After alcohol cleansing, no microorganisms were detected. Overall hand hygiene compliance was 39 percent before touching a patient, 29.4 percent before a clean/aseptic procedure, and 47.5 percent after touching a patient’s surrounding. Although previous reports identified health care workers’ mobile phones as a reservoir for various multidrug-resistant bacteria, none had shown that alcohol cleansing can reduce the detection of bacteria on mobile phones.17

Creating a Policy
What we need is a sound and feasible policy with respect to mobile phone usage in hospital settings. Today mobile phones are important devices for both the professional and social lives of their users. However, restrictions on the use of mobile phones in certain areas of the environment where the percentage of bacteria present is likely high (such as in hospitals, dental clinics, lecture theatres, canteens, business centers, toilets, and other such places) are difficult and thus not a practical solution.

Users of mobile phone hence need to be advised to use antibacterial wipes to make their mobile phones germ free at all times. Also advocated is strict adherence to infection control and precautions such as hand washing and good hygienic practice among the users of mobile phones, to prevent the possibility of phones as vehicles of transmission of both hospital and community-acquired bacterial diseases.

Conclusion
Health professionals, from microbiologists, epidemiologists, doctors, and dentists to behavioral scientists and occupational health and safety consultants, need to take note of how and where we are using our cellphones, draft new guidelines and prevention tips, and help raise awareness about the health risks of using an unclean cell phone.

However, we recommend that patients and doctors be educated by clear guidelines and advised on inpatient mobile phone etiquette, regular cleaning of phones, hand hygiene, and advised not to share phones or related equipment with other inpatients in order to prevent transmission of bacteria.

Cellphones are now an extension of a person's lifestyle, accompanying them everywhere. Everyone should clean their cell phones -- but especially doctors, dentists, and nurses, whose hygiene impacts patients' well-being.

References
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This article originally appeared in the March 2012 issue of Occupational Health & Safety.

About the Authors

Dr. Abhinav Singh is an assistant professor in the Department of Public Health Dentistry at the People's College of Dental Sciences in Bhopal, India.

Dr. Bharathi Purohit, MDS, is an assistant professors in the Department of Public Health Dentistry at the People's College of Dental Sciences in Bhopal, India.

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