Breaking NewsAbout copperThe use of copper in hospitals canprevent horizontal transmission of genes

Cost-effectivePut a price on bug-bustingCopper touch surfaces in hospitalintensive care units can pay forthemselves in less than 12 months

Copper FactsMan’s oldest metalA copper pendant discovered in what is now northern Iraq dates back to about 8700 BC

Copper inhospitals

• Copper is man's oldest metal, dating back more than 10,000 years. A copper pendant discovered in what is now northern Iraq dates back to about8700 BC

• The Romans obtained their copper from Cyprus. It was called aes Cyprium, which means ‘metal of Cyprus’. This was later shortened to cyprium and even later to coprum, eventually becoming known in Englishas copper

• Copper is a mineral and is used widely in industry because of its high ductility, malleability, thermal and electrical conductivity and resistance to corrosion

• The melting point of pure copper is 1,981°F (1,083°C, 1356°K) Currently, there are more than 450 recognised copper alloys; brasses and bronzes being the most well known. Brasses are mainly a mixture of copper and zinc, while bronzes are mainly copper along with alloying elements such as tin, aluminum, silicon or beryllium. Alloys are identified by numbers preceded by a ‘C’ and more than 350 have been acknowledged as having antimicrobialproperties

• Copper-rich foods include grains, nuts and seeds, organ meats such as liver and kidneys, shellfish, dried fruits, legume vegetables such as string beans and potatoes, chicken and some unexpected sources such as cocoa and chocolate

Copper facts

Last month, York Health Economics Consortium (YHEC) revealed abusiness case model showing that the installation of antimicrobialcopper touch surfaces in hospital intensive care units pays for itselfin less than 12 months due to the resulting reduction in bacteria andthe potential saving from reduced healthcare associated infections1.It draws on clinical trial results from Selly Oak Hospital in the WestMidlands and others overseas, which have continued to increasethe evidence base for the efficacy of copper and copper alloys infighting superbugs such as MRSA. This week BBH editor, JoMakosinski, spoke to BRYONY SAMUEL of Copper DevelopmentAssociation about the impact of this research and what it means forthe future of infection control in healthcare settings

The bug-busting effect of copper was nota 21st-Century discovery. Bronze is arguably mankind’s oldestmetal, giving its name to a periodfollowing its development nearly 6,000years ago. Bronze today is a widely-usedcopper alloy that benefits from itsantimicrobial efficacy, and ancientGreek soldiers are reported to havescraped the bronze from their swordsinto open wounds to reduce thelikelihood of infection. Copper was also a mainstay in themedical chests of the ancient Egyptians,who performed complex medicaloperations using copper alloyinstruments and alleviated infectionswith copper-containing salves. Inaddition, copper vessels are still used inIndia to store water as it is widelyrecognised to limit the growth ofharmful pathogens.Of course, in modern times the burdenof proof is much greater than thataccepted by ancient cultures. But, a fewthousand years after those earlydiscoveries, scientists are once againrecognising the impact copper and itsalloys - collectively termed‘antimicrobial copper’ - have onreducing the presence of bacteria,particularly on touch surfaces.“There is now a solid evidence basefrom laboratory experiments andclinical trials around the world,” saysSamuel. “This is a big step change forthe health service, which has beenlooking for the most effective ways ofreducing bioburden in medicalenvironments.”

The UK has taken a lead in evidencegathering, mainly through the work ofProfessor Bill Keevil, chairman ofenvironmental healthcare at theUniversity of Southampton. Picking upwhere the ancient civilisations left off,he was behind the first laboratory testsdemonstrating the ability of copper andcopper alloys to rapidly and completelykill bacteria, viruses and fungi. To see ifthese findings could be applied to thehealthcare environment, a major clinicaltrial was undertaken at Selly OakHospital in Birmingham, assessing thereduction in contamination achievableby installing antimicrobial coppersurfaces. The research, carried out on a busymedical ward in 2007, found a 90-100%reduction in bioburden on antimicrobialcopper surfaces. This was the first timeits bug-busting properties had beenobserved outside of the laboratory.Subsequent trials in the US and Chilerecorded similar results, despite theirvery different climates. These providevital evidence of the efficacy of copper atnormal room temperatures, negating theneed for specific climate control and theassociated costs.However, the biggest development interms of collecting the evidence tosupport its widespread use came from athree-centre Department of Defense-funded trial in the US, which went astep further by looking at the knock-oneffect of controlling bioburden in aclinical environment. Preliminaryresults showed that patients treated in aroom in which just six key touch

Copper in hospitals

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This is a big stepchange for the healthservice, which hasbeen looking for themost effective ways ofreducing bioburdenin medicalenvironments

surfaces had been upgraded withantimicrobial copper equivalents had agreater than 40% lower risk of acquiringa healthcare associated infection (HCAI)than those treated in non-copper rooms.Samuel says: “It was well-establishedthat antimicrobial copper surfacesdrastically lower contamination –continuously and in between regularcleans – but no one had previouslyexplored the effect that has on patients.The US trial shows that thisintervention has a direct impact onpatient outcomes, and as such can savelives and money. The business caserecently developed by YHEC sheds morelight on these results.”Research has shown that the hospitaltouch surfaces most likely to harbourhigh levels of pathogens are,unsurprisingly, those nearest to thepatient and used most frequently bythem, visitors and healthcare workers.The US trial found six major sources:bed rails, overbed tables, chair arms,nurse call buttons, IV poles, and datainput devices such as keyboards. Where these products are concerned,replacing the touch surfaces withantimicrobial copper has been found todestroy pathogens and break the chainof infection.The reason why copper has this effect isstill under investigation by teamsaround the world, including ProfessorKeevil. What is known is that coppercauses a cascade of negative events in

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• Uses for copper over the millennia have included making the chisels used to smooth the limestone blocks of the great pyramids, for medical equipment and instruments, as currency, to clad the underwater hulls of ships and to prevent seawater corrosion in marine piping systems, for cookware due to its high heat transfer properties, and for weapons and armour. It is also widely used in architecture, including the massive doors to the temple of Amen-Re at Karnak in Egypt, which were clad with copper; the solid copper ‘Golden Temple’ in Kunming, China; and the famous baptistery doors of Italy's Florence Cathedral

• Copper is an essential nutrient in our daily diet. It is needed for the normal growth and development of human foetuses, infants and children. In adults, it is necessary for the growth, development and maintenance of bone, connective tissue, brain, heart and many other body organs. Copper is also involved in the formation of redblood cells, the absorption and utilisation of iron, and the synthesis and release of life-sustaining proteins and enzymes.

• AND FINALLY…… A copper strip barrier can keep snails and slugsfrom entering your garden. The slime they generate creates an electrical charge when contacting the copper and discourages the pests from crossing

microbial cells, causing them to die veryrapidly. In laboratory tests, copperbound to proteins that do not require itcaused leakage of potassium orglutamate through the outer membraneof bacteria, disturbed osmotic balance,and created oxidative stress bycatalysing local redox reactionsgenerating hydrogen peroxide. The Copper Development Associationhas taken all this evidence and is nowturning it into simple guidance forhealthcare organisations. It alsoprovides an independent overview of thescience and details of the growing rangeof products currently available on themarket.Samuel says: “The evidence is growingvery rapidly, so it can be difficult forpeople to keep up with the latestdevelopments. We want healthcareorganisations to understand exactlywhat copper can do to help withinfection prevention and control,offering a cost-effective additionalmeasure alongside hand hygiene andregular surface cleaning to create asafer environment for patients, theirvisitors and healthcare workers.”In terms of choosing products, thosemade from pure copper exert the mostrapid effect. Many alloys containingmore than 60% copper are also knownto offer significant antimicrobialefficacy. More than 450 alloys are nowregistered with the US EnvironmentalProtection Agency as being permitted

Copper facts

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to make public health claims, which is afirst for solid surfaces.Alloys are attractive to architects anddesigners as they offer a wide variety ofcolours – from the gold brasses andwarm brown bronzes to a silver thatlooks like stainless steel – thusproviding options to suit any designaesthetic.Samuel says: “The advantage of alloys isin the choices they offer, both in termsof colour and properties. Brass andbronze are very hard-wearing and alsoextremely familiar to us – we see themall around us in daily life, from statuesto door furniture to coinage, even asstair rails and edges at LondonUnderground stations.”But does this mean hospitals will haveto pay a premium up front to installcopper surfaces? Samuel claims not.She says: “The cost of the material is avery tiny part of the overall cost of aproduct. Many copper alloys areextremely versatile and easy to workwith, so they do not present a challengefor manufacturers who are likelyaccustomed to using them already. Aspart of a planned renovation or a new-build, antimicrobial copper touchsurfaces are a very appealing option interms of what they offer a hospital.YHEC’s business case model shows justhow quickly payback can be achievedthrough reduced patient bed days andtreatment costs, and of course that’s

without taking into account reducedsuffering and mortality, which arewithout price.”This value is evident in themarketplace, with a handful of forward-thinking firms offering to makeproducts using copper for no additionalprice. These include Allgood and PeglerYorkshire, where product marketmanager, Mike Dickinson, said: “As thehealthcare industry strives to preventthe transfer of infectious bacteria, it isimperative that manufacturers developnew products to help combat the issuesfacing the sector. “The results of research conducted byspecialists across the world has shownthat the antimicrobial benefits of copperfar outweigh any other product on themarket. These are the most-effectivetouch surfaces and are ideal for thehealthcare environment where theirinherent, continuous ability to killbacteria will supplement infectioncontrol measures.” “The best time to consider this issue isduring a refurbishment,” adds Samuel.“Hospitals will want to look at theparticular environment they areplanning, whether it’s a general ward orsomething more specialist such as anintensive care unit or – as with anantimicrobial copper installation atSheffield’s Northern General Hospital –a Cystic Fibrosis (CF) unit. They need todecide what their needs are and I wouldencourage them to ask questions orcome to us for advice and assistance.”As hospitals in the UK continue toembrace copper as a new surfacematerial, studies are ongoing in France,Spain, South Africa, Greece and Japan,and Professor Keevil is undertakingfurther work to determine exactly whycopper has this effect on such a varietyof microbes. UK health centres that have alreadyembraced the use of copper for infectioncontrol include Craigavon Hospital inNorthern Ireland, where copperironmongery has been installed in thetrauma and orthopaedic areas and inthe maternity unit and operatingtheatres. Traditional fittings have beenreplaced with copper products for thepast three years as part of a drive byMilligan Reside Larkin Architects toshow how the design of buildings can

It was well-established thatantimicrobial coppersurfaces drasticallylower contamination– continuously and inbetween regularcleans – but no onehad previouslyexplored the effectthat has on patients.The US trial showsthat this interventionhas a direct impacton patient outcomes,and as such can savelives and money

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aid infection control.Copper touch surfaces were also usedduring the refurbishment of the adultrehabilitation unit at HomertonUniversity Hospital in London. Theproducts are from Allgood’s Contegorange and are an example of how acopper alloy can be used to give theappearance of stainless steel, while stillretaining the infection preventionproperties of copper.Graham Shirville, Chairman of Allgood,said of the installation: “The rangeoffered the client the antimicrobialprotection of copper with theappearance of stainless steel, fitting inwith the desired aesthetic while helpingto protect patients from the pathogensthat cause healthcare-associatedinfections.”And speaking about the impact copperhas had on the CF unit at the NorthernGeneral Hospital, one of its consultants,Dr Frank Edenborough, said: “In a bidto set the gold standard for infectionprevention in CF, we felt that coppercould make an important contributiontowards minimising surfacecontamination from hands or coughing,killing potentially-dangerous pathogensin between cleans and augmentingrigorous hygiene protocols. It is ourhope that, in this way, copper will helpreduce the risk of infections."Architect Rebecca Haverty of RaceCottam Associates, the practice behindthe cutting-edge unit, added that it wasbecoming a more importantconsideration for designers. “Common materials such as plasticsmay look clean, but they have noinherent antimicrobial efficacy," shesaid. "Antimicrobial copper can help tofight infection, so we were very keen touse it. It seems almost too good to betrue and yet it's proven to work. Therange of alloys available means anyproject can gain from the benefits ofcopper. We chose to use an almost purecopper to make a statement, but anickel silver finish would look good too."

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breaking news

Breaking NewsThis week new research from theUniversity of Southampton has shownthat the use of copper in hospitals canprevent horizontal transmission ofgenes, which is largely blamed for thedevelopment of antibiotic resistance.

A newly-published paper, which hasappeared in the journal mBio, showsthat while horizontal gene transfer(HGT) can take place on frequently-touched surfaces such as door handles,trolleys and tables made fromtraditional stainless steel, theintroduction of copper prevents thisprocess from occurring and rapidly killsbacteria on contact. The discovery will be increasinglyimportant in the fight again antibioticresistance, which has led to anincreasing number of difficult-to-treathealthcare associated infections. Report lead author, Professor BillKeevil, chairman of environmentalhealthcare at the university, said:“While studies have focused on HGT invivo – an experiment that is done in thebody of a living organism – this workinvestigates whether the ability ofpathogens to persist in theenvironment, particularly on touchsurfaces, may also play an importantrole.

“Here, we show prolonged survival ofmultidrug-resistant Escherichia coli andKlebsiella pneumoniae on stainless steelsurfaces for several weeks. However,rapid death of both antibiotic-resistantstrains and destruction of plasmid and

genomic DNA was observed on copperand copper alloy surfaces, which couldbe useful in the prevention of infectionspread and gene transfer.”Showing that HGT occurs on touchsurfaces further supports theimportance of the environment ininfection prevention in hospitals andother healthcare settings.Professor Keevil said: “We know manyhuman pathogens survive for longperiods in the hospital environment andcan lead to infection, expensivetreatment, blocked beds and death.What we have shown in this work is thepotential for strategically-placedantimicrobial copper touch surfaces tonot only break the chain ofcontamination, but also actively reducethe risk of antibiotic resistancedeveloping at the same time. “Provided adequate cleaning continuesin critical environments, copper can beemployed as an important additionaltool in the fight against pathogens.”

We want healthcareorganisations tounderstand exactlywhat copper can do tohelp with infectionprevention andcontrol, offering acost-effectiveadditional measurealongside handhygiene and regularsurface cleaning tocreate a saferenvironment forpatients, theirvisitors andhealthcare workers