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Cystic fibrosis: Infection prevention & control recommendations for universities, colleges and institutes of further and higher education – A practical guide
Source, transmission, cross infection, hazards, risks within higher education.
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Recommendations to protect people with cystic fibrosis at university/college.
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Importance of risk assessment and good communication.
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Guidance for students, educators, health/wellbeing and healthcare teams.
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Glossary of clinical, microbiological and educational/pedagogical terms.
Abstract
Background
The avoidance of cross-infection remains of critical importance to prevent the transmission of cystic fibrosis (CF)-related microbial pathogens to persons/people with cystic fibrosis (PwCF). To date, there has been a paucity of infection prevention and control (IPC) guidance relating to infection risk at higher educational institutions. With improvements in treatments, more PwCF are now attending universities/colleges and educational institutions now seek CF-specific guidance on IPC from clinical CF teams/centres.
Methods
Real world infection-related questions from university students, educators, university support staff and the CF multidisciplinary team were received and collated from various stakeholders, including individual consultations and focus group sessions with two local universities. Subsequently, evidence-based recommendations were compiled from existing peer-reviewed literature and from cystic fibrosis organisations. Glossaries were constructed relating to clinical, microbiological and educational/pedagogical terminology to aid with the understanding amongst these stakeholder groups.
Results
This review addresses CF-related IPC recommendations across five areas of university/college life, including (i) on campus estate, (ii) teaching (lectures/tutorials/small study group work/group assignments), (iii) laboratory practicals, (iv) field trips/study visits/work placements and (v) residential accommodation and lists practical recommendations to help prevent the transmission of infections to PwCF students.
Conclusions
It is important that the educational institutional environment is safe permitting the PwCF student to enjoy their educational experience and journey through higher education, culminating in achievement of their educational goals, employment and independent living. The guidance presented in this review is intended to equip educational establishments in creating their own bespoke and robust IPC policies relating to PwCF students.
Cystic fibrosis (CF) is an autosomal recessive disease of mainly Caucasian populations of European ancestry, which usually manifests by a continuous cycle of respiratory inflammation and lung infection, which may become chronic, leading to increasing disease severity [
]. In a Person/People with CF (PwCF), the condition manifests itself in many ways and involves many organs, particularly the lungs and the gut. The cystic fibrosis transmembrane conductance regulator (CFTR) protein is an ion channel, the function of which is to control ion transport of chloride and bicarbonate ions and water secretion and absorption in various epithelial cell surfaces in the body, particularly the sweat glands, pancreas and the surface of the lung [
]. Mutations in the CFTR gene result in the production of thick viscous sputum in the lungs as a result of the physiological problems of transporting chloride ions, allowing the entrapment of environmental bacterial and fungal organisms, which may eventually lead to chronic colonisation and infection [
]. Therefore, PwCF are vulnerable to acquiring organisms from the environment or through cross infection from other PwCFs. As these infections can become chronic and adversely affect morbidity and mortality, it is of utmost importance to understand the biology of these organisms, so that mitigating interventions may be adopted to help reduce cross infection, both in and outside of healthcare.
New treatments, particularly the CFTR modulators have contributed to a dramatic and rapid improvement in wellbeing, in terms of increased life expectancy, improved Quality of Life (QoL) and more stable CF disease, leading to new opportunities for young adults with PwCF [
]. These opportunities have contributed to increased independent living, employment, travel, financial independence, starting a family, as well as entry to third level education at universities and colleges [
]. A recent report published by Cystic Fibrosis Ireland entitled “Independent Living and Cystic Fibrosis” showed that there was a 11% increase in PwCF who had completed third level education during the 20 year period, 1998–2017 [
]. The authors of this report indicated that this increase in third level participation and attainment inferred both an improved ambition and capacity for those PwCF seeking independent living [
In France, a study by Laborde-Castérot and colleagues, showed that in a population of 207 adults with CF attending an adult CF centre in Paris, 39 PwCF (19%) were currently students in education [
]. Ninety four PwCF (57%) had studied at least 2 years at university and 28 (17%) had a Master's degree. Indeed, the educational level of the French PwCF was reported as higher than that of the general population. In Italy, a 2021 study showed that the educational level in the adult study population (n = 196) was 58% attaining a high school diploma/enrolled university and 23% had attained a degree or postgraduate degree, i.e., 81% pursuing education post-secondary school [
]. In a UK study published in 2014, 40% (102/254) of survey respondents indicated that they had attained an educational attainment of a post-secondary level qualification [
Entry to third level education carries new and relatively uncharted infection risks to the PwCF, in that there is a greater likelihood that many more PwCF may now attend the same educational institution. Relative stability of their disease may attract PwCF into careers and course choices, which previously PwCF may not have considered. To date, the primary source of information relating to third level education has been guidance documents published by national CF charities. These resources largely support PwCF in considering factors such as distance to the academic institution, travel time, healthy eating and independent living. The primary guidance provided in relation to universities and colleges, relates to how these institutions can support students with CF by making reasonable adjustments e.g. extended deadlines for coursework and provision of recorded lecture materials [
Whilst these resources for PwCF and universities/college are valuable for general practical considerations, there is a paucity of guidance relating to infection prevention and control within the third level education setting, with institutions being directed to “ask your student or their clinical team for more information about possible infection risks from the environment” [
The current seminal Infection Prevention and Control (IPC) CF guidelines detail practices to minimise the acquisition of infection in the healthcare, home and other settings, with a short section on CF IPC within schools (Section IV.I.4), which, as the authors suggest, may in part be applicable to universities [
]. However, outside these general CF IPC guidelines, specific recommendations are currently lacking with regard to IPC procedures for higher education, including universities, colleges and institutes of further and higher education. Therefore, it is the aim of this document to help guide higher education institutions through the provision of such IPC recommendations, by presenting evidence-based information, which will allow robust risk assessment and risk management policies to be undertaken.
Methodology
Real world infection-related questions from our university/college students with CF were noted and addressed at clinic, during the course of the CF patients' routine clinical care, by our CF Team at Belfast City Hospital. Additionally, following consent from these students, university health and wellbeing teams and educational teams expressed the need for further guidance in relation to practical aspects of IPC at university/college, to ensure that students were safe during their academic studies and training, whilst attending their higher and further educational institutions. All group discussions with educational stakeholders did not identify any individual or institution. Subsequently, all questions from stakeholders were collated and evidence-based recommendations were compiled by the CF healthcare team (the authors) from existing peer-reviewed literature and from published reports from cystic fibrosis organisations. Formal ethical approval was not required, as this was not considered Research, as defined by the UK Policy Framework for Health and Social Care Research.
The recommendations in this current review relate to IPC and are based solely on common infection hazards and risk factors for PwCF when attending further and higher educational institutions. There may be other requirements of the PwCF attending university, including educational and social needs, that this IPC-focused document will not address and which can be captured through other mechanisms, i.e. bespoke assessment with disability service/health and wellbeing teams. The recommendations presented in this review focus on common IPC-related educational queries and encountered situations, and as such are not exhaustive as it is not possible to cover every potential IPC-related eventuality. These proposed recommendations have been constructed in concert with the CF IPC guidelines of 2013 [
] and further evidence-based literature to consider robust and proportionate IPC measures, which educational institutions may embed. Together, these will help inform and guide universities and colleges to protect PwCF students enrolled at their institution, as well as helping clinical paediatric and adult CF MDT teams to provide practical guidance to their patients entering third level education.
Career counselling
Choosing a career is a daunting task for any adolescent and teenager. However, for the PwCF, this task is further complicated in considering several health and wellbeing issues associated with various career pathways. Prior to applying for a further or higher education course, it is advised that PwCF should discuss their career ambitions/aspirations and choice of subject requirements with their education careers team, as well as their CF healthcare team, in order to seek career counselling in terms of the practical limitations their condition could potentially impose in both the short and long term. Zupanic and Skerjanc [
] suggested that such discussions should commence before completing primary school education, in order to gain an appreciation of the PwCF's psycho-physical abilities, as well as their professional goals [
]. Discussion at such an early age starts a dialogue between the young PwCF, their parents, teachers and CF healthcare team and allows for the continual adaptability of career choice, prior to the selection of academic subjects which will largely dictate final career choice. Such conversations if left until transition between paediatric and adult care centres could potentially lead to poorly informed career choices, thereby leaving little scope for redirection at such a late stage, with potential accompanying psychological disappointment. At present, there is a paucity of formal career counselling information for PwCF, commencing at an early age, however Zupanic and Skerjanc have proposed guidelines on career counselling of young PwCF [
Pedagogical learning and teaching approaches in higher education
Historically, conventional student education has been based on the delivery of subject specific courses by means of face-to-face lectures, tutorials and practical classes during a defined period of time on campus. This model has undergone substantial innovative changes over the last three decades which have been mainly driven through technological advances, particularly in relation to digital technologies and the requirement for a more flexible learning pathway. The United Nations Education Scientific and Cultural Organization (UNESCO) have produced The Education 2030 Agenda which encourages all countries to develop well-articulated education systems that offer flexible learning pathways which provide benefits for students in relation to greater choices in education, adaptable study and career pathways suitable for students’ personal situations and cleaner career profiles for the labour market [
UNESCO. Education 2030: Incheon Declaration and Framework for Action for the implementation of Sustainable Development Goal 4: ensure inclusive and equitable quality education and promote lifelong learning opportunities for all.
SDG 4 - policies for flexible learning pathways in higher education: taking stock of good practices internationally.
IIEP-UNESCO.2015; (Working Papers. SDG 4 - Policies for flexible learning pathways in higher education: taking stock of good practices internationally. Year of publication) (Available from:) ([Accessed 18 October 2022])
]. This is important as employers seek graduates who are “employment-ready” and as such, education providers embed transferable employability skills within the core curriculum coupled with opportunities to develop such skills and higher order cognitive skills in a practical manner during small group activities, practical sessions and experiential placements. These drivers have resulted in the delivery of higher education courses many of which are accredited by professional bodies and approved by regulatory bodies. Today, there is a myriad of interactions on how the students engage with their education, including (i) the time committed to learning (fulltime, part-time), (ii) how teaching is delivered (self-directed learning, synchronous, asynchronous), (iii) the reason for learning (vocational, undergraduate, postgraduate, continual professional development (CPD), apprenticeships) and (iv) where teaching is delivered i.e., the physical and virtual educational estate (on-campus, online, blended learning, work placement). Please see Supplementary Table 1 for a glossary of clinical, microbiological and educational/pedagogical terms associated with this review. The complexity of such contemporary and flexible learning models coupled with the form of engagement as detailed above, effectively creates a personalised and unique educational experience for each student. This shift in the paradigm of learning and teaching methods necessitates an appreciation of potential new risks for the transmission of infection within further and higher education, as was most recently experienced during the SARS-CoV-2 pandemic [
]. For students with CF, it is important to holistically consider their individual educational programme in terms of IPC, to minimise infection risks, as a “one size fits all” approach does not allow for all the intricacies that arise from such a modern education and personalised learning plan for each PwCF student.
Transmission of infection within cystic fibrosis
In order to perform a robust risk assessment, the various routes of transmission of infectious pathogens relating to cystic fibrosis within the university/college setting, must be considered. Effective infection prevention advice is primarily based on three principles, namely understanding (i) the biology of the microbial pathogens of concern, (ii) the routes of transmission and (iii) the “at risk” groups.
There are a number of microbiological organisms which are of clinical importance in cystic fibrosis and which have been cultured from respiratory samples from PwCF, namely the Gram-negative organisms Pseudomonas aeruginosa, members of the Burkholderia cepacia complex particularly Burkholderia cenocepacia, Stenotrophomonas maltophilia, Achromobacter xylosoxidans, Haemophilus influenzae, the Gram- positive organisms, namely Staphylococcus aureus and methicillin- resistant S. aureus, non-tuberculous mycobacteria especially Mycobacterium abscessus and the fungal pathogens Aspergillus fumigatus and Scedosporium apiospermum complex [
]. PwCF are also at risk of acquiring respiratory viruses, which have been reported to increase the risk of pulmonary exacerbations in PwCF which in turn has a potential impact on lung function and the duration of antibiotic treatment [
These microbial pathogens may be acquired by the PwCF through several routes of transmission as detailed in Fig. 1. Many of the CF relevant organisms are ubiquitous within the environment, particularly in soil and water. However, person-to-person transmission is of concern both between PwCF and also non-PwCF, in relation to contact transmission via skin such as hands and mucous membranes. The production of respiratory aerosols and droplets contaminated with these organisms present a significant risk of infection from an infected person to the nasal mucosa, conjunctiva, or mouth of the PwCF. Within the university community, cystic fibrosis may be a condition of students, academic staff, non-academic staff/support staff as well as visitors to the university as shown in Supplementary Figure 1. Recognition of these potential risks and routes of transmission between these individuals, should be considered when performing a risk assessment.
Fig. 1Sources and routes of transmission of infection in person/people with cystic fibrosis. ∗According to Wang and colleagues [
Whilst PwCF students do not generally pose an infection risk to other non-PwCF immunocompetent students or staff in terms of their CF-related respiratory pathogens, it must be acknowledged that such pathogens, for example, antibiotic-resistant bacteria and non-tuberculous mycobacteria (NTMs), may pose an infection risk to students and staff who are immunocompromised or immunosuppressed, e.g. transplant recipients, individuals undergoing chemotherapy and individuals with HIV. In the case of such immunocompromised/immunosuppressed individuals, a further risk assessment, in conjunction with their healthcare team is advocated. When considering any IPC interventions, it is important to map all potential interactions between the PwCF individual and other individuals within the university/college community and training, placement and field trip environments (Fig. 2).
Fig. 2Routes of transmission of infectious agents between individuals with cystic fibrosis (CF) and individuals without CF (Non-CF). Abbreviations: CF, cystic fibrosis; HIV, human immunodeficiency virus; MRSA, methicillin-resistant Staphylococcus aureus; NTM, non-tuberculous mycobacteria.
It is strongly advised to undertake a risk assessment in relation to the career choice and educational programme chosen by the PwCF. Whilst PwCF are not generally obliged to disclose their CF to university/college staff or peers, it is encouraged that the PwCF discusses their individual needs and concerns with both their CF healthcare team and the university teams, namely senior academics responsible for course delivery, university health and wellbeing teams, as well as university accommodation facilitators, should the PwCF wish to stay in university- controlled accommodation.
There are two main potential routes of transmission of CF pathogens to PwCF students within the university/college community, namely (i) cross infection from other PwCF and (ii) acquisition of CF pathogens from the environment, as detailed in Fig. 3. Cross infection of CF pathogens between PwCF is well documented [
], but has not been described with specific reference to universities and colleges and there is a paucity of published evidence regarding the specific risks that the university environment poses to the PwCF student.
Fig. 3Considerations of infection risks for person/people with cystic fibrosis attending universities and colleges. Abbreviation: CF, cystic fibrosis.
Once university/college health and wellbeing teams have been notified of individuals who have declared cystic fibrosis as a health condition, the university should undertake a risk assessment to identify potential crossover in timetabling within courses, modules, practical classes and tutorial groups, where two or more students with CF could be in attendance (Fig. 3). This risk assessment should also identify the estate where potential crossovers are anticipated to occur, as well identifying risks from the university environment (Fig. 3). Once these risk assessments are known, then appropriate risk management with proportional mitigating IPC interventions can be put in place to minimise the infection risk and safeguard PwCF students.
In all discussions between the PwCF student and university teams, there needs to be an appreciation and upholding of confidentiality and consent for the exchange of information and details between all the parties. The disability provisions of the UK Equality Act (2010), Part 6, Chapter 2 (Further & Higher Education) states:- “A duty to make reasonable adjustments applies to the responsible body of such an institution” [
]. Therefore, universities and colleges have a legal obligation to accommodate disabled students by making reasonable adjustments, which should be duly considered within the context of Infection Prevention and Control, whilst simultaneously safeguarding the PwCF student's wellbeing and safety.
PwCF students are equally vulnerable to acquiring infections which are circulating within the general (non-CF) student population, e.g. COVID-19, influenza, common cold, mumps, food-poisoning, meningitis, etc. As such, all students should have an awareness of infections currently circulating within the immediate student community. There are several general IPC interventions which should be recommended to both PwCF and non-PwCF alike, including (i) ensuring up-to-date vaccination in accordance with the local public health vaccination schedule (ii) promotion of hand hygiene through adequate handwashing, drying and alcohol gel facilities throughout the campus, (iii) wearing of facing coverings/masks, social distancing, isolation, when advocated by local public health bodies and (iv) cough and respiratory etiquette.
The guidance offered below highlights potential infection risks to the PwCF student attending universities and colleges, which should be considered in conjunction with the general IPC policies in place for all students at such institutions. The IPC mitigations below are not exhaustive, however are suggestions which could be considered when preparing bespoke risk assessments and mitigations for each individual PwCF enrolled student, reflecting their individual circumstances and overall course requirements.
This document considers the potential sources (Fig. 1) and transmission of CF pathogens to the PwCF student, in terms of cross infection (Fig. 1, Fig. 2, Fig. 3) and environmental transmission routes (Fig. 1, Fig. 3).
Cross infection & environmental acquisition
Microbial pathogens, including those clinically associated with CF and other general pathogens can be transmitted via several routes, as detailed in Fig. 1, Fig. 3.
There is no reliable way to completely prevent cross infection in cystic fibrosis (Australian CF guidelines), therefore, several organisations including the US Cystic Fibrosis Foundation (CFF) [
] only permit one person with CF to be present at an indoor event organised by these organisations. Furthermore, Cystic Fibrosis Australia does not support or promote indoor events where it is known that more than one person with CF is invited. At present, there are no recommendations for cross infection for PwCF attending the same classes at university/college, however, CFF recommends that people with CF attending the same day care and/or school should not be in the same room at the same time, unless they live in the same household (CFF) [
PwCFs are advised to practise social distancing from other people with cystic fibrosis, however it is uncertain what constitutes a “safe” distance in order to prevent cross infection [
]. Currently, the CFF IPC Guidelines recommend separation with a distance of at least two metres in all settings, in order to reduce droplet transmission [
]. This guideline is irrespective of the PwCF's sputum microbiology. More recently, following evidence from Wood and colleagues, Cystic Fibrosis Australia have recommended maintaining at least two metres distance, and preferably four metres apart [
]. This advice is based on the demonstration that P. aeruginosa, other Gram-negative bacteria, and S. aureus are aerosolised during coughing and can travel up to four metres, as well as remaining viable within droplet nuclei for up to 45 min [
During the winter months, when respiratory viral infections are most prevalent, PwCF students may have concerns regarding the potential transmission and acquisition of such viral illness, from other students including non-PwCF students. Guidance from Cystic Fibrosis Australia in relation to such similar concerns within the workplace advises to “maintain at least 2 m, preferably 4 m, distance from co-workers with colds and flu-like symptoms” [
]. Consideration could also be given to PwCF through the provision of reasonable adjustments in such situations, including for example, the availability of e-learning teaching materials and online assessment.
(a) University/college estate communal facilities
Effective IPC in relation to cross infection, has traditionally relied on PwCF avoiding physical contact with other PwCF [
]. To support PwCF in this manner, it is advised that University/College health and wellbeing teams initially contact each PwCF known to them, to ascertain if they would be willing to share contact details and form a virtual PwCF support group, consisting of their student PwCF peers. Such a group would be self-managed by PwCF and would offer peer support whist at university in addition to minimising cross infection. Each academic year or when necessary, newly enrolled PwCF students will be made aware of the group and encouraged to interact, if they so wish, in the interests of PwCF IPC wellbeing. A voluntary code of practice between the PwCF is optimal when all PwCF engage with each other so that together they can come to an agreement, relating to avoidance of physical contact in shared spaces within the university estate, which may pose an infection risk (Fig. 3).
PwCF could interact virtually by means of various digital platforms such as MS TEAMS, Facetime, WhatsApp, to avoid close contact by mutual agreement and personal arrangements. Emerging digital technology may also be able to assist minimising contact while on the university/college estate, if the PwCF so wishes, including several locator apps on smartphones, although these have not been trialled yet for these purposes. Real-time locating systems (RTLS) are local tracking systems that identify the physical locations of personnel and equipment in real time and are beginning to find application within healthcare systems [
]. Overman and colleagues have suggested that RTLS is a useful and effective adjunct methodology in process and quality improvement, work-flow analysis, and patient safety within the healthcare setting [
]. Such RTLS could potentially be used to aid in the management of PwCF movement in communal settings around educational institutions, which may in turn help minimise potential cross infection amongst PwCF. However, irrespective of any digital locator applications, there remains a concern surrounding privacy and as such should only be adopted with full consent amongst participating individuals.
There is a high burden of treatment associated with the management of CF, including maintaining optimal lung function through good airway clearance and antibiotic therapies, nutritional therapy and managing complications. Fig. 4 details the spectrum of medications employed by PwCF. PwCF have commented on this high treatment burden and have indicated that this should be a topic that requires further study, to help minimise it [
]. This high treatment burden has led to challenges in adherence, especially within the PwCF age group, who would be attending universities and colleges [
]. Furthermore, for many first year students, this may be the first time that they have sole responsibility for the management of their medications, as they have recently transitioned from paediatric to adult care and may have recently moved away from home to attend educational institutions. One study showed that young adults who had moved out of home reported lower adherence than those living at home [
]. It is important to support students with CF whilst on campus, in order to maximise their adherence to medications, particularly if they should require these during timetabled studies. Cystic Fibrosis Australia has recommended that a private space is available in case the PwCF needs to take nebulised medications [
]. Such a reserved space may also be utilised for taking other medications (including insulin, pancreatic enzymes, dry powder inhalers) whilst on campus. However, with this, care needs to be taken to avoid PwCF sharing such reserved areas, either during medication treatments or subsequent to treatments, due to cross infection risks from other PwCF and the environment.
Fig. 4Common medications prescribed in cystic fibrosis therapy. Abbreviations: GI, gastrointestinal; i. v., intravenous.
To date, there has not been any evidence-based studies relating to the effectiveness of IPC measures in the case of multiple individuals with CF simultaneously attending the same lecture theatre venue or smaller study rooms. Guidance has been provided in relation PwCF attending classes within the same school/playgroup, however, the physical size of the classroom and the number of individuals in attendance would be much smaller in such cases compared to large lecture theatres. Within the healthcare setting, during attendance at out-patient clinics, PwCF are advised to maintain a distance of at least 2 m from other PwCF, as well as wear a mask [
]. Once again, such guidance cannot be directly translated and applied to the university setting, due to the fact that healthcare estates operate under different physical parameters to educational institutions, including forced ventilation/air movement by means of regulated air changes per hour and air filtration [
Centers for Disease Control and Prevention Environmental infection control guidelines. Appendix B. Air. Guidelines for environmental infection control in health-care facilities.
], as well as mandatory vacating of consulting rooms for minimum time periods between patients. Wang and colleagues have calculated the residence time of aerosols of varying size in still air as estimated from Stokes’ law for spherical particles and concluded the time required for an aerosol of 100, 5, or1 μm to fall to the ground (or surfaces) from a height of 1.5 m is 5 s, 33 min, or 12.2 h, respectively (See Supplementary Figure 2) [
]. Hence these data show the potential risk of contaminated air from infected individuals in rooms with no ventilation and this should be considered when selecting rooms to hold teaching activities in the case of classes with multiple PwCF as well as subsequent classes utilising such rooms following occupation by an individual with CF. Other factors to consider for such airspace is temperature and relative humidity, as these have an important effect on the survival of such pathogens [
As such, the university should identify potential overlaps in all timetabled formal teaching and training, where two or more PwCF would be required to be in attendance. Where possible, all such risks should be avoided by timetabling PwCF into different cohorts and time slots. PwCF should not be placed in pairs for group activities and practicals, small study groups, small tutorial groups or small assignment groups, with other PwCF in face-to-face teaching. PwCF can interact with such groups virtually or alternatively be placed in another group. Furthermore, the estate occupied by such groups needs to be well ventilated.
The infection risk associated with multiple PwCF attending a lecture theatre is currently unknown and difficult to quantify, due to the facts that lecture theatres are of different sizes, possess various airflows and the varied respiratory flora of the individual PwCF, hence it is difficult to robustly take universal IPC interventions when two or more individuals must attend. As such arrangements should be provided where PwCF do not wish to physically attend with other PwCF such as alternating physical attendance, provision of live streaming, recorded lecture availability and handouts, with support provided by the lecturer for those individuals who cannot physically attend the live session.
Laboratory practicals, laboratory work placements and laboratory research
The microbiology laboratory
A significant threat to the health and wellbeing of the PwCF is when working with microbiological materials containing clinically relevant CF organisms. Such a scenario is realised during university/college laboratory practical classes, laboratory work placements and in research laboratories, where materials containing such biohazards are handled by the student. With regard to CF bacterial and fungal pathogens (P. aeruginosa, Pandoraea spp., M. abscessus, B. cenocepacia, A. fumigatus) licenced vaccines do not exist to help protect the PwCF from accidental laboratory exposure and acquisition, therefore immunisation/vaccination strategies cannot be relied upon to protect the PwCF student from such exposure. PwCFs should ensure that their vaccination schedule is complete and up-to-date before coming to university/college.
There are two primary hazards in the microbiology laboratory, namely (i) the transfer of microbiological pathogens from cultures to the PwCF student and (ii) the transfer of microbiological pathogens from clinical (human & veterinary), biological and environmental samples to the PwCF student. Laboratory manipulation of these materials accounts for the majority of laboratory-acquired infection risk through the routes of inhalation, inoculation, ingestion and contamination of skin and mucus membranes [
]. Supplementary Table 2 describes these routes of exposure to infectious agents in greater depth. These hazards apply to both PwCF and non-PwCF individuals and as such, biosafety guidelines for the handling of microorganisms have been published. In the UK, the Health and Safety Executive have published general guidelines on the “Management and operation of microbiological containment laboratories”, in order to provide all types of laboratories including research and teaching laboratories with guidance under the Health and Safety at Work Act (1974) [
]. Similarly in the US, the Centers for Disease Control, and Prevention (CDC) have published the document entitled “Biosafety in Microbiological and Biomedical Laboratories” (6th Edition) [
ASM task committee on the revision of the 2012 laboratory biosafety guidelines. Guidelines for biosafety in teaching laboratories version 2.0: a revised and updated manual for 2019.
The above guidelines provide general laboratory biosafety best practice guidance and these should be consulted as seminal resources for educational institutions, when performing a risk assessment in conjunction with the institution's occupational health team and local/national regulatory authorities.
In addition to these aforementioned guidelines, further consideration is required for the PwCF (Table 1). The PwCF should be made aware that the risk to their health from participation in microbiology practical sessions could be extremely hazardous. Many organisms which are routinely used in microbiology practical sessions are classified as opportunistic pathogens to immunocompetent individuals, however in the case of PwCF, these organisms, particularly those which are classified as antibiotic-resistant, potentially pose increased risk to the PwCF in terms of morbidity or mortality. Whilst we are unaware of any reports describing laboratory-acquisition of microorganisms to PwCF during laboratory practical sessions, there have been numerous reports of laboratory acquisition of microorganisms to non PwCF, including Burkholderia pseudomallei, Burkholderia mallei [
Table 1Infection prevention and control (IPC) considerations in relation to laboratory-based activities conducted by person/people with cystic fibrosis (PwCF).
1. Students
1.1. Routine hand washing 1.2. Good laboratory practice (e.g. no eating, no drinking, storage of personal items) 1.3. PwCF should not work in pairs or in small groups with another PwCF 1.4. PwCF should wear their own laboratory coat/gown and should never share a laboratory coat/gown from another student. All laboratory coats/gowns should be laundered before use
2. Activities
2.1. PwCF are strongly advised not to undertake laboratory activities involving microbiology (viruses, bacteria, fungi, parasites), either formally in Microbiology- designated practicals or in any other practical sessions which may not be classified as a ”Microbiology practical”, but contains an element of microbiology 2.2. PwCF are strongly advised not to undertake laboratory activities involving biological specimens originating from PwCF (e.g. sputum, primary cell lines, nasal swabs, gut microbiome, cough swabs, etc) 2.3. PwCF are strongly advised not to undertake laboratory activities involving environmental materials which are likely to harbour CF-related pathogenic microorganisms harmful to the health of PwCF (e.g. waters, food spoilage specimens, soils, manure, compost, etc) 2.4. PwCF are strongly advised to avoid laboratory activities involving aerosol generating techniques when working with materials likely to harbour CF-related organisms
3. Laboratory workspace
3.1. PwCF are strongly advised not to work in close proximity to other students participating in laboratory work involving those detailed in 2.1.-2.4. above
3.2. PwCF are strongly advised not to share laboratory equipment (e.g. pipettes) with other individuals involved in activities as detailed 2.1.-2.4. above
3.3. It should be assured that the laboratory has adequate wash hand basins and hand drying facilities for hand hygiene
4.1. Where a PwCF undertakes any laboratory practical work, the university/college are advised to prepare the laboratory (irrespective of the prior use of the laboratory). Such preparation should include cleaning and disinfection of all laboratory work surfaces, communal equipment and the laboratory environment. 4.2. The university/college should seek guidance from their local/national authority on the procedures to clean and disinfect the laboratories and how to deal with spillages of biological agents. In the UK, these are detailed in “Safe Working and the Prevention of Infection in Clinical Laboratories and Similar Facilities” https://www.hse.gov.uk/pubns/clinical-laboratories.pdf Caution: The regimes used are dependent on the organisms which are being handled in the laboratory. However, it is important to note that organisms which are described as “non-pathogenic” to individuals with intact immune systems may be pathogenic to individuals with cystic fibrosis and indeed other individuals with impaired immune systems 4.3. All laboratory waste materials from previous practical classes, will be disposed of prior to the PwCF entering the laboratory
5. University considerations
5.1. Prior to commencement, all practicals, projects or research/investigative projects to be undertaken by the PwCF require a full IPC risk assessment to be performed to ensure suitability and safety. 5.2. The university may wish to provide an appropriate alternative “dry” form of assessment, to replace the wet microbiology-related practicals, which will assess the learning outcomes and satisfy professional or regulatory requirements of accredited courses.
Consideration should also be given to pathological specimens including blood, sputum, urine, and faeces, which may harbour infectious agents, are destined for non-microbiology analyses e.g. biochemical, pathological, haematological investigation. As it has been widely documented that laboratory coats are frequently contaminated with microbiological organisms [
], it is important that students do not share these and ensure that laboratory coats are laundered frequently.
The IT laboratory
The IT laboratory may be defined as a bespoke computer suite dedicated to subject specific classes, workshops or generalised IT facilities in university maintained estate, such as computer suites, programming suites and animation studios. Additionally, the IT laboratory may accommodate generalised study facilities including those housed in educational institutional libraries, cafes and accommodations.
It has been noted that computer keyboards and mice are commonly contaminated within university settings. In a recent study, Ababneh and colleagues found that 18/239 (7.5%) keyboards and mice at the Jordan University of Science and Technology were positive for S. aureus, with two positive for MRSA [
]. With regard to P. aeruginosa, keyboards have also been shown to harbour this pathogen. At the main multi-user internet centre at the Al-Mustansiriya University, Baghdad, Iraq, P. aeruginosa was isolated from 8/25 (32%) keyboards and 2/25 (8%) mice [
]. Such IT hardware may therefore be considered a potential source of these organisms to PwCF individuals and therefore controls are required to minimise the potential of contact transmission.
PwCF ideally should use their own personal computer/laptop/iPad and other IT hardware and be able to download software onto their own personal computer to avoid the use of communal equipment, potentially used by other PwCF. Where and when this is not possible due to licencing agreements, required processing capacity, storage, etc, then an agreement should be made between the PwCFs, as to which IT Suite computers they will use routinely. To further reduce the potential transmission of microorganisms from keyboard or mouse to PwCF, PwCF may bring their own wireless mouse and keyboard, or alternatively their own keyboard covers may be used.
PwCF are advised to maintain good hand hygiene by washing and drying their hands, as well as using alcohol-based gel, before and after use of communal IT devices/hardware.
The music room
PwCF should avoid sharing musical instruments, especially those instruments from the woodwind (flute, clarinet, oboe, cor anglais, bassoon, saxophone) and brass section (trumpet, cornet, horn, trombone, tuba), which are required to be physically blown, with the potential for contamination with upper and lower respiratory tract pathogens (including tuberculosis), as well as pathogens from the gastrointestinal tract (Helicobacter pylori, Salmonella enterica). PwCF students should not share a musical instrument with another PwCF. It is advised that PwCF music students purchase their own instrument and always use this, thus avoiding the need to share with any other CF or non-CF student [
Always blow your own trumpet! Potential cross-infection hazards through salivary and respiratory secretions in the sharing of brass and woodwind musical instruments during music therapy sessions.
]. PwCF students, especially woodwind and brass players, should disinfect their musical instrument on a regular basis to avoid the build-up of biofilm on the interior walls of the instrument. Furthermore, care should be exercised when using small music practice rooms, to ensure that there is adequate ventilation and sufficient time to elapse between music students using the same shared rooms, especially if any breath-activated woodwind or brass instruments have been used. Recent studies have described steam disinfection protocols to aid in the disinfection of mouthpieces of brass instruments [
]. Music students playing other contact musical instruments, including keyboard instruments such as the piano, stringed instruments (violin, viola, cello, double bass) and percussion instruments (timpani, drums, triangle, cymbals, xylophone) should practice good hand hygiene.
The gym
PwCF students studying sport science, physiotherapy, occupational therapy and related subjects requiring the use of gym facilities and equipment need to be aware of potential infection risks from the use of shared equipment, particularly methicillin-resistant S. aureus (MRSA). The CFF recommends that PwCF should avoid direct contact with people with skin and soft-tissue infections caused by MRSA unless wounds are covered, hand hygiene is performed frequently, personal items (e.g., towels) are not shared, sports equipment is cleaned between use, and cleaning protocols for environmental surfaces are established to reduce the risk of MRSA transmission (Recommendation 57) [
All the aforementioned provisions within the educational establishment also apply during field trips, study visits and work placements. However, additional infection related issues may present as a result of the complexity of the activity being undertaken. The range and variety of such activities does not permit a “one-size fits all approach” and as such, students are advised to discuss a formal IPC risk assessment of such activities with their CF healthcare team and work placement/field trip officer, before any such work is undertaken.
In relation to periods of study or study-related activities outside of the home country, consideration of adequate provision of travel and health related insurance is crucial and should be considered. CF travel and health insurance is complicated and expensive, therefore the educational establishment needs, along with the PwCF student, to collectively ensure that adequate coverage is in place at the time of booking travel arrangements and throughout the duration of the visit. Other general travel related considerations need addressed relating to medications, medical device requirements, fitness to fly, vaccinations, activities etc [
]. We have prepared an educational video for PwCF to help them plan travel, which may be viewed at the following link https://youtu.be/-HZ0OdlQyws.
For PwCF students wishing to take study visits/placements within the healthcare setting, special considerations are required and it is advised that there is discussion between the student PwCF and the host occupational health team and their own CF-healthcare team; see Position Statement on “Work environment risks for health care workers with cystic fibrosis” [
]. Furthermore, these guidelines encourage PwCF who work in a healthcare profession to disclose their diagnosis to their occupational health service to determine the safest work assignment [
]. Additionally, it is important that any risk assessment considers both the potential for transmission of clinically significant organisms from infected service users to the PwCF placement student, but also the risk of the PwCF placement student transferring microorganisms from their chest infections to the potentially vulnerable service user [
There are a number of aspects relating to staying in university/college maintained accommodation, primarily relating to cross infection and acquisition of environmental pathogens from the residential setting (See Table 2). Additionally, there may be other accommodation requirements, related to the impact of the student's disease but which are not related to infection prevention (e.g. the requirement for a car-park space, the requirement for a ground floor room), which need to be addressed on a case-by-case basis.
Table 2Infection prevention and control considerations in relation to persons/people with cystic fibrosis (PwCF) availing of university-controlled accommodation.
1. Minimising cross infection
1.1. PwCF should not share accommodation with any other PwCF, bedrooms, kitchens, bathrooms, toilets, living areas, recreational areas, laundry facilities or any other area within residential accommodation. 1.2. When staying in university-controlled accommodation (e.g. Halls of Residence), only one PwCF should be housed within a non-smoking/non-vaping block/building, which is self-contained (i.e. there is no requirement to access communal facilities outside the block/building).
2. Room facilities
2.1. PwCF ideally require ensuite facilities thus avoiding communal bathrooms/shower rooms and toilet facilities. 2.2. Optimally from an infection control viewpoint, PwCF may wish to avail of self-contained studio accommodation, where available. 2.3. PwCF should have access to a potable water supply in their room. 2.4. If a potable water supply is not available in their individual room, this should be clearly labelled to ensure that non-potable water is not used for brushing teeth or for nebuliser hygiene and a source of potable water is available in the kitchen cold water tap. 2.5. PwCF rooms should have adequate ventilation, either through mechanical ventilation, especially wet areas (bathrooms, shower rooms & toilets) or through the ability to open windows, to allow venting of nebulised antibiotics and nebulised medication and aid in the removal of airborne pathogens. 2.6. PwCF rooms should have adequate plug sockets to support normal domestic living in addition to supporting power requirements for CF equipment, including nebulisers, compressors, steam disinfector [
], kettle, refrigerator. An adequate power supply is required to allow simultaneous use of such equipment. 2.7. PwCF rooms should be equipped with a dedicated refrigerator to allow safe/controlled storage of CF medications, including insulin, nebulised antibiotics, DNAse, etc.
3. Room maintenance
3.1. Accommodation should be maintained in good condition, with an adequate supply of hot and cold potable running water. 3.2. Where possible and in line with local regulations, hot water thermostats should be set at > 55 °C as lower temperatures have been reported to facilitate the presence of non-tuberculous mycobacteria (NTM) in plumbing systems. Certain local regulations may prevent hot water thermostats to be set at high temperatures, which may allow the survival of the NTMs. 3.3. PwCF should not be housed in accommodation with signs of damp and mould or in buildings undergoing structural renovations, or where there is dust generated from building work/repairs. 3.4. Water taps and showers of PwCF rooms and kitchens should be maintained appropriately to minimise risk from waterborne Legionella organisms, particularly following periods of resident absence. 3.5. Prior to the PwCF taking up residence, with respect to their individual room, all wet areas, including sinks, taps, shower, showerhead and toilet are washed and disinfected by university housekeeping staff. This action should be repeated following prolonged periods of room vacancy. 3.6. Where possible, during termtime, routine cleaning and disinfection as detailed in 3.4. should be provided by university housekeeping at a time during the day when the room is unoccupied by the PwCF. 3.7. Communal vacuum cleaners and vacuum cleaners used in the accommodation of PwCF should be equipped with HEPA filtration units. 3.8. The kitchen area, appliances and refrigerator are cleaned and disinfected regularly and rubbish is disposed of, to ensure that the potential transmission of bacteria and fungi from these sources is minimised.
The future of IPC guidelines in the era of CFTR modulator therapies
With increasing numbers of PwCF on CFTR modulator therapies, does this alter IPC advice, including that for PwCF attending universities and colleges? For those PwCF whom their CFTR mutations do not align with clinical benefit from any of the modulators, then established IPC guidance remains in place. Equally, this should also be the case for those PwCF who are taking modulators, but where there has been little or marginal clinical improvement. Equally, IPC recommendations should remain unaltered and remain in place for those PwCF who are taking modulators and where these have had major positive impact of CFTR expression and function accompanied by marked clinical improvement and quality of life. However, the impact on airway infection is conflicting and further research is required to ascertain the short and long term effects of modulator therapies on microbial ecology, as well as the initiation and duration of therapy [
]. The reduction in sputum production and cough frequency may translate into a need to reconsider IPC guidelines at a future date. However, until there is robust evidence, existing IPC guidelines should hold firm and avoid becoming complacent in order to prevent the transmission of CF-related pathogens to this PwCF population attending educational institutions.
Conclusions
As more PwCF are considering further and higher education, it is important that this environment is safe thereby permitting the PwCF student to enjoy their educational experience and journey through higher education, culminating in achievement of their educational goals, employment and independent living. Evidence-based risk assessment with appropriate risk management strategies form the pillars of a successful IPC policy. The guidance presented in this review is intended to equip educational establishments in creating their own bespoke and robust IPC policies relating to PwCF students. In order to achieve maximum benefit in terms of safeguarding PwCF students attending such institutions, it is encouraged that the PwCF student communicates with both their educational institution and their healthcare team. It is intended that this review addresses the paucity of IPC guidance for PwCF students, their educational institutions, as well as their CF healthcare teams and adds value in creating a safe environment conducive to educational endeavour.
Availability of data and material
None available.
Authorship statement
All authors were involved in the draft and revision of this paper.
Declaration of competing interest
None.
Funding
This project was a product of the Cystic Fibrosis Study Buddies Programme designed to enable improved health literacy and essential skills for life and employability in young CF adults and supported by a Charitable Grant from Vertex Pharmaceuticals Inc., USA (CG-2017-106614). Vertex Pharmaceuticals did not play any role in project conceptualisation, design, execution, analysis, nor any editorial role in manuscript writing or approval.
Provenance and peer review
Not commissioned; externally peer reviewed.
Ethical considerations
Ethical approval is not required as this is an evidence-based guideline. Formal ethical approval was not required, as this was not considered Research, as defined by the UK Policy Framework for Health and Social Care Research.
Acknowledgements
The authors wish to thank Student Health and Wellbeing Staff at Queen's University, Belfast and Ulster University, Coleraine, Northern Ireland, for their insight into student health and well-being. The concerns raised by local PwCF students have helped to shape this guidance document and we thank the PwCF for this input.
Appendix A. Supplementary data
The following are the Supplementary data to this article:
2030: Incheon Declaration and Framework for Action for the implementation of Sustainable Development Goal 4: ensure inclusive and equitable quality education and promote lifelong learning opportunities for all.
SDG 4 - policies for flexible learning pathways in higher education: taking stock of good practices internationally.
IIEP-UNESCO.2015; (Working Papers. SDG 4 - Policies for flexible learning pathways in higher education: taking stock of good practices internationally. Year of publication) (Available from:) ([Accessed 18 October 2022])
ASM task committee on the revision of the 2012 laboratory biosafety guidelines. Guidelines for biosafety in teaching laboratories version 2.0: a revised and updated manual for 2019.
Always blow your own trumpet! Potential cross-infection hazards through salivary and respiratory secretions in the sharing of brass and woodwind musical instruments during music therapy sessions.
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