双语文章|美国口腔颌面外科医师学会发布新冠疫情期间次氯酸消毒使用指导

冠状病毒在全球范围内的流行已经对医疗保健和经济造成了的大规模破坏。目前尚无有效的抗病毒药物或批准的疫苗，这意味着必须采取有效的消毒预防措施来应对COVID-19。特别是口腔颌面外科医师在为患者提供所需护理时具有高风险，随着世界各地有越来越多口腔颌面外科诊所开办，有必要降低患者和医生之间传播COVID-19的风险。

　　医院外科医生需要一种廉价、易得、无毒、实用性强并且可以对COVID-19病毒（新型冠状病毒）进行有效消杀的消毒剂，次氯酸成为不二选择。因此，美国口腔颌面外科医师学会的专家撰写了一份次氯酸的介绍和相关应用，发表在《J Oral Maxillofac Surg》杂志上，以指导次氯酸的正确使用。现由电解水技术频道工作人员翻译如下：

　　The surgeon needs to have an inexpensive, available, nontoxic, and practical disinfectant that is effective in sanitizing against the COVID-19 (Coronavirus Disease 2019) virus. The purpose of this article was to review the evidence for using hypochlorous acid in the office setting on a daily basis. The method used to assemble recommendations was a review of the literature including evidence for this solution when used in different locations and industries other than the oral maxillofacial clinic facility. The results indicate that this material can be used with a high predictability for disinfecting against the COVID-19 (Coronavirus Disease 2019) virus.

　　摘要

　　医院外科医生需要一种廉价、易得、无毒、实用性强并且可以对COVID-19病毒（新型冠状病毒）进行有效消杀的消毒剂。本文主要综述了在医疗办公环境中使用次氯酸消毒的案例，通过文献综述的方法，收集次氯酸溶液在不同地点和行业（口腔颌面诊所及设施除外）中使用的案例以此得到次氯酸溶液使用意见。结果表明，次氯酸溶液在针对COVID-19病毒的消毒中具有很高的可行性。

　　COVID-19 Virus Structure and Mechanism of Infection

　　Coronavirus Disease 2019 (COVID-19) is a novel virus. It causes severe acute respiratory syndrome. Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) is the agent responsible for a surface-tosurface communicable disease that had infected approximately 4.7 million persons as of May 17, 2020.1 Health care providers need options to limit and control the spread of the virus between themselves and patients.

　　COVID-19病毒的结构和感染机理

　　COVID-19是一种新型的冠状病毒，它会导致严重的急性呼吸道综合症。例如，严重急性呼吸系统综合症冠状病毒2（SARSCoV-2）是一种可接触传播的传染病病原体，截至2020年5月17日，已有大约470万人感染了该病毒1。因此，医护人员需要采取多种措施来限制和控制病毒在他们和病人之间传播。

　　COVID-19 is an enveloped, positive-sense, single stranded RNA virus approximately 60 to 140 nm in diameter. The virus’s Spike glycoprotein S1 firmly binds to the angiotensin converting enzyme 2 (ACE2) receptor, which allows entry into the host cell.2-4 COVID-19 infection creates a cytokine storm, severe pneumonia, multiple-organ failure, and acute cardiac injury.5,6

　　COVID-19是一种有包膜的单股正链RNA病毒，直径在60至140 nm之间。该病毒的刺突糖蛋白S1可以与血管紧张素转换酶2（ACE2）受体紧密结合，从而可以进入宿主细胞2-4。COVID-19感染会引起细胞因子风暴、严重肺炎、多器官衰竭和急性心脏损伤5,6。

　　译者注：细胞因子风暴"(cytokine storm)，即病毒感染机体后机体产生了过多的细胞因子，造成过度反应。

　　Transmission occurs through touch or aerosol spreading of the virus. A common pathway of spreading this virus is through respiratory aerosols from an infected person.7 During speech, humans emit thousands of oral fluid droplets per second that can remain airborne for 8 to 14 minutes.8 COVID-19 is detectable for up to 3 hours in surface aerosols, for up to 4 hours on copper, for up to 24 hours on cardboard, and for up to 2 to 3 days on plastic and stainless steel.9,10 There is a need to disinfect surfaces potentially exposed to COVID-19 to prevent transmission.

　　COVID-19可以通过直接接触或气溶胶进行传播，感染者呼吸道产生的气溶胶是这种病毒的常见传播途径7。研究表明，人类在讲话过程中，每秒会释放成千上万的口腔液滴，这些液滴可以在空气中停留8至14分钟8，为病毒的传播提供了有效的途径。还应注意的是，COVID-19可在气溶胶中存在长达3个小时，在铜板上存在长达4个小时，在纸板上存在长达24个小时，在塑料和不锈钢上存在长达2到3天9,10。因此，需要对可能附着COVID-19的物体表面进行消毒，以防止病毒传播。

　　Use of Disinfectants

　　Currently, the US Environmental Protection Agency has recommended numerous disinfectants against COVID-19 including hypochlorous acid (HOCl).11 This article focuses on HOCl.

　　消毒剂的使用

　　目前，美国环境保护署已经推荐多种针对COVID-19的消毒剂，其中就包括次氯酸（HClO）11。接下来，本文重点讨论的消毒剂是HClO。

　　Recommendations for Office Use

　　Importance of aerosol size to disinfection and application

　　Individuals working in the dental and medical field using surgical and high-speed handpieces are at risk from aerosolization. Aerosols are defined as particles less than 50 mm in diameter. Particles of this size are small enough to stay airborne for an extended period before they settle on environmental surfaces or enter the respiratory tract.41,42 Additionally, a true aerosol or droplet nuclei may be present in the air of the operatory for up to 30 minutes after a procedure.41

　　医疗办公环境使用建议

　　气溶胶大小对消毒和应用的重要性

　　气溶胶一般定义为直径小于50 mm的颗粒。这种微粒尺寸足够小，在沉降到环境表面或进入呼吸道之前，可以在空气中停留较长的时间41,42。牙科和医学领域中工作的人员在使用高速外科手持器械时，手术过程中因高速产生的气溶胶或液滴核在手术后可以在空气中存在长达30分钟，这种有可能携带病菌的气溶胶使得医护人员存在受感染的风险41。

　　Particles are classified based on size: Coarse particles measure 2.5 to 10 mm; fine particles, 0.1 mm to less than 2.5 mm; and ultrafine particles, less than 0.1 mm. The nose typically filters air particles larger than 10 mm. If a particle is smaller than 10 mm, it can enter the respiratory system. If smaller than 2.5 mm, it can enter the alveoli. A particle smaller than 0.1 mm, or an ultrafine particle, such as the COVID-19 virus, can enter the bloodstream or target the lungs.

　　颗粒根据尺寸可以分成三类：尺寸在2.5~10 mm之间为粗颗粒；尺寸在0.1~2.5 mm之间为细颗粒；尺寸小于0.1 mm为超细颗粒。对于人体来说，空气中大于10 mm的颗粒会被鼻子过滤，而小于10 mm的颗粒能进入呼吸系统，尺寸小于2.5 mm的颗粒可以进入肺泡，小于0.1 mm的颗粒或超细颗粒（例如COVID-19病毒）则可以进入血液或肺部。

　　Sotiriou et al42 showed that the concentrations of small particles (<0.5 mm) generated during dental drilling procedures were much higher than the concentrations of larger particles (>1 mm). Ultrasonic and sonic transmission during nonsurgical procedures had the highest incidence of particle transmission, followed by air polishing, air-water syringe, and high-speed handpiece aerosolization.43 One study found that ultrasonic instrumentation can transmit 100,000 microbes/ ft3 with aerosolization of up to 6 ft and, if improper air current is present, microbes can last anywhere

　　from 35 minutes to 17 hours.44

　　Sotiriou等人42的研究表明，在牙齿钻孔过程中产生小颗粒（<0.5 mm）的浓度远高于大颗粒（> 1 mm）的浓度。在非手术过程中，超声波和声波传播引起的颗粒传播量最高，其次是空气抛光、空气-水注射器和高速机头雾化43。一项研究发现，超声仪器可通过长达6英尺的气溶胶传播微生物（100000微生物/英尺），如果存在不适当的气流，微生物可以在任何地方存活35分钟至17小时44。

　　MOUTH RINSE 漱口

　　If HOCl is used as a mouth rinse, one must assume that a portion of the rinse will be swallowed. The systemic and gastrointestinal effects of ingesting HOCl, from the perspective of its use in mouthwash, was evaluated in an animal study.45 Seventeen mice were given free access to HOCl water as drinking water. No abnormal findings were observed in terms of visual inspections of the oral cavity, histopathologic tests, or measurements of surface enamel roughness, showing no systemic effect.

　　如果将HClO用作漱口水，则必须假定一部分漱口水会被吞咽。因此，从漱口水的使用角度出发，通过动物实验评估了摄入HClO对全身和胃肠道的影响45。实验中，17只小鼠可以自由饮用HClO水，实验一段时间后，在口腔的视觉检查、组织病理学检查或表面釉质粗糙度的测量方面均未观察到异常，也未有系统性的影响。

　　OTHER CLINICAL APPLICATIONS 其他临床消毒应用

　　Ophthalmology 眼科

　　HOCl is used in the treatment of blepharitis by reducing the bacterial load on the surface of the periocular skin. Twenty minutes after application of a saline hygiene solution containing HOCl at 100 ppm, a greater than 99% reduction in the staphylococcal load was achieved.46

　　HClO可以通过减少眼周皮肤表面的细菌负荷而用于睑缘炎的治疗。在眼周围使用含100ppm HClO的生理盐水作用20分钟后，葡萄球菌负荷降低了99％以上46。

　　Biofilm 生物膜

　　HOCl may be effective for cleaning biofilmcontaminated implant surfaces. HOCl significantly lowered the lipopolysaccharide concentration of Porphyromonas gingivalis when compared with sodium hypochlorite and chlorhexidine and was well tolerated by the oral tissues.47 HOCl significantly reduced bacteria on toothbrushes; it was effective as a mouthwash and for toothbrush disinfection.48

　　HClO可有效清洁受生物膜污染的植入物表面。与次氯酸钠和洗必泰相比，HClO显著降低了牙龈卟啉单胞菌的脂多糖浓度，并且口腔组织有很好耐受性47。此外，HClO可显著减少牙刷上的细菌，因此HClO可作为漱口水和牙刷的有效消毒剂48。

　　Wound Care 伤口护理

　　In a clinical study on intraperitoneal wound care, patients underwent lavage of the peritoneal cavity with 100ppm HOCl and washing of the wound with 200 ppm.49 No adverse effects were observed. HOCl has been shown to be an effective agent in reducing wound bacterial counts in open wounds.50 In irrigation solution in an ultrasonic system, HOCl lowered the bacterial counts by 4 to 6 logs. By the time of definitive closure, the bacterial counts were back up to 105 for the saline solution– irrigated control wounds but remained at 102 or lower for the HOCl-irrigated wounds. Postoperative closure failure occurred in more than 80% of patients in the saline solution group versus 25% of those in the HOCl group.

　　在一项腹膜内伤口护理的临床研究中，患者用100ppm的HClO冲洗腹腔，并用200 ppm的HClO清洗伤口，在伤口处理过程中患者没有观察到不良反应49。目前，研究已经证明HClO是减少开放伤口中细菌的有效试剂50，例如，在超声波处理系统的冲洗溶液中，HClO可以将细菌数降低4至6个对数单位。在伤口完全闭合时，用盐水冲洗处理的伤口中细菌数恢复到105，而HClO冲洗处理的伤口细菌数则在102及以下。同时，用盐水处理的患者80％以上出现伤口术后闭合失败；而HClO处理组中，只有25％的患者出现伤口术后闭合失败。

　　Hand Sanitizing 手卫生

　　Hand antiseptics are alcohol based or non–alcohol based containing antibiotic compounds.51 Chlorinebased sanitizers, at a concentration of 50 to 100 ppm, are effective against bacteria and viruses.52 HOCl specifically used for hand sanitizers is effective at 100- to 200-ppm strengths.53,54

　　手部消毒剂是含酒精或不含酒精的抗菌化合物51。浓度为50至100 ppm的氯系消毒剂可有效抵抗细菌和病毒52，专门用于洗手液的HClO在100~200 ppm的浓度就可以有效杀菌53,54。

　　Surface Application 物表消毒

　　A study looked at disinfecting outpatient surgical centers using HOCl.55 After cleaning, the rooms in the HOCl cleaning and disinfection study arm had significantly lower bacterial counts than

　　the rooms that underwent standard cleaning and disinfection.

　　一项着眼于使用HClO对门诊手术中心进行消毒的研究表明55，HClO清洗和消毒后，研究室的细菌数明显少于进行标准清洗和消毒的房间。

　　HOCl Applied by Spray or Fogger 喷雾或雾化方法使用HClO

　　A fogger takes a solution and creates a small aerosol mist, ideally less than 20μm in size, to disinfect an area. HOCl fogs are highly effective in the microbial disinfection of surfaces. The fogging process can alter the physical and chemical properties of the disinfectant. It was found that fogging reduced the AFC concentration by approximately 70% and increased the pH by approximately 1.3, making the solution slightly more basic; it is speculated that the loss of chlorine resulted from evaporation of chlorine gas.56,57 Because the changes in the properties of hypochlorous fogs are predictable, pre-fogging adjustment of the concentration and pH of the solution makes it possible to control the concentration levels to the desirable range to inactivate pathogens after fogging. When the appropriate concentrations are used, a study found 3 to 5 log10 reductions in both the infectivity and RNA titers of all tested viruses on both vertical and horizontal surfaces, suggesting that fogging is an effective approach to reduce viruses on surfaces.40,58

　　喷雾器能将溶液制成小的雾状喷雾对某一区域进行消毒，理想情况下，喷雾液滴的大小应小于20μm，HClO喷雾对物体表面的微生物消毒效果非常显著。雾化过程会改变消毒剂的物理和化学性质，结果表明，雾化会使AFC浓度降低约70％，pH值升高约1.3，溶液的碱性略微提高，这种雾化造成的氯损失是由含氯溶液蒸发引起的。由于次氯酸雾的性质变化是可以预测的，因此在雾化前调节溶液的浓度和pH值可以将浓度控制在理想的范围内，雾化后的HClO能有效灭活病原体。一项研究发现，当使用适当浓度的HClO时，所有被测病毒在垂直和水平表面上的传染性和RNA滴度均降低了3至5个对数单位，这表明雾化是物体表面消毒的有效方法40,58。

　　HOCl solutions appear to be virucidal based on concentrations above 50 ppm. HOCl was evaluated against a low-pathogenic avian influenza virus (AIV), H7N1.59 The HOCl solutions contained 50-, 100-, and 200-ppm chlorine at pH 6. Spraying with HOCl decreased the AIV titer to an undetectable level (<2.5 log10TCID50/mL) within 5 seconds, with the exception of the 50-ppm solution harvested after spraying at a distance of 30 cm. When HOCl solutions were sprayed directly onto sheets containing the virus for 10 seconds, the solutions of 100 and 200 ppm inactivated AIV immediately. The 50-ppm solution required at least 3 minutes of contact time. These data suggest that HOCl can be used in spray form to inactivate AIV.59,60 When the aerosol was not sprayed directly onto an inoculated surface, a lower amount of solution had a chance to come into contact with the AIV. It required at least 10 minutes of contact to be effective.61

　　如果浓度高于50 ppm，HClO溶液具有一定的杀病毒作用。利用低致病性禽流感病毒（AIV）H7N1对HClO的杀病毒性进行了评估59，使用三种具有不同AFC浓度的HClO溶液进行测试，有效氯浓度分别为50、100和200 ppm（pH值均为6）。除了50 ppm的HClO溶液外，在30 cm处喷洒HClO溶液后，可在5秒内将AIV滴度降至不可检测的水平（<2.5 log10TCID50/mL）59,60。将HClO溶液直接喷到含有病毒的薄片上10秒钟，100和200 ppm的HClO溶液立即使AIV失活，而50 ppm的HClO溶液至少需要3分钟的接触时间才能使AIV失活。以上结果表明HClO可以通过喷雾的形式使AIV失活。另外，如果没有将喷雾直接喷洒到AIV接种表面上，只有少量的溶液与AIV接触时，则至少需要10分钟的才能使AIV失活61。

　　The ability of a sprayer to make smaller particles may help a solution’s molecules to be suspended in the air for a longer period because of their low settling velocity rate. This may increase the solution’s chance of coming into contact with pathogens and inactivating them. Thus, the fogger used should have an aerosol

　　size less than 20 mm.62

　　喷雾器产生较小颗粒的能力会降低HClO溶液的沉降速度，从而有助于溶液中的HClO分子在空气中悬浮更长的时间，这会增加HClO与病原体接触并使它们灭活的机会。同样需要注意的是，使用喷雾器产生的气溶胶尺寸应小于20μm62。

　　Discussion 讨论

　　The coronavirus pandemic has caused both a massive health care and economic disruption across the world. The current unavailability of an effective antiviral drug or approved vaccine means that the implementation of effective preventive measures is necessary to counteract COVID-19. Oral-maxillofacial surgeons are high-risk providers providing needed care to patients. As more OMS and surgical offices open during reopening in the United States and elsewhere in the world, the need to reduce the risk of transmission of COVID-19 between patients and providers is necessary. It is widely believed that with proper screening and discretion, along with adequate personal protective equipment, there is a low probability of becoming infected. The goal of this article is to provide information regarding disinfection in the clinical office setting using HOCl, a relatively inexpensive, nontoxic, noncorrosive, and well studied compound.

　　冠状病毒在全球范围内的流行已经对医疗保健和经济造成了的大规模破坏。目前尚无有效的抗病毒药物或批准的疫苗，这意味着必须采取有效的预防措施来应对COVID-19。特别是口腔颌面外科医师在为患者提供所需护理时具有高风险，随着世界各地有越来越多口腔颌面外科诊所开办，有必要降低患者和医生之间传播COVID-19的风险。人们普遍认为，经过适当的筛查和谨慎的处理，再加上适当的个人防护设备，就可以使得感染的可能性降低。本文的目的是提供有关在临床中使用HClO（一种相对便宜、无毒、无腐蚀和研究充分的化合物）进行消毒的事实。

　　HOCl has uses in many industries from farming and restaurants, regarding food, to health care applications, including chronic wound care and disinfection. 34,36,43,45,46,63 In addition to the use of HOCl as a liquid-based disinfectant, fogging with hypochlorous vapor has shown virucidal activity against numerous types of viruses and bacteria.40,56,57 This is of potential benefit to disinfect large spaces such as medical and dental offices where aerosols can be airborne for extended periods.42,44,64 In terms of particle size, oral-maxillofacial surgeons may be at a slightly lower risk than their dental counterparts because ultrasonic scaling and high-speed handpieces create smaller particles that remain airborne longer.42 However, aerosols are still created with surgical handpieces. Additionally, the COVID-19 virus can be present on some surfaces for days, and the disinfection of all surfaces of an operatory is important to reduce transmission.9,10

　　HClO已应用于许多行业中，从农业和餐饮业到食品业，再到医疗保健行业（包括慢性伤口护理和消毒）34,36,43,45,46,63。除了使用HClO作为液体消毒剂外，用雾化的HClO溶液也可以对多种类型病毒和细菌的活性进行杀灭40,56,57。这对消毒较大的空间（例如医疗和牙科诊所）具有一定的优势，因为在这些空间中，气溶胶可以长时间在空气中存在。另一方面，就颗粒大小而言，口腔颌面外科医生的患病风险可能比其牙科同行略低，因为超声波洗牙和高速机头会产生更小的颗粒，使得消毒剂可以在空气中存在更长的时间。但是，手术机头仍会产生气溶胶，这将有利于病毒的传播。此外，COVID-19病毒可以在某些表面上存在数天，对医护人员所在工作室进行消毒对于减少病毒传播十分重要9,10。

　　Many properties of HOCl contribute to why it may be the disinfectant of choice in the OMS setting. It can be made on-site inexpensively. A gallon of HOCl can be purchased from manufacturers but it is far more economical for an oral-maxillofacial surgeon to produce the solution on-site in the office.65 A variety of HOCl systems costing less than $275 are available on the market.66 By combining non-iodinated salt, water, and electricity,33 1 L of HOCl can be made in 8 minutes and the process can be repeated many times throughout the day. By comparison, a pack of common disinfecting wipes containing quaternary ammonium compounds costs between $4 and $15 for a pack containing 80 sheets. These wipes may only last a day or two depending the size of the office and area to clean. Shortages of these products can occur, making sourcing them difficult as well.67

　　HClO的许多特性都表明它是口腔颌面外科诊所优良的消毒剂选择。虽然从制造商处也可以购买一定量的HClO溶液，但是对于口腔颌面外科医生而言，在办公室现场生产HClO溶液要经济得多65。市场上可以买到各种价格低于275美元的HClO装置66，仅仅需要非碘盐、水和电33，就可以在8分钟内制成1 L的HClO溶液，并且在一天内可以多次制备HClO溶液。相比之下，一包有80张含季铵化合物的普通消毒湿巾的价则为4至15美元，并且根据牙科工作地点和需清洁区域的大小，这些湿巾只能使用一两天，而且这些产品可能会出现供货不足、难以采购的现象67。

　　In addition to using HOCl in the form of wipes for disinfecting, using HOCl vapors through a fogging machine is an economical way to disinfect a large operating room or suite in which aerosols were produced during surgery. Foggers or misting machines are handheld machines and can be purchased for a reasonable cost.68 The aerosol mist ideally should be less than 20μm in size to maximally disinfect an area. It is important to note that the fogging process can alter the physical and chemical properties of the disinfectant, making it more dilute and basic. As mentioned before, the AFC concentration can be reduced by approximately 70% and the pH can increase by about 1.3.40 To make a vapor as effective as a solution containing 100 ppm of HOCl, the solution would need to be concentrated. The fine mist can be left in the empty surgical room without thought regarding harmful chemical effects; the surfaces are then wiped clean and dry after a few minutes and, for a more dilute solution, after 10 minutes.

　　HClO除了以湿巾形式的进行消毒之外，通过雾化机产生HClO雾气是对大型手术室或手术期间产生气溶胶的房间进行消毒的一种经济方法，雾化机或喷雾机一般是手持式的，并且购买价格比较优惠68。理想情况下，气溶胶雾的尺寸应小于20μm，这样可以最大程度地消毒一个区域。值得注意的是，雾化过程会改变消毒剂的物理和化学性质，使得溶液浓度降低且碱性增强。如前所述，雾化后HClO溶液的AFC浓度可降低约70％，pH值可提高约1.340。要使雾化后的HClO溶液与100 ppm的HClO溶液一样有效，必须将溶液进行浓缩。细雾可以在手术室的空气中长时间停留，并且无有害的化学作用，只需要在几分钟后，将其擦拭干净。对于更稀的HClO溶液，则需在10分钟后，将其擦拭干净。

　　HOCl is one disinfectant that, when combined with adequate personal protective equipment, screening and social-distancing techniques, hand washing, and high-volume evacuation suction, may help reduce the transmission of COVID-19 in the outpatient OMS setting. It comprises many of the desired effects of the ideal disinfectant: It is easy to use, is inexpensive, has a good safety profile, and can be used to disinfect large areas quickly and with a broad range of bactericidal and virucidal effects.

　　当HClO与适当的个人防护设备、筛查和社交疏导技术、洗手和大容量空气处理装置结合使用时，可以减少口腔颌面外科门诊环境中COVID-19的传播机会。HClO具有理想消毒剂的许多特性：易于使用，价格便宜，具有良好的安全性，可用于大面积区域快速消毒，并具有广泛的杀菌作用。因此，HClO是一种十分有效且理想的消毒剂。