**4. Cleaning and disinfection protocols for emergency medical vehicles**

It is self-evident that surfaces or items that have come into contact with a patient's blood, body fluids, fecal matter or exposed skin should be considered as potentially contaminated. Since pathogenic microbes can survive outside the human body for extended periods the handling of contaminated objects is a means by which infection can spread [22]. A recurrent route of infection transmission is when a paramedic's gloved or ungloved hands touch a contaminated surface or medical equipment and/ or there is patient contact with contaminated surfaces or items [23]. For this reason, it is imperative that items of patient care equipment (such as blood pressure cuffs, monitors, stethoscopes and stretchers) that make routine contact with skin and/or mucous membranes undergo a two-step cleaning and disinfection process following every response [24]. Defined as the simple removal of foreign and organic materials from a surface or object, cleaning using water, detergents and a scrubbing action physically removes but does not kill or prevent the growth of microbes. Conversely, disinfection kills or disables microbes present on contaminated surfaces, an operation that is customarily fulfilled with regulated chemical products [25].

The notable findings of one study showed that the number of sites contaminated inside an ambulance increased from 57% before cleaning and disinfection to 86% afterwards [3]. Hence, not only were many areas till contaminated with bacteria others that were previously uncontaminated became freshly contaminated as a result of poor cleaning technique acting as an inadvertent means of spread. The deficiency in performance of regular manual infection control protocols has been associated with operator error, principally concerning selection, formulation, distribution and contact time of the disinfectant [22, 23, 25]. Perspectives on improving effectiveness include staff training programs, continuing education, real-time feedback on the thoroughness of cleaning and disinfection procedures, routine microbiological inspection of surface hygiene, and the use of fluorescent markers or assays to ascertain the robustness of the process [25]. Although these actions can, separately and collectively, improve the efficacy of standard measures to decontaminate in the shortterm, their sustainability is yet to be explored. The application of non-manual vehicle disinfection lowers the possibility of human errors linked to traditional cleaning methods and offers the prospect of more effective elimination of pathogens, thereby decreasing infection transmission [26]. However, at present definitive evidence is lacking to demonstrate the clinical effectiveness of non-touch or automated disinfection procedures, including those utilize steam cleaning, hydrogen peroxide or ultraviolet light irradiation, to eradicate or suppress infection rates in ambulances [27, 28].
