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Presently, World Health Organization (WHO) and its affiliates are integral parts of a social institute which is responsible for provision of full health services for the public as a center for training of health staff and other segments of the society. Keeping people healthy, especially those individuals who deal with in hospitals and related centers, has a direct relationship with getting a proper insight into the factors giving rise to nosocomial infections (1). Since those centers are among important centers to deal with patients, so, nosocomial infections would be unavoidable in case of health and safety issues which are not taken into sufficient account. Having their roots in microorganisms which are exist in hospitals, nosocomial infections might infect individuals during their hospitalization (2). Such infections cast shadow on outcomes of the works by the best surgeons and incur economic losses through keeping occupied hospital beds for a long time, challenging one of the most significant objectives of the world health systems’ macro policies, i.e., giving an access to the public for health facilities which are available in different countries. Seven to ten percent of hospitalized patients are affected by nosocomial infections, thereby remaining hospitalized for more than four to five days (3). During the last two decades, affection by such infections has been increased by 36 percent (4). In Iran, nosocomial infections have been reported to affect patients by more than 25 percent (5). Therefore, hospitals’ and hospital-related systems’ bacterial infections are among the issues which are relevant to hospital health. Bacterial infections in ambulances and other facilities might occur in different levels which are in contact with patients and medical staff (6).
In recent years, control of microorganisms at different levels of residential and industrial environments has been turned into a main concern. To deal with it, many surfaces impregnated with antimicrobials are employed in medical environments. In addition, those surfaces which are used in food industries, agriculture, construction and sewage should be able to diminish microbial loads (7). There are studies which have reported a transmission of bacteria from different levels. However, the role which is played by environmental surfaces in transmission of diseases has still remained as a scientific controversy, and few scientific findings are available on transmission of bacteria from environmental surfaces to hands and from hands to mouth (8).
Drops of water which are emitted from mouth and nose during sneezing, coughing and talking are referred to as nuclear droplets after the drops’ cores are dried off. Given its size and weight, a drop’s core could remain suspended in the air for a longtime and cause a transmission of diseases (6). When they are deposited and located on different surfaces including facilities, blankets, etc., the droplets might cause a transmission of spore-like microorganisms. Moreover, the dusts with animals or human origins are important respecting spread of germs which might produce diseases and allergies; so, air conditioning systems are found to be inefficient in removal of particle contaminants (9-10). In the meantime, exceeding than 30 new infectious diseases have been identified in the world during the last decades and millions of people are currently affected by infectious agents. New organisms like cryptosporidium and new strains of Escherichia coli caused a wide range of pandemics with their chief transmission cause being direct and indirect contacts after water- and food-borne transmissions (11-13).
In Iran, Arami et al. conducted their study to determine hepatitis B contamination of surfaces and instruments in dental clinics. After relevant tests carried out in 96 sample locations, a HBV was identified. Researchers proposed a calcium-hypochlorite disinfection to reduce microbial contamination (14). In a study by Movahhedi et al. about the microbial contamination of the air of Imam Khomeini and ShahidZare hospitals of Sari, Iran, it was revealed that microbial contamination is existent at all departments of those hospitals, including the general surgery unit. Among observed microbial indices, staphylococcus, pseudomonas aeruginosa and gram-positive cocci were the most prevalent ones, respectively (15).
Salmanzadeh et al. in their study about 174 patients with nosocomial infections in Ahwaz, Iran,, showed that infections are prevalent in most nosocomial departments such as Intensive Care Units, Orthopedics, Surgery, Gynecology and Obstetrics. Moreover, the highest degrees are related to SSI infections (16). The study by Saeidimehr et al on nosocomial infections in Ahwaz Oil Company hospital demonstrated that the highest degree of nosocomial infections is found in Internal Medicine Units (46.55%) and the least in CCU (1.72%) (17).
In Iran, few studies have focused on determination of the microbial contamination of public surfaces. This is, therefore, a mandatory to conduct studies in this regard given necessity of the identification of potentially-infected surfaces and presentation of proper solutions aimed at maintaining individuals’ health (18).The fact that there are numerous facilities in an ambulance, with some of which such as splints, cervical braces, long backboards, scopes, etc., having direct contacts with patients’ bodies; and the reality is the patients and their caregivers are all transported in the limited space of an ambulance to the nearest hospital add to the necessity of conducting the present research in order to identify and investigate the microbial contaminations at emergency ambulances’ surfaces and impact of disinfectants thereon. Most importantly, this study is preceded by no similar investigation executed as yet.
Aims of the study:
This study was conducted wishing to determine bacterial infection degrees in ambulances servicing in pre-hospital emergency medical services unit of the Qom University of Medical Sciences of Iran.
 

Materials & Methods

This research is a descriptive-analytical study which was carried out in 2015. A number of 132 ambulances from those servicing in the Qom Medical Emergency Response Center of Iran were examined for their bacterial infections on medical utensils and equipment. Required numbers of ambulance samples were calculated to be 12 with confidence margin being 95% and overall prevalence of positive cultures being 80% (19). In each ambulance, 11 sites were sampled and cultured. This number was chosen, using simple random method from the code allocated to each ambulance.
 
After the identification codes were assigned to each ambulance and the number of ambulances which were required for simple sampling method was calculated, eleven samples were specified. Pre-moistened sterile swabs were used to primarily check different places of each ambulance, including front door knobs, keys, steering wheel, stretchers, internal walls, scissors, bag valve masks, oxygenation moisturizers, drawer knobs, laryngoscopes and medical headsets.
Then samples were transferred to the Shahid Beheshti laboratory under standard conditions. They were exposed to Brain Heart Infusion Broth (BHI Broth) media for 24 hours at 37°C in order to permit bacteria, if any, to develop under this reinforcing environment. Then, samples were kept in blood agar and Eosin Methylene Blue (EMB) agar culture medium only to be intermittently studied for their bacterial development. In order to identify the type of the bacteria which had grown in these environments, complementary tests, different environments, solutions and diagnostic discs were applied; then, microbiological tests such as Gram staining, Catalase test, Oxidase test and Coagulase test as well as chemical methods like fermentation of sugars were taken. Laboratorial outcomes, information related to place, order of operation of sampling process and density of the disinfectant were all recorded.
Frequency tables and descriptive statistics such as mean and SD were employed to describe the data. T-Test was operated to analyze the data, using SPSS ver. 16. Level of significance was regarded to be less than 5%.
 
 

Results

This research was conducted on 32 samples of equipments in 12 ambulances servicing in the Qom emergency medical services unit, Iran. Statistical results showed that bacterial contaminations over the ambulance utensils and equipments are categorized into two groups, staphylococcus coagulase and bacillus, the latter of which constituting a higher percentage of infections. In oxygenation moisturizers, for instance, the one hundred percent of infections were caused by bacillus. (Table 1)
From among the examined medical instruments, the highest infection prevalence rate was observed in stretchers (100%) and the lowest in oxygenation moisturizers (8.4%). From the infected equipments, in addition, four instruments (37%) were mobile and eight of them (63%) were immobile.
Statistical results indicated that among the twelve examined ambulance parts, 66.6% of infections were observed in steering wheels, 50% in switches, 58.4% in front door knobs, 33.3% in laryngoscope blades, 100% in stretchers, 75% in rear internal walls, 8.4% in oxygenation moisturizers, 50% in drawer knobs, 33.3% in stethoscopes, 41.6% in bag valve masks and 41.6% in scissors (Table 2).

Table 1( determination of degree and type of ambulance utensils’ infection rates

Utensils and Equipment	Type of Bacteria	Percentage
steering wheels	staphylococcus coagulase	40%
	bacillus	60%
switches	staphylococcus coagulase	42.8%
	bacillus	57.2%
front door knobs	staphylococcus coagulase	37.5%
	bacillus	62.5%
laryngoscope blades	staphylococcus coagulase	40%
	bacillus	60%
stretchers	staphylococcus coagulase	35.7%
	bacillus	64.3%
internal walls	staphylococcus coagulase	45.4%
	bacillus	54.6%
oxygenation moisturizers                        bacillus	bacillus	100%
drawer knobs	staphylococcus coagulase	71.4%
	bacillus	28.6%
stethoscope	staphylococcus coagulase	50%
	bacillus	50%
bag valve masks	staphylococcus coagulase	66.6%
	bacillus	34.4%
scissors	staphylococcus coagulase	60%
	bacillus	40%