Mannequin Cleaning - Overview

Update 1983: Centers for Disease Control, 1978 Hepatitis Surveillance report No.42, Pages 34-36

Members of the Multidisciplinary Ad Hoc Committee for Evaluation of Sanitary Practices in Cardiopulmonary Resuscitation Training representing the following organizations:

American Heart Association: Subcommittee on Emergency Cardiac Care
American Red Cross: First Aid and CPR Programs
Centers for Disease Control: Center for Infectious Diseases
Centers for Disease Control: Laboratory Program Office

In the past years, we have received numerous inquiries concerning the possible role of cardiopulmonary resuscitation (CPR) training mannequins in transmitting viral hepatitis type B. Recently, inquiries have been received about the potential for transmission of not only hepatitis B but Acquired Immunodeficiency Syndrome (AIDS), herpes viruses and various upper and lower respiratory infections (influenza, infectious mononucleosis, tuberculosis, etc.). The use of CPR mannequins has increased rapidly because of expanded training programs sponsored by medical emergency organizations. To date, it is estimated that over 40 million people have had direct contact with mannequins during training courses. In the United States, a number of companies distribute multiple model lines of mannequins for training programs in hospitals, police and fire department, service organizations, lay groups, and schools as part of health, first aid, and physical education courses. Since practicing with a mannequin is an integral part of CPR training, the care and maintenance of the mannequins is of utmost importance. Instructors and training agencies rely heavily on manufacturer’s recommendations for mannequin use and maintenance, and these recommendations should be examined carefully before purchasing mannequins.

To our knowledge, the use of CPR training mannequins has never been documented as being responsible for an outbreak or even an isolated case of bacterial, fungal, or viral disease. It is our opinion, however, that mannequin surfaces may present a risk of disease transmission under certain circumstances and that these surfaces should be cleaned and disinfected consistently to minimize the risk. Although the major portion of the following discussion was written in 1978 pertaining only to sanitary practices that should be followed to prevent transmission of hepatitis type B, the current revision by the Ad Hoc Committee for Evaluation of Sanitary Practices in Cardiopulmonary Resuscitation Training is applicable to lessening the risks of transmitting a wide variety of infectious diseases.

There are several important control considerations in CPR training. First, the act of mouth-to-mouth or mouth-to-nose artificial respiration obviously requires close physical contacting which a potential rescuer must ignore his or her concerns for personal protection or aesthetic apprehensions to save the life of a victim. Accordingly, in training sessions, students are urged to overcome such hesitations, and they may practice on mannequins contaminated by the hands and oral fluids of previous students. This situation becomes especially obvious during the practice of two rescuers in which the mannequin cannot be adequately cleaned between uses by the two students. Also, the practice of removing upper airway obstruction involves sweeping the back of the mannequin throat with a finger, and in this situation, contamination from previous students may be smeared on the mannequin face. In practice, there is usually no pause at this point to decontaminate the face before beginning mouth-to-mouth breathing. Additionally, the valve mechanisms and lungs in mannequin airway invariably become contaminated during use, and if they are not appropriately dismantled and cleaned after class, they may serve as contamination sources for subsequent classes. There is no recognized evidence, however, that the mannequin valve mechanisms produce aerosols even when air is forcibly expelled during chest compression exercises.

Some manufacturers have provided protective face shields for mannequins to improve hygienic conditions during training sessions, but it is unlikely that students learning the two-rescuer resuscitation method would change such shields after each use. Protective shields and detailed instructions for sanitizing the mannequins between uses by students and classes are available from several manufacturers.

When dealing with potential contamination by microorganisms having either unknown chemical resistance levels (e.g. AIDS) or resistance levels that have not been fully characterized (e.g. hepatitis and herpes viruses), the mannequins pose a difficult disinfection program. Although there are several intermediate-to-high level disinfectants recommended for use in instances of contamination such as hepatitis B, the majority would meet with objection because of either material incompatibility with the mannequin (e.g. staining or other damage of plastic materials by iodine compounds) or undesirable residues, odors, or toxicities may affect students (e.g. formaldehyde, glutaraldehyde) when used during the training sessions. Alcohol’s, quaternary ammonium compounds, and phenolics are not generally recommended since proper contact times for effective action are difficult to achieve (e.g. alcohol’s evaporate rapidly) or the compounds have limited actions against certain viruses and bacterial).

Recommendations 
These guidelines for mannequin decontamination appear with permission from the Heart & Stroke Foundation of Canada. This information appears in the "HSFS BLS Instructors Handbook - 1996."