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TABLE 1 HUMAN RESERVOIRS AND TRANSMISSION OF INFECTIOUS AGENTS
Reservoir
Transmission vehicle
Infectious agent
Blood, needle stick, other
Hepatitis B and C; HIV/AIDS, S.
Blood
contaminated equipment
aureus, S. epidermidis
S. aureus, E. coli,
Tissue
Drainage from a wound or incision
Proteus spp
Droplets from sneezing or
Influenza viruses,
Respiratory tract
coughing
Strep spp., S. aureus
Hepatitis A, Shigella spp, Salmonella
Gastrointestinal tract
Vomitus, feces, bile, saliva
spp
Urinary tract
Urine
E. coli, enterococci
N. gonorrhoeae,
Reproductive tract and
Urine and semen
T. pallidum, Herpes simplex virus
genitalia
type 2, Hepatitis B
MODES OF TRANSMISSION
Direct contact
is person-toperson
transmission of
pathogens
through
touching,
biting, kissing,
or sexual
intercourse
Indirect
contact
is the spread of
pathogens by
an inanimate
go-between, an
intermediary
between the
portal of exit
from the
reservoir and
the portal of
entry to the
host. Inanimate
objects such as
patient-care
equipment,
cooking or
eating utensils,
handkerchiefs
and tissues,
soiled laundry,
and door knobs
are common
vehicles that
can transmit
infection.
Droplet
transmission
can spread
diseases such as
influenza,
pertussis
(whooping
cough), and
some forms of
bacterial
meningitis.
Droplets are
produced when
the infected
person coughs,
sneezes, or
speaks, and
they travel only
about three feet
before drying
out or falling to
the ground.
Airborne
transmission
can occur when
respiratory
droplets
evaporate,
leaving behind
droplet nuclei
that are so
small they
remain
suspended in
the air. Like
tuberculosis,
chickenpox,
measles,
possibly SARS,
and smallpox.
Vector-borne
can spread
diseases such as
influenza,
pertussis
(whooping
cough), and
some forms of
bacterial
meningitis.
Droplets are
produced when
the infected
person coughs,
sneezes, or
speaks, and
they travel only
about three feet
before drying
out or falling to
the ground.
Standard Precautions are to be used with all patients, regardless of diagnosis.

Handwashing. Wash hands with plain soap or waterless antiseptic agent (alcohol-based
product) after touching blood, body fluids, and contaminated items, whether or not gloves
are worn. Wash hands immediately after gloves are removed, between patient contacts, and
when otherwise indicated. It may be necessary to wash hands between tasks and procedures
on the same patient to prevent cross-contamination of different body sites.

Gloves. Wear clean gloves when touching blood, body fluids, and contaminated items. Put
on clean gloves just before touching mucous membranes and nonintact skin. Change gloves
between tasks and procedures on the same patient after contact with material that may
contain a high concentration of microorganisms. Remove gloves promptly after use, before
touching noncontaminated items and environmental surfaces, and before going to another
patient, and wash hands immediately.

Mask, eye protection, face shield. Wear a mask and eye protection or a face shield to
protect mucous membranes of the eyes, nose, and mouth during activities that are likely to
generate splashes or sprays of blood or body fluids (such as suctioning, irrigation, or
delivery of the newborn).

Gown. Wear a gown to protect skin and to prevent soiling of clothing during activities that
are likely to generate splashes or sprays of blood or body fluids. Select a gown that is
appropriate for the amount of fluid likely to be encountered. Remove the soiled gown as
promptly as possible and wash hands.

Patient-care equipment. Handle used patient-care equipment soiled with blood or body
fluids in a manner that prevents skin and mucous membrane exposures, contamination of
clothing, and transfer of microorganisms to other patients and environments. Clean or
reprocess reusable equipment before using it for the care of another patient. Ensure that
single-use items are discarded properly.

Environmental control. Follow hospital procedures for the routine care, cleaning, and
disinfection of environmental surfaces, beds, bedrails, bedside equipment, and other
frequently touched surfaces.

Linen. Handle, transport, and process used linen soiled with blood or body fluids in a
manner that prevents skin and mucous membrane exposures and contamination of clothing
and that avoids transfer of microorganisms to other patients and environments.

Occupational health and bloodborne pathogens
o Take care to prevent injuries when using or disposing of needles, scalpels, and other
sharp instruments or devices. Never recap used needles using both hands or use any
other technique that involves directing the point of a needle toward any part of the
body. Do not manipulate used needles by hand. Place used disposable syringes and
needles, scalpel blades, and other sharp items in appropriate puncture-resistant
containers that are located as close as practical to the area in which the items were
used.
o Use mouthpieces, resuscitation bags, or other ventilation devices as an alternative to
mouth-to-mouth resuscitation methods in areas where the need for resuscitation is
predictable.

Patient placement. Place a patient who contaminates the environment or who does not
assist in maintaining appropriate hygiene (children, patients with altered mental status) in a
private room. If a private room is not available, consult with infection control professionals
regarding patient placement or other alternatives. If it is necessary for an infected patient to
share a room with a noninfected patient, it is important that roommates are selected
carefully and that patients, personnel, and visitors take precautions to prevent the spread of
infection.
Contact Precautions are designed to minimize transmission of organisms that are easily
spread by contact with hands or objects. Think of these germs as being sticky.





Patient Placement. Place the patient in a private room. When a private room is not
available, place the patient in a room with a patient(s) who has active infection with the
same microorganism but with no other infection ( cohorting ). Consultation with infection
control professionals is advised before cohorting.
Gloves and handwashing. In addition to wearing gloves, as outlined under Standard
Precautions, wear gloves when entering the room. Change gloves after contact with
infective material that may contain high concentrations of microorganisms, such as fecal
material or wound drainage. Do not soil the environment with used gloves. Remove gloves
before leaving the patient's room and wash hands immediately. After glove removal and
handwashing, ensure that hands do not touch potentially contaminated environmental
surfaces or items in the patient's room.
Gown. Wear a gown when entering the room if you anticipate that your clothing will have
substantial contact with the patient, environmental surfaces, or items in the patient's room,
or if the patient is incontinent or has diarrhea, an ileostomy, a colostomy, or wound
drainage not contained by a dressing. Remove the gown before leaving the patient's
environment. After gown removal, ensure that clothing does not contact potentially
contaminated environmental surfaces.
Patient transport. Limit the movement and transport of the patient from the room to
essential purposes only. If the patient is transported out of the room, ensure that precautions
are maintained. Notify the receiving department of precautions prior to transport.
Patient-care equipment. When possible, dedicate the use of noncritical patient-care
equipment (stethoscope, BP cuff, thermometer, etc.) to a single patient or cohort of patients
to avoid sharing among patients. Clean and disinfect any equipment that must be brought
out of the room befor use with others.
Droplet Precautions are designed to prevent transmission of diseases easily spread by largeparticle droplets produced when the patient coughs, sneezes, or talks, or during the
performance of procedures.

Patient placement. Place the patient in a private room. When a private room is not
available, place the patient in a room with a patient(s) who has active infection with the
same microorganism but with no other infection (cohorting). When a private room is not
available and cohorting is not achievable, maintain at least three feet between the infected
patient and other patients and visitors. A negative-pressure room is not necessary, and the
door may remain open.


Mask. Wear a mask (a simple isolation or procedure mask, not an N-95 respirator) when
working within three feet of the patient. (Some hospitals require wearing a mask to enter
the room.)
Patient transport. Limit the movement and transport of the patient from the room to
essential purposes only. If transport or movement is necessary, put an isolation mask on the
patient, if possible. Notify the receiving department of precautions prior to transport.
Airborne Precautions are designed to prevent transmission of diseases spread by the true
airborne route. These organisms are released from the patient in respiratory droplets, which
evaporate shortly after release. Most organisms die when they dry out, but the organisms of
these few diseases—tuberculosis, chickenpox, measles, SARS, and smallpox—can survive
drying out. The droplet nuclei (small-particle residue of evaporated droplets) remain
suspended in the air and can be dispersed widely by air currents within a room or even over
a long distance.
Note: Airborne Precautions are the only type that requires a negative-pressure room with door kept
closed and use of an N-95 respirator.




Patient placement. Place the patient in a designated negative-pressure room. Keep the
room door closed and the patient in the room, as feasible.
Respiratory protection. Wear an N95 respirator when entering the room of a patient with
known or suspected infectious pulmonary tuberculosis. Susceptible persons should not
enter the room of patients known or suspected to have measles or chickenpox if immune
caregivers are available. If susceptible persons must enter the room of a patient with
measles or chickenpox, they should wear an N95 respirator. Persons immune to measles or
chickenpox do not need to wear respiratory protection. (See additional information about
N-95 respirators in the section on personal protective equipment.)
Patient transport. Limit the movement and transport of the patient from the room to
essential purposes only. If transport or movement is necessary, place a surgical mask on the
patient, if possible. Notify the receiving department of precautions prior to transport.
Additional precautions for preventing transmission of tuberculosis. Consult CDC's
Guidelines for Preventing the Transmission of Tuberculosis in Healthcare Facilities for
additional prevention strategies.
HAND HYGIENE
Hand hygiene is still the single most important procedure for preventing the spread of infection!
This is because healthcare facilities bring many reservoirs (the patients and staff) into close contact
with many susceptible hosts (the patients and staff). We cannot eliminate the reservoirs and
susceptible hosts, so we must eliminate the mode of transmission. We must not carry germs
from reservoir to susceptible host!
Hand hygiene includes both using alcohol-based hand hygiene products and washing with soap
and water (Box 7). Alcohol-based hand hygiene products are preferred over soap and water when
hands are not visibly soiled. Alcohol-based products are better in three ways:



They kill the germs better.
They leave skin in better condition.
They are quicker and easier to use, so people use them more.
Use hand hygiene products only on dry hands. Use enough of the product so that hands are dry
again in 15 seconds, and rub hands together until they are completely dry.
If hands are visibly soiled, wash with soap and water, using friction, for at least 10 to 15 seconds.
(Sing "Happy Birthday" twice.) Note that special hand hygiene guidelines are required for surgical
staff. Refer to your hospital policy or to the CDC Hand Hygiene Guideline at the CDC website.
Hand hygiene should be done at all of the following times:











When hands are visibly dirty or are visibly soiled with blood or other body fluids, wash
hands with soap and water.
If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating
hands in all other clinical situations.
Before having direct contact with patients.
Before donning sterile gloves for any invasive procedure.
After contact with a patient's intact skin (taking a pulse or blood pressure, lifting a patient).
After contact with body fluids or excretions, mucous membranes, nonintact skin, and
wound dressings.
If moving from a contaminated body site to a clean body site.
After contact with contaminated items or environments.
After removing gloves.
Before eating and after using a restroom, wash hands with soap and water.
Wash hands with soap and water if exposure to Bacillus anthracis (anthrax) is suspected or
proven. The physical action of washing and rinsing hands under such circumstances is
recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have
poor activity against spores.
Always wet hands before applying soap, to minimize skin irritation. Avoid preventable portals of
entry!
TABLE 2
IMMUNIZING AGENTS RECOMMENDED FOR HCWs
Generic name
Indications
Hepatitis B
recombinant
Healthcare personnel at risk of exposure to blood and body fluids
vaccine
Influenza vaccine Healthcare personnel with contact with high-risk patients or working in
(inactivated whole chronic care facilities; personnel with high-risk medical conditions and/or ≥65
or split virus)
yr
Measles live virus Healthcare personnel born in or after 1957 without documentation of (a)
vaccine
receipt of two doses of live vaccine on or after their 1st birthday, (b)
physician-diagnosed measles, or (c) laboratory evidence of immunity; vaccine
should be considered for all personnel, including those born before 1957, who
have no proof of immunity
Mumps live virus Healthcare personnel believed to be susceptible can be vaccinated; adults born
vaccine
before 1957 can be considered immune
Healthcare personnel, both male and female, who lack documentation of
Rubella live virus receipt of live vaccine on or after their 1st birthday, or of laboratory evidence
vaccine
of immunity; adults born before 1957 can be considered immune, except
women of childbearing age
Varicella zoster live Healthcare personnel without reliable history of varicella or laboratory
virus vaccine
evidence of varicella immunity
TABLE 3 OTHER IMMUNIZING AGENTS FOR SPECIAL CIRCUMSTANCES
Generic name
Indications
Healthcare personnel in communities where (a) MDR-TB is prevalent,
(b) strong likelihood of infection exists, and (c) full implementation of
BCG vaccine (for
TB infection control precautions has been inadequate in controlling the
tuberculosis)
spread of infection (Note: BCG should be used after consultation with
local and/or state health department)
Not routinely indicated for U.S. healthcare personnel; persons who work
Hepatitis A vaccine
with HAV-infected primates or with HAV in a laboratory setting should
be vaccinated
Meningococcal
polysaccharide
Not routinely indicated for healthcare workers in the United States
(quadrivalent A, C,
W135, and Y) vaccine
Healthcare personnel in close contact with persons who may be
Polio vaccine
excreting wild virus and laboratory personnel handling specimens that
may contain wild poliovirus
Personnel who work with rabies virus or infected animals in diagnostic
Rabies vaccine
or research activities
Tetanus and diphtheria
All adults; tetanus prophylaxis in wound management
(Td)
Typhoid vaccines: IM,
Personnel in laboratories who frequently work with Salmonella typhi
SC, and oral
Personnel who directly handle cultures of or animals contaminated with
Vaccinia vaccine
recombinant vaccinia viruses or orthopox viruses (monkeypox, cowpox,
(smallpox)
vaccinia, etc.) that infect human beings
Source: CDC, 1998.
PREVENTION OF VIRAL TRANSMISSION TO HCW
Any healthcare worker who receives a needle or other significant exposure to potential HIV, HSV,
HBV, or HCV infection should follow the guidelines issued by CDC.

Immediately after exposure to blood of a patient:
o Wash needlesticks and cuts with soap and water.
o
o



Flush splashes to the nose, mouth, or skin with water.
Irrigate eyes with clean water, saline or sterile irrigants.
Immediately report the incident to personnel within your agency (usually employee health
and/or the ED) who are responsible for managing exposures.
Complete an injury report.
Seek appropriate medical evaluation and follow-up, which includes the following:
o Identification and documentation of the source individual when feasible and legal.
o Testing the source individual's blood when feasible and consent is given. If the
source will not voluntarily submit to HIV testing and a blood sample is not
available, medical and non-medical personnel may seek a court order directing the
source of the exposure to submit to HIV-testing.
o Making results of the test available to the source individual's healthcare provider.
o Collection and testing of blood (with consent) of exposed healthcare provider.
Follow-up testing at 6 weeks, 3 months, and 6 months.
o Postexposure prophylaxis (PEP), if medically indicated, should be started as soon as
possible after exposure. Consultation on postexposure prophylaxis against HIV can
be obtained (free, 24/7) via the PEPline sponsored by the CDC. This number should
be readily available in all areas where PEP may be prescribed. Hepatitis B vaccine
is available for HBV exposure. There is no vaccine for hepatitis C and no treatment
that will prevent infection. Immune globulin is not advised.
o Medical counseling regarding personal risk of infection or risk of infecting others.
POSTEXPOSURE PROPHYLAXIS FOR Health Care Workers
Disease
Indication
Diphtheria
For healthcare personnel exposed to diphtheria or identified as carriers
May be indicated for healthcare personnel exposed to feces of infected persons
Hepatitis A
during outbreaks
HBV-susceptible healthcare personnel with percutaneous or mucous-membrane
Hepatitis B
exposure to blood known to be HBsAg seropositive
Personnel with direct contact with respiratory secretions from infected persons
Meningococcal without the use of proper precautions (eg, mouth-to-mouth resuscitation,
disease
endotracheal intubation, endotracheal tube management, or close examination of
oropharynx)
Personnel with direct contact with respiratory secretions or large aerosol droplets
Pertussis
from respiratory tract of infected persons.
Personnel who have been bitten by human being or animal with rabies or have
Rabies
had scratches, abrasions, open wounds, or mucous membranes contaminated
with saliva or other potentially infective material (eg, brain tissue)
Personnel known or likely to be susceptible to varicella and who have close and
Varicella zoster prolonged exposure to an infectious healthcare worker or patient, particularly
virus
those at high risk for complications, such as pregnant or immunocompromised
persons