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MODULE 9 UNIT 9.2 -INFECTION CONTROL MODULE 9 UNIT 9.2 Infection Control Page i Rev March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL LB Cleaning Consulting Services L EA B U B U R U Z C.E.H., C.A.H., R.E.H., BSAIV 2988 O’Hara Lane Surrey BC V4A 3E5 [email protected] Phone/Fax 604-538-3023 Cell 604-813-610 Lea’s 38 year career in Cleaning Management began as a hospital cleaner which provided the ground work that led her to a variety of management positions and experiences from Assistant to Director of Services and the unique fortune of working across Canada. Lea has had the opportunity of gaining experience in all facets of cleaning management. Working directly for or consulting to facilities that span the acute, mental health, long term and chronic care sectors; contract cleaning; to a wide variety of government facilities ranging from highway yards to day care centers, jails and includes rehabilitation centres. Lea was most recently Corporate Cleaning Consultant with BC Buildings Corporation where she was responsible for researching, development, training, providing technical advise and standards for over 4000 buildings throughout the province and 50 cleaning management staff. Lea’s scope of responsibility included all external cleaning consulting services for federal, provincial and public sector clients. Lea created the provincial template for cleaning management manuals and processes, which set the standards for the entire province, and produced a master purchasing manual which outlined the purchase requisition specifications for the purchase of all products, supplies and minor equipment. The purchasing included a BC Green Standard for the purchase of environmentally responsible cleaning chemicals. A nationally recognized speaker and author, Lea has been called upon by many organizations to assess, and implement programs for improving the standards of their cleaning. She is a recognized trainer and facilitator who has designed and delivered a variety of cleaning related management programs. In addition to her work with BC Building Corporation, Lea designed and delivered programs to organizations as diverse as the B.C. Ferries Corporation and the Attorney General of Canada. Lea’s expertise is recognized by certifications and professional designations from the Province of BC, the USA International Executive Housekeepers Association and the Canadian Administrative Housekeepers Association. To attain and maintain the highest international educational credentials in the field of Cleaning Management, Lea continues her passion by attending courses via numerous colleges and institutions. Available Services: Public Speaking on a variety of subjects, Cleaning Consulting, and Training. Page ii Rev March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Table Of Contents Introduction ....................................................................................................................................1 Definitions .......................................................................................................................................1 Infection ..................................................................................................................................................................... 1 Nosocomial Infection................................................................................................................................................. 1 Community Acquired Infections ................................................................................................................................ 1 Factors Influencing the Spread of Infection ................................................................................2 Source of Infection .................................................................................................................................................... 2 Microbial (Causative) Agent...................................................................................................................................... 2 Portal of Exit.............................................................................................................................................................. 2 Portal of Entry ........................................................................................................................................................... 2 Mode of Transmission ............................................................................................................................................... 2 Susceptible Host ........................................................................................................................................................ 3 Summary .........................................................................................................................................3 Infection Control Program............................................................................................................3 Description ................................................................................................................................................................ 3 The Infection Control Committee ................................................................................................4 Role of the Cleaning Department and Other Support Service Groups Whose Roles and Responsibilities Impact The Indoor Environment ............................................................................................................................................ 4 Education in Infection Control .....................................................................................................5 Resources ................................................................................................................................................................... 5 Orientation ................................................................................................................................................................. 5 To Minimize Transmission of Infection .................................................................................................................... 5 On-going Training ..................................................................................................................................................... 5 Control of Microorganisms in the Environment.........................................................................6 General Information................................................................................................................................................... 6 Cleaning Procedures and Schedules .......................................................................................................................... 6 Disinfection ............................................................................................................................................................... 6 Environmental Testing ..................................................................................................................8 Routine Testing.......................................................................................................................................................... 8 Outbreak Related Testing .......................................................................................................................................... 8 Standard Precautions ....................................................................................................................9 What are Standard Precautions? ................................................................................................................................ 9 Isolation Categories ................................................................................................................................................... 9 Preventive Measures ....................................................................................................................10 Routine Precautions ................................................................................................................................................. 10 Isolation Precautions................................................................................................................................................ 12 Isolation - Occupied - Patient Unit .............................................................................................13 Material, Equipment, Supplies and Chemicals ........................................................................................................ 13 Daily Cleaning Procedures ...................................................................................................................................... 14 See Separate Isolation Discharge Cleaning Procedures in the Systems Health Care Section of the Cleaning Management Manual. .............................................................................................................................................. 14 Maintenance of Cleaning Equipment ........................................................................................15 Proper Handwashing ...................................................................................................................16 Page iii Rev March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Hand Hygiene Guidelines Fact Sheet from CDC ......................................................................17 How To Remove Disposable Gloves ...........................................................................................18 How To Handle Garbage Safely .................................................................................................19 How to Clean up Spills of Blood and Certain Body Fluids ......................................................19 What to Do when An Exposure Incident Occurs ......................................................................20 Influenza .......................................................................................................................................21 Influenza Vaccine – Why You Should Have It..........................................................................21 Why Should You Get the Flu Vaccine? ................................................................................................................... 21 How Effective Is the Flu Vaccine? .......................................................................................................................... 21 Why Don't More People Receive Flu Vaccine? ....................................................................................................... 22 Why Does Influenza Vaccine Have To Be Taken Every Year? .............................................................................. 22 When Should You Receive Influenza Vaccine? ...................................................................................................... 22 Latex Allergies ..............................................................................................................................23 What is rubber? ........................................................................................................................................................ 23 What Health Problems Are Associated With Rubber Products? ............................................................................. 23 Sensitization: How do you become allergic? ........................................................................................................... 24 Summary of Allergic Reactions ............................................................................................................................... 24 What Should I do if I Have A Health Problem That May Be Related To Rubber Products? .................................. 24 How Are You Exposed To Natural Rubber Latex Proteins? ................................................................................... 25 Who May Be At Risk of Developing A Natural Rubber Latex Protein Allergy? .................................................... 25 How Can the Risk of Developing A Natural Rubber Latex Protein Allergy Be Minimized? .................................. 25 What If You Must Wear Personal Protective Equipment Like Gloves? .................................................................. 26 How Do You Know If You Are Allergic To Natural Rubber Latex Proteins? ........................................................ 29 Is There A Cure for Natural Rubber Latex Protein Allergy? ................................................................................... 29 What Can You do if You Have A Natural Rubber Latex Protein Allergy? ............................................................. 29 What May Contain Natural Rubber Latex? ............................................................................................................. 30 How To Handle Anthrax and Other Biological Agent Threats ...............................................31 Ozone.............................................................................................................................................33 BCBC ...................................................................................................................................................................... 33 Research .................................................................................................................................................................. 33 Ozone-Generating Devices ...................................................................................................................................... 33 Bedbugs .........................................................................................................................................33 Cockroaches..................................................................................................................................33 Clostridium Difficile ....................................................................................................................34 The clinical symptoms of associated with Colostridium difficile: ........................................................................... 34 The complications from Colostridium difficile-associated dissease: ....................................................................... 34 How is it transmitted ................................................................................................................................................ 34 Keeping it under control .......................................................................................................................................... 34 E coli (Some Basics) .....................................................................................................................35 Hamburger Disease (Hemorrhagic Colitis) ...............................................................................35 What Is It? ............................................................................................................................................................... 35 What Are the Symptoms? ........................................................................................................................................ 35 Where Does the Disease Come From? .................................................................................................................... 35 How Do You Avoid Contracting This Disease? ...................................................................................................... 36 What About Treatment for the Disease? .................................................................................................................. 36 Hepatitis C ....................................................................................................................................36 Page iv Rev March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL What Is Hepatitis C? ................................................................................................................................................ 36 How Common Is Hepatitis C? ................................................................................................................................. 36 What Are the Symptoms of Hepatitis C? ................................................................................................................. 37 How Can I Tell If I Have Hepatitis C? .................................................................................................................... 37 Is There A Treatment for Hepatitis C? .................................................................................................................... 37 How Is the Hepatitis C Virus Spread? ..................................................................................................................... 37 Lice ................................................................................................................................................38 What Is Lice? ........................................................................................................................................................... 38 Infectious Period ...................................................................................................................................................... 38 Transmission ............................................................................................................................................................ 38 Treatment ................................................................................................................................................................. 38 Methicillin Resistant Staphylococcus Aureus (MRSA) ...........................................................39 What is MRSA (along with VRE referred to as ARO's- Antibiotic resistant organisms)? ....................................... 39 How is MRSA Spread? ............................................................................................................................................ 39 Why is MRSA a Problem? ....................................................................................................................................... 39 How to Keep MRSA Under Control ........................................................................................................................ 40 Necrotizing Fasciitis (Flesh-Eating Disease) .............................................................................40 What Is It? ............................................................................................................................................................... 40 What are the symptoms of the disease? ................................................................................................................... 40 What Causes It? ....................................................................................................................................................... 40 How Is It Spread? .................................................................................................................................................... 40 How Can It Be Prevented? ...................................................................................................................................... 41 How Is It Treated? ................................................................................................................................................... 41 What Are My Chances of Getting It? ...................................................................................................................... 41 Norwalk Virus and Norwalk-like virus (NVL). ........................................................................41 What are the Symptoms of the Norwalk Virus ........................................................................................................ 42 Treatment of the Norwalk Virus .............................................................................................................................. 42 Disinfection of Norwalk .......................................................................................................................................... 42 The Management of a Norwalk Outbreak ................................................................................................................ 42 The Best Deterrent for Norwalk .............................................................................................................................. 43 Scabies ...........................................................................................................................................43 What Is Scabies? ...................................................................................................................................................... 43 How Is Scabies Spread?........................................................................................................................................... 43 What Are the Symptoms? ........................................................................................................................................ 43 How Do You Know If You Have Scabies? ............................................................................................................. 43 How Is Scabies Treated? ......................................................................................................................................... 44 Preventing the Spread of Vancomycin-Resistant Enterococci (VRE) ....................................44 Epidemiology of VRE (also with MRSA referred to as ARO's) .............................................................................. 44 Microbiology of Enterococci ................................................................................................................................... 44 Antibiotic Resistance in Enterococci ....................................................................................................................... 44 Risk Factors for VRE............................................................................................................................................... 45 Recommendations .................................................................................................................................................... 45 SARS Threat Emphasizes Need for Disinfection, Proper Cleaning ........................................46 Viruses ...........................................................................................................................................47 West Nile Virus ............................................................................................................................48 Notification .............................................................................................................................................................. 48 Statements And Definitions .........................................................................................................49 What Is The Difference Between A Sanitizer, A Disinfectant, And A Chemical Sterilant? .................................... 49 What Is A Registered Hospital-Type Disinfectant? ................................................................................................. 49 Page v Rev March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL How Can You Compare Different Types Of Hospital-Type Disinfectants? ............................................................ 49 Why Is Soil Load Tolerance And Hard Water Effectiveness Important? ................................................................ 49 Is The Parts Per Million (ppm) Actives Relevant To Disinfectant Product Performance? ...................................... 49 What Are The Various Roles Of CDC, OSHA, EPA? How Do They Affect Infection Control Practices? ........... 49 What Are The Primary Differences Between Bacteria, Viruses, And Endospores? ................................................ 50 Do You Need A TB-Effective Product For General Environmental Hard Surface Disinfection? ........................... 50 Why Do Some Facilities Choose The TB Microbe As A Disinfectant Guideline Standard?................................... 50 What Products Are Effective Against TB? .............................................................................................................. 50 What Is The OSHA Recommendation For Cleanup Of Blood Spills And Other Body Fluids? .............................. 50 Can HIV-1, (AIDS Virus) Be Killed Via Disinfectants? ......................................................................................... 50 Why Is The Hepatitis B Virus (HBV) An Issue? Are There Any EPA-Approved Products Effective Against Hepatitis B? ............................................................................................................................................................. 51 What Are The Pros / Cons Of Phenolics, Iodophors, Quaternaries, Chlorine?........................................................ 51 Is The Choice Of Disinfectant The Only Issue Regarding Effective Infection Control? ......................................... 52 Why Is Hand Washing So Important? ..................................................................................................................... 52 What Infection Control Factors Are Important In Nursery Isolette / Incubators? ................................................... 52 Will All Disinfectants Clean And Disinfect In One Step? ....................................................................................... 52 Are Disinfection Needs Different In Nursing Homes Than In Hospitals? ............................................................... 52 What About Disinfection For Schools? Is It Really Necessary? ............................................................................. 52 What Areas Are Critical In Dietary?........................................................................................................................ 52 Is Odor Control Really Necessary? Won't A Proper Housekeeping Program Eliminate The Need For Odor Control? ................................................................................................................................................................... 53 Are There Specific Disinfection Issues In Veterinary Areas? .................................................................................. 53 What pH Range Is Favorable For Disinfection? ...................................................................................................... 53 Won't Alkaline pH Disinfectants And / Or Cleaners Harm Floor Finish Appearance? ........................................... 53 Are All 1/2 Ounce/Gallon Quaternary Ammonium Disinfectants The Same? ......................................................... 53 How Do You Calculate REAL In-Use Cost? ........................................................................................................... 53 Are Disinfectants Used For Medical Instrument Soaking? ...................................................................................... 54 Glossary ........................................................................................................................................55 List Of Reportable Communicable Diseases In British Columbia .........................................57 Page vi Rev March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Introduction Infection Control is a program designed to reduce the spread of infection among patients and staff in a health care facility. The risk of infection is not the same in all facilities. It is dependent on the person’s illness or degree of debilitation and the medical/surgical procedures performed in the facility. Control procedures are established to reduce the numbers of micro-organisms and to prevent the spread of infectious agents by air, food and water, or direct contact with exudates or contaminated sources. This requires a team approach from all staff. Cleaning Services has the responsibility of reducing the microbial populations in the health care environment by routine maintenance and cleaning schedules, removal of infectious wastes, and the education of their staff in procedures that ensure their safety and minimize transmission of pathogenic organisms. They are vital and an important component of the Infection Control Program. Definitions Infection Taber et al defines infection as “the state or condition in which the body or a part of it is invaded by a pathogenic agent (microorganism or virus) that, under favourable conditions, multiplies and produces injurious effects. Localized infection is usually accompanied by inflammation, but inflammation may occur without infection.” Nosocomial Infection A nosocomial infection is one which expresses itself in a person in whom the infection was not present or incubating at the time of admission. An infection is also classified as nosocomial if it is directly related to or is the residual of a previous facility admission. Community Acquired Infections Infections, which do not fit the above criteria, are considered to be community acquired. Page 1 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Factors Influencing the Spread of Infection Microorganisms are very much a part of our world. The fact that they are invisible to the naked eye does not diminish their influence and effect on our day-to-day lives. Microorganisms perform a variety of essential functions for us. In fact, they interact with every living creature, usually to the benefit of all. It is safe to say that life, as we know it, could not be sustained without them. Because microorganisms can, in certain circumstances, threaten our well being or existence, control measures have been developed to inhibit their spread. These control measures are based on knowledge of the main factors, which influence the spread of microorganisms. These factors are: Source of Infection Sources of infection include: People: both healthy and sick Fomites (inanimate objects or materials on which disease-producing agents may be conveyed) Instruments Patient equipment, e.g., lines, tubes Food Water Air Vectors such as mosquitoes, flies, and birds Microbial (Causative) Agent There are several categories of microorganisms that can cause infection. These are bacteria, viruses, fungi, and parasites. Some of these microorganisms are more pathogenic, i.e., likely to cause disease, than others. However, if conditions are favorable, any microorganism is capable of causing disease in humans. Portal of Exit The exit of the pathogen is dependent on the location of the microorganism in the body. Microorganisms can be expelled from the respiratory tract during breathing, coughing, or sneezing; and from the gastrointestinal (GI) tract via saliva, emesis, feces, or drainage from sites within the GI tract. Urine, blood, genital secretions, and drainage from wounds may also carry microorganisms out of the body. Portal of Entry These may be the same as the portals of exit. All of the portals have natural barriers that protect the body from microorganisms. The barriers are normally effective but may allow microorganisms to enter if the barriers are damaged or if they have been compromised by invasive medical devices, e.g., catheters. Mode of Transmission Microorganisms can be transmitted from their source by seven routes: Direct Hand Contact - This is the most common mode of transmission. Indirect Contact - This occurs with exposure to contaminated fomites such as surgical dressings. Droplet Contact - This can involve the conjunctiva, nose, or mouth as a result of sneezing or coughing by an infected person. It is considered contact rather than airborne since droplets usually travel no more than three feet. Airborne Transmission - This occurs by dissemination of an infectious agent by either droplet nuclei or dust particles in the air. The agent is widely dispersed by air currents and inhaled. Blood Borne Transmission - Microorganisms are transmitted by percutaneous injury and contact with mucosa or a raw wound. Fomite - Fomites consist of inanimate objects such as food, clothing, drugs, equipment, or furniture. Page 2 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Vectors - Vectors, e.g., mosquitoes, flies, and birds, carry microorganisms as part of their normal flora. Susceptible Host Occasionally, circumstances arise where the normal balance between micro-organisms and their host is disturbed. This may be due to a disease process, altered immune status, infancy or old age, invasive procedures, drug therapy, poor nutrition, irradiation, etc. Should the host develop an infection as a result of this disturbance, a new reservoir of microorganisms would be established, thus further increasing the risk of infection to other people. Summary By understanding the basic roles and functions of microorganisms in our environment, we can apply the procedures in this manual to interrupt the chain of source-transmission-host. Good personal hygiene cannot be overemphasized and the careful handling and disposal of all body secretions and excretions is mandatory. Appropriate hand washing, carefully done, remains the single most important element in controlling the spread of infection. Infection control is everybody's business. Infection Control Program Description The Infection Control Program provides a resource service to medical and Facility staff, to give workable guidelines, advise, report and/or arbitrate on Facility infections, and reportable diseases in order to provide a safe environment for patients, residents, staff and visitors. The program must provide: Recommendations on Facility policies related to infection control measures to include aseptic procedures, isolation requirements and sanitation techniques. Effective surveillance, investigation, review and recording of data pertinent to infection control. Orientation and in service programs for employees. Distribution of information to medical and paramedical staff in matters related to infection control. Liaison with community agencies regarding infection control issues. Information and recommendations relevant to the purchase of equipment and supplies used for sterilization, disinfection and decontamination practices. Information and recommendations relevant to structural design and renovation of areas as they pertain to infection control. Page 3 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL The Infection Control Committee Role of the Cleaning Department and Other Support Service Groups Whose Roles and Responsibilities Impact The Indoor Environment Environmental services must be represented on a multi-disciplinary committee that addresses infection and safety of patients/residents and staff. The role of the environmental services group on such a committee should include: a) Expressing staff concerns and need of clarification around specific cases, or procedures relating to infection control. b) Providing for acceptance, procedures, equipment and maintenance that have an Infection Control application. e.g.: Staff training requirements Cleaning schedules Product selection and usage Equipment selection and maintenance Maintenance of air conditioners, air ducts, laundry chutes, ice machines, etc. c) Quaternary Ammonia Germicidal detergents : To provide a list of the chemical germicidal detergents used in environmental cleaning, with appropriate information on effective use of the agent (i.e. spectrum of microbial inhibition with OAOC current method of testing, reference for these claims from an independent laboratory, any and all Canadian recognized testing protocol, the DIN number and, although not mandatory in a Health Care Facility, it is advisable to require a PCP number. Stability and shelf life In-use cost, relative to equivalent germicidal chemical cleaning agents The Infection Control Committee should minute their approval/recommendation for each quaternary ammonia germicidal detergent, where its use is not required, where it is to be used and controlled in specific and metered dilution in accordance with the label instructions. d) To express managerial concerns regarding communications, labour and supplies, to ensure an acceptable standard of safety is obtained. e) To participate as required during outbreaks of infection by: Provision of information to staff. Provision of additional labour and supplies as required. Co-operation with other departments in tracking the source of an outbreak, which may include sampling of the environment or personnel. Page 4 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Education in Infection Control Professional cleaning staff must be taught the procedures necessary to prevent the spread of infectious agents and the precautions necessary to protect themselves and others. Resources The resources required are: A hospital Infection Control Manual and Cleaning Services Procedure manual must be complementary to each other. Training is required whether as a prerequisite or in-house training by a recognized approved trainer. Resource people to provide short in-services training on current infection topics, to provide interest and enforce the training they have received. Orientation New staff members must be made aware of the specifics of the site Infection Control Program at orientation. Points to cover: Availability of policy and procedure manuals, and where they can be found. Knowledge review of the procedures required. Responsibility of staff members regarding hand washing. Availability of a supervisor/infection control practitioner/employee health nurse to answer concerns around infection. To Minimize Transmission of Infection Professional cleaning management staff must become: Knowledgeable about how microorganisms are transmitted, Knowledgeable regarding the methods used to reduce and prevent transmissions such as Isolation procedures, Practiced in Isolation cleaning procedures, Practiced in the adherence to procedures and effective use of germicidal detergents, Practiced in using effective hand washing techniques, Practiced in the proper use and handling of protective gowns, masks and gloves, On-going Training To update and enforce current policies and procedures would include: Ongoing routine general precautions as a refresher. Precautions required in specific cases of infection as they advise. Topics - around infectious disease, microbiology and infection control as part of an ongoing in-house training refresher program. Page 5 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Control of Microorganisms in the Environment General Information Microorganisms are shed from people, food, plants and all objects within the hospital. They attach to dust particles in the air, and fall on horizontal surfaces. Humans exude, sputum, feces, etc., contain vast numbers of bacteria and viral particles. Where such spillage is obvious, immediate clean-up follows, but less obvious contamination such as results from sneezing or coughing adds an additional invisible bio-burden to the environment. Where moisture is present, bacteria will multiply to produce large populations. The Infection Control Program depends on routine cleaning procedures preventing the build-up and transmission of infectious agents. This is accomplished by: a) the entrapment and physical removal of dirt, dust and exudates. b) taking measures to ensure that all containers and equipment, which contain fluids, do not become heavily contaminated and disperse microorganisms into the environment. Cleaning Procedures and Schedules Cleaning methods and schedules may vary with the use of the area to be cleaned, the floor surfacing, and the amount and type of soiling present. Equipment, such as stretchers, wheel chairs, crutches, etc., require scheduled cleaning, in addition to any special procedures required relating to specific contamination. Special areas may be designated by the Health Care Team where there may be an increased risk of infection due to: The procedures undertaken (e.g., operating rooms). Increased environmental soiling (e.g., incontinent patients). Increased environmental contamination from an infected source. These areas require more frequent cleaning and/or the use of a chemical-disinfecting agent following the routine cleaning procedure. Disinfection The term “disinfection” denotes the killing of microorganisms that cause infection (with the exception of bacterial spores). Disinfection is used for equipment or areas where short-term reduction of microorganisms is important, but the area or equipment need not be sterile. Heat and chemical products are the most common disinfecting agents. Heat A temperature of 65 degrees C (160 degrees F) for 10 minutes or 71 degrees C (175 degrees F) for 3 minutes will kill the microorganisms responsible for infection. Washing machines, washer-pasteurizes and washer-sanitizes are all used for this purpose. The temperature of the water should be monitored and recorded for each load, as should the time interval of disinfection. Where the temperature does not come up to that required, the manufacturer or Maintenance Department must be notified and corrective procedures taken. Chemical Chemical disinfection is used in areas where short-term reduction of microorganisms is important and the item cannot be disinfected by heat. Chemical disinfection is very effective if properly administered. The following points should be kept in mind: 1. Germicidal detergents must be obtained from companies that provide references on their products and micro-biological testing reports and should also be ISO certified. 2. Chemical germicidal detergents are inactivated by certain materials. Hard water, organic material, natural materials such as rubber, cotton and wood, and man-made materials such as nylon and plastics, all to some degree affect the chemical. 3. The tested and approved concentration must be used. Where the concentration is less than that, which is recommended, microorganisms can frequently be found growing in the germicidal detergent solution. Where the germicidal detergent is used at a higher concentration than recommended, there is a risk to staff Page 6 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL 4. 5. 6. of skin sensitivity and damage to articles being disinfected while the product may lack in performance, in addition to money wasted. The reverse is true where less than the recommended dilution is used. Freshly prepared solutions of the germicidal detergent at the recommended dilution rate must be used. Many germicidal detergents deteriorate over a period of time, once diluted with water. A deteriorated solution will allow the growth of bacteria in the holding container. If not prepared daily, a procedure for dating and recall should be required. Container, lid/spray mechanism must be washed and dry before refilling. Bacteria must be in contact with the germicidal detergent to be killed. If there is dirt or grease covering the microorganisms, the germicidal detergent cannot do its job. Good cleaning is necessary before using a germicidal detergent on any grossly soiled area. The germicidal detergent is actively reducing the number of bacteria only while the area is wet. Moisture is required for killing. All germicidal detergents take time to do their work; they do not act instantly. The length of time is dependent upon the number of organisms present, the amount of dirt and organic material present and the strength of solution used. Good cleaning before applying the germicidal detergent removes organic material and reduces the number of bacteria, allowing a shorter disinfection time. Hypochlorites and alcohol are the most rapid of the disinfectants, however they are very harmful to surfaces and persons as well as having no cleaning ability. Germicidal detergents must only be used for cleaning areas or equipment that: Cannot be subjected to any heat; and where the build-up of microorganisms poses an immediate and life threatening infection hazard. Fogging Fogging of rooms with chemical disinfectants, a very outdated process, must not be done. It may be detrimental to the health of patients and staff, physically damage electrical systems, and is ineffective in reducing infection rates. Page 7 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Environmental Testing Routine Testing Routine environmental testing is not recommended. The number and types of bacteria present in mop water and on horizontal surfaces has been shown to bear no direct relationship to the infection rate of the institution. Therefore, there are no standards to compare results against (i.e. no magic number below which one is “safe”). Conversely, there are recorded occasions where visibly dusty equipment taken into operating rooms has been suspected as the source of wound infection. Dusty or visibly soiled equipment in surgical areas is not acceptable, no matter what the bacterial count is. The physical wet removal of dust and soil, followed by visible inspection on a regular basis, provides a safer environment than reliance on microbiological testing. The microbiological testing of chemical disinfecting and germicidal detergent agents requires media neutralizing agents and incubation temperatures not available in most hospital clinical laboratories. The manufacturer is responsible for having its products tested, and must supply a report from an approved industrial laboratory giving method and results tested under the latest OAOC requirements, meeting all current Canadian test requirements and displaying a DIN number. As well as it is advisable to require a PCP number. The interpretation of the report may require assessment by a microbiologist or the Infection Control Committee. Outbreak Related Testing Where the reservoir of a specific microorganism is being investigated, microbiological sampling may be required. Laboratory personnel under the direction of the Chairperson of the Infection Control Committee or an Infection Control Consultant must obtain the sampling. Page 8 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Standard Precautions What are Standard Precautions? Standard Precautions are the basic precautions that must be applied to all patients to protect the health care worker from infectious diseases. Other terms used are: Universal Precautions (and by 2002 changed to Standard Precautions), Body Substance Precautions, Standard Blood and Body Fluid Precautions, etc. The basic premise of all the terms is similar. It is important that each agency adopt the precautions that are suitable for their type of facility. One of the particular goals is to prevent the spread of blood-borne pathogens! Isolation Categories There are three categories of isolation, which involve precautions over and above the use of Standard Precautions. For all isolation categories it is recommended to limit the movement and transport of isolated patients for essential purposes only. Airborne Precautions Applies to diseases which are spread by the airborne route, e.g. measles, varicella, tuberculosis Person to be nursed in a negative pressure single room, or cohorted with people with the same infection, if necessary Person to be confined to the room Door to the person's room to be kept closed Anyone not immune should avoid entering the room, or must wear a mask Person to wear a mask (if able) when leaving the room If a person is unable to wear a mask, staff escorting, treating or examining to do so. Droplet Precautions Applies to diseases which are spread by droplets, e.g. influenza, pertussis, Diphtheria, etc. Person to be nursed in a single room or cohorted with people with the same infection Anyone who is not immune to the disease approaching within three feet of the patient is to wear a mask Person to wear a mask (if able) when leaving room If person unable to wear a mask, staff escorting, treating or examining patient to do so Contact Precautions A new category of isolation which addresses the emergence of antibiotic-resistant and epidemiologically significant micro- organisms. As of late both VRE and MRSA are being referred to as ARO's (Antibiotic Resistant Organisms). Applies to Clostridium difficile, Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant enterococcus (VRE), or as mentioned ARO's etc. Person to be nursed in a single room or cohorted with people infected with the same micro-organism, if necessary Gloves are to be worn for all person contact, and must be removed and hands washed with an anti-microbial agent immediately before leaving room Gowns are to be worn if it is anticipated that clothing will have substantial contact with the person, environmental surfaces and items in the person's room, or if the person is incontinent, has diarrhea, or has wound drainage not contained by a dressing Masks are to be worn if the person has the micro-organism in the respiratory tract and is coughing up sputum Person’s care items, bedside equipment, and frequently touched surfaces to be cleaned daily and the use of a separate cloth for each cleanable surface. Page 9 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Housekeeping to be informed. The use of a pH balanced quaternary germicidal detergent with VRE and MRSA claims (as soon as these are available in Canada) . When possible, dedicate the use of non-critical care equipment and items such as stethoscope, sphygmomanometer, bedside commode, or electronic thermometer to a single person (or cohorts); if equipment is shared with people not on contact isolation, then adequately clean and disinfect them before use on another person Preventive Measures Routine Precautions Rationale: For every case of recognized infection in a patient or staff member, there will be many more (10 - 100 fold) who may carry and disperse the same infecting agent and yet have no symptoms. They may be chronic carriers or those in the early stage of the disease before symptoms appear. This necessitates the observance of routine precautions, which must be followed at all times in all patient areas. They are the most important factors in preventing the spread of infection to other patients and staff. The routine general precautions must be reviewed with all new staff members, and in-service reviews provided to regular and on-call staff on a routine basis. They are required for all categories of health care from acute to long-term care. These procedures protect the staff member, and their routine observance prevents work related acquisition of infection and/or the high level of anxiety that can occur when the diagnosis of infectious disease is made on patients who have been in hospital for several days or weeks. Hand Washing Hand washing has been shown to eliminate, or markedly reduce, hand carriage of infectious organisms. The microorganisms and soil becomes suspended in the soap, and can be rinsed off. Thorough rinsing and drying is important to prevent skin breakdown. Hand washing is mandatory: When coming on duty When hands are obviously soiled After contact with a source that is likely to be contaminated with excretions or secretions of any kind if wearing protective gloves (e.g., fecal contaminated equipment, spillage, dirty cleaning equipment, etc.). After personal use of the toilet After blowing or wiping nose Before leaving and on returning to patient areas (coffee, lunch breaks, taking out waste) Between use of gloves Procedure: 1. 2. 3. 4. 5. 6. 7. Roll up sleeves so that the whole hand can be washed without wetting the sleeves. Wash hands for a minimum of 15 seconds. Wash hands with soap from dispenser and steady flow of warm water. Wash wrists and hands with friction motion, paying particular attention to areas of direct contact, e.g. fingers and fingertips. Rinse hands well by allowing water to flow from wrist to fingertips. Dry hands using towels from a no touch system to avoid contamination from the dispenser. Turn tap off with paper towel, as tap is considered contaminated. Take an additional paper towel to mop up any excess moisture or soap on basin edge - discard in waste. Soap Container: A collapsible container system with a guarantee of no air exchange. It is not only safer, but also a much more labour saving, dispensing process. The rubber nozzle and tip styles have the ability to grow bacteria while refillable soap dispensers must never be used. Any system where air replaces the soap space in the container, or where air can be drawn into the orifice no matter how small the opening, is an inherent danger of contamination and must be avoided Page 10 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL at all cost. By the year 2001 the process of dispensing the hand soap in foam with a collapsible container that is recyclable holds the lead in technology. Soap: A neutral non-medicated soap is preferred for general use as there is less frequent hypersensitivity or other skin problems. Choosing a Lotion hand soap with good skin care additives may be selected for specific areas. Antiseptic soaps are often used in high-risk areas, and these dedicated dispensers must clearly identify the type of soap refill required to avoid errors. Gloves Disposable glove(s) are available and must be worn when task to be performed could cause even the most minimal contamination. They are obviously mandatory when a staff member has open areas on his/her hands. Gloves should be washed before being removed and hands must be washed once gloves are removed. Protective Clothing - Gowns/Aprons These should be worn when a staff member's clothing is likely to become soiled with feces, urine or even the most minimal of secretions. Bedding Mattresses and pillows must be covered with impervious plastic to allow cleaning as required. Waste Waste must be handled in a safe manner. Waste from any person must be contained in plastic or other moistureimpervious bags, which are closed before being placed in the "collection" bag. Collection of waste with bare hands, or by shaking items from one container to another, is a health hazard and must not be practiced. Needles, glass, etc. must not be placed in the regular waste. Place in a puncture-resistant container and close securely, follow instructions for disposal. Biomedical or Infectious Waste Biomedical wastes are discarded materials of medical origin (i.e. blood administration sets, laboratory specimens, etc.) which, due to their nature and source, require specific treatment before, or special handling for, disposal. Infectious wastes are those which may be contaminated with the causative agents or toxic products of a communicable disease (i.e. grossly soiled dressings, blood soaked materials) capable of transmitting disease to susceptible individuals or animals. 1. 2. 3. 4. Only staff trained in the safe handling of Biomedical Waste are permitted to handle or transport it. Waste is placed in a properly labeled and colour-coded container, lined with a plastic bag of appropriates thickness and composition to withstand puncture or leaking during transportation. Before movement of this waste to a separate and secure storage area, the bag must be sealed with plastic tie or tape. The storage area must be locked and access restricted to authorized personnel. NOTE: Soiled diapers do not require special treatment before disposal unless the patient has frequent bleeding from the rectum or vagina, in which case the blood-soaked diaper must be handled as Infectious Biomedical Waste. Sharps are needles, syringes, blades, lancets, clinical glass (glass possibly contaminated with blood, body fluids or chemicals) and any other clinical item that could cause a cut, puncture, or abrasion. Sharps 1. 2. 3. Sharps are placed in special puncture-resistant containers. Do not fill beyond level indicated on container. Do not overfill by forcing items into the container. Page 11 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL 4. 5. 6. Do not attempt to put your fingers into the container for any reason. When the container is full a lid attached by hinge is pressed until it locks closed. Specially licensed carriers for disposal as Biomedical Waste normally move the sealed container to a central collection area for pickup. Isolation Precautions Microorganisms causing infection are spread by different routes. Specific precautions are taken to prevent transmission and are called isolation precautions. The precautions chosen are directed at the mode of transmission and the infectivity of a particular pathogen. Thus, different precautions will be required for different infectious diseases, and in some types of infection the precautions may be task-related. Precautions Isolation precautions include: Hand washing on entering and leaving the room. A single room may, or may not, be required. Masks - where the infectious agent is transmitted through the air. Gloves - where hands are likely to become contaminated with infectious material (disposable non-sterile gloves). Single-use gowns - where clothing may become soiled with infectious materials, or for all entering the room in highly infectious, airborne diseases. Bagging - removal of linens and all other items from an isolation area in impervious bags for processing or disposal. Double bagging may be done. Isolation Systems: Disease Specific/Category Specific The two major systems of isolation in acute care hospitals are "Disease Specific" and "Category Specific". In "Disease Specific" isolation systems the precautions are initiated to prevent transmission of the pathogen causing the specific disease. "Category Specific" isolation groups infectious diseases with the same route of transmission together, with the same precautions for all diseases in the group (e.g., all infections spread by the fecal-oral route require enteric precautions). Seven isolation categories are in common use: strict isolation, contact isolation, respiratory isolation, tuberculosis isolation, enteric precautions, drainage/secretion precautions, and blood/body fluid precautions. The policies and procedures for handling infected cases must be available in a hospital's Infection Control Manual. Isolation per se may not be appropriate for care homes or residential institutions, but the precautions, hand washing, use of gloves and gowns are. Notification in Cases of Recognized Infections Nursing is responsible for notifying all departments of the precautions required for persons who require entrance to an isolation area or room A card system or symbol denoting infection is frequently used. Services covering housekeeping, linen services and waste collection work closely with the nursing staff to ensure: The necessary equipment is in the room. Staff members are familiar with the precautions being used. There are sufficient supplies available. Schedules for cleaning, collection of laundry and waste are compatible with the specific needs of the case. Equipment (including all surfaces as well as the wheels) used in an isolation room is thoroughly and completely cleaned and disinfected before use in another area. Management Separate written procedures for cleaning isolation areas will be developed around the isolation system in use in the facility. Written procedures must be discussed and approved by the Infection Control Committee of the facility, and all staff members must be familiar with the equipment, the procedures and the lines of communication. Page 12 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Isolation - Occupied - Patient Unit These Isolation Procedures are for general types of Isolation, however, for infectious conditions such as VRE and MRSA whether suspect or factual separate cleaning cloths impregnated with a quaternary pH balanced germicidal detergent with VRE and MRSA claim must be used for every single individual item. For Discharge Cleaning see the separate procedures for VRS, MRSA and Standard Isolation in the SYSTEMS HEALTH CARE section of the BCBC Cleaning Management Manual. Isolation equipment is clearly marked and generally placed in the Isolation Room when it is set up Material, Equipment, Supplies and Chemicals Inside Room Set Up 1 - wet mop handle - quick release 1 - wet mop (launderable) 1 - floor pail and wringer 1 - set washroom bowl cleaning caddy with mop 1 - impervious laundry bag 1 - gallon container with measure device, quaternary pH balanced germicidal detergent solution with VRE and MRSA claim. Outside Room 1 - utility cart 1 - hand pail * - long sleeved gowns * - disposable non-latex gloves * - wet mops 1 - red- bio-hazard bin (sharps container) if required * - hand sanitizer - optional waste container with plastic liner - good supply of required plastic liners * - dispenser supplies Take Into Room 1 - Wet mop (launderable) * - single use cleaning cloths * - dispenser supplies- small amount * - plastic liners * amounts are determined by need Due to the extent and nature of the cleaning required it is recommended that daily routine of an Isolation room cleaning be done at the last of the work shift. NOTE: Anything that goes into this room must stay in or be thoroughly washed with a quaternary pH balanced germicidal detergent solution prior to removal. Wear disposable gloves- shoe coverings are not necessary. Dispose of gloves in the coated impervious waste bag in the interior of the room. Wear long sleeved gown and upon completion of the room fold (exposed side in) and place in laundry bag inside the room and then double bag into the lined linen hamper outside of the room. NOTE: All used linens, must be placed in impervious laundry bags. Mops must be used once only and never returned to the solution. Mops must be placed in a small black plastic bag and then placed in the laundry bag. Yellow plastic bags are only used for BSP and generally supplied and used by nursing. NOTE: Dry mopping is NOT permitted. Page 13 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Daily Cleaning Procedures 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Leave cleaning cart outside the room Take all necessary supplies into the room. Place “Wet Floor” at entrance to the room. Bag all waste. Using cleaning cloths impregnated with a quaternary pH balanced germicidal detergent, clean all dispensers inside and out. With the paper products restock with a minimum amount. Using cleaning cloths impregnated with a quaternary pH balanced germicidal detergent, start at one side of the door and working around the entire room clean all surfaces of cabinets, lockers, bed side and over bed tables, I.V. poles, wheelchairs, commodes, call bell and cord, B.P. cuff, medical apparatus, reachable lights, window sills, sinks, counters, and any other furnishings For washroom follow washroom cleaning procedures. Wet mop entire floor area. Place used mop in laundry. Using cleaning cloths impregnated with a quaternary pH balanced germicidal detergent wash down cleaning equipment. Use a fresh side for each surface. Transfer bagged waste into the appropriate container Remove gown- fold exposed side in and place in laundry. Remove gloves-place in waste. Wash your hands and then use hand sanitizer See Separate Isolation Discharge Cleaning Procedures in the Systems Health Care Section of the Cleaning Management Manual. For Isolation Discharge Cleaning of a Standard Patient Unit For Isolation Discharge Cleaning of a VRE Patient Unit For Isolation Discharge Cleaning of a MRSA Patient Unit. Page 14 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Maintenance of Cleaning Equipment Microorganisms multiply rapidly in solutions and wet equipment; thus, the equipment itself can become both the reservoir and means of dispersal of potential pathogens. This can be prevented by: Implementing single use cloths (or use disposable ones). Always changing the wet mop heads and always using uncontaminated cleaning solutions . Use of equipment, which prevents dispersal of microorganisms into the air. Check equipment with filters to ensure the filter traps the dust, and change filters as required. Ultra high speed floor burnishing may add significant dust particles and microorganisms to the air, and their use in acute health care facilities is questionable. The reduction and /or elimination of spray buffing. The procedure of Spray buffing is much worse than high speed buffing as it places chemicals and moisture combined with the dust and organisms into the air stream, because of this it is not recommended for Health Care. Many older Health Care facilities have floors containing asbestos while others have floor composition where the only maintenance option is spray buffing. We find that these are being replaced as funding permits. However any system that sprays a cleaner containing a solvent or a solvent cleaner and finish combination solution is banned. Ideally for Health Care all flooring would require no finish or sealer and by the year 2000 we are seeing more of this type of claim making them (other than Marmoleum) the ideal choice. Cleaning, decontaminating and drying of all cleaning equipment on a regular basis (usually at the end of each shift). Supplies which can be laundered such as cloths and mop heads, must be set aside and processed through washing machines and dryers. Floor pails and wringers should be of a type with as smooth a surface as possible and must be cleaned thoroughly after use. Fresh solutions of cleaning agents and germicidal detergent solutions must be used each day. Sprayers are banned wherever possible and exchanged for flip or squirt bottles. If a sprayer is permitted then pasteurization, a temperature of 65 degrees C (160 degrees F) for 10 minutes, may be required to decontaminate the container or spray assembly where physical cleansing and complete drying is not possible. Page 15 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Proper Handwashing 1. Wet Hands 4. Rub soap over the back and the front of both hands 7. Work the finger tips into the palms to clean under the nails 2. Add Soap to palms 5. Clean your knuckles 3. Rub hands together to create a lather 6. Clean the space between the thumb and index finger 9. Dry with a paper towel and then use it to turn off the tap 8. Rinse well Total Wash Time: 20 – 30 seconds Page 16 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Hand Hygiene Guidelines Fact Sheet from CDC Improved adherence to hand hygiene (hand washing or the use of alcohol-based hand rubs) has been shown to terminate outbreaks in health care facilities, to reduce transmission of antimicrobial resistant organisms and reduce overall infection rates. The Centers for Disease Control has released guidelines to improve adherence to hand hygiene in health care settings. In addition to traditional hand washing with soap and water, CDC is recommending the use of alcohol-based hand rubs by health care personnel along with the following guidelines: Hand washing with soap and water remains a sensible strategy for hand hygiene in non-health care settings and is recommended by CDC and other experts. When health care personnel's hands are visibly soiled, they should wash with soap and water. The use of gloves does not eliminate the need for hand hygiene. Likewise, the use of hand hygiene does not eliminate the need for gloves. Gloves reduce hand contamination by 70 percent to 80 percent, prevent crosscontamination and protect patients and health care personnel from infection. Hand rubs should be used before and after each patient just as gloves should be changed before and after each patient. When using an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. Note that the volume needed to reduce the number of bacteria on hands varies by product. Alcohol-based hand rubs significantly reduce the number of microorganisms on skin, are fast acting and cause less skin irritation. Health care personnel should avoid wearing artificial nails and keep natural nails less than one quarter of an inch long if they care for patients at high risk of acquiring infections. When evaluating hand hygiene products for potential use in health care facilities, administrators or product selection committees should consider the relative efficacy of antiseptic agents against various pathogens and the acceptability of hand hygiene products by personnel. Characteristics of a product that can affect acceptance and therefore usage include its smell, consistency, color and the effect of dryness on hands. As part of these recommendations, CDC is asking health care facilities to develop and implement a system for measuring improvements in adherence to these hand hygiene recommendations. Some of the suggested performance indicators include: Periodic monitoring of hand hygiene adherence and providing feedback to personnel regarding their performance; Monitoring the volume of alcohol-based hand rub used/1000 patient days, monitoring adherence to policies dealing with wearing artificial nails and focused assessment of the adequacy of health care personnel hand hygiene when outbreaks of infection occur. Allergic contact dermatitis due to alcohol hand rubs is very uncommon. However, with increasing use of such products by health care personnel, it is likely that true allergic reactions to such products will occasionally be encountered. Page 17 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL How To Remove Disposable Gloves If you have come in contact with blood or body fluids, follow these steps to make sure your hands do not come in contact any contamination that may be on the used gloves: With both hands gloved, grasp the outside of one glove at the top of the wrist. Peel off this glove from wrist to fingertips while turning it inside out, as you pull the glove off your hand and away from you. Hold the glove you just removed in your gloved hand. With the ungloved hand peel off the second glove by inserting your fingers on the inside of the glove at the top of your wrist. Turn the glove inside out while tilting it away from you, leaving the first glove inside the second. Dispose of the entire bundle promptly into a designated refuse container. Wash your hands thoroughly with soap and water as soon as possible after removing gloves and before touching noncontaminated objects and surfaces. A secondary safe precaution is to use a hand sanitizer following had washing and drying. Page 18 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL How To Handle Garbage Safely Follow these steps to prevent contact with sharps and other items improperly discarded in garbage: 1. Handle garbage as little as possible. 2. Use waterproof garbage bags. 3. Be alert. If possible, look for sharps sticking out of the bags. Listen for broken glass when you move the bag. 4. Don't compress garbage or reach into garbage containers with your bare hands. 5. Don't use your bare hands to pick up garbage that has spilled out of an over-flowing container. Wear puncture-resistant and liquid-resistant gloves (the type worn by firefighters), or use other tools designed for picking up garbage. 6. Don't let garbage bags get too full, if possible. Leave enough free space at the top of the bag, so that when you grab it, you grab the top of the bag only - not any of the contents. You may have to change bags more often to prevent them from getting too full. This will also make them lighter -and thus easier to hold away from your body. 7. Hold garbage bags by the top of the bag, away from your body. Don't hold garbage bags against your body. 8. Don't place one hand under the bag to support it. 9. Dispose of wastes according to federal, provincial, and local regulations. How to Clean up Spills of Blood and Certain Body Fluids Once any exposure incident has been attended to. Clean up spills as soon as possible. Don't clean up blood and certain body fluids unless you have been trained to do so and have the equipment and PPE needed to do so safely. Kits that contain the supplies needed to clean up spills are available from safety supply companies. Procedures for cleaning up spilled blood and certain body fluids should include the following steps: 1. Restrict access to the area. 2. Make sure plastic bags are available for removal of contaminated items from the spill site. Have germicide detergent ready. 3. Dispose of any sharps first. 4. Wear disposable, waterproof gloves (such as non- latex, neoprene, nitrile and vinyl) If necessary wear other PPE, such as a face shield and gown, to act as a barrier against contact with blood and certain body fluids and the germicide detergent. Check the Material Safety Data Sheet (MSDS) to find out what type of glove to use. 5. Cover your shoes or boots with disposable, waterproof covers if they could become contaminated during clean up. 6. Wipe up visible material first with disposable towels (or in another way that prevents direct contact with blood and certain body fluids). Dispose of the material and paper towels in waterproof bags. 7. After you have carefully removed all the obvious material, it may be necessary to change gloves. Then decontaminate the area by carefully pouring over the spill site a pH balanced quaternary germicide detergent approved for use as a hospital disinfectant. Leave the solution on for 10 minutes, and then wipe it up with disposable towels. Discard the towels in the waterproof garbage bags. 8. Clean and decontaminate all soiled, reusable equipment and supplies. Properly discard any disposable items. 9. Wear the gloves to remove other protective equipment such as face shields and footwear covers. Dispose of or clean PPE (for example, face shields, aprons, boot covers) according to the manufacturer's directions. 10. Properly remove and dispose of your gloves. Wash your hands. Page 19 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL What to Do when An Exposure Incident Occurs The following exposure incidents are potentially harmful: Skin is punctured with a contaminated sharp A mucous membrane (the eyes, nose, or mouth) is splashed with blood and certain body fluids Non-intact skin is splashed with blood and certain body fluids If any of the above exposure incidents occurs, follow these steps: 1. Get first aid immediately. If the mucous membranes of the eyes, nose, or mouth are affected, flush with lots of clean water at a sink or eyewash station. If there is a sharps injury, allow the wound to bleed freely. Then wash the area thoroughly with nonabrasive soap and water. If an area of non-intact skin is affected. wash the area thoroughly with non- abrasive soap and water. 2. Report the incident. Report the incident as soon as possible to your supervisor and first aid attendant, or occupational health staff. This should not cause significant delay in seeking medical attention. 3. Seek medical attention immediately. Seek medical attention immediately; preferably within two hours; at the closest hospital emergency room, or at a health care facility if there's no hospital emergency room in the vicinity. Immunizations or medications may be necessary; these may prevent infection or favorably alter the course of the disease if you do become infected. Blood tests should also be done at that time. You may need to see your family doctor within the next five days for follow-up, such as counseling and medications. Page 20 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Influenza Influenza, the “flu” is a very contagious disease caused by a virus. Flu symptoms can include a runny nose, headache, muscle pain, fever, nausea, and diarrhea. Although colds and various other viruses cause similar symptoms, true influenza weakens a person much more than other viruses. That's why it's important for children and adults with ongoing health problems to protect themselves against this seasonal disease. How Is It Spread? Influenza can be spread very easily from person to person, by direct touching of the infected person or by touching articles infected with mucous from the person's nose or throat. The virus can also be spread through the air from person to person. How Dangerous is Influenza? The biggest danger from influenza is that it wears down your body's ability to fight other infections that you may get while you still have the flu. Bacterial pneumonia and viral pneumonia are two infections that can occur as a result of influenza. Various diseases of the nervous system can also begin when your body is weakened from the flu. Sometimes, these other infections or diseases can lead to death. Statistics show that more than 1000 Canadians die every year from influenza. Prevention is Possible Some children and adults are identified by their doctors as being at “high risk” for flu. They and their household contacts are advised to get a flu vaccination every year. People with ongoing heart, lung or kidney disease, or with diabetes, cancer, anemia, or immune system disorders are especially at risk. Children and teenagers being treated with acetylsalicylic acid (ASA or aspirin) for long periods of time are also at high risk. Some high risk children cannot be vaccinated with the flu vaccine, because of the weakened state of their health. In cases like this, it is even more important for their household contacts (including other children) to get the flu vaccine to protect these high risk children from being exposed to the flu virus. Influenza Vaccine – Why You Should Have It Why Should You Get the Flu Vaccine? By being immunized, you will protect yourself and your family against the flu. You will also lose less time from work and other activities. How Effective Is the Flu Vaccine? In healthy adults, flu vaccine is 70% to 90% effective in preventing the flu when there is a good match between the flu virus in the vaccine and the flu virus circulating in the community. For the elderly living in the community, influenza immunization reduces hospitalization by about 70% and death by about 85%. Among nursing home residents, influenza immunization can reduce the risk of hospitalization by about 50%, the risk of pneumonia by about 60% and the risk of death by 75% to 80%. Page 21 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Why Don't More People Receive Flu Vaccine? Concerns about vaccine effectiveness: Some people do not receive the flu vaccine because they believe it doesn't work. Two common reasons for this belief are: People may have been sick after they received flu vaccine, mistake their illness for the flu, and believe that the vaccine failed to protect them. Vaccine effectiveness varies from one person to another. Studies of healthy young adults have shown that the vaccine is 70% to 90% effective in preventing the flu. In other words, infrequently, some people may not get protection after being immunized. However, if these people get the flu, it is usually much milder than it would have been had they not been immunized. In the elderly and those with chronic medical conditions, influenza immunization is often less effective. However, immunization still reduces the severity of the flu and the risk of serious complications and death. Concerns about vaccine side effects: Some people believe that the vaccine causes bad side effects or that it may even cause the flu. The flu shot will not give anyone the flu. The vaccine is made from dead influenza viruses. Influenza vaccine causes no side effects in most people. The most serious side effect that can occur is a severe anaphylactic (shock- like) reaction in some people who have a severe allergy to eggs, since the viruses used in the vaccine are grown in hens' eggs. For this reason, people who have a shock-like reaction to eggs should not receive the influenza vaccine. Less than one-third of those who receive vaccine have some soreness, swelling, or redness at the site where the shot was given, and about 5% to 10% have mild side effects, such as headache or a low fever for about a day after vaccination. These side effects are most likely to occur in young adults who have received the whole-virus vaccine and those receiving vaccine for the first time. The BC Ministry of Health provides split-virus vaccine. Why Does Influenza Vaccine Have To Be Taken Every Year? Protection from the vaccine generally begins within about 2 weeks after immunization, peaks at about 4-6 weeks and may last 6 months or longer. However, in the elderly, protection may fall off in 4 months or less. When Should You Receive Influenza Vaccine? In order to ensure good protection from late December until early March, the time when most of the flu happens in BC, it is important to time immunization well. The best time to be vaccinated is October to mid-November. In BC, a November 1st start-date has been chosen for the yearly flu vaccination campaign. This start-date is especially important for the elderly and those with chronic medical conditions whose immunity may drop off in 4 months or less. Page 22 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Latex Allergies What is rubber? “Rubber” is a flexible; elastic substance made from either: Sap collected from rubber trees (natural rubber latex) Various artificial mixtures (synthetic rubber) Natural rubber latex contains complex compounds (proteins) that may cause specific health problems. Chemicals added to the natural rubber latex during processing may also cause a particular skin condition. Synthetic (artificial) rubber does not contain any natural rubber latex proteins. Common synthetic rubbers are butyl (isobutylene), neoprene (polychloroprene) and nitrile (acrylonitrile butadiene) rubber. Synthetic rubber does, however, contain some of the same chemicals that are added to natural rubber latex during processing. Therefore, workers using synthetic rubber may develop a particular skin condition due to these chemicals. The words “latex” and “rubber” are often used interchangeably and do not always mean natural rubber latex. For example, latex paints and caulkings are usually synthetic products that do not contain natural rubber latex and its proteins. It is impossible to tell by looking at a rubber product if it is made from natural rubber latex or synthetic rubber. What Health Problems Are Associated With Rubber Products? Not everyone who uses rubber products will develop health problems. Health problems that do occur are grouped into two types of reactions - irritant (non-allergic) reactions and allergic reactions (it is possible to have more than one of these health problems). Irritant reactions Irritant contact dermatitis is a skin rash that results from direct damage to the skin - it is NOT an allergic reaction. It is the most common health problem associated with products like gloves made of either natural rubber latex or synthetic rubber. Factors that may lead to this type of dermatitis include: Irritants such as residual soaps, detergents, hand creams, cleaning materials, disinfectants, and other chemical agents left on the skin are trapped under the gloves, causing skin irritation. Prolonged dampness from sweating in gloves softens the skin, making skin vulnerable to chafing and rubbing by the gloves. Powders inside some gloves (used to make them easier to put on and remove) may adsorb skin oils, drying the skin and causing irritation. Repetitive hand washing may also cause the skin to become dry and irritated, as can using alcohol-based solutions and rough paper towels. Allergic reactions Rubber products may cause over reactions by the body's defense (immune) system, called hypersensitivity or allergic reactions. These reactions are much less common than the irritant reaction mentioned previously, and are caused by substances called antigens. Animal dander, house dust, and pollens are examples of well-known antigens that cause allergic conditions. A common allergic condition is hay fever. Two types of hypersensitivity reactions are associated with rubber products: Rubber chemical allergy Allergic contact dermatitis is a skin rash caused by the body's immune response to the chemicals added during the processing and manufacturing of BOTH natural rubber latex and synthetic rubber. This condition is more common than the natural rubber latex protein allergy. Page 23 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Natural rubber latex protein allergy This allergic reaction is associated ONLY with natural rubber latex products. It is caused by the body's immune response to protein(s) in the natural rubber latex itself. Several symptoms may occur including: Hives Red, watery, itchy eyes Runny nose, sneezing Asthma (wheezing and shortness of breath) In extreme cases, some people may suffer a potentially severe allergic reaction known as anaphylaxis. This reaction occurs within minutes of exposure to proteins in natural rubber latex, and is recognized by the appearance of severe breathing difficulties and falling blood pressure. Left untreated, this reaction may result in death. Anaphylaxis is a medical emergency that requires immediate treatment by a qualified person. Those who are susceptible to this reaction may be advised by their doctors to wear a Medic-Alert bracelet and carry an allergy kit (e.g., Epipen®, Ana-kit®) with them at all times. The kit contains medication that will ease their condition during anaphylaxis until emergency medical personnel can treat them. Sensitization: How do you become allergic? To develop an allergy to something, (e.g., chemical additives or natural rubber latex proteins) you must have been exposed to the substance at least once previously. Your body then develops an immune response, and you become sensitized to it. You probably will not be aware of this at the time you become “sensitized”. You can have an allergic reaction following any subsequent exposure to the substance. Summary of Allergic Reactions Characteristics Cause Route of exposure Once sensitized, time to onset of symptoms after exposure Symptoms Life threatening? Type of Allergy Rubber chemical allergy Natural rubber latex protein allergy (allergic contact dermatitis) Allergic reaction to chemical Allergic reaction to protein(s) only additives in natural rubber latex or in natural rubber latex synthetic rubber Skin contact Direct skin contact. Mucous membrane contact. Inhalation Anywhere from 6 hours to 5 days Usually immediate, anywhere from a few minutes up to one hour. Skin rash only Possible swelling of eyelids, lips, face; watery, itch eyes; runny nose; sneezing, coughing, wheezing; chest tightness; shortness of breath; hives; skin rash; rapid heart rate; low blood pressure. No Potential anaphylaxis What Should I do if I Have A Health Problem That May Be Related To Rubber Products? If you suspect you suffer from symptoms (for example, skin problems or hives) that may be related to rubber products, seek medical attention for assessment, diagnosis, and treatment. Your doctor may refer you to a skin specialist (dermatologist) or an allergy specialist who may conduct tests to determine if a rubber chemical or natural rubber latex protein allergy exists. Page 24 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL If you and your doctor think the problem is work related, report your condition to your supervisor or employer as soon as possible. The person receiving your report must investigate your concerns and ensure any necessary corrective action is taken immediately. How Are You Exposed To Natural Rubber Latex Proteins? You may be exposed to natural rubber latex proteins at or away from work by: Direct contact with a natural rubber latex product If you wear gloves containing natural rubber latex, your skin is in direct contact. If your dentist uses a natural rubber latex dental dam in your mouth, your mucous membranes are in direct contact with the dam. If you use contraceptive barriers such as condoms, diaphragms and cervical caps that may contain natural rubber latex, you are in direct contact. Contact with airborne natural rubber latex proteins Natural rubber latex proteins can bind onto the powder used inside some natural rubber latex gloves. When the gloves are put on and removed, the powder can become airborne. Airborne powder carrying the proteins may be a major cause of natural rubber latex sensitization. The powder may also cause allergic symptoms if it contacts the eyes and other mucous membranes. In addition, airborne powder can be inhaled not only by the glove wearer, but also by others in the area, and cause respiratory symptoms such as wheezing or shortness of breath. Glove powder may stay airborne for a while, or it may settle and contaminate clothing and work surfaces. Who May Be At Risk of Developing A Natural Rubber Latex Protein Allergy? People who have, or have had, repeated exposure to natural rubber latex products may be at higher risk of developing a natural rubber latex protein allergy than those who don't have repeated exposures. Workers who are regularly exposed to natural rubber latex products and in whom health problems have been reported, include: Health care workers such as doctors, nurses, dentists, dental hygienists, lab technicians, etc. {mostly through the use of natural rubber latex gloves) Workers who process and manufacture natural rubber latex products Recently, workers in many other occupations have increased their use of natural rubber latex products (particularly gloves) including: Ambulance attendants, firefighters, police officers, and first aid attendants Housecleaning, janitorial, hairdressing, and food service workers Other workers who wear natural rubber latex gloves for protection Others possibly at risk of developing a natural rubber latex protein allergy may include: People who have had multiple surgeries, childbirth’s or medical procedures, or frequent exposure to natural rubber latex medical products People who have active skin problems (such as irritant or allergic contact dermatitis ) People with allergic conditions (like eczema, hayfever, and asthma) People with certain food allergies (for example, bananas, avocados, chestnuts, kiwi fruits) How Can the Risk of Developing A Natural Rubber Latex Protein Allergy Be Minimized? If you are considered at risk of developing a natural rubber latex protein allergy, minimize your exposure to natural rubber latex products as much as possible. Since many medical and consumer products contain components made of natural rubber latex, completely avoiding these products is difficult. Minimizing exposure to powder from natural rubber latex gloves is also thought to reduce the risk of developing this allergy. Page 25 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Strategies for minimizing exposure to natural rubber latex include: Elimination The most effective method to minimize exposure is to eliminate unnecessary use of natural rubber latex products. For example, some workers use natural rubber latex gloves when there is currently no need to even wear gloves. This may be the case in the food service industry where workers may wear gloves due to concerns about contaminating food. Practicing good personal hygiene, that includes appropriate hand washing, will help prevent food contamination by workers. (In the future, food service workers may not be allowed to contact “ready-to-eat” foods, i.e., foods that do not need further cooking before being eaten, with their bare hands. In this case, utensils and trays can be used to directly handle food and eliminate the need to wear gloves.) Substitution Where it is impossible to eliminate the use of a particular item, substitute the natural rubber latex product with another appropriate one that does not contain natural rubber latex. If there is no such suitable or available substitute, use a product (i.e., gloves) that contains as little natural rubber latex (i.e., low protein) as possible. Also choose low protein natural rubber latex gloves that are powderless. Minimizing exposure If natural rubber latex products must be used, only use them when absolutely necessary and for as short a time as possible. Always wash your hands as soon as possible after wearing natural rubber latex gloves, to remove the natural rubber latex proteins. It may also be possible to wear an underglove that is free of natural rubber latex. This will minimize exposure by direct skin contact. Engineering controls Install effective ventilation in work areas to decrease airborne natural rubber latex proteins. This may be feasible in some industrial applications such as natural rubber latex manufacturing. Administrative Controls These may include: Purchasing policies. Where possible, avoid purchasing natural rubber latex products. If natural rubber latex products are necessary, obtain information from manufacturers on the protein content of their products and choose one (i.e., gloves) with a low protein content. Powderless natural rubber latex gloves are also available. Work procedures. Develop and follow work procedures that eliminate or minimize the use of natural rubber latex products. If powdered natural rubber latex gloves are worn, workers should remove them from their hands without flicking or snapping them. Snapping gloves releases glove powder carrying natural rubber latex proteins into the air. Education and training. Workers exposed to natural rubber latex products need to know which products contain natural rubber latex and what health problems are associated with the products, especially the natural rubber latex protein allergy. To reduce the risk of developing this allergy, workers should be trained in work procedures that reduce their exposure to natural rubber latex. Workers should be instructed to report any health problems that may be related to natural rubber latex to their employer. What If You Must Wear Personal Protective Equipment Like Gloves? Personal protective equipment (such as gloves) may be required to protect workers from biological or chemical hazards. Many gloves are made of natural rubber latex. Other protective equipment such as respirators, aprons, and boots may also contain natural rubber latex. If possible, choose personal protective equipment, like gloves, that is free of natural rubber latex. In some cases, however, it may not be possible to use a product that is not made from natural rubber latex and still obtain the same degree of protection from the hazard. When natural rubber latex products must be used, obtain information from manufacturers on the protein content of their products, and choose a product with a low protein content. Page 26 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Powderless, low-protein natural rubber latex gloves are available, but are not suitable for workers with a confirmed natural rubber latex protein allergy. These workers should only use gloves that are not made from natural rubber latex. The use of powderless, low protein natural rubber latex gloves by co-workers, however, may reduce airborne protein levels enough to allow a sensitized worker to continue working in the same area. It may also help prevent other workers from developing the natural rubber latex protein allergy. Some gloves may be marketed as “hypoallergenic” (i.e., less likely to cause allergy) this term was originally used to indicate that gloves may contain less chemical additives. Such gloves may therefore be suitable for workers with allergic contact dermatitis caused by the chemical additives. However, “hypoallergenic” does not necessarily mean that the gloves are free of natural rubber latex. As such, these gloves may not be suitable for those with a natural rubber latex protein allergy. If gloves are labelled “non-latex” or “latex-free” they should not contain natural rubber latex proteins, but may contain chemical additives. Manufacturers or suppliers of the gloves should be contacted to answer any questions on rubber chemical additives and natural rubber latex protein content. Page 27 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL HOW TO REMOVE DISPOSABLE GLOVES If you have come in contact with blood or body fluids, follow these steps to make sure your hands do not come in contact any contamination that may be on the used gloves: With both hands gloved, grasp the outside of one glove at the top of the wrist. Peel off this glove from wrist to fingertips while turning it inside out, as you pull the glove off your hand and away from you. Hold the glove you just removed in your gloved hand. With the ungloved hand peel off the second glove by inserting your fingers on the inside of the glove at the top of your wrist. Turn the glove inside out while tilting it away from you, leaving the first glove inside the second. Dispose of the entire bundle promptly into a designated refuse container. Wash your hands thoroughly with soap and water as soon as possible after removing gloves and before touching noncontaminated objects and surfaces. A secondary safe precaution is to use a hand sanitizer following had washing and drying. Page 28 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL How Do You Know If You Are Allergic To Natural Rubber Latex Proteins? You should describe to your doctor in detail any adverse reactions you have had to rubber products. Your doctor may then refer you to an allergist. The allergist may test your sensitivity to natural rubber latex and make a diagnosis. Is There A Cure for Natural Rubber Latex Protein Allergy? Currently, there is no “cure” for a natural rubber latex protein allergy. Once you develop this condition, the concern is that the reactions may become more severe after each exposure, or that you may react to lower and lower exposures. It is also possible to have a severe reaction the very first time you are re-exposed, even to a very small amount. What Can You do if You Have A Natural Rubber Latex Protein Allergy? If you do develop a natural rubber latex protein allergy, you must avoid natural rubber latex as much as possible, both at work and away from work. Seek advice and information from your allergist and family doctor. Controlling symptoms with medications while continuing to be exposed may increase sensitivity and severity of reactions. The following are ways to cope with this allergy: Inform your employer (with a note from your doctor) that you must avoid exposure to natural rubber latex. Work with your employer to achieve this; ask for assistance in identifying and modifying your risk. Your employer must investigate the situation, and take corrective action. Contact your company's occupational health and safety department or health nurse, if there is one. Work with purchasing personnel to determine if natural rubber latex products can be eliminated or substituted with products that do not contain natural rubber latex. Consider informing the workplace first aid attendants about your natural rubber latex protein allergy. While your exact medical diagnosis is your personal information, you may choose to tell them that you have this allergy, as this will help them provide you with appropriate first aid if you have an allergic reaction at work. This is particularly important it you suffer from anaphylaxis. Avoid exposure to natural rubber latex products at all times. Directly contact only products free of natural rubber latex and work in an area free of airborne glove powder from natural rubber latex gloves. Low protein, powderless natural rubber latex gloves are not suitable for workers with a natural rubber latex protein allergy. However, if coworkers use such gloves, it may reduce the airborne protein levels enough to allow the sensitized worker to continue working in the same area. General use of these gloves may also help prevent others from developing this condition. A list of products containing natural rubber latex and their alternatives should be made available to workers by their employer. If you have been diagnosed by your doctor as having a natural rubber latex protein allergy, inform other medical practitioners (including dentists) of your allergy before you are examined or treated. This will help ensure that they use products that do not contain or have a minimum amount of natural rubber latex. Scheduling your appointments first thing in the day may minimize exposure to airborne protein from natural rubber latex glove powder. Further precautions may be necessary if you require surgery or hospitalization. Wear a Medic-Alert bracelet that identifies the natural rubber latex protein allergy, and discuss with your doctor the need to carry an allergy kit (e.g. Epipen® Ana-kit®) for use in case of an emergency. Learn how to use the kit. When travelling to areas where medical supplies are limited, carry with you a variety of sizes of gloves that are not made from natural rubber latex, in case you need emergency medical or dental work. Avoid certain foods to which people with natural rubber latex protein allergy also tend to be allergic (for example, bananas, avocados, chestnuts, and kiwi). Page 29 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL What May Contain Natural Rubber Latex? In health care: Gloves, surgical and examination blood pressure cuff tubing catheters, diapers, dental dams, elastic wrap, endotracheal tubes, ambu bags, IV access, medication vial stoppers, oxygen masks, reflex hammers, stethoscope tubing, electrode bulbs, pads, groundings, ventilator circuits, bulb syringes, cannulas, dressings, tourniquet tubing Gtubes, buttons, tapes, jobst spandex products, OR masks, hats, Penrose drains resuscitators, and suction tubing. At other worksites: Art supplies, carpet backing, bandages, rubber bands, erasers, rubber gaskets, rubber mats, rubber stamps, tires, tubes, and rubber gloves. Personal Protective Equipment: Aprons, boots, gloves, and respirators. At home and in the community: Baby bottle nipples, balloons, balls, toys, condoms/diaphragms, crutches- underarm pads and grips, diapers, elastic in clothing, exercise stretch band, foam rubber lining on splints, incontinence pads, rubber pants, soothers, teething rings, wheelchair cushions, handles on sports racquets/tools, and food touched by natural rubber latex gloves. Page 30 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL How To Handle Anthrax and Other Biological Agent Threats For The Most Current Information On This Subject Go To HTTP://WWW.PEP.BC.CA The following information was supplied to BCBC staff in the fall of 2001. There have been numerous reports of suspicious packages and anthrax threat letters being received in British Columbia. Most were empty envelopes; some contained powdery substances. No cases of anthrax have been discovered to date in Canada. DO NOT PANIC Anthrax organisms can cause infection in the skin, gastrointestinal system, or the lungs; however, disease can be prevented after exposure to the anthrax spores by early treatment with the appropriate antibiotics. Anthrax is not spread from one person to another person. Police, health and emergency management organizations have developed a protocol for responding to potential bioterrorism situations. If a suspicious package or situation is discovered we advise staff to observe the following protocol. If you receive or discover a suspicious envelope or package: 1. 2. 3. 4. 5. 6. 7. 8. Do not shake or empty the contents of any suspicious envelope or package. PLACE the envelope or package in a plastic bag or some other type of container to prevent leakage of contents. If you do not have a container, then COVER the envelope or package with anything (e.g., clothing, paper, trash can, etc.) and do not remove the cover. Section off the area to prevent others from entering (i.e., keep others away). Remain away from other people until otherwise instructed. WASH your hands with soap and water to prevent spreading any powder to your face. What to do next… If you are at HOME, then report the incident to local police. If you are at WORK, then report the incident to local police, and notify your building security official or an available supervisor. LIST all people who were in the room or area when this suspicious letter or package was recognized. Keep this list as it may be required by local public health authorities or law enforcement officials. The police, in consultation with other BC emergency service providers, will recommend any further action that should be taken. Page 31 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL If you open an envelope or package and you find a threat and it contains powder, what should you do? 1. DO NOT try to CLEAN UP the powder. COVER the spilled contents immediately with anything (e.g., clothing, paper, trash can, etc.) and do not remove this cover! 2. Then LEAVE the room and CLOSE the door, or section off the area to prevent others from entering (i.e., keep others away). 3. WASH your hands with soap and water to prevent spreading any powder to your face. 4. What to do next… Stay where you are and: If you are at HOME, then report the incident to local police. If you are at WORK, then report the incident to local police, and notify your building security official or an available supervisor. 5. REMOVE ONLY heavily contaminated outer clothing as soon as possible and place in a plastic bag, or some other container that can be sealed. This clothing should be kept in the bag/container until further instructions are given. 6. 6.SHOWER with soap and water as soon as possible. Do Not Use Bleach Or Other Disinfectant On Your Skin. 7. If possible, list all people who were in the room or area, especially those who had actual contact with the powder. Keep this list as it may be required by local public health authorities or law enforcement officials. 8. The police, in consultation with other BC emergency service providers, will recommend any further action that should be taken. If there is a concern or question of room contamination by aerosolization (warning that airhandling system is contaminated, or warning that a biological agent has been released in a public space) what should you do? 1. 2. 3. Turn off local fans or ventilation units in the area. LEAVE area immediately. CLOSE the door, or section off the area to prevent others from entering (i.e., keep others away). 4. What to do next… If you are at HOME, dial “911” or report the incident to local police. If you are at WORK, dial “911” or report the incident to local police and notify your building security official or an available supervisor. 5. If appropriate SHUT down air handling system in the area, if possible. 6. If possible, list all people who were in the room or area. Keep this list as it may be required by local public health authorities or law enforcement officials. 7. The police, in consultation with other BC emergency service providers, will recommend any further action that should be taken. Page 32 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Ozone BCBC Does not use ozone generating devices for everyday use and we strongly recommend that our clients don't use them because of the health concerns associated with them. Ozone generating devices have commonly been marketed to building occupants and homeowners to eliminate indoor aircontaminants, odours and produce a "fresh" indoor smell. Ozone, even in low concentrations, does pose a health risk to those with chronic lung conditions (including asthma), the very young and the very old. People fitting this profile do work and visit government buildings. Research Has indicated that ozone actually doesn't eliminate the problem chemicals - it's free radical activity simply converts odourous contaminants to other chemical compounds - these are often associated with less odour, but may be more hazardous than the primary contaminants. Ozone-Generating Devices May have a role as part of a building remediation process following fire damage to reduce or eliminate smoke odours. In this case, I recommend that the client be notified, in advance, that the device(s) will be used and indicate that personnel should not be present during its operation. The device(s) should be used during the weekend when the building does not need to be occupied. The area should be well ventilated after use, to reduce the amount of residual ozone in the space prior to the space being occupied at the start of business on Monday." Bedbugs A wingless blood sucking bug-reddish brown in color (Cimex Lectularis). Found in bedding, cracks, crevices in walls and ground baseboards. Their presence are detected by their odor, blood stains and excretory spots. Generally cleanliness is the first line of defense. Cockroaches Cockroaches are pale tan, mahogany or black in color with long slender antennae. The 4 types or roaches most commonly found in institutions are: 1. The German roach-Blatella Germanica-the craton bug. 2. Brown-banded roach- Supella Supelectillium. 3. Oriental roach- Blatella Orientalis-Shad roach. 4. American Roach- Periplanetta Americana- The Bombay Canary The Cockroach is an ancient creature that has adapted itself to the abode of man and can be the most troublesome insect in an institution. The offensive secretions of these insects, and their loathsome habit of crawling on filfth, then onto dishes and food; has made them among the most despised of vermin. They are also potential carriers of disease. Control measures include complete cleanliness and removal or denial of access to food, storing foods properly in closed containers. and use of insecticides. Certified pest control firms are licensed to treat cockroach infestation. Page 33 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Clostridium Difficile Colostridium difficile is a spore forming, gram positive anaerobic basillus that produces two exotoxins: Toxin A and Toxin B. It is the most common cause of antibiotic-associated diarrhea (AAD). It accounts for 15-25% of all episodes of ADD. The strain largely exists in Canada; however by late 2004 the threat of it moving into the United States was not unrealistic. The clinical symptoms of associated with Colostridium difficile: Watery diarrhea Fever Loss of appetite Nausea Abdominal pain/tenderness The complications from Colostridium difficile-associated dissease: Pseudomembranous colitis (PMC) Toxic ,egacolon Perforations of the colon Sepsis Death (rarely) How is it transmitted Colostridium difficile is shed in feces. Any surface, device or material (e.g. commodes, bathing tubs, and electronic rectal thermometers that become contaminated with feces may serve as a reservoir for these spores. The spores are transferred to patients mainly by the hands of healthcare personnel who have touched a contaminated surface or item. Keeping it under control Difficile can be life threatening, but keeping a clean and safe environment is paramount to keeping this bacteria under control. Keeping cleaning staff educated as to the dangers of ineffective cleaning practices will help protect facilities, patients and guests and where advised that it does exist using ‘Contract Precautions’. Page 34 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL E coli (Some Basics) Escherichia coli has been recognized as a common place microorganism found in the intestinal tract of man and other warm blooded animals. This species has served as an indicator for fecal contamination in water, food and so on. Now E coli 0157:H7 has emerged in the last decade to gain our respect as a foodborne pathogen. The bacterium is a facultative anaerobe which means it can survive in the presence or absence of oxygen. It is Gram negative bacterium which is not fastidious in it's nutritional requirements. The organism causes hemolytic uremic syndrome (HUS). Symptoms include severe stomach pain, fever in roughly one-third of the cases and severe diarrhea for at least two days which can lead to bloody diarrhea. The symptoms generally occur within three days of ingestion which is the time needed for the toxin to produce symptoms in the patient. People at risk for serious illness are children under the age of 10 years and elderly people. There are serious complications that can arise if the symptoms go untreated. The disease can be spread as long as the patient is shedding the organism in the stool. "The microbe was thought to be typically transmitted by food through ingestion of improperly cooked meat. More recently the pathogen has been found to be spread through fruits and vegetables as the organism is in fertilizer used in food production accompanied by the food not being properly washed prior to consuming. Also, bacteria on hands of daycare providers after diapering can be spread if thorough hand washing has not occurred". The pathogenic cycle can be stopped with proper cooking of meat or poultry, washing raw foods properly prior to consumption, thorough hand washing during the cooking process and in child or elderly care settings. Using antimicrobial products such as hard surface disinfectants and sanitizers as well as effective hand washing will aid in breaking the pathogenic cycle. Hamburger Disease (Hemorrhagic Colitis) What Is It? Despite the many pleasures of summer, it's important not to become an unwitting, complacent victim of “hamburger” disease. It is also known as “barbecue season syndrome” because it happens to people more often in the summer, when people cook hamburgers on barbecues and don't cook the ground meat well enough. The medical name for hamburger disease is Hemorrhagic Colitis. This disease is a form of food poisoning caused by the E. coli bacteria. E. coli bacteria are often found in under-cooked meats, especially in ground beef. What Are the Symptoms? Infection is characterized by watery diarrhea, which in serious cases may become quite bloody. Vomiting, abdominal cramps and a mild fever may also accompany the diarrhea. The symptoms, which can start about two days after eating contaminated food, typically last between five and ten days. In a small number of cases, the E. coli toxin (or poison) results in a serious, sometimes fatal illness called Hemolytic Uremic Syndrome (HUS). This can result in kidney failure, anemia, and internal bleeding, and can be especially dangerous to young children and the elderly. Where Does the Disease Come From? The bacteria that produce these toxins (or poisons) are found in most food animals, including beef, pork, and poultry products. Human infection is usually caused either by eating under-cooked meat or by drinking unpasteurized milk. Ground meat is particularly hazardous, compared to whole pieces of meat like steaks and chops. This is because the bacteria, which get onto the surfaces of cut meat during the butchering process, get mixed right through the meat during the grinding process. Page 35 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL How Do You Avoid Contracting This Disease? In British Columbia, as many as 400 cases of hamburger disease is reported every year. It is thought that many thousands of other, less serious cases are not reported to local health officials. Your best protection against getting infected with E. coli is a combination of two things: preparing your food safely in the first place, and then cooking it well. Refrigerate or freeze meat as soon as possible after buying; Thaw meat in the refrigerator, not at room temperature; Wash your hands thoroughly before preparing food, after handling raw meat, and after using the toilet; Either cook the hamburger patties right away, or keep them in the refrigerator until you are ready to cook them. Don't let raw meat sit around at room temperature; Wash and sanitize all utensils, cutting boards and counters to prevent bacteria from raw meats from contaminating other foods; You can make an effective sanitizing solution by mixing one half ounce of bleach into a gallon of water, or a teaspoon of bleach in a liter of water; Cook all meats thoroughly the center of a properly cooked hamburger patty should be brown, not pink, and the juices should run clear; Serve cooked meats immediately or keep them hot (above 140 degrees F) until you are ready to serve them. What About Treatment for the Disease? Anyone who has cramps and/or bloody diarrhea should consult their physician. Drinking lots of clear fluids is important. Do not take anti-diarrhea medicine unless you first consult your physician. Hepatitis C What Is Hepatitis C? Hepatitis C is a disease of the liver caused by the hepatitis C virus (HCV). Hepatitis C was identified in 1989. Before 1989, this type of hepatitis was called non-A, non-B hepatitis, meaning that it was not caused by the viruses that produce hepatitis A or hepatitis B (two other viruses that can cause hepatitis). How Common Is Hepatitis C? The total number of people in Canada who have hepatitis C is believed to be between 90,000 and 300,000. This means that up to one in every one hundred people in Canada have hepatitis C. Most of these people have not been tested and do not know they have the disease. It is not possible to tell by looking at a person whether they have hepatitis C. All blood products and donors in Canada are now tested for hepatitis C. The rate of hepatitis C infection in transfused patients in Canada is now near zero. People at higher risk of having hepatitis C infection include: People who have received a blood transfusion or blood product before 1990; People who have received an organ or tissue transplant before 1990; or Those who have used injection drugs. Although information on hepatitis C in other countries, particularly in the developing world, is less available, there may be a higher risk in countries where the blood supply is not tested or where contamination can occur through Page 36 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL medical procedures. People who come to Canada from such countries, including internationally adopted children, should consider having HCV testing. What Are the Symptoms of Hepatitis C? Some people feel well, have no symptoms and, therefore, don't know they have hepatitis C infection. Other people may have a brief illness with symptoms of hepatitis usually appearing six to nine weeks after they have been infected with the virus. Symptoms of acute hepatitis C infection may include: fever, tiredness, jaundice (yellow skin or eyes), abdominal pain, dark urine, loss of appetite, nausea (sick to your stomach). Other people will begin to experience long-term health concerns which are difficult to diagnose (for example, tiredness, lack of energy, or digestive problems). How Can I Tell If I Have Hepatitis C? After the hepatitis C virus infects your body, antibodies appear in your blood. A blood test can detect these antibodies and show if you have been infected with the hepatitis C virus. However, these tests do not show whether you are still carrying the virus in your body. So, if you have tested positive for the virus, assume you are infected and can infect other people. Is There A Treatment for Hepatitis C? People who test positive for hepatitis C should see their family doctor regularly and have their blood tested to see how their liver is functioning. They may also be referred to a specialist for further testing and assessment. Some people with hepatitis C may be offered treatment with anti-viral drugs, such as interferon. In rare instances those with advanced liver damage from hepatitis C require liver transplantation. How Is the Hepatitis C Virus Spread? The virus is usually spread by direct contact with the blood of an infected person. This happens most often by: Having received a transfusion of blood or blood product in a country where the blood supply is not tested for hepatitis C. In Canada, this applies only to transfusions before 1990. As of June 1990 all blood and blood products have been screened Used needle and syringe; or Sharing drug snorting or injection equipment such as needles and syringes. On the street, some of this equipment may be known as rigs, works, and water. Other situations where blood-to-blood contact from a hepatitis C infected person can occur but where the risk is much lower include: Sharing toothbrushes, dental floss, razors, nail files, or other items which could have tiny amounts of blood on them; Skin-piercing procedures such as tattoos, body-piercing, acupuncture or electrolysis if the equipment is not sterile; Unprotected sexual intercourse; An infected mother passing it to her newborn infant. Whether breast milk can transmit the virus is not yet known. Avoiding these situations can help to prevent you from becoming infected with hepatitis C. Page 37 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Lice What Is Lice? Lice are called ectoparisites because they live outside the host's body. They are wingless parasites of warm blooded animals . There are three types of human lice, which are usually, but not always, confined to a certain part of the body. They are named according to the region of the body that they infest or their general appearance: head louse, body louse, and pubic or crab louse. These creatures cannot fly or jump, but head and body lice can move quickly, passing rapidly from host to host. Head Lice: (Head Louse- Pediculus Humanus Capitus) Head lice generally prefer the fine hairs of the head, especially around the ears and the nape of the neck, or eyebrows and eyelashes. Adult larvae and nits are visible to the naked eye: Adult lice are reddish-brown Unhatched eggs are pearly white Hatched eggs are translucent Itching is common and secondary bacterial infections may occur due to scratching. Articles of clothing that cannot be machine-washed may be dry cleaned OR sealed in a plastic bag for no less than 10 days. Body Lice: (Body Louse- Pediculus Humanus Humanus) Body lice are found on clothing (inside seams) and they reach from the clothing to suck blood from the host. The infested person may be covered with hemorrhagic macules and papules where skin has been punctured, and vertical scratch marks may be found which follow clothing seams. Articles that cannot be machine-washed may be dry cleaned OR sealed in a plastic bag for no less than 30 days. Pubic Lice (Crab Louse or Public Louse-Phthirus Pubis)) Pubic lice infest the hairs in the pubic area. They also infest hair of the face (including eyelashes), axillae and body surfaces. Pubic lice is common. Crab lice - Articles that cannot be machine-washed may be dry cleaned OR sealed in a plastic bag for no less than 24 hours. Infectious Period Lice can be transmitted up until the time they are eradicated by treatment with permethrin (NIX). Patients admitted to hospital with lice (pediculosis) or patients who develop it after admission are placed on isolation precautions for 48 hours following treatment. Transmission Lice are transmitted through direct or indirect contact Head lice are transmitted through contact with infested hair or with articles such as brushes, combs, headgear or clothing of the infected person. Transmission of pubic lice is usually by sexual contact. Treatment NIX cream or lotion, depending whether hair or body requires treatment, may be ordered from Pharmacy. For Head Lice, the preferred treatment is I % Permethrin cream rinse. This is used after the hair is shampooed and towel dried. In some studies, 1-% permethrin cream rinse was 99% efficacious compared with Lindane, and is less Page 38 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL toxic. Permethrin remains on the hair at considerable levels for at least two weeks, despite repeated normal shampooing. Pubic Lice are more difficult to eradicate, and two treatments are recommended regardless of using either 1% Lindane or I % Permethrin. Some studies show that 40% of patients treated remain infested with pubic lice, hence the need for a second treatment. The treatment of Body Lice initially is to remove the patient from the environment associated with the infestations, and disposal or sterilization of the clothing. If this is not effective, then a single head-to-toe treatment of 1% Lindane is usually sufficient to kill any stray lice, which may be present on the body. Lindane should only be used after this has been tried. Two single treatments of 5% Permethrin is also effective. To reduce the risk of spreading lice machine-wash articles such as clothing, towels and bedding and items that cannot be machine-washed may be dry cleaned OR sealed in a plastic bag for no less than 10 days. Thoroughly vacuum carpets, upholstered furniture, pillows and mattresses. Methicillin Resistant Staphylococcus Aureus (MRSA) What is MRSA (along with VRE referred to as ARO's- Antibiotic resistant organisms)? MRSA (Methicillin-Resistant Staphylococcus Aureus) is a strain of a common organism, Staphylococcus aureus that has become resistant to Methicillin (which is the British equivalent to Cloxacillin, the standard treatment for this organism). It was named in Britain where it was discovered. The organism is also usually resistant to Oxacillin, Cefazolin, Nafcillin, and, often, Tetracycline and Gentamycin. It is a worldwide problem and is on the increase. Positive MRSA cultures may indicate: Colonization – This occurs when the organism is multiplying in or on a body site, but no clinical signs and/or symptoms, or immune response occurs. Common areas of colonization are the anterior nares (nostrils) and skin folds. A person who is colonized with MRSA is able to transmit it to another, which can result in MRSA infection. Infection - This occurs when the organism has entered a body site, is multiplying in tissue and is causing the clinical manifestations of disease - fever, draining wound or immune response. MRSA is more likely to infect someone who is susceptible, usually the weak or elderly. How is MRSA Spread? The most common means of spreading MRSA is by direct hand contact. (Hands may become contaminated by contact with patients who have MRSA). Those who have MRSA in their nostrils (nasal carriers) may touch their noses with their hands and then transmit the organism to someone else. Colonization of the health care worker may occur if hands are not washed and barriers (such as gowns and gloves) are not properly used. Why is MRSA a Problem? While a number of cost-effective antibiotics are available for treating regular Staphylococcus aureus infections, it is not the same for MRSA. MRSA is sensitive to few antibiotics, the main one being Vancomycin, which costs approximately $600 for ten days treatment, and is a more toxic antibiotic to use than Cloxacillin. Once MRSA becomes established in a health care facility, it is very difficult to remove. Page 39 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL How to Keep MRSA Under Control Isolation should be initiated when the preliminary lab report suggests Cloxacillin resistance. Sometimes the preliminary resistance may be incorrect, in which case the isolation may be discontinued. The person is to be placed in a private room. Gloves are to be used for all contact with the person; must be worn by all persons having direct contact with the person and must be changed appropriately between procedures on the same person. Hands are to be washed; after contact with the person and after removing gloves. Isolation gowns are to be worn prior to any contact with person and must be removed before leaving the person's room. Do not reuse the person’s equipment without first having it cleaned or disinfected. People with MRSA leaving their room for procedures must wash hands, and put on a gown. If the MRSA person is sent to another area, the receiving area must be advised of the isolation procedures. Necrotizing Fasciitis (Flesh-Eating Disease) What Is It? Necrotizing fasciitis (neck-roe-tie-zing fa-shee-eye-tis) is more commonly known by the public as flesh-eating disease. The disease got this nickname as it can spread through human tissue (flesh), destroying it at a rate of almost three centimeters per hour in some cases death can occur within 18 hours. When the bacteria spread along the layers of tissue that surround muscle (called the fascia), it is called necrotizing fasciitis. What are the symptoms of the disease? Symptoms include fever, feeling unwell, redness and severe pain at the site of the infection. The original site of infection may be a minor wound or injury such as a small cut or bruise. The infection can spread up the affected arm, leg, or other body part very quickly. An important clue to this disease is very severe pain that is out of proportion to what you would expect from the type of wound or injury you may have had. However, necrotizing fasciitis has also occurred when there has been no known wound or injury. What Causes It? Necrotizing fasciitis is caused by a number of different bacteria; one of them is the Group A streptococcus. These bacteria also cause sore or strep throat, scarlet fever, impetigo, and rheumatic fever. Researchers do not know why the normally mild Group A streptococcus bacterium sometimes acts in a destructive way and cause necrotizing fasciitis. Many scientists believe the bacteria makes proteins that destroy body tissue directly, as well as causing the body's immune system to destroy its own tissue while fighting the bacteria. How Is It Spread? The Group A streptococcus is often found in the nose and throats of healthy people. It is normally passed from person to person through close personal contact with an infected person, such as through kissing, sharing forks or spoons or cigarettes. Those at highest risk are: Persons living in the same household; People who share the same sleeping arrangements; or People who have direct contact with the mouth or nose secretions of the case. Page 40 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL How Can It Be Prevented? There is no vaccine to prevent Group A streptococcal infection. Antibiotics are recommended for close contacts of cases of necrotizing fasciitis caused by Group A streptococcus (for example, persons living in the same household). Since this severe form of streptococcal infection can progress so rapidly, the best approach is to seek medical attention as soon as telltale symptoms occur. Remember -an important clue to this disease is very severe pain at the site of infection. It also makes good sense to always take good care of minor cuts, to reduce the chance of infection getting into the tissues under the skin. How Is It Treated? Antibiotics are an important part of the treatment for these infections. However, antibiotics on their own are not usually enough. This is because necrotizing fasciitis cuts off the blood supply to body tissue, and the antibiotics must be carried by blood to the infected site in order to work. Surgery, combined with antibiotics is the usual treatment. However, researchers are investigating other methods that can be used to supplement antibiotics and surgery. What Are My Chances of Getting It? Your chances of getting necrotizing fasciitis caused by Group A streptococcus are very low. In BC, about 2 or 3 out of 1 million persons get it per year. It is important to remember that even for those who have close, prolonged contact with a person with necrotizing fasciitis, the chance of getting it is very low. Some people are known to have a higher risk of getting the disease. Illicit injection drug use is the most important risk factor. Other risk factors include skin wounds (burn, trauma, surgery), immunosuppression due to disease (e.g. HIV/AIDS), other chronic disease (e.g. chronic heart, lung or liver disease, alcoholism), chicken pox, and recent close contact with a person who had necrotizing fasciitis caused by Group A. Norwalk Virus and Norwalk-like virus (NVL). Norwalk is a common cause of food poising-it rates fifth in the top 10 causes of food poisoning. Norwalk is called a 'emerging pathogen". It was identified and labeled as recently as 1972 from a fecal sample taken during a 1963 outbreak in Norwalk, Ohio. Family name- Norwalk and NVL are ion the family of viruses called Calicviridea (calici means cup like) Genus name- Norovirus Species name- there are several species and each species can have several strains. These are non-enveloped viruses. 'See Viruses for explanation.' The BC Centre for Disease Control describes the Norwalk-like virus as a form of viral gastroenteritis. Different from influenza, which causes symptoms such as cough, sore throat, fever and muscle aches that last up to five days. NVL (norwalk like virus) presents itself with sudden onset of nausea, cramping, chills and fever. Vomiting and diarrhea are part of the package. Norwalk because it is a gastrointestinal complaint is often mistaken for stomach flu because it brings with it flu-like symptoms such as fever, cramping, chills and vomiting. Norwalk is a very easily transmitted fast-acting virus that usually runs its course of vomiting and diarrhea in a few days. It can be spread through the stool and vomit of the infected person; as well it can be spread through food, water or ice handled by a sick persons and also by minute droplets in the air. These minute droplets can be inhaled through the nose or mouth or land on objects such as countertops, toys, sinks and taps etc. where it can survive for several days. The best defense against it spread is proper hand-washing. The daily thorough cleaning with a good quality germicidal detergent is of course essential to all hand touchable surfaces in a health care setting. By 2003 there is a move in some facilities particularly in the USA to use an Accelerated Hydrogen Peroxide formula, not for the general cleaning, but for the thorough disinfecting of surfaces where an outbreak of the Norwalk virus exists. If there is an outbreak, irrespective of what product is used for the cleaning, swab testing after thorough cleaning is the only way one will know if the virus has been eliminated from the suspect surfaces. Page 41 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Ease of transmission is the main reason Norwalk is common in nursing homes, daycare's, schools, children's camps and cruise ships. High loss of body fluid can be deadly to the elderly and the very young and those with compromised immune systems. What are the Symptoms of the Norwalk Virus Norwalk Virus usually lasts from 48-72 hours but since it is a virus there is no antibiotic. vomiting diarrhea cramping chills Treatment of the Norwalk Virus Just keeping up with the fluid losses is not enough. Effected persons need to rehydrate with an over-the-counter electrolyte replacement drink. Disinfection of Norwalk This virus is so infectious that even if just one infected person carries Norwalk into a hospital emergency room or goes to visit their relative at another facility, the result (12-24 hours later) could be the start of a Norwalk outbreak. For Healthcare facilities Noroviruses are a real impact to the budget because they are so difficult to kill and so easily transmitted from people, objects and from the air. To disinfect Norwalk and NVL from surfaces the USA Centre For Disease Control in Atlanta, GA, recommends three types of disinfectants, Bleach, Phenolics and Accelerated Hydrogen Peroxide. Not recommended by the USA's CDC are quaternary ammonium chloride disinfectants. The inclusion of phenolics in this list of disinfectants is controversial. Most textbooks don't include phenolic compounds for reliable disinfection of non-enveloped viruses. The USA, CDC recommendation is based upon a study claiming that a double-strength phenolic solution would be sufficient to kill the viruses. If a phenolic disinfectant is used it cannot be used around children or any food contact surfaces, aside from this phenolics are extremely corrosive and detrimental to the user and by the year 2003 you rarely see it in use. The recommended concentration of bleach varies depending on which study you read, although a 10 minute contact time is universal. The USA CDC recommends a 1,000 parts per million dilution-approximately 1:50 of household bleach and water. Other studies recommend a dilution of 1:9. Neither of these dilutions would be safe for use on fabrics or carpets and could cause serious damage to floor coatings and other hard surfaces. Dr. Syed Satter of the Centre of Research on Environmental Microbiology at the University of Ottawa is the lead researcher into applications of Accelerated Hydrogen Peroxide. He is quoted as having determined that the Canadian made disinfectants are effective against non-enveloped viruses like Norwalk in their regular dilution and at a five minute contact time. These chemicals once diluted are safe for use on all surfaces including fabrics, although prolonged contact with soft metals like brass and copper might cause mild corrosion. The problem is none of these disinfectants have ever been tested directly against Norwalk or NVL. Human Caliciviruses won't grow in the lab so researchers use Feline Calicivirus as a surrogate. It is for this reason that chemical manufacturers can't make claims on their labels that they can kill Norwalk. The Management of a Norwalk Outbreak The management of Norwalk outbreak requires particular attention to two things: Hand Hygiene and effective disinfection. Healthcare facilities with good hand washing practices and well-run, well financed housekeeping departments have a head start. Page 42 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Hand washing is critical. The use of alcohol hand sanitizers is recommended for day-to-day use and during any outbreak, although for non-enveloped viruses alcohol, is no more effective than hand washing with soap and water. The use of antiseptic hand soap provides no added benefit over regular hand soap and could even be detrimental. There are some who say that during the normal course of cleaning a hospital, ordinary detergents are satisfactory for most surfaces and disinfection is necessary only in special areas however most facilities still use a good quality pH balanced quaternary germicidal detergent solution just to be on the safe side. In the USA during suspected or confirmed Norwalk/NVL outbreak, hard surfaces should be cleaned well and then disinfected with diluted bleach or an Accelerated Hydrogen Peroxide product. The BC Centre for Disease Control only recognizes the use of a diluted bleach solution. Disinfecting is particularly important in washrooms that are used by more than one person. Fabric and carpets which would obviously be damaged by bleach should be cleaned with water art a temperature of at least 71 degrees Celsius (160 degrees F.) which would mean truck- mounted extractor or portables with an internal heater. Speed of response is critical. For eg. if infected vomit is allowed to sit on a floor, countertop or sink etc. and untreated even for a short period of time, many others in the area can be infected. It has to be cleaned up and disinfected as soon as possible, but not with a vacuum. The Norovirus is very small and will easily pass through even a Hepa vacuum filter. Prime targets Professional cleaning staff are prime targets for Norwalk/NVL. If they do not wash their hands often, especially after removing their gloves, they are very vulnerable. The Best Deterrent for Norwalk The simplest way to stay ahead of the Norwalk: Wash your hands-clean your surroundings and hope you do not get an invasion. Scabies What Is Scabies? Scabies is an infection of the skin caused by a very small insect-like parasite called a mite. How Is Scabies Spread? Scabies is usually spread by direct skin to skin contact with an infected person. Exchanging clothes and towels or sharing a bed are less common ways of contracting scabies. Some people arc embarrassed to discover they have scabies, even though it can be caught by anyone and does not indicate poor personal hygiene. What Are the Symptoms? The female scabies mite lays her eggs just under the surface of the skin. These eggs hatch in three to four days, then move out to the surface or the skin where they mature. There they mate and repeat the life cycle, gradually spreading the infestation. For four to six weeks after infection there may be no symptoms, then the person will usually begin to feel an intense itchiness, which is often worse at night. A red rash will accompany the itchiness. The most common rash sites include the webs between the fingers, the insides of the wrists and elbows, the breasts, the male genitals, the abdomen, the back, and buttocks. Scabies are rarely found above the neck, except in infants. How Do You Know If You Have Scabies? The most common sign of scabies is persistent, increasingly severe itching. Page 43 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL In severe cases, the tiny, grey-white scabies “burrows” can sometimes be seen. They look like wavy, raised threads just under the skin surface. Because itching and skin rashes have many causes, only your doctor can say for sure if you have scabies. Your doctor does this by looking at a tiny sample of skin scrapings under the microscope. How Is Scabies Treated? You should see your doctor for advice on treatment for scabies. There are a number of lotions or creams that can be obtained from pharmacies. It is important to read the label carefully and follow directions exactly. Remember to put on clean clothes and bedding after the treatment. Launder all recently used clothing, towels, kitchen linens and bed linens in hot water and detergent. Any clothing that cannot be laundered should be stored for at least fourteen days before reusing. Preventing the Spread of Vancomycin-Resistant Enterococci (VRE) Epidemiology of VRE (also with MRSA referred to as ARO's) Enterococcus species are now recognized as important nosocomial pathogens. They have emerged as the second or third most common cause of nosocomial infections. Since the automated procedures used in many clinical laboratories do not efficiently detect vancomycin resistance, concerns have been raised that moderate vancomycin resistance has been unrecognized in many U.S. health care facilities. The prevalence of VRE has increased in Europe over the past 10 years since being identified in 1986. The epidemiology of VRE in Canada has not been fully elucidated. The first isolates, from two patients, were reported in 1993. Although sporadic reports of small numbers of colonized and/or infected patients have been made, the first outbreak of VRE in Canada occurred in the autumn of 1995 and involved 38 patients, the majority of whom were receiving dialysis. Microbiology of Enterococci For many years, enterococci were considered relatively harmless avirulent flora with little potential for human infection. They are found as normal commensal flora of the gastrointestinal tract in 95% of healthy individuals and as non-pathogenic colonizing flora in the vagina, oral cavity, perineal area, hepatobiliary tract, and upper respiratory tract. Open wounds and decubitus ulcers may act as reservoirs for enterococci. The most commonly encountered species include Enterococcus faecalis (E. faecalis) and E faecium. Enterococci are hardy organisms and are able to survive on environmental surfaces for extended periods. Several studies have found multi-resistant strains of enterococci on various objects in the patient's environment, including bed rails, night tables, curtains, bathroom sinks, toilet rings, electronic thermometers, and other patient-care equipment. Antibiotic Resistance in Enterococci Enterococcal species are intrinsically resistant to many antibiotics and have demonstrated a remarkable capacity to acquire resistance. Enterococci have constitutive resistance to cephalosporins, penicillinase resistant penicillins, clindamycin, low-level aminoglycosides, and probably trimethoprim-sulfamethoxazole. Over the past 2 decades there have been an increasing number of reports of Enterococcus species with induced resistance to multiple antibiotics, and therapeutic options have become increasingly limited. The first evidence of high level resistance of Enterococcus species to streptomycin and gentamicin was documented in the 1970s, and during the 1980s the prevalence of these resistant strains increased dramatically in several locales in North America and Europe. Page 44 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL The development of resistance to vancomycin, which is potentially much more problematic, was first reported in Europe in 1986. Since then, outbreaks of VRE infections have been described in several institutions and other health settings in the United States. The vancomycin-resistance trait in Enterococcus species is transferable, and perhaps the greatest threat of VRE is the potential emergence of vancomycin resistance in methicillin-resistant Staphylococcus aureus (S. aureus), which would create a major concern. Risk Factors for VRE Several studies have identified risk factors for VRE infection and/or colonization. These factors include previous antibiotic therapy, multiple antibiotic therapy, vancomycin therapy, indwelling Foley catheters, central venous catheterization, renal insufficiency, increased duration of hospital stay, multiple hospital admissions, and the elderly population. These studies have demonstrated the transmission of VRE by direct patient contact or by carriage on the hands of health care personnel, contaminated environmental surfaces and contaminated patient care equipment. Environmental contamination is attributed largely to heavy shedding as may be more often seen in patients with diarrhea or fecal incontinence, or uncontained draining wounds. Recommendations The use of a single room with a private bathroom is essential for VRE positive patients with diarrhea, fecal incontinence, an ileostomy or colostomy, or open wounds, or in whom illness or age may compromise basic personal hygienic practices. Infants, toddlers, and cognitively or functionally impaired elderly patients are unaware of good hygienic practices. The large amount of hands-on care they require increases the likelihood of infection being transmitted or acquired. Therefore, education of parents and family members about the role of good hand washing and prompt disposal of diapers and soiled garments in the prevention of VRE transmission is of utmost importance. Health care personnel should wear gloves and gowns when entering the room of a patient who has been placed in isolation. It is important to change gloves between patient care tasks. Gloves and gowns should be removed before leaving the patient's room and hands washed carefully with an antiseptic agent or an antiseptic hand rinse if sinks are not readily available. After hand washing, the hands should not contact potentially contaminated environmental surfaces in the patient's room. For patients in isolation, equipment such as stethoscopes, blood pressure cuffs, scales, and all thermometers and thermometer components, including the electronic thermometer base should remain in the room to be used with the patient colonized/infected with VRE. These items should be cleaned and appropriately disinfected before being used with other patients. Screening surveys (perirectal swabs or stools, cultures of open wounds and drainages) should be conducted of roommates of patients newly found to be VRE positive. There should be a policy for discontinuation of isolation. The optimal requirements are unknown, and individual discretion is required based on the setting, the patient population and other factors. A facility may choose to discontinue isolation precautions once the patient is reasonably well, continent of stool and cable of self-care with good hygiene. Policies must be in place for the thorough cleaning and disinfection of environmental surfaces {bed rails, call bells, bedside tables, commodes, bathrooms) that may have been contaminated. All items must be cleaned using separate cloths. pH balanced quaternary germicidal detergents with VRE/MRSA claims are effective for cleaning when special attention is given to visibly soiled areas. Communication with housekeeping, nursing and administrative personnel is of particular importance in this setting. Transfers to other facilities such as long term care, rehabilitation, or other acute care facilities should not be delayed for patients who are colonized or infected with VRE. The facility receiving the patient should be notified that the patient has VRE. It should be able to provide appropriate isolation and care based on the assessment of the individual patient. Page 45 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL SARS Threat Emphasizes Need for Disinfection, Proper Cleaning With severe acute respiratory syndrome (SARS) spreading in Asia at a rate of about 200 cases a week, and people around the world looking for ways to protect themselves from this potentially deadly disease. The World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), and other public health organizations continue to investigate the SARS virus, but as of June 2003 there is no known prevention or cure. While no disinfectant products are registered by the Environmental Protection Agency (EPA) to kill the viruses associated with SARS, similar viruses can be inactivated by EPA-registered germicides that provide low- or intermediate-level disinfection during general use. Manufacturers are offering product recommendations and guidelines for battling the spread of the virus, which features fever and pneumonia like symptoms. THE CDC states that SARS appears to be spread primarily via aerosol from the cough or sneeze of an infected individual, which is subsequently inhaled by an uninfected individual in close proximity. The virus may also persist on environmental surfaces for several hours before becoming inactive. THE CDC recommends frequent, aggressive hand washing and the use of alcohol-based hand rubs if contact with a SARS infected individual is suspected. DISPOSABLE GLOVES should be worn during cleaning procedures. If feasible, opening the windows in the room during housekeeping duties can reduce concentration of potential aerosols in the air. Fans can also be used to achieve air exchange with the exterior. PROPER HAND WASHING should be performed between room cleanings to minimize cross-contamination is perhaps the most important factor in preventing transmission. Hands can be washed with water and appropriate hand soap. If hands are not visibly soiled, an appropriate alcohol-based sanitizer can be used. GERMICIDALS The CDC recommends the use of disinfectants (germicidals) registered with the EPA as Hospital Disinfectants for use on surfaces where contamination is suspected. Surfaces that are frequently touched by hands: door knobs, light switches, water fountain handles, push bars, controls, knobs for adjustment or opening, countertops, desks, elevator buttons and panels should be cleaned with clean cloths and a no re-dipping process. A separate side should be used for each and every surface. Other surfaces necessitating extra care include HVAC vents, and filters. FLOORS need to be damp mopped with detergent solution when soiled, or thorough vacuuming for carpets, with traffic lane cleaning and/or extraction when necessary. No re-dipping techniques should be implemented to prevent solution contamination such as the process when using a ‘Microfiber’ flat mop in order to prevent spreading of contamination throughout the facility. LINENS should be washed daily and handled with a minimum of agitation and shaking. They should be bagged at the site of collection and transported using a single closed laundry bag. Linens must be machine-washed using appropriate detergent followed by a quality sanitizer in the rinse cycle to further reduce the risk of contamination. HEALTH CARE ACCORDING TO THE WORLD HEALTH ORGANIZATION, "disposable equipment should be used wherever possible in the treatment and care of patients with sars and disposed of appropriately. if devices are to be reused, they should be sterilized in accordance with manufacturers' instructions. surfaces should be cleaned with broad spectrum disinfectants of proven antiviral activity." FOR ISOLATION UNITS, and for decontamination of rooms occupied by a patient suffering from SARS, the following extra measures should be observed: Use a hospital grade disinfectant at dilutions according to label instructions for floor and wall decontamination. Use a no re-dipping process so that fresh solution are in constant use. If surfaces are heavily soiled, pre-cleaning with an appropriate detergent is recommended followed by a secondary clean using a germicidal. Extra care must be taken Page 46 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL in the cleaning of items usually in contact with a patient's skin and hands.For fluid or blood spill cleaning, standard cleaning and disinfection procedures all ready in place should be followed. FOOD HANDLERS , It is very important that staff handling food are fully trained and practice good food safety hygiene procedures. Hands should be washed with an appropriate soap after touching contaminated surfaces, or if in contact with secretions from the mouth, nose or eyes (e.g. after covering mouth/nose to sneeze or cough). Care must also be exercised in changing table covers or wiping tables between customers. A Sanitizer registered for food contact surfaces is recommended. Particularly critical items in food premises are wares and utensils. For low temperature machine ware washing, a sanitizer is recommended as a rinse. For high temperature machines, it is expected that the combination of heat and detergent will be sufficient for decontamination. For manual ware washing it is recommended to use an appropriate manual dishwashing detergent followed by a sanitizing rinse. Viruses When viruses are named they are given a family name, then a genus name, then a species name and then a strain name. Virus classification depends on four factors: size, shape, type and genetic material and the presence of an envelope-a coating of fatty lipid tissue. An enveloped virus (HIV, Hepatitis B and C and Influenza) is not resistant to disinfection. Drying or heat or exposure to a disinfectant or even exposure to a detergent can damage the lipid envelope. Once punctures, the guts of the virus leak out and the virus dies. Non-enveloped viruses like Norwalk and Norwalk-like viruses pose a much greater challenge because they don't have an envelope and are harder to kill. Page 47 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL West Nile Virus West Nile virus was first detected in North America in the New York City area in 1999. By the end of 2001, the virus had spread to 27 states, with 66 confirmed human cases of illness due to the virus, including nine deaths. During 2001, the virus was also detected in birds and mosquitoes in southern Ontario, but no human illnesses were identified. What Is It West Nile virus is a mosquito-borne illness and a species of mosquito that can carry the disease exists in BC. People normally contract West Nile virus through the bite of an infected mosquito. What Is the Risk The risk of contracting the disease is very low - in areas where mosquitoes do carry the virus, much less than 1% of the mosquitoes are infected. Most people infected with the virus experience no symptoms at all. Approximately 20% of infected people will experience mild flu-like symptoms lasting a week or less. Symptoms typically include fever, headache and body aches - a rash on the trunk of the body and swollen lymph glands may also be present. Some individuals, however, may experience a much more severe illness, such as meningitis or encephalitis. Notification Report March 2003 Spring is approaching, and with the warm weather comes mosquitoes. West Nile virus has not yet reached BC, but public health professionals expect that it will do so some time during the mosquito season this year - between mid-May and late September/October. The BC Centre for Disease Control will notify the public of any increase in risk, either in BC or in neighboring provinces or states. Media Contact: Dr. Murray Fyfe, BC Centre for Disease Control, 604 660-3199 Dr. Muhammad Morshed, BC Centre for Disease Control , 604 660-6074 For more information on West Nile virus: BC CDC - West Nile virus information page: http://www.bccdc.org/content.php?item=148 This page is currently under construction, so many of the links are not yet operable. Click on the Q and A link - it will allow you to view or download a pdf file that outlines most of what is currently known about West Nile virus. Health Canada - West Nile virus information page: http://www.hcsc.gc.ca/english/iyh/diseases/west_nile.html This site outlines precautions that you can take to reduce your risk of being bitten by an infected mosquito. Look under the "What You Can Do" section near the bottom of this page. Health Canada - Use of Personal Insect Repellents containing DEET: http://www.hc-sc.gc.ca/pmra-arla/english/pdf/rrd/rrd2002-01-e.pdf Health Canada - Surveillance information http://www.hc-sc.gc.ca/pphb-dgspsp/wnv-vwn/index.html Canadian Cooperative Wildlife Health Centre - Reporting Sick or Dead Birds http://wildlife.usask.ca/WestNileAlertHTML/WestNileAlertEng5.htm People should not handle dead birds, unless directed by their local health authority. Report all dead birds to your local health authority first. Your local health authority will indicate if any additional action is required and if so, what to do. Page 48 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Statements And Definitions What Is The Difference Between A Sanitizer, A Disinfectant, And A Chemical Sterilant? A sanitizer destroys or removes 99.999% of all microbes present in 30 seconds. A disinfectant destroys 100% of all actively growing microbes, but does not destroy endospores. A sterilant destroys all forms of microbial life including spores For environmental hard surface contamination, the use of detergent disinfectants with excellent cleaning capability is recommended. Sanitizers do not kill 100% of all pathogens while chemical sterilants are poor cleaners and too expensive. What Is A Registered Hospital-Type Disinfectant? This is a disinfectant registered and approved by the federal EPA exhibiting 100% destruction of three microorganisms: Staphylococcus aureus, Salmonella choleraesuis, and Pseudomonas aeruginosa. All hospital-type disinfectants are not equal in terms of the number of microbes they destroy or in their label claims. How Can You Compare Different Types Of Hospital-Type Disinfectants? First check to insure the product is EPA registered. Compare the label claims. Check for microorganism effectiveness and compare the dilution ratios for cleaning and disinfection, the soil load tolerance, the hard water tolerance, and odor counteract ant capability. Why Is Soil Load Tolerance And Hard Water Effectiveness Important? Because you are disinfecting "dirty" surfaces with tap water dilutions. Dirt (organic matter) and hard water salts deactivate or use up the disinfectant molecules before they can kill microorganisms. Is The Parts Per Million (ppm) Actives Relevant To Disinfectant Product Performance? No. Disinfectant product performance is based more on the "total formulation" than solely on ppm of the active. A high ppm active concentrate formula simply diluted with water would not be as effective as a lower ppm formula "built" to be an effective disinfectant. A high performance disinfectant includes: Chelating or sequestering agents to tie up hard water ions which can inactivate many disinfectants. Dialkyl or twin chain quaternary which remain more active in hard water Surfactants, builders, pH adjusters, and solubilizing agents to remove organic matter (dirt/soils) which can deactivate disinfectant active ingredients. In summary, the ppm of the active has no correlation to disinfection effectiveness. Rather, the total formulation, including hard water tolerance and soil load capability, should be used to rank disinfectant effectiveness. What Are The Various Roles Of CDC, OSHA, EPA? How Do They Affect Infection Control Practices? As related to disinfectants, the federal EPA registers disinfectant claims and label/brochure copy. Making a disinfectant claim without EPA approval is illegal. OSHA is a state/federal agency formed to ensure safe working conditions. OSHA has formed specific procedures which it feels help protect health care workers from contracting harmful diseases such as HIV-1 (AIDS virus). The CDC was formed to investigate the cause and elimination of disease outbreaks. The CDC has formed specific guidelines for health care for prevention and control of infectious diseases. Page 49 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL What Are The Primary Differences Between Bacteria, Viruses, And Endospores? Bacterium are single-celled microorganisms that use organic and inorganic matter for food. They reproduce via fission. Typical bacteria of concern in health care are: Escherichia coli, Staphylococcus aureus, Salmonella and Pseudomonas. A virus is a molecular substance that typically contains a protein coat surrounding genetic material. Viruses are capable of replication only in living cells and cause diseases such as AIDS (HIV-l) and hepatitis (HBV). Methods to control bacteria and viral infections include the use of disinfectants with excellent cleaning capacity, compulsive and frequent hand washing, programmed housekeeping practices, and proper handling and storage of food supplies. Endospores are bacterium in a non-reproducing stage that have a protective coating around them. Endospores can only be killed via autoclaving, ethylene oxide gas, or chemical sterilants. The best way to keep endospore counts low on environmental hard surfaces is good housekeeping practices that remove endospores from the environment. Do You Need A TB-Effective Product For General Environmental Hard Surface Disinfection? No. First, TB is not the prime causative source for hospital infections. That is why the EPA has specified Staphylococcus aureus, Salmonella, and Pseudomonas as required-kill organisms on hospital-type disinfectants. Second, many TB cases are not hospital restricted... they are treated on an outpatient basis. Third, TB transmission is via the airborne route. Disinfection of hard surfaces has no impact on bacteria or viruses in the air. Why Do Some Facilities Choose The TB Microbe As A Disinfectant Guideline Standard? Because of lack of information or misinformation. Some people mistakenly believe that if a product can destroy the TB microbe, then it will be effective against all other bacteria/ viral pathogens. Scientific research/data does not support this conclusion. For general cleaning and disinfection of environmental hard surfaces, CDC allows the use of any EPA-registered hospital-type disinfectant. What Products Are Effective Against TB? TB is not transmitted on inanimate housekeeping surfaces. Instead, it has an airborne mode of transmission. Any EPA-registered quaternary disinfectant detergent is adequate for cleaning "housekeeping" surfaces in facilities where TB is present. In Canada (not the USA) as late as July 2001 Phenolics were still listed as the only current hospitaltype disinfectants effective against TB. However this is very misleading as phenolics cannot kill the TB spore and where TB presence has been found on inanimate surfaces it is the spore that is found and neither the phenolic not the quaternary are effective. Phenolics, are not recommend for their general use for environmental hard surface disinfection because of other major deficiencies. Instead quaternary ammonium compounds for most hospital disinfection procedures is recommended. There are current no Canadian labeled quaternary ammonium products on the market that can make the claim of effectively killing the TB bacteria. However many Canadian quaternaries of the same formulation when labeled for the US market are able to state and substantiate the claim. What Is The OSHA Recommendation For Cleanup Of Blood Spills And Other Body Fluids? There are a number of alternatives to sodium hypochlorite (bleach), EPA-registered products that are tuberculocidal, or any EPA-registered product effective against HIV-l. There are a wide variety of products that meet these guidelines and constitute an avoidance of the damage caused by bleaches. Can HIV-1, (AIDS Virus) Be Killed Via Disinfectants? Yes, there are a number of disinfectants registered with the EPA that kill HIV-l. HIV-l effectiveness can be assured by reviewing EPA-registered disinfectant labels/literature. Page 50 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Why Is The Hepatitis B Virus (HBV) An Issue? Are There Any EPA-Approved Products Effective Against Hepatitis B? Hepatitis B is an issue because OSHA is seeking methods to protect health care workers from this blood-borne pathogen as well as HIV-l. As of this date, no disinfectant products are registered by the EPA to kill HBV because testing parameters have not been agreed upon. What Are The Pros / Cons Of Phenolics, Iodophors, Quaternaries, Chlorine? Phenols Sodium Hypochlorite (bleach) PRO Effective against TB microbe which is airborne BUT not the TB spore Low use concentrations Low water temperatures Not affected by hard water Rapid kill on pre-cleaned surfaces Iodophors Quaternary Ammonium Compounds (QAC) Page 51 Rev: March 2005 Rapid kill time on pre-cleaned surfaces Not affected by hard water Excellent cleaners allow onestep clean/disinfect High soil load tolerance, remains active Hard water tolerant, remains active Less-toxic, less harmful to the skin Non-staining Non-corrosive Full spectrum bacteria/ virus kill of prime hospital pathogens Use solutions have long life CON Irritating to health care workers' skin Depigmentation of the skin Toxic Causes hyperbilirubinemia in infants Poor water solubility causes ineffective disinfection Corrosive to metals (equipment, furniture) Deactivates when exposed to UV light (sunlight, fluorescent lights) Rapidly deactivates in presence of soil Fresh solutions must be made daily (labor cost) Surfaces require pre-cleaning prior to disinfection (labor cost) Hot/warm water flashes off active ingredients Will bleach out fabrics, carpeting and clothing if splashed or spilled on it Rapidly deactivated by organic soil load Poor cleaner Toxic Must pre-clean surfaces prior to disinfection (labor cost) Inactivated by anionic detergents Staining of skin, clothes, hard surfaces Interferes with chemistry test evaluations In Canada cannot claim to kill the TB microbe LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Is The Choice Of Disinfectant The Only Issue Regarding Effective Infection Control? No, there are a number of variables. First, health care workers should avoid contact with anything moist/wet from any patient. Therefore, protective apparel such as caps, goggles, gloves, and gowns is important. Second, workers exposed to blood/body fluids more than twice-a-week should be vaccinated to prevent Hepatitis B infections. Third, food handling and storage practices in the dietary department must meet local/state health codes. Fourth, and most important, proper and compulsive hand washing procedures must be used throughout the facility. Why Is Hand Washing So Important? Proper hand washing is critical because most pathogenic bacteria are spread via hand contact, not from hard surfaces. All people within a health care facility should follow handwashing procedures after direct contact with any patient... i.e., nursing staff, doctors, technicians, other employees, visitors, and other patients. The primary success of a hand washing program is dependent upon education and attitude. Without education/proper attitude, no hand washing program will be effective. What Infection Control Factors Are Important In Nursery Isolette / Incubators? Infant formulas contain sugar and incubators usually involve moisture. This combination creates an ideal environment for bacteria growth. Phenols must not be used on this equipment. Phenols can be absorbed by the infant's skin and cause an excess of bile in the infant's blood (hyperbilirubinemia). The recommended product is any quaternary ammonium compound. Will All Disinfectants Clean And Disinfect In One Step? No. To obtain an EPA rating as a "one-step cleaner/disinfectant," testing must show that the disinfectant retains efficacy in the presence of a 5% organic load. This data must be noted on the product label/literature/brochures. A large number of disinfectants have this one-step rating. Are Disinfection Needs Different In Nursing Homes Than In Hospitals? No. The same infection control practices should be used in both. In fact, many nursing home residents have low ability to fight off infections, making infection control even more critical. What About Disinfection For Schools? Is It Really Necessary? Yes, school disinfection is important to prevent transmission of disease between school students. Key focus areas would be desk tops, restrooms, shower stalls, locker rooms, gym mats, swimming areas, physical therapy areas, and dietary. What Areas Are Critical In Dietary? First, follow proper food handling/storage procedures. Second, insist on frequent hand washing approved handcare products. Third, sanitize all food contact surfaces with a no-rinse quaternary disinfectant/sanitizer. Fourth, keep dumpster areas free of insects and microbes with an automatic system fifth, use a protein degreaser on floors and other (non0food) surfaces. Page 52 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Is Odor Control Really Necessary? Won't A Proper Housekeeping Program Eliminate The Need For Odor Control? Odor control is essential in many institutions. First, good housekeeping practices do not address odors emanating from patients (cancer, burns, gangrene). Second, housekeeping cannot be everywhere at once... problem odors (incontinency) will spread a lot faster than a containment crew can cover. And third, many objectionable odors have no relation to housekeeping... cigarette smoke, lab chemicals, food service exhaust, etc. Some quaternary ammonium germicidal detergents have unique odor counteractants neutralize these odors without perfume masking. Are There Specific Disinfection Issues In Veterinary Areas? Disinfection efficacy is the same as in hospitals. Disinfectants should tolerate high soil loads, hard water, and be nontoxic. Again, proper hand washing is imperative. In animal research labs, quaternaries with odor counteractants should be avoided to prevent problems with chemical analysis. What pH Range Is Favorable For Disinfection? This depends on the soil load and the disinfectant in question. The pH ranges of use dilutions of 9 to 10.5 are preferred in high soil load applications because for general detergency other that the electrolytic technology the higher pH will provide better cleaning... the prime prerequisite for effective disinfection. For the general populous of use dilution pHs should not exceed 10.5 so as not to cause floor finish damage and minimize employee risk. Acidic pH products (iodophors, and phenols) are poor cleaners and therefore are poor choices as disinfectants. Won't Alkaline pH Disinfectants And / Or Cleaners Harm Floor Finish Appearance? No. Alkaline disinfectants (7.1-10.5 pH) will not harm floor finish shine if properly diluted. If dilution over-use cannot be controlled, then pH balanced germicidal detergent product should be used. Even if floor finish dulling occurs, it is easy to restore with buffing. Are All 1/2 Ounce/Gallon Quaternary Ammonium Disinfectants The Same? No. First, 1/2 ounce/gallon may apply to cleaning or sanitizing claims on one label and disinfecting claims on another label. Second, some 1/2 ounce/gallon disinfectants require a pre-cleaning step while others don't. Third, there are a wide range of differences in other label claims... hard water tolerance, soil load, registered microorganisms. Rule of thumb: Always read the labels and check the use dilution. How Do You Calculate REAL In-Use Cost? The key data you need is price/gallon, use concentration (be sure to use the clean/disinfect level), and the method of control. EXAMPLE: Which has the lower real in-use cost: (A.) a $21.00/gallon, 1/2 ounce (1:256) dilution with automatic preset control OR (B.) a $9.50/gallon, 2 oz (1:64) dilution with no dilution control. A. Divide $21.00/gallon by 256 = 0.08203 use cost/gallon 0.08203 x zero waste factor = 0.08203 use cost/gallon B. Divide $9.50 by 64 =0.1484 0.1484 x 1.25 waste factor (lSSA data) = 0.1855 use cost/gallon CONCLUSION: Although disinfectant A costs 121% more per gallon of concentrate, disinfectant A will save 56% in actual cost per month. The waste factor can be eliminated by using systems like Page 53 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Are Disinfectants Used For Medical Instrument Soaking? Only as a pre-cleaning/presoaking step prior to sterilization. Instruments should be sterilized (100% kill of all microorganisms and endospores) with pressurized steam, gas, or chemical sterilants. Key features to compare chemical sterilants include length of contact time required, effectiveness at room temperature, skin irritation data, dilution cost, and odor. Page 54 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Glossary Abscess: A localized collection of pus in a cavity. Aerobe: Any organism that lives only in the presence of free oxygen. Airborne Transmission: Occurs by the dissemination into the air of droplet nuclei or dust particles containing an infectious agent and subsequent inhalation by a susceptible host. Anaerobe: An organism that grows in the absence of free oxygen. Antibody: Specific chemical substance (immunoglobulin) produced by the body in reaction to the invasion by antigens. Antigen: A substance, which provokes an immune response. Antimicrobial: Ability of a substance to inhibit or kill microorganisms. Antiseptic: Chemical compound that inhibits bacterial growth (does not necessarily kill bacteria). The term is usually reserved for compounds applied to living tissues. Asepsis: Absence of microorganisms. Aseptic Technique: The performance of a procedure so as not to introduce disease-producing organisms in a field of work. Autoclave: Apparatus used for sterilizing medical supplies usually by means of steam under pressure. Alternative systems employ ethylene oxide gas. Carrier: A person in apparently good health who harbours and disseminates an infective organism Cohort: A group of individuals distinguished by a common characteristic such as date of admission or infection. Colonization: The entry, development, and multiplication of a potentially infectious organism without clinical signs of infection in the host. Communicable Disease: An illness due to a specific infectious agent or its toxic products, which can be transmitted to a susceptible host. Community Acquired Infection: An infection either active or incubating prior to hospital admission. Community Acquired Neonatal Infection: A neonatal infection acquired during gestation, labour or delivery, related to organisms that infect or colonize the mother during this time; or an infection acquired by a neonate known to be related to exposure of the infant following discharge to a community member with a similar infection, e.g.: Group A Streptococci in a sibling. Congenital Infection: An infection acquired prior to rupture of the membranes. Contact-Direct: Direct and essentially immediate transfer of infectious agents by actual physical contact with infectious secretions or droplets. Contact-Indirect: Transmission of an infectious agent via a contaminated object where the organism persists until transferred to another host. Contamination: The presence of potentially infectious organisms on an inanimate object. Cross Infection: Infection passed from person to person. Decontamination: The process of rendering a body, object or area free of potentially infectious organisms. Disinfectant: A chemical substance that inhibits or destroys microorganisms. The term is usually reserved for compounds applied to inanimate objects. Drainage and Skin Precautions: Procedures taken to prevent the spread of disease where pathogens exist in drainage from wound or skin infections. Endemic: A disease that is consistently present in a human community. Endogenous Infection: Infection caused by microbes derived from the host's own flora. Endometritis: Inflammation and/or infection of the lining of the uterus. Enteric Isolation: Procedures used to prevent the spread of disease caused by pathogenic organisms from feces. Epidemic: A definite increase in the incidence of a disease above its expected occurrence. Epidemiology: The study of the causes, control and trends of disease in a given population. Flora: The normal microbial population and other colonizers of body surfaces. Fomites: Any article or substance other than food (e.g. toys, bedding, clothing) that may harbour pathogenic microorganisms and thus serve as a vehicle of transmission of infection. Immunity: A natural or acquired resistance to a specific disease. Immunization: Alteration of the immune system; the induction of a protective antibody against a specific agent or toxin. Page 55 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL Infection: The entry, development and multiplication of a disease- causing organism with apparent clinical symptoms in the host. Inflammation: Protective reaction by tissues to chemical, bacterial, mechanical, or toxic irritation. Symptoms may include pain, heat, swelling, redness, and exudate. Intrapartum Infection: An infection acquired during labour. Isolation: Use of specific measures and/or separation of infected patients to prevent spread of pathogenic organisms to other patients, staff, and visitors. Microorganisms: A plant or animal microscopic in size. Nosocomial Infection: a) Hospital/Facility associated infection. An infection which was not present or incubating at the time of admission. b) Infection manifested after the patient is discharged and subsequently re-admitted to be treated for that infection. Opportunistic Infection: Infection produced where organisms not pathogenic in their usual habitat produce disease when introduced to a new more susceptible site. Pasteurization: Destruction of heat labile organisms. Does not kill heat resistant organisms such as spores. Pathogen: A microorganism capable of causing disease. Protective Isolation: Procedures taken to prevent the spread of infectious diseases to a particular patient who has reduced resistance to infection. Purulent: Containing pus. Pyrexia -Unknown Origin: A temperature greater than 38.0 °C for more than 48 hours. Resistance: The ability to prevent the development of disease. Reservoir: Where organisms maintain their presence, metabolize, and replicate. Room Ventilation: Balanced Ventilation: The air pressure in such areas is similar to that in neighbouring rooms and corridors. Negative Ventilation: The air pressure in the room is lower than that in the surrounding rooms or corridors (used with airborne diseases such as Varicella-zoster [Chickenpox]). Positive Ventilation: The air pressure in the room is higher than that in the surrounding rooms or corridors (used in operating rooms). Sanitary: Promoting or pertaining to conditions which can prevent infectious disease. Clean. Sterile: Free of all living microorganisms. Sterilization: Process of destruction of all microorganisms by exposure to chemical or physical agents. Susceptible: Not possessing sufficient resistance to a particular pathogenic agent and therefore at risk of becoming infected; the opposite of immune. Toxin: The poisonous substance liberated by certain organisms. Vector: A living carrier of disease organisms from the infected person or animal to a susceptible host. Virulence: The measure of the ability of an organism to cause disease. Page 56 Rev: March 2005 LB Cleaning Consulting Services MODULE 9 UNIT 9.2 -INFECTION CONTROL List Of Reportable Communicable Diseases In British Columbia Reflecting amendments to the CD Regulations made by Order In Council on February 17, 2000 SCHEDULE A: (reportable by all sources Including laboratories) Anthrax Acquired Immune Deficiency Syndrome Botulism Brucellosis Cholera Congenital Infections: Toxoplasmosis, Rubella, Cytomegalovirus. Herpes Simplex, Varicella-Zoster, Hepatitis B Virus, Listeriosis and any other congenital infection Cryptosporidiosis Cyclospora infection Diphtheria: Cases Carriers Encephalitis: Post-infectious Subacute sclerosing panencephalitis Vaccine-related Viral Foodborne Illness: All causes Gastroenteritis epidemic: Bacterial Parasitic Viral Genital Chlamydia Infection Giardiasis Hantavirus Pulmonary Syndrome Hemorrhagic Viral Fevers Hemolytic Uremic Syndrome (HUS) Hepatitis Viral: Hepatitis A Hepatitis B Hepatitis C Hepatitis E Other Viral Hepatitis Invasive Group A Streptococcal Disease Invasive Haemophilus Influenzae Type B Infection Invasive Streptococcus Pneumoniae Infection Leprosy Lyme Disease Measles Meningitis: All causes (i) Bacterial; Hemophilus Page 57 Rev: March 2005 Pneumococcal Other (ii) Viral Meningococcal Disease: Bacteremia Meningitis Mumps Neonatal Group B Streptococcal Infection Pertussis (Whooping Cough) Plague Poliomyelitis Rabies Reye Syndrome Rubella: Congenital Rubella Syndrome Tetanus Tuberculosis Typhoid Fever and Paratyphoid Fever Venereal Disease: Chancroid Gonorrhea -all sites Syphilis Waterborne Illness: All causes Yellow Fever SCHEDULE B: (reportable by laboratories only) All specific bacterial and viral stool pathogens: (i) Bacterial: Campylobacter Salmonella Shigella Yersinia (ii) Viral Amoebiasis Borrelia burgdorferi infection Cerebrospinal Fluid Micro-organisms chlamydial Diseases, including Psittacosis Herpes Genitalis Influenza Legionellosis Leptospirosis Malaria Methicillin-Resistant Staphylococcus Aureus (MRSA) Q Fever Rickettsial Diseases Vancomycin-Resistant Enterococci (VRE) LB Cleaning Consulting Services
