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Principles of Infection Control and Personal Protective Equipment Learning Objectives • Demonstrate knowledge of the principles of infection control • Recognize gaps in infection control infrastructure • Recognize ways to address gaps in infection control infrastructure in different situations • Demonstrate proper selection and use of personal protective equipment Session Overview • Disease transmission • Introduction to personal protective equipment (PPE) – How to use PPE – Demonstration • Infection control precautions – In health care facilities – In the community Routes of Disease Transmission Chain of Infection + Quantity of pathogen Virulence Route of transmission Port Sensitive host Routes of Transmission • Respiratory – Cough – Sneeze • Fecal-oral – Feces contaminate food, environment, or hands • Vector-borne – Transmitted by insects Routes of Transmission Contact Direct Contact Indirect Contact • Host comes into contact with reservoir • Disease is carried from reservoir to host • Kissing, skin-to-skin contact, sexual intercourse • Contaminated surfaces (fomites) • Contact with soil or vegetation Routes of Transmission Droplet Large droplets within 1 meter transmit infection via: – Coughing, sneezing, talking – Medical procedures Examples: • Diphtheria • Pertussis (Whooping Cough) • Meningococcal meningitis Routes of Transmission Airborne (droplet nuclei) Very small particles of evaporated droplets or dust with infectious agent may… – Remain in air for a long time – Travel farther than droplets – Become aerosolized during procedures Examples: • Tuberculosis • Measles (Rubeola) Transmission of Influenza Viruses Seasonal Influenza in Humans Avian Influenza in Humans Yes Probable (human to human) Airborne During aerosolgenerating procedures Yes? Contact Yes? Yes (bird to human) Droplet Infection Control Methods and Personal Protective Equipment Hand Washing Method • Wet hands with clean (not hot) water • Apply soap • Rub hands together for at least 20 seconds • Rinse with clean water • Dry with disposable towel or air dry • Use towel to turn off faucet Alcohol-based Hand Rubs • Effective if hands not visibly soiled • More costly than soap & water Method • Apply appropriate (3ml) amount to palms • Rub hands together, covering all surfaces until dry Personal Protective Equipment (PPE) • When used properly can protect you from exposure to infectious agents • Know what type of PPE is necessary for the duties you perform and use it correctly Types of PPE • Gloves • Gowns • Masks • Boots • Eye protection Types of PPE Gloves • Different kinds of gloves – – – Housekeeper gloves Clean gloves Sterile glove • Work from clean to dirty • Avoid “touch contamination” – • Eyes, mouth, nose, surfaces Change gloves between patients Types of PPE Gowns • Fully cover torso • Have long sleeves • Fit snuggly at the wrist Types of PPE Masks and Respirators: Barriers and Filtration • Surgical masks – – • Cotton, paper Protect against body fluids and large particles Particulate respirators (N95) – – • Fit testing essential Protect against small droplets and other airborne particles Alternative materials (barrier) – Tissues, cloth Types of PPE Particulate Respirators • Three types: disposable, reusable, powered air purifying respirators • Disposable Particulate Respirators – Classified N95, N99, N100, R95, R99, R100, P95, P99, P100 – Letter indicates oil resistance: N = not resistant, R = somewhat resistant, P = strongly resistant – Number is percent of airborne particles filtered (e.g. N95 filters 95% of particles) Types of PPE Boots Eye Protection – Face shields – Goggles PPE Supplies • Maintain adequate, accessible supplies • Creative alternatives (not proven to be effective) – Mask: tissue, scarf – Boots: plastic bags – Gown: laboratory coat, scrubs Working with Limited Resources • Avoid reuse of disposable PPE items – Consider reuse of some disposable items only as an urgent, temporary solution – Reuse only if no obvious soiling or damage • When prioritizing PPE purchase – Masks – Gloves – Eye protection Infection Control Precautions Precaution Levels All levels require hand hygiene • Standard Precautions Transmission based precautions: • Contact Precautions • Droplet Precautions • Airborne Precautions Standard Precautions • Prevent the transmission of common infectious agents • Hand washing key • Assume infectious agent could be present in the patient’s – – – – Blood Body fluids, secretions, excretions Non-intact skin Mucous membranes PPE for Standard Precautions Wear: If: • • • • Gloves Gowns Touching – – – Respiratory secretions Contaminated items or surfaces Blood & body fluids • Soiling clothes with patient body fluids, secretions Eye • Protection and / or Mask Procedures are likely to generate splashes / sprays of blood, body fluids, secretions, excretions Contact Precautions Taken in addition to Standard Precautions • Limit patient movement • Isolate or cohort patients • Gown + gloves for patient / room contact – Remove immediately after contact • Do not touch eyes, nose, mouth with hands • Avoid contaminating environmental surfaces Contact Precautions • Wash hands immediately after patient contact • Use dedicated equipment if possible – If not, clean and disinfect between uses • Clean, then disinfect patient room daily – Bed rails – Bedside tables – Lavatory surfaces – Blood pressure cuff, equipment surfaces Cleaning and Disinfection for Contact Precautions • Detergents – – – • Remove dirt, soiling Mechanical force essential Flush with clean water Disinfectants – – – – Kill viruses, bacteria Decontaminate surfaces Type depends on infectious agent Use after detergent Droplet Precautions • Prevent infection by large droplets from – Sneezing – Coughing – Talking • Examples – – – – Neisseria meningitidis Pertussis Influenza Avian influenza (probable) Droplet Precautions Taken in addition to Standard Precautions • Place patients in single rooms or cohort 3 feet apart • Wear surgical mask within 3 feet of patient • Wear face shield or goggles within 3 feet of patient • Limit patient movement within facility – Patient wears mask when outside of room Airborne Precautions Taken in addition to Standard Precautions • Prevent spread of infection through very small (< 5 microns) airborne particles • Examples – – – – Tuberculosis Measles Varicella Variola Airborne Precautions • Use for influenza patients when: – History of travel to country with avian influenza activity within 10 days AND – Hospitalized with severe febrile respiratory illness – Or are otherwise under evaluation for avian influenza Airborne Precautions • N95 respirator (or equivalent) for personnel – Check seal with each use • Patient in isolation • Negative pressure isolation room, if available – Air exhaust to outside or re-circulated with HEPA filtration • Patient to wear a surgical mask if outside of the isolation room Negative Pressure Isolation Room Natural Ventilation Cohorting Room 1 meter Aerosol-generating Procedures (Example; Endotracheal intubation) • N95 particulate respirator – If not available, wear tight fitting surgical mask and face shield • • • • Eye protection Gloves and hand washing Gown and waterproof apron Isolation room with negative pressure, if available • Hair cover optional Choosing the Appropriate PPE Avian Influenza • Likely large droplet transmission • Possible airborne transmission • Recommended PPE varies depending on situation Interviewing - Asymptomatic Exposed Persons and Contacts • Low-risk activity • Routine use of PPE not recommended • Maintain 3 feet distance between interviewer and interviewee • Use proper hand hygiene – May use hand sanitizer (at least 60% alcohol) if hands not visibly soiled Interviewing - Symptomatic Exposed Persons • Higher risk activity • PPE recommended in community and healthcare facility – Contact precautions – Droplet precautions – N95 respirator • In healthcare facility, person should be placed in airborne isolation room Specimen Collection – Exposed Persons and Birds • High-risk aerosol-generating procedure • PPE recommended – Gloves – Gown – Goggles or face-shield – N95 or better respirator Avian Influenza Infection Control in Health Care Facilities Influenza Transmission Effective Infection Control Prevents Transmission From ... • Patients to health care workers • Patients to patients • Patients to family members providing care Avian Influenza Precautions Standard precautions Droplet precautions Airborne Precautions Precautions for Suspected or Confirmed Cases • Place patient in a negative air pressure room • To create a negative air pressure room: – Install exhaust fan and direct air from inside to an outside area with no person movement • Place patients in rooms alone – Alternative: cohort patients away from other patient care areas with beds > 1 meter apart Precautions for Suspected or Confirmed Cases • Limit number of health care workers, family members and visitors • Designate experienced staff to provide care • Limit designated staff to avian influenza patient care • Teach family and visitors to use PPE Precautions for Collecting Specimens • Notify laboratory in advance • Health care worker collecting specimen should wear full barrier PPE • Place specimen in leak-proof bag • Hand deliver, if possible • Label specimen clearly as “suspected avian influenza” Precautions for Suspected or Confirmed Cases Patient Infection Control Precaution Acute influenza symptom + travel to AI country in 10 days Surgical mask for patient, use respiratory hygiene Isolation room, use of PPE Test for influenza A/H5 Apply all infection control precautions Confirmed Influenza A/H5 Different diagnosis Maintain required infection control precautions Adults and adolescents > 12 years: Continue for 14 days after resolution of fever Re-evaluate the precaution measures Environmental Decontamination • Cleaning MUST precede decontamination • Disinfectant ineffective if organic matter is present • Use mechanical force – Scrubbing – Brushing – Flush with water Environmental Decontamination: Disinfecting • Household bleach (diluted) • Quaternary ammonia compounds • Chlorine compounds (Chloramin B, Presept) • Alcohol – Isopropyl 70% or ethyl alcohol 60% • Peroxygen compounds • Phenolic disinfectants • Germicides with a tuberculocidal claim on label • Others Using Bleach Solutions • First clean organic material from surfaces or items • Wipe nonporous surfaces with sponge or wet cloth – Allow to dry • Immerse items for 30 minutes • Use fresh diluted bleach daily! Waste Disposal • Use Standard Precautions – Gloves and hand washing – Gown + Eye protection • Avoid aerosolization • Prevent spills and leaks – Double bag if outside of bag is contaminated • Incineration is usually the preferred method Managing Linens and Laundry • Use Standard Precautions – Gloves and hand hygiene – Gown – Mask • Avoid aerosolization – do not shake • Fold or roll heavily soiled laundry – Remove large amounts of solid waste first • Place soiled laundry into bag in patient room Avian Influenza Infection Control in the Community Preventing Transmission in the Community • Respiratory etiquette – Cover nose / mouth when coughing or sneezing • Hand washing! Avian Influenza and Food • Heat to > 70°C to kill the avian influenza virus • Consumption of any raw / undercooked poultry ingredients is risky – – Runny eggs Meat with red juice • Separate raw meat from cooked or ready-toeat foods to avoid cross-contamination • Wash hands before and after preparing food Patients Cared for at Home • Potential for transmission! • Must educate family caregivers • Fever / symptom monitoring • Infection control measures – Hand washing – Use of available material as PPE Patients Cared for at Home • Handle laundry with gloves; do not shake to prevent aerosolization • Use disposable or dedicated dishes, utensils • Decontaminate the home environment – Frequent cleaning before disinfection Decontamination of Dishes and Eating Utensils • Use disposable items when available • Wash with detergent and hot water – Wear rubber gloves Precautions for Handling Corpses • Mortuary staff should use Full Barrier PPE • Anyone handling a corpse infected with avian influenza should be informed Application of Infection Control Activities during an Investigation Location Influences Actions • Medical facilities • Homes • Farms • Markets • Rural versus Urban areas Anticipate Exposures Contact with. . . • Infected individuals • Individuals suspected to be infected • Potentially contaminated substances • Potentially contaminated surfaces / items • High-risk procedures • Animals Assess Existing Infection Control Infrastructure • Policies and procedures • Authority • Human resources • Financial resources • Engineering resources Assess Existing Infection Control Infrastructure • Do policies describe PPE for health care workers? • Are procedures in place for patient room cleaning? • Are there negative air pressure rooms? • Will you need to promote respiratory and hand hygiene in the community? Assessing Infection Control Needs During an Investigation Overview • Components of infection control infrastructure • Infection control in healthcare facilities • Infection control in the community Components of Infection Control Infrastructure • Policies • Human resources • Procedures • Financial resources • Authority • Engineering resources Assessing Infection Control Infrastructure Example: cleaning patient rooms • Policies – When to clean, what to clean • Procedures – Cleaning products, order of surfaces to clean • Authority – Enforcing policies and procedures Assessing Infection Control Infrastructure Example: Cleaning patient rooms (continued) • Human resources – Staff to clean rooms • Financial resources – Money to buy cleaning products • Engineering resources – Cleaning equipment – Hand hygiene facility (sink) Sustainability • Evaluate infection control knowledge • Evaluate infection control procedures • Develop a sustainable program • Encourage routine practice • Build local capacity Sustainability Example • Hospital outside a large city • Has basic infection control program • You notice healthcare personnel – Recapping needles – Not wearing eye protection when doing invasive procedures • Help staff develop appropriate policies and procedures Authority • Communication with various administrative levels • Policies may already exist – National – Regional – Local • Adapt to the facility you are working in How to Put on and Remove Personal Protective Equipment Sequence for Donning PPE 1. Wash hands 2. Gown 3. N95 Particulate respirator – Perform seal check 4. Hair cover 5. Goggles or face shield 6. Gloves Gown • Select appropriate type and size • Opening may be in back or front • Secure at neck and waist • If too small, use two gowns – Gown #1 ties in front – Gown #2 ties in back Surgical Mask • Place over nose, mouth and chin • Fit flexible nose piece over nose bridge • Secure on head with ties or elastic • Adjust to fit N95 Particulate Respirator • • • • • Pay attention to size (S, M, L) Place over nose, mouth and chin Fit flexible nose piece over nose bridge Secure on head with elastic Adjust to fit and check for fit: Inhale – respirator should collapse Exhale – check for leakage around face Eye and Face Protection • Position goggles over eyes and secure to the head using the ear pieces or headband • Position face shield over face and secure on brow with headband • Adjust to fit comfortably Gloves • Don gloves last • Select correct type and size • Insert hands into gloves • Extend gloves over gown cuffs Key Infection Control Points • Minimize exposures – Plan before entering room • Avoid adjusting PPE after patient contact – Do not touch eyes, nose or mouth! • Avoid spreading infection – Limit surfaces and items touched • Change torn gloves – Wash hands before donning new gloves Duration of PPE Use Surgical Masks (if N95 not available) – Wear once and discard – Discard if moist N95 Particulate Respirators – May use just one with cohorted patients Eye Protection – May wash, disinfect, reuse Sequence for Removing PPE 1. 2. 3. 4. 5. 6. 7. 8. 9. Remove in anteroom when possible Untie gown and remove shoe covers Gloves Wash hands Gown (and apron, if worn) Goggles Mask Cap (if worn) Boots Wash hands Removing Gloves (1) • Grasp outside edge near wrist • Peel away from hand, turning glove inside-out • Hold in opposite gloved hand Removing Gloves (2) • Slide ungloved finger under the wrist of the remaining glove • Peel off from inside, creating a bag for both gloves • Discard Removing A Gown 1. 2. Unfasten ties Peel gown away from neck and shoulder 3. 4. 5. Turn contaminated outside toward the inside Fold or roll into a bundle Discard Removing Goggles or A Face Shield • Grasp ear or head pieces with ungloved hands • Lift away from face • Place in designated receptacle for disinfecting or disposal Removing a Mask • Lift the bottom elastic over your head first • Then lift off the top elastic • Discard • Don’t touch front of mask If You MUST Reuse PPE.. • Use during one shift and for one patient • Discard at the end of each shift GOWN • Hang gown with outside facing in MASK OR RESPIRATORS • Put the mask into the sealable bag • May touch the front of the mask, but wash hands immediately after removing Hand Washing • Between PPE item removal, if hands become visibly contaminated • Immediately after removing all PPE • Use soap and water or an alcoholbased hand rub Summary • Influenza transmission occurs mainly through respiratory droplets – Contact can be prevented using PPE – Virus can be inactivated with infection control procedures – Hand washing is key • PPE must be donned and removed appropriately to prevent contamination of wearers and environments • Guidelines for using PPE and infection control measures for avian influenza in humans should be practiced until they are routine Glossary Decontamination - The removal of harmful substances such as chemicals, harmful bacteria, or other organisms, from exposed individuals, rooms, and furnishings in buildings or in the outside environment. Disease transmission - The process of the spread of a disease agent through a population Infection control - Measures practiced by health care personnel in health care facilities to prevent the spread of infectious agents Personal protective equipment - Specialized clothing or equipment worn by a worker for protect from a hazard References and Resources • Avian influenza, including influenza A (H5N1), in humans: WHO interim infection control guideline for health care facilities Revised 24 April 2006. http://www.who.int/csr/disease/avian_influenza/guidelines/infectionc ontrol1/en/index.html • Practical Guidelines for Infection Control in Health Care Facilities. SEARO Regional Publication No. 41; WPRO Regional Publication. 2004. http://w3.whosea.org/LinkFiles/Update_on_SEA_Earthquake_and_T sunami_infection-control.pdf • US Centers for Disease Control and Prevention. “Cover Your Cough” http://www.cdc.gov/flu/protect/covercough.htm • Elizabeth A. Bolyard, et al. Centers for Disease Control and Prevention. Guideline for infection control in health care personnel, 1998. http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/InfectControl98.pdf