Infection Prevention and Control for Epidemic- and Pandemic-Prone Acute Respiratory Diseases

Learning Objectives
Describe basic infection-control principles.

Discuss core infection-control measures in health-care settings.

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Presentation Overview
Basic infection control principles
Core infection control measures used in health care settings

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Basic Infection Control Principles

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Aim of Infection Control

Basic infection control measures reduce risk of transmission of pathogens from a known or unknown source

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Chain of Infection

+
Quantity of pathogen Virulence Routes of transmission Portal of entry into host Susceptible host
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Routes of Transmission
Contact: Infections spread by direct or indirect contact with patients or the patient-care environment
(e.g., shigellosis, viral hemorrhagic fevers)

Droplet: Infections spread by large droplets generated by coughs, sneezes, etc. (e.g., Neisseria meningitidis,
pertussis)

Airborne (droplet nuclei): Infections spread by particles that remain infectious while suspended in the air (TB, measles, varicella, and variola)
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Source control measures -Cough etiquette, cleaning, disinfection Modes of transmission Portal of entry into the host -Adding barriers, e.g., PPE Host
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Breaking the Chain of Infection

-Contact: hand hygiene -Droplet: distance from source >1 m -Airborne: ventilation -Vector: bednets

-Strengthen host defences, e.g., vaccination

Transmission of Epidemic- and Pandemic-Prone Acute Respiratory Diseases

Seasonal Influenza in Humans SARS and Current Avian Influenza in Humans
most likely route (SARS) possible (AI) possible during aerosol generating procedures most likely route (SARS) H5N1: (bird to human), and possible (human to human)
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Droplet
Airborne Contact

most likely route

possible during aerosol generating procedures possible

Core Infection Control Measures in Health Care Settings

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Core Infection Control Measures in Health Care Settings (1)

Early recognition and reporting
Infection control precautions

Hand hygiene: alcohol-based hand rub, hand washing

PPE: gloves, gowns, masks/respirators, eye protection
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Core Infection Control Measures in Health Care Settings (2)

Patient accommodation
Environmental cleaning and waste disposal Occupational health management

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WHO

Prevention is Primary

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CDC

Early Recognition in Health Care Facilities

Health care facility staff must quickly identify and separate potential sources of infection from susceptible hosts

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How to identify rapidly

Rapid identification of Patients with Epidemic- or PandemicProne Acute Respiratory Diseases:

Clinical indications
Severe acute febrile respiratory illness (e.g., fever > 38C, cough, shortness of breath) Exposure history consistent with ARD of potential concern

Epidemiological indications
History of travel to area affected by ARDs Possible occupational exposure Unprotected contact with ARDs patient(s)
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Infection Control Precautions

Standard precautions
Should be applied for ALL patients

Transmission-based precautions*
Contact Droplet Airborne
*Transmission-based precautions are often used empirically, according to the clinical syndrome and the likely etiological agent
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Standard Precautions
Hand hygiene
Respiratory hygiene/cough etiquette

Use of personal protective equipment (PPE)

Prevention of needle sticks/sharps injuries

Cleaning and disinfection of the environment and equipment

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Droplet Precautions
Protection against respiratory pathogens transmitted by large droplets In addition to Standard Precautions:
Use a medical mask when < 1 m of patient Maintain a distance 1 meter between infectious patient and others Place patient in a single room or cohort with similar patients Limit patient movement
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Contact Precautions
Protection against contact with large droplets In addition to Standard Precautions:
Use non-sterile, clean, disposable gloves, gown, apron (only if gown is not impermeable) Use disposable or dedicated reusable equipment (which must be cleaned and disinfected before use on other patients) Limit patient contact with non-infected persons Place patient in a single room or cohort with similar patients

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Airborne Precautions
Protection against inhalation of tiny infectious droplet nuclei In addition to Standard Precautions:
Use particulate respirator Place the patient in adequately ventilated room ( 12 air changes per hour) Limit patient movement

Use airborne precautions for performance of any aerosol-generating procedures associated with pathogen transmission
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Hand Hygiene
Hand hygiene should be performed:
before and after any direct contact with a patient after contact with blood, body fluids, secretions and excretions after contact with items contaminated with blood, body fluids, secretions and excretions, including respiratory secretions

Use alcohol-based hand rub or wash hands with soap and water
Wash hands if visibly soiled
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Respiratory Hygiene and Cough Etiquette

Part of standard precautions
Education of health care workers, patients and visitors Source control measures (e.g., cover cough to prevent dissemination of infectious droplets)

Hand hygiene
Spatial separation (> 1 meter) of persons with acute febrile respiratory symptoms
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Personal Protective Equipment

Courtesy of K. Harriman

Types of PPE Used in Healthcare Settings

Gloves protect hands

Gowns/aprons protect skin and/or clothing

Masks and respirators protect mouth/nose Respirators protect respiratory tract from airborne infectious agents

Goggles protect eyes

Face shields protect face, mouth, nose, and eyes
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PPE for Standard Precautions: Based on Risk Assessment

IF direct contact with blood & body fluids, secretions, excretions, mucous membranes, non-intact skin Gloves Gown

IF there is the risk of spills onto the body and/or face Gloves Gown Face protection (mask plus eye protection goggle or visor; face shield)
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PPE for Transmission-Based Precautions

Used in addition to Standard Precautions Contact Precautions Gloves Gown Droplet Precautions Medical mask Airborne Precautions Particulate respirator
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Masks and Respirators: Barriers and Filtration

Surgical masks Protect against body fluids and large particles Particulate respirators (e.g., N95) Protect against small particles and other airborne particles Alternative materials (barriers) Tissues, cloth
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PPE for Persons Providing Care for Patients with Acute Febrile Respiratory Illness, Including Patients with Suspected or Confirmed AI Infection
HH Gloves Gown Medical Mask Entry to isolation room/area, but no anticipated patient contact Close contact (< 1 meter) with infected patient in or out of isolation room/area Particulate Respirator Eye Protection

Risk Asst

Risk Asst

Risk Asst

Risk Asst

Performance of aerosolgenerating procedure on patient

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PPE for Interviewing Exposed Persons and Contacts of ARDs Patients

Asymptomatic exposed persons and contacts (low-risk) Routine use of PPE not recommended Maintain 1 meter distance between interviewer and interviewee Use proper hand hygiene Symptomatic exposed persons (higher-risk) PPE recommended in community and health care facility: Contact and Droplet Precautions In health care facility, person should be placed in adequately ventilated room ( 12 air changes per hour), if possible Maintain a distance of > 1 meter, if possible
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PPE for Specimen Collection Exposed Persons

Collecting respiratory specimens is a high-risk, aerosol-generating procedure PPE recommended
Gloves Gown Goggles or face shield N95 or higher level respirator
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CDC

Patient Accommodation
Isolate patients with droplet or airborne spread diseases from other patients Separate wards, areas, or establish rooms for infectious patients where isolation facilities do not exist
Only those patients with epidemiological and clinical information suggestive of a similar diagnosis should share rooms

Separate patients by at least 1 meter

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Patient accommodation: Natural Ventilation Room

1 meter

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Duration of IC measures for Avian and Pandemic Influenza

Adults and adolescents > 12 years of age from time of admission until 7 days after symptoms resolved Infants and children 12 years of age from time of admission until 21 days after symptoms resolved For immunocompromised patients, pathogen shedding may be protracted
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Environmental Cleaning and Waste Disposal

Environmental cleaning:

Use appropriate procedures for the routine cleaning and disinfection of environmental and other frequently touched surfaces
Waste disposal: Treat waste contaminated with blood, bodily fluids, secretions and excretions as clinical waste, in accordance with local regulations
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WHO

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

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Autopsy Precautions for Influenza A (H5N1)

Follow standard PPE procedures for autopsies
Anyone handling a corpse should follow standard precautions for blood and body fluids

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Occupational Health Management During an Outbreak

Monitor staff who work with patients with an infectious disease of potential concern for symptoms Screen for symptoms of influenza-like illness among staff reporting for duty (fever, cough)
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WHO

Implementation of Core Infection Control Measures During Rapid Containment

Early recognition and reporting Infection control precautions

Hand hygiene
PPE: gloves, gowns, masks/respirators, eye protection Patient accommodation Environmental cleaning and waste disposal Occupational health management
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Hospital Preparedness: Key Points

Apply standard precautions routinely in all health-care settings
Place all patients (suspected or confirmed with an infectious ARD) in a room or area separate from other patients Practice both standard and droplet precautions when caring for patients with infectious ARD

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Important Components for HC Facility Infection Prevention and Control Program

Available supplies and equipment (PPE, disinfectants)

Policies and guidelines for procedures

Ongoing educational programs for healthcare facility staff Process for monitoring staff health to identify and to prevent staff-to-patient and patient-to-staff spread of infection
Jamaica IC Guidelines

Infection Control for ARD in Heath Care Settings

Patient
Symptoms acute ILI + Risk Factor Investigation for ARD of potential concern
Report to Public Health Authorities

Infection control precautions

Standard and droplet precautions

Single room adequately ventilated, if possible

Confirmed ARD of potential concern

Single room adequately ventilated ( 12 air changes per hour), if possible
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Different diagnosis

Reassess precautions

Environmental Decontamination
Cleaning MUST precede decontamination Disinfectant ineffective if organic matter is present Use mechanical force
Scrubbing Brushing Flush with water
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Environmental Decontamination: Disinfecting

Household bleach (diluted) Quaternary ammonia compounds Peroxygen compounds Phenolic disinfectants Germicides with a tuberculocidal claim on label Others

Chlorine compounds (Chloramin B, Presept)

Alcohol Isopropyl 70% or ethyl alcohol 60%
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Using Bleach Solutions

First clean organic material from surfaces or items
Wipe nonporous surfaces with sponge or wet cloth Allow to dry

Use fresh diluted bleach daily!

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