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Infection Control of

Aerosol Transmissible
Diseases

Overview

Transmission of Communicable Diseases

Principles of Infection Control

Application to Aerosol Transmissible Diseases


(ATDs)

Interactive exercises

Resources in packet

The Chain Model of


Communicable Diseases
Infectious agent
Reservoirs and/or sources
Portals of exit
Modes of transmission
Portals of entry
Susceptible hosts

The Chain Model of


Communicable Diseases
Infectious agent
Reservoirs and/or sources
human
animal
Environment

Portal(s) of exit:

Respiratory tract
GI tract
Genital/urinary tract
Breaks in skin

The Chain Model of


Communicable Diseases
Modes of transmission
Direct contact
Indirect contact

Portals of entry
Susceptible hosts

Modes of Transmission
Direct Transmission
Direct Contact
Droplet

Indirect Transmission
Vehicle-borne
Vector-borne
Airborne

Vertical transmission (mother to infant)

Infectious Aerosols

Department of Medical Microbiology,


Edinburgh University

Transmission of Infections by
Respiratory Aerosols

Droplets: land directly on mucosal lining of nose,


mouth, eyes of nearby persons or can be inhaled.
Highest exposures within 3-6 feet.

Airborne: aerosols become smaller by evaporation;


small aerosols ( 10 microns) remain suspended for
longer periods, if inhaled travel deep into the lungs.

Contact: Aerosols/ secretions contaminate nearby


surface. Touch surfaces can infect self or others.

Relative contribution of three routes varies with agent.

Modes of Transmission via


Infectious Respiratory
Secretions

Airborne: tuberculosis, measles, varicella,


smallpox, SARS, avian influenza

Droplet: meningococcal meningitis, rubella,


pertussis, common cold, SARS, influenza*
Indirect contact: (fomite) RSV, SARS

*Influenza traditionally droplet, increasing


evidence for airborne component

Infection Control in a
Health Care Setting
Review

Infection Control in a Health Care


Setting
Basic principles
Standard precautions
Transmission-based precautions
Seasonal influenza in health care settings
Vaccination of HCWs
TB screening of HCWs
Proper donning and doffing
Choose your PPE

Basic Principles
All body fluids are potentially infectious
(except sweat)

blood and blood-tinged fluids including open-wounds

stool, urine, vomit, respiratory secretions, saliva,


semen, vaginal secretions, breast milk, other
body fluids such as pericardial and synovial fluids

Minimize exposure to potentially infectious


body fluids
Infection control measures designed to
break the chain of transmission

Standard Precautions in
Health Care Settings
1. Appropriate hand hygiene
2. Barrier protective equipment:

if splash, splatter, or sprays can be


reasonably anticipated
choose appropriate PPE as needed:
gloves, gown, mask, eye protection (face
shield, goggles)

3. Proper use and handling of patient


care equipment

Standard Precautions in
Health Care Settings
4. Proper environmental cleaning and disinfection
5. Proper Handling of Linen
6. Adherence to Bloodborne Pathogens Standards
7. Proper patient placement
8. Respiratory Hygiene/Cough Etiquette
9. Safe injection practices

Expanded Isolation Precautions:


Transmission-based Standards

When standard precautions are not


enough
Additional measures based on mode
of transmission

Contact Precautions
Droplet Precautions
Airborne Precautions

Transmission-Based
Precautions: Contact
Precautions

For known or suspected infections that


represent an increased risk of spread by
direct or indirect contact with the
patient or the patients environment

Transmission-Based
Precautions: Contact
Precautions

Personal Protective Equipment

Gown & Gloves for all patient


interactions
Don PPE on entry, discard before exiting
room. (in addition to Standard
Precautions)

Examples: MRSA, C difficile, Norovirus,


other GI pathogens, RSV, antibioticresistant pathogens

Transmission-Based
Precautions:
Droplet
Precautions
Single room preferred, no special ventilation

Patient: Mask if transport necessary.


Instruct on respiratory hygiene/cough
etiquette
HCWs wear surgical or procedure mask
within 6 feet of patient. Eye protection if
splash, spray anticipated

(in addition to Standard Precautions)

Transmission-Based
Precautions: Airborne
Precautions
Airborne Infection Isolation Room (AIIR) if available

Patient: Mask if transport necessary (as tolerated).

Health care workers (HCWs):

N95 respirator prior to entry into room, discarded after exit.


Higher level respirators for aerosol-gen procedure. Careful attention
to proper putting on & taking off (don/doff) respirator, including
seal check.

Hand hygiene before & after don/doff.

Alert others if need to transfer

(in addition to Standard Precautions)

Seasonal Influenza in
Healthcare Settings
CDC and CDPH guidelines updated 2010
Multi-faceted approach
Flu vaccine for HCWs
Implementation of respiratory hygiene and
cough etiquette
HCWs with ILI stay home
Source Control

Seasonal Influenza in
Healthcare Settings: Isolation
Precautions
Droplet precautions for all patients with
suspect influenza (ILI)
ILI Temp >37.8 C (100 F) plus new cough or
sore throat
Ideally, place patients in single room
Surgical mask for close patient contact
Employer may allow N95 during routine care as
option

Patient should be transported with surgical


mask.

Seasonal Influenza in
Healthcare Settings: Isolation
Precautions
For aerosol-generating procedures: N95
respirator + standard precautions (gown,
gloves, goggles for spray/splash)

Aerosol generated procedures


Sputum induction, bronchoscopy, elective
intubation and extubation, autopsies
CPR, emergent intubation, open suctioning of
airways

Vaccination of HCWs
Protect patients, protect yourself and other HCWs
CDC recommends
Measles, mumps, rubella (MMR): vaccinate unless
documentation of immunity or previous vaccination
Varicella: vaccinate unless documentation of immunity
or previous vaccination
Tdap
Yearly influenza vaccination
Hepatitis B: vaccinate unless documentation of
previous vaccination

Vaccination of HCWs
Cal/OSHA ATD & Bloodborne Pathogen
Standard
Employer must offer to those who are not
vaccinated or immune:

MMR and varicella vaccination


Tdap
Seasonal influenza vaccination
Hepatitis B vaccination

No cost to employee
Employer must maintain on file: records of
immunity, vaccine, or declinations

Tuberculosis Screening
for Health Care Workers
Title 22 and Cal/OSHA ATD Standard
TB screening at hire and then annually for
all licensed healthcare facilities in CA (e.g.,
acute care hospitals, skilled nursing
facilities, primary care clinics)

Sequence for Donning PPE


1. Gown

2. Mask or Respirator

www.cdc.gov/ncidod/dhqp/ppe.html

Sequence for Donning PPE


3. Goggles/Face Shield

4. Gloves

www.cdc.gov/ncidod/dhqp/ppe.html

Sequence for Removal of


PPE
1. Gloves

www.cdc.gov/ncidod/dhqp/ppe.html

Sequence for Removal of


PPE
2. Goggles/Face Shield

www.cdc.gov/ncidod/dhqp/ppe.html

Sequence for Removal of


PPE
3. Gown

www.cdc.gov/ncidod/dhqp/ppe.html

Sequence for Removal of


PPE
4. Mask or Respirator

www.cdc.gov/ncidod/dhqp/ppe.html

What Type of PPE Would You


Wear?
Giving a bed bath?
Generally none

Suctioning oral secretions?


Gloves and mask/goggles or a face shield
sometimes gown

www.cdc.gov/ncidod/dhqp/ppe.html

What Type of PPE Would You


Wear?
Transporting a patient in a wheel chair?
Generally none required

Responding to an emergency where blood


is spurting?
Gloves, fluid-resistant gown, mask/goggles

www.cdc.gov/ncidod/dhqp/ppe.html

What Type of PPE Would You


Wear?
Taking vital signs
Generally none

Drawing blood from a vein?


Gloves

www.cdc.gov/ncidod/dhqp/ppe.html

What Type of PPE Would You


Wear?
Cleaning an incontinent patient with
diarrhea?
Gown, gloves

Taking vitals on a patient with suspect TB?

N95 respirator

www.cdc.gov/ncidod/dhqp/ppe.html

Controlling the Spread of


Aerosol Transmissible
Diseases in Health Care
Settings
Breaking the Chain

Health care and public safety


settings
Unique challenges for control of ATDs

Diversity of job titles and duties


Unique business of caring for the ill
Societal behaviors related to caregiving
Exotic and unique exposures
Suspension of usual self protection behaviors
Emphasis on confidentiality

Aerosol Transmissible Diseases in


Health Care and Public Safety
Settings
Droplet

Meningococcal
meningitis
Pertussis
Mumps
Rubella (German
measles)
Strep pharyngitis
Influenza

Airborne

Tuberculosis
Varicella
(chickenpox)
Measles
SARS
Avian influenza
Smallpox
Influenza

Hierarchy of Infection Prevention


and Control Measures
Elimination of Potential
Exposures

Protects
most
people

Engineering Controls
Administrative
Controls
PPE
Protects
only the
wearer

Hierarchy of Control
Technologies
Goal is to reduce exposures to a hazard
Order in which these elements are
selected to control exposure is important

Elimination of Potential Exposures


Engineering controls
Administrative and work practice controls
Personal protective equipment/apparel

Elimination of Potential
Exposures
Example: patients with mild influenza like
illness stay home

Engineering Controls
Physically separates the employee from the
hazard
Does not require employee compliance to be
effective
Examples:
physical barriers at triage
airborne infection isolation room for patients
with known or suspect airborne infectious
diseases

Administrative Controls/
Workplace Practices
Policies, procedures, and programs that
minimize intensity or duration of exposure
Examples:
signs on door of an airborne isolation room
triage, mask symptomatic patient
provide tissues/ masks/hand sanitizer to public

Standard procedures/ behaviors in caring for


patients e.g. hand hygiene, HCW vaccination
Only as good as enforcement

Personal Protective
Equipment
Lowest level of hierarchy - requires employee
compliance for efficacy
Means higher elements of hierarchy fail to
adequately protect employee
May involve use of gowns, gloves, eye/splash
protection or respirators
Last line of defense

Face Masks vs.


Respirators
Loose fitting, not designed
to filter out small aerosols
Place on coughing patient
(source control)
HCW should wear mask to
protect patient during
certain procedures (e.g.,
surgery, LP)

protect HCW
droplet precautions
Mask + goggles for
anticipated spray/splash

N95

Tight fitting respirator,


designed to filter the
air
Protects the wearer
HCW should wear
when concerned
about transmission by
airborne route

Reasons for Respiratory


Protection
Engineering controls not feasible or sufficient
Employees must wear N95 respirators (or higher
level of protection) in the following circumstances
Entering a room with patient with suspect or confirmed
airborne infectious disease
When performing high-hazard (aerosol-generating)
procedures on persons with suspect/confirmed airborne
infectious disease or influenza
When emergency response employees/others must
transport in a closed vehicle, a patient with
suspect/confirmed airborne infectious disease

Aerosol-Generating
Procedures
Sputum induction, bronchoscopy, elective
intubation and extubation, autopsies
CPR emergent intubation, open suctioning of
airways

What you should do


when you hear Ah-choo!
Likely communicable?
airborne vs. droplet ?

Choose appropriate source control and PPE


Reportable Disease? Contact local health
department. Some require immediate action
Title 17 reporting requirement

Aerosol Transmissible
Diseases
Breaking
the
Chain
Source control
stay home, isolate or separate mask patient

Respiratory hygiene, cough etiquette


Hand hygiene
HCW protection
Vaccinate
Droplet Mask
Airborne- N95 respirator

References
CDC
2007 Guideline for Isolation Precautions:
Preventing Transmission of Infectious Agents in
Healthcare Settings
http://www.cdc.gov/hicpac/2007IP/2007isolation
Precautions.html
Guideline for Hand Hygiene in Health-Care
Settings MMWR 2002; vol. 51, no. RR-16
http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf

References
Cal/OSHA
Aerosol Transmissible Disease Standard
http://www.dir.ca.gov/Title8/5199.html
Appendix A
http://www.dir.ca.gov/Title8/5199a.html

References
Seasonal Influenza Infection Control
Guidelines 2010
CDC:
http://www.cdc.gov/flu/professionals/infectionco
ntrol/index.htm
CDPH
http://www.cdph.ca.gov/programs/immunize/Do
cuments/CDPHGuidanceFluPreventionHCS2010
1105.pdf
Cal/OSHA http://www.dir.ca.gov/dosh/CalOSHA_influenza_guidance_11-5-10.pdf

Questions?