Universal Precautions

Transmission based Precautions

 HISTORY
• 1983-CDC Guideline for Isolation Precautions in
Hospitals
• Provided two systems for isolation: category-specific
and disease-specific.
• Protective Isolation eliminated
• Blood Precautions expanded to include Body Fluids.
• Categories included Strict, Contact, Respiratory, AFB,
Enteric, Drainage/Secretion, Blood and Body Fluids.
• Emphasized decision-making by users.
• 1985-88- Universal precautions
• Developed in response to HIV/AIDS epidemic.
• Dictated application of Blood and Body Fluid precautions to
all patients, regardless of infection status.
• Did not apply to feces, nasal secretions, sputum, sweat,
tears, urine, or vomitus unless contaminated by visible blood.
• Added personal protective equipment to protect health care
workers from mucous membrane exposures.
• Handwashing recommended immediately after glove
removal. Added specific recommendations for handling
needles and other sharp devices
• 1996-Guideline for Isolation Precautions in Hospitals
• Prepared by the Healthcare Infection Control Practices
Advisory Committee (HICPAC).
• Melded major features of Universal Precautions and Body
Substance Isolation into standard precautions to be used
with all patients at all times.
• Included three transmission-based precaution
categories: airborne, droplet, and contact .
• Listed clinical syndromes that should dictate use of
empiric isolation until an etiological diagnosis is
established.
 Chain of Transmission

• For an infection to spread, all links must be connected

• Breaking any one link, will stop disease transmission!

• Infection prevention practices used to avoid
the transmission of infectious agents
• One of the most important strategies to
prevent transmission of infectious agents
• First line of defense to break the chain of
infection
• Effectiveness of Standard Precautions
depends on how well steps are followed
• IPC: A basic requirement for outbreak
preparedness and a critical element of readiness
• Infection Prevention and Control (IPC)
• should be an ongoing activity
undertaken/supported by the national
programme and by the IPC focal
point/team/committee, the health care
facility senior management officials and
• all staff at the facility level
 Benefits of IPC
• Protecting yourself
• Protecting your patients
• Protecting your family & community

• IPC: A basic requirement for outbreak

preparedness and a critical element of
readiness
 IPC goals in
outbreak preparedness

1. To reduce transmission of health care

associated infections
2. To enhance the safety of
staff, patients and visitors
3. To enhance the ability of
the organization/health facility
to respond to an outbreak
4. To lower or reduce the risk of the
hospital (health care facility)
itself amplifying the outbreak
 THE COVID19 TEAM (TCT)
• Medical Superintendent
• Nursing Superintendent
• General physician
• Pulmonologist
• HOD Dept of Microbiology
• 1 Nodal officer (exclusive for COVID)
• Infection Control Nurse (exclusive for COVID)
• Sanitation Inspector (exclusive for COVID)
• Head of Casualty/ EMD
• Head of OPD
• Patient Counselor/ medical social worker
• The term universal precautions refers to the
concept that all blood and bloody body fluids
should be treated as infectious because
patients with bloodborne infections can be
asymptomatic or unaware they are infected
• In 1996, the CDC expanded the concept and
changed the term to standard precautions, which
integrated and expanded the elements of universal
precautions to include contact with all body fluids
(except sweat), regardless of whether blood is
present.
• In dentistry, standard precautions would include
controlling exposure to saliva as well as blood, since
those are the only two bodily fluids potentially
encountered during dental treatments(OPIM)
• Standard Precautions are the minimum
infection prevention practices that apply to all
patient care, regardless of suspected or
confirmed infection status of the patient, in
any setting where health care is delivered.
 Elements of Standard Precautions
1. Hand hygiene
2. Respiratory hygiene
3. PPE according to the risk assessment
4. Safe injection practices, sharps management and injury
prevention
5. Safe handling, cleaning and disinfection of patient care
equipment
6. Environmental cleaning
7. Safe handling and cleaning of soiled linen
8. Biomedical Waste management
• Used with any patient, regardless of their
known or suspected infection status
• Assumes any patient’s blood or body fluid
may be infectious
• Consider what type of infection control
practices should be used based on the level of
anticipated contact with the patient
• “Risk Assessment”
• Risk assessment is critical for all activities, i.e.
assess each health care activity and determine
the personal protective equipment (PPE) that is
needed for adequate protection
What do additional precautions include?
Standard Precautions
+
Special accommodations/isolation (i.e. single room, space
between beds, separate toilet etc.)
+
Signage
+
PPE
+
Dedicated equipment and additional cleaning
+
Limit transport
+
Communication
• When Standard Precautions alone cannot
prevent transmission, they are supplemented
with Transmission-Based Precautions.
• This second tier of infection prevention is
used when patients have diseases that can
spread through contact, droplet or airborne
routes (e.g., skin contact, sneezing, coughing)
and are always used in addition to Standard
Precautions.
 COVID-19
• It is not certain how long the virus that causes
COVID-19 survives on surfaces, but it seems to
behave like other coronaviruses (SARS & MERS).
• Studies suggest that coronaviruses (including
preliminary information on the COVID-19 virus) may
persist on surfaces for a few hours or up to several
days.
• This may vary under different conditions (e.g. type of
surface, temperature or humidity of the
environment).
Droplet spread vs Airborne
 COVID-19
Modes of Transmission :

1) Primarily transmitted between people through respiratory

droplets and contact routes
2) Transmission may also occur through fomites in the immediate
environment around the infected person that is
• Direct contact with infected people
• Indirect contact with surfaces (e.g. stethoscope, thermometer)
3) Airborne transmission may be possible in specific circumstances
in which procedures or support treatments that generate
aerosols are performed
Hand Hygiene
Hand hygiene: WHO 5 moments
Steps of handwashing
 Why is respiratory hygiene important?

• Good respiratory hygiene/cough etiquette

can reduce the spread of microorganisms
(germs) that cause respiratory infections
(colds, flu).
 PPE
• Personal Protective Equipments (PPEs) are
protective gears designed to safeguard the
health of workers by minimizing the exposure
to a biological agent.
• Components of PPE Components of PPE are
goggles, face-shield, mask, gloves,
coverall/gowns (with or without aprons), head
cover and shoe cover.
• Risk assessment: risk of exposure and extent
of contact anticipated with blood, body fluids,
respiratory droplets, and/or open skin
• Select which PPE items to wear based on this
assessment
• Perform hand hygiene according to the WHO
“5 Moments”
• Should be done for each patient, each time
Hospital setting (Out patient Dept)
In-Patient Services
Emergency Department
Pre-hospital (Ambulance services)
Other Supportive/Ancillary services
 Principles for using PPE
• Change PPE immediately if it becomes contaminated or
• damaged

• PPE should not be adjusted or touched during patient

care; specifically
• never touch your face while wearing PPE
• if there is concern and/or breach of these practices,
leave the patient care area when safe to do so and
properly remove and change the PPE
• Always remove carefully to avoid self-contamination
(from dirtiest to cleanest areas)
 Points to remember while using PPE
1. PPEs are not alternative to basic preventive public
health measures such as hand hygiene, respiratory
etiquettes which must be followed at all times.
2. Always (if possible) maintain a distance of at least 1
meter from contacts/suspect/confirmed COVID-19
cases
3. Always follow the laid down protocol for disposing off
PPEs as detailed in infection prevention and control
guideline available on website of MoHFW.
 Important precautions while wearing and
removing a mask
 While wearing the triple layer mask, first tie the
upper strings at top of the head and then tie the
lower strings at back of the neck.
 For N95 mask, while holding pull the top strap over
your head so it rests high on the back of your head
and pull the bottom strap over your head and
position it around your neck, below your ears.
 While removing the mask great care must be
taken not to touch the potentially infected
outer surface of the mask.
 To remove mask first untie the string below
and then the string above and handle the
mask using the upper strings.
 Do not let the mask be hanging around the
neck!
 Fit Test
How to determine whether the mask is fit
correctly around mouth and nose?
• Cover nose and mouth with your hands and
blow and blow air into the mask. If the air
leaks around the nose or at the edges of the
mask, then re adjust the mask
 N95 Mask Fitting –
Do a seal check before you enter the room!
 Contact precautions

• intended to prevent transmission of infectious

agents, including epidemiologically
important microorganisms, which are spread by
direct or indirect contact with the patient or the
patient's environment e.g., VRE, C. difficile,
noroviruses and other intestinal tract pathogens;
RSV
• single-patient room is preferred
• other patient placement options e.g., cohorting,
Spatial separation of > 3 feet
 Droplet precautions

• to prevent transmission of certain pathogens

spread through close respiratory or mucous
membrane contact with respiratory
secretions, namely respiratory droplets
• small aqueous droplets produced by
exhalation, consisting of saliva or mucus and
other matter derived from respiratory tract
surfaces.
• Droplet sizes range from <5 µm to 1000 µm
• B. pertussis, influenza virus, adenovirus, rhinovirus, N.
meningitidis, and group A streptococcus (for the first
24 hours of antimicrobial therapy)
• Because certain pathogens do not remain infectious
over long distances in a healthcare facility, special air
handling and ventilation are not required to prevent
droplet transmission
• single patient room is preferred; cohorting- Spatial
separation of > 3 feet and drawing the curtain
between patient beds
• Healthcare personnel wear a simple mask (a
respirator is not necessary) for close contact
with an infectious patient, which is generally
donned upon room entry.
• Patients on droplet precautions who must be
transported outside of the room should wear
a mask if tolerated and follow Respiratory
Hygiene/Cough Etiquette.
 Airborne precautions

• prevent transmission of infectious agents that remain

infectious over long distances when suspended in the
air, e.g., rubeola virus [measles], varicella virus
[chickenpox], M. tuberculosis, and possibly SARS-CoV
• preferred placement for patients who require airborne
precautions is: airborne infection isolation room (AIIR)
• Whenever possible, non-immune HCWs should not care
for patients with vaccine-preventable airborne diseases
(e.g., measles, chickenpox)
• For HCWs, education about use of respirators, fit-
testing
• single-patient room that is equipped with special air
handling and ventilation capacity i.e., monitored
negative pressure relative to the surrounding area
• predefined Heating, Ventilation and Air
conditioning (HVAC) criteria
– specify 12 ach (air changes per hour)
– maintain the room temperature around 70F to 75F, while
keeping the relative humidity (rh) to be minimum of 30%
during winters and maximum of 60% during summers
• Use of appropriate transmission-based precautions at
the time a patient develops symptoms or signs of
transmissible infection, or arrives at a healthcare facility
for care, reduces transmission opportunities
• Since the infecting agent often is not known at the time
of admission to a healthcare facility, transmission-based
precautions are used empirically, according to the
clinical syndrome and the likely etiologic agent
• modified when the transmissible pathogen is identified
or ruled out based on diagnostic lab tests.
THANKS!