Principles of Infection Control and Personal Protective Equipment

1. Principles of Infection Control and Personal Protective Equipment May, 2007

2. 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

3. 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

4. Routes of Disease Transmission

5. Route of transmission Port Quantity of pathogen Virulence Chain of Infection + Sensitive host

6. Routes of Transmission • Respiratory • Cough • Sneeze • Fecal-oral • Feces contaminate food, environment, or hands • Vector-borne • Transmitted by insects

7. Direct Contact Host comes into contact with reservoir Kissing, skin-to-skin contact, sexual intercourse Contact with soil or vegetation Indirect Contact Disease is carried from reservoir to host Contaminated surfaces (fomites) Routes of TransmissionContact Examples:

8. Routes of TransmissionDroplet Large droplets within ~1 meter (3 feet) transmit infection via: • Coughing, sneezing, talking • Medical procedures Examples: • Diphtheria • Pertussis (Whooping Cough) • Meningococcal meningitis

9. Routes of TransmissionAirborne (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)

10. Transmission of Influenza Viruses

11. Infection Control Methodsand Personal Protective Equipment

12. Hand Washing Method • Wet hands with clean (not hot) water • Apply soap • Rub hands together for about 20 seconds • Rinse with clean water • Dry with disposable towel or air dry • Use towel to turn off faucet

13. 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

14. 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

15. Types of PPE • Gloves • Gowns • Masks • Boots (for agricultural settings, not used for human healthcare) • Eye protection

16. 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

17. Types of PPE Gowns • Fully cover torso • Have long sleeves • Fit snuggly at the wrist

18. 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

19. 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)

20. Types of PPE Boots (non-hospital settings) Eye Protection • Face shields • Goggles

21. PPE Supplies • Maintain adequate, accessible supplies • Creative alternatives (studies not done to asses effectiveness) • Mask: tissue, scarf • Gown: laboratory coat, scrubs

22. 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

23. Infection Control Precautions

24. Precaution Levels All levels require hand hygiene • Standard Transmission based precautions: • Contact • Droplet • Airborne

25. 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

26. PPE for Standard Precautions Wear: • Gloves • Gowns • Eye Protection and / or Mask If: • Touching • Respiratory secretions • Contaminated items or surfaces • Blood & body fluids • Soiling clothes with patient body fluids, secretions, or excretions • Procedures are likely to generate splashes / sprays of blood, body fluids, secretions, excretions

27. 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

28. 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

29. 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

30. Droplet Precautions • Prevent infection by large droplets from • Sneezing • Coughing • Talking • Examples • Neisseria meningitidis • Pertussis • Seasonal influenza

31. Droplet Precautions Taken in addition to Standard Precautions • Place patients in single rooms or cohort 3 feet apart • Wear surgical mask within 3 feet or 1 meter of patient • Wear face shield or goggles within 3 feet or 1 meter of patient • Limit patient movement within facility • Patient wears mask when outside of room

32. Airborne Precautions Taken in addition to Standard Precautions • Prevent spread of infection through inhalable airborne particles • Examples • Tuberculosis • Measles • Varicella • Variola

33. Airborne Precautions • Use for confirmed or suspected avian influenza cases

34. Airborne Precautions for Avian Influenza • N95 respirator (or equivalent) for personnel • Check seal with each use • Patient in isolation • Airborne 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

35. Negative Pressure Isolation Room

36. Natural Ventilation Cohorting Room 1 meter

37. 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

38. Choosing the Appropriate PPE

39. Avian Influenza • Currently not easily transmitted human to human • Routes of transmission to humans not known, cannot rule-out any routes • Current transmission from poultry to human or human to human for H5N1 requires very close contact

40. 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

41. 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 • Maintain a distance > 3 feet if possible

42. Specimen Collection – Exposed Persons and Birds • High-risk aerosol-generating procedure • PPE recommended • Gloves • Gown • Goggles or face-shield • N95 or better respirator

43. Avian InfluenzaInfection Control in Health Care Facilities

44. Influenza Transmission Effective Infection Control Prevents Transmission From ... • Patients to health care workers • Patients to patients • Patients to family members providing care

45. Avian Influenza Precautions Standard precautions Droplet precautions Airborne Precautions

46. Precautions for Suspected or Confirmed Cases of Influenza A (H5N1) • 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 where no people are located • Place patients in rooms alone • Alternative: cohort patients away from other patient care areas with beds > 3 feet apart • Avoid placement in rooms with stagnant air and poor airflow/ventilation

47. Precautions for Suspected or Confirmed Cases of Influenza A (H5N1) • 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

48. Precautions for Suspected or Confirmed Cases of Influenza A (H5N1) • Keep isolated from others as much as possible until: • At least 7 days after symptom onset AND • At least 48 hours after fever has subsided without taking fever-reducing medicines (Whichever is longer) • Depending on the specific circumstances suspect or confirmed cases that have completed isolation for at least 7 days,and who are no longer symptomatic, may not be considered a source of exposure to others.

49. 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”

50. 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 Apply all infection control precautions Test for influenza A/H5 Re-evaluate the precaution measures Different diagnosis Confirmed Influenza A/H5 Maintain required infection control precautions • Adults and adolescents > 12 years: Continue for 10 days after resolution of fever unless case is ruled-out through confirmatory laboratory methods