Global Health Prep Course 2008

1. Infection Prevention in Settings with Limited Resources Global Health Prep Course 2008 W. Charles Huskins, MD, MSc Mayo Clinic, Rochester, MN November 8, 2008 Disclosures: None

2. Healthcare-associated infections in settings with limited resources are… • Caused by agents typically associated with infections in tropical settings • Infrequent because most care is not associated significant risk • Similar to those in settings with adequate resources • Unfortunate but mostly unavoidable

3. Protect your patients! Protect yourself!

4. Infection Organisms Source/cause Respiratory & GI infections RSV, influenza, etc Rotavirus, etc Giardia, Cryptosporidium Salmonella Shigella Vibrio cholera Person-to-person, via direct, indirect or droplet spread Contaminated infant formula, enteral feedings Improperly prepared/stored food Contaminated water Contaminated surfaces Systemic viral infections Measles, varicella, rubella, mumps Airborne spread from infected persons TB M. tuberculosis Airborne spread from unidentified and/or inadequately treated persons Protect Your Patients and YourselfFrom “community infections” spread in healthcare settings

5. Overcrowding

6. Inadequate Sinks and Suppliesfor Hand Hygiene

7. Protect Your Patients and YourselfFrom “community infections” spread in healthcare settings • Hand hygiene • Use an alcohol-based hand rub in most situations • Wash hands with soap & water if visible contamination • Barrier precautions • Wear gloves for contact with blood, body fluids, secretions, excretions, mucous membranes, & non-intact skin • If limited in supply, use new gloves for contacts with blood & body fluids and reused gloves for other types of contacts • If limited in supply, dip gloved hands in diluted household bleach (0.05% chlorine concentration) for 1 minute between contacts; remove soiling by washing with soap and water first. • Wear goggles & mask if splashing/aerosolization possible • Wear gowns if soiling of clothing is possible

8. Simple Solutions to Improve Hand Hygiene Alcohol-based hand rub & container with clean gloves on cart Cistern with clean water, soap & clean, single use cloth towels on cart

9. WHO Clean Care is Safer CareThe First Global Patient Safety Challenge http://www.who.int/gpsc/en/

10. Infection Control for Viral Hemorrhagic Fevers in the African Healthcare Setting • Detailed descriptions of IC procedures for VHF • Practical descriptions of general IC procedures • Standard Precautions • Isolation Precautions • Disinfection of reusable supplies & equipment • Disinfection water for drinking, cooking & cleaning • Disposal of waste • Safe burial practices http://www.cdc.gov/ncidod/dvrd/spb/mnpages/vhfmanual.htm

11. Protect Your Patients and YourselfFrom “community infections” spread in healthcare settings • Additional measures for infections spread by airborne or droplet contact • Cohort patients with same disease • Avoid cough-inducing procedures • Ensure adequate ventilation • Close doors and use out-facing window or wall fan todirect air out of building • Ultraviolet germicidal irradiation may be appropriate in some situations

12. WHO Guidelines for Preventing Spread of TB in Healthcare Settings http://www.who.int/tb/publications/who_tb_99_269/en/index.html

13. Initial Management of a Patient with Suspected TB • Provide face mask or tissues • Instruct in cough hygiene – cover nose and mouth when coughing or sneezing • Dispose of tissues, cloths or masks in no-touch waste receptacles after use • Direct to a separate waiting area • Deliver services quickly (ahead of the queue) • Refer to a TB diagnostic & treatment facility

14. Infection Organisms Source/cause Hepatitis, AIDS Hepatitis B & C viruses HIV Blood products Unsafe injection practices Contaminated fluids/meds & sharps Malaria Chagas Disease Plasmodium sp. Trypanosoma cruzi Blood products Unsafe injection practices Contaminated fluids/meds Hemorrhagic fever Ebola, Lassa Fever, Marburg, etc Direct contact with blood, body fluids, or mucous membranes Unsafe injection practices Contaminated sharps Protect Your Patients and YourselfFrom bloodborne infections

15. Protect Your Patients and YourselfFrom bloodborne infections • Blood products • Eliminate unnecessary transfusions • Screen products appropriately • Administer products appropriately • Injections • Use sterile needles & syringes • Prevent contamination of injection equipment and fluids or medications • Sharps injuries • Avoid handling sharps • Dispose sharps properly

16. http://www.who.int/injection_safety/toolbox/en/LeafletBestPracticesPrinter.pdfhttp://www.who.int/injection_safety/toolbox/en/LeafletBestPracticesPrinter.pdf

17. http://www.who.int/injection_safety/toolbox/en/LeafletBestPracticesPrinter.pdfhttp://www.who.int/injection_safety/toolbox/en/LeafletBestPracticesPrinter.pdf

18. Internal mechanism blocks plunger once it is fully pressed. Additional shield to cover needle creating a protective cap Internal mechanism cracks plunger completely once it is fully pressed Needle is pulled back inside the syringebarrel upon retraction of the plunger Syringes for Injection Safety Reuse & Needlestick Prevention Features Reuse Prevention Feature

19. Infection Organisms Source/cause Bloodstreaminfections Gram negative rods Staph. aureus Candida IV catheters Contaminated fluids and medications Urinary tractinfection Gram negative rodsCandida Urinary catheters & open collection systems Surgical site infection Staph. aureus Gram negative rods Poor technique Contaminated instruments No/late/inadequate prophylaxis Postpartum endometritis Gram negative rods Anaerobes Intrapartum exams Contaminated instruments No/late/inadequate prophylaxis Protect Your PatientsFrom infections associated with invasive devices and procedures

20. GBS E. coli Klebsiella, Pseudomonas, Acinetobacter & other gram negative rods S. aureus Others Etiology of Invasive Bacterial Infections in Newborns 0-3 day in Hospitals, 1990-2004 Zaidi AKM, Huskins WC, Thaver D, et al. Lancet 2005; 365:1175-88

21. Inappropriate Use of Invasive Devices

22. Lack of Acceptable Quality Supplies & Equipment

23. Contaminated IV Fluidsand Medications

24. Inadequate Sterilization/Disinfection Procedures

25. Protect Your PatientsFrom infections associated with invasive devices and procedures • Invasive devices • Eliminate unnecessary use • Remove as soon as possible • Use sterile devices and supplies • Use aseptic technique during insertion and care • Maintain closed systems • Invasive procedures • Eliminate unnecessary use • Use sterile instruments and supplies • Use aseptic/sterile technique • Use peri-procedure antimicrobial prophylaxis as indicated (clean-contaminated, contaminated, dirty procedures)

26. Infection Control Assessment ToolA Standardized Approach for Improving Hospital Infection Control Practices • Modules for assessment and problem-solving regarding • Infection control programs • Practices: hand hygiene, isolation & standard precautions, injections, IV catheters, fluids & meds, urinary catheters, sterilization/disinfection • Areas: general wards, labor & delivery, surgery, ICUs • Ancillary services: microbiology, pharmacy, employee health, waste management • Developed and supported by • Rational Pharmaceutical Management Plus Infection Control Project team • USAID Rational Pharmaceutical Management Plus Project, Management Sciences for Health, Washington DC