Principles of Infection Control and Personal Protective Equipment May, 2007

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

Routes of Disease Transmission

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

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

Routes of Transmission Contact 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) Examples:

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

Routes of Transmission Airborne (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)

Infection Control Methods and Personal Protective Equipment

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

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

Infection Control Precautions

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

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

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

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

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

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

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

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

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

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

Negative Pressure Isolation Room

Assessing Infection Control Needs During an Investigation

Components of Infection Control Infrastructure Policies Procedures Authority Human resources Financial resources Engineering resources

Assessing Infection Control Infrastructure Example: cleaning patient rooms Policies –When to clean, what to clean Procedures –Cleaning products, order of surfaces to clean Authority –Enforcing policies and procedures

Assessing Infection Control Infrastructure Example: Cleaning patient rooms (continued) Human resources –Staff to clean rooms Financial resources –Money to buy cleaning products Engineering resources –Cleaning equipment –Hand hygiene facility (sink)

How to Put on and Remove Personal Protective Equipment

Sequence for Donning PPE 1.Hand hygiene 2.Gown 3.N95 Particulate respirator –Perform seal check 4.Hair cover 5.Goggles or face shield 6.Gloves

Gown Select appropriate type and size Opening may be in back or front Secure at neck and waist If too small, use two gowns –Gown #1 ties in front –Gown #2 ties in back

Surgical Mask Place over nose, mouth and chin Fit flexible nose piece over nose bridge Secure on head with ties or elastic Adjust to fit

N95 Particulate Respirator Pay attention to size (S, M, L) Place over nose, mouth and chin Fit flexible nose piece over nose bridge Secure on head with elastic Adjust to fit and check for fit: Inhale – respirator should collapse Exhale – check for leakage around face

Eye and Face Protection Limited human to human transmission of H5N1 has occurred to date Position goggles over eyes and secure to the head using the ear pieces or headband Position face shield over face and secure on brow with headband Adjust to fit comfortably

Gloves Don gloves last Select correct type and size Insert hands into gloves Extend gloves over gown cuffs

Key Infection Control Points Minimize exposures –Plan before entering room Avoid adjusting PPE after patient contact –Do not touch eyes, nose or mouth! Avoid spreading infection –Limit surfaces and items touched Change torn gloves –Wash hands before donning new gloves

Duration of PPE Use Surgical Masks (if N95 not available) –Wear once and discard –Discard if moist N95 Particulate Respirators –May use just one with cohorted patients Eye Protection –May wash, disinfect, reuse

Sequence for Removing PPE Remove in anteroom when possible 1.Gloves 2.Hand hygiene 3.Gown (and apron, if worn) 4.Goggles 5.Mask 6.Cap (if worn) 7.Hand hygiene

Removing Gloves (1) Grasp outside edge near wrist Peel away from hand, turning glove inside-out Hold in opposite gloved hand

Removing Gloves (2) Slide ungloved finger under the wrist of the remaining glove Peel off from inside, creating a bag for both gloves Discard

Removing A Gown 1.Unfasten ties 2.Peel gown away from neck and shoulder 3.Turn contaminated outside toward the inside 4.Fold or roll into a bundle 5.Discard

Removing Goggles or A Face Shield Grasp ear or head pieces with ungloved hands Lift away from face Place in designated receptacle for disinfecting or disposal

Removing a Mask Lift the bottom elastic over your head first Then lift off the top elastic Discard Don’t touch front of mask

Hand Washing Between PPE item removal, if hands become visibly contaminated Immediately after removing all PPE Use soap and water or an alcohol- based hand rub

Summary Influenza transmission occurs mainly through respiratory droplets –Contact can be prevented using PPE –Virus can be inactivated with infection control procedures –Hand washing is key PPE must be donned and removed appropriately to prevent contamination of wearers and environments Guidelines for using PPE and infection control measures for avian influenza in humans should be practiced until they are routine

Glossary Decontamination - The removal of harmful substances such as chemicals, harmful bacteria, or other organisms, from exposed individuals, rooms, and furnishings in buildings or in the outside environment. Disease transmission - The process of the spread of a disease agent through a population Infection control - Measures practiced by health care personnel in health care facilities to prevent the spread of infectious agents Personal protective equipment - Specialized clothing or equipment worn by a worker for protect from a hazard