1. Infection Control in the Hospital Setting Vickie Brown, RN, MPH, CIC Associate Director Hospital Epidemiology UNC Health Care

2. Hospital Epidemiology Director ­­ William Rutala, PhD, MPH Medical Director ­­ David Weber, MD, MPH Public Health Epidemiologist ­­ Emily Sickbert-Bennett, MS Infection Preventionists ­­ Becky Brooks, RN, CIC ­­ Tina Adams, RN ­­ Brenda Featherstone, RN ­­ Lisa Teal, RN ­­ Kirk Huslage, RN, MPH Location: 1 st Floor, West Wing, Memorial Hospital Office Hours: Monday – Friday 7:30 AM to 4 PM Phone: 966-1638

3. Infection Control Resources l Infection Control Policies on Hospital Intranet http://intranet.unchealthcare.org/hospitaldepartments/infection /policies http://intranet.unchealthcare.org/hospitaldepartments/infection /policies l Infection Control on call pager available 24/7: 216-6652

4. PURPOSES OF EPIDEMIOLOGY l To plan and evaluate interventions and prevention strategies more effectively by knowing: The distribution of disease Its determinants in person, place, and time

5. CHAIN OF INFECTION l Infection requires a “chain” of events l The role of the hospital epidemiologist/infection control is to understand this chain and the most efficient means of interrupting transmission

6. CHAIN OF INFECTION Causative agent Susceptible host Reservoir Inoculating dose Portal of exit Portal of entry Environmental survival Mode of transmission

7. SOURCES OF PATHOGENS l People Endogenous: Normal flora or reactivation Exogenous: People (staff, visitors) or environment l Animals l Arthropods (insects) l Environment

8. Normal Skin Micro-Flora Numbers per square centimeter of skin surface (cfu/cm 2 ). Numbers of bacteria that colonize different parts of the body

9. ICU Setting: Multiple Sources of Pathogens

10. Basic Modes of Transmission l Contact -victim contact with source Direct-physical contact between source (e.g., MRSA on medical student’s hands) and victim (patient medical student is examining) Indirect-victim contacts contaminated inanimate object (e.g., ultrasound probe contaminated with MRSA or VRE) l Droplet -infectious droplets deposited on mucous membranes of the nose or mouth l Airborne -airborne phase in disease dissemination l Vectorborne -not a significant source in US healthcare facilities

11. Isolation Precautions to Prevent the Transmission of Infections to Patients and Personnel

12. STANDARD PRECAUTIONS l Hand hygiene: Before and after each patient contact & after gloves removed l Gloves: When touching contaminated items (blood, body fluids, secretions, excretions). If it is wet and not yours, wear gloves! l Mask, eye protection, face shield: whenever splashes or sprays of body fluids possible l Gown: Whenever splashes or sprays of body fluids possible

13. Personal Protective Equipment (PPE) Gloves Gown Mask Eyewear Wear your personal protective equipment correctly!

14. AIRBORNE PRECAUTIONS l Used for patients with known or suspected diseases transmitted by airborne droplet nuclei (<5 microns) l Private room Negative air pressure in relation to the corridor >6 air exchanges per hour Direct discharge of air to the outside l Personnel: Respiratory protection required N-95 respirator Limit transport of patient to essential purposes

15. AIRBORNE PRECAUTIONS Representative pathogens l M. tuberculosis l Varicella l Zoster l Measles HCWs required to wear a respirator to enter room

16. SPECIAL AIRBORNE PRECAUTIONS l Used for patients with known or suspected diseases transmitted by airborne droplet nuclei and contact l Private room (must meet airborne isolation guidelines) l Personnel: Respiratory protection required N-95 respirator Eye protection: Shield or goggles Gowns and gloves when entering room l Limit transport of patient to essential purposes

17. SPECIAL AIRBORNE PRECAUTIONS Representative pathogens l Avian influenza l Monkey pox l SARS Co-V l Smallpox l Viral hemorrhagic fever (e.g., Ebola, Lassa)

18. DROPLET PRECAUTIONS l Used for diseases spread via large droplets (>5 microns) l Private room Special air handling not required l Personnel Surgical mask upon entering room

19. DROPLET PRECAUTIONS Representative pathogens l Invasive N. meningitidis l RSV l Bordetella pertussis l Rubella l Mumps l Group A streptococcal pharyngitis l Influenza H1NI Precautions

20. CONTACT PRECAUTIONS l Used for pathogens that can easily be transmitted by contact with patient and/or items in the patient’s environment Private room Gloves and gown when entering room Careful hand hygiene

21. Representative Pathogens l Methicillin-resistant S. aureus (MRSA) l Vancomycin-resistant enterococcus (VRE) l C. difficile l Norovirus l Multiply-drug resistant (MDR) gram negative rods (e.g., B. cepacia, P. aeruginosa, Acinetobacter) All of the above organisms can survive on environmental surfaces for long periods of time and can be transiently carried on hands.

23. Bloodborne Pathogens

24. UNC Hospital Employees

25. BLOODBORNE PATHOGENS TRANSMITTED BY NEEDLESTICKS Big 3 l Hepatitis B l Hepatitis C l HIV Others l Argentinean VHF (Junín virus) l Blastomycosis l Brucellosis l Corynebacterium diphtheria l Cryptococcus l Dengue l Diphtheria l Ebola virus infection l Herpes simplex I l Leptospirosis l Malaria l Marburg VHF l Mycobacterium marinum l Mycoplasma caviae infection l Rocky Mountain spotted fever l Syphilis l Toxoplasmosis l Tuberculosis l Varicella zoster l West Nile Tarantola A, et al. AJIC 2006;34:367-75

26. Campus Health l Blood/body fluid exposure reporting: 966-6561 l After hours, weekends call Health Link: 966-2281 l Additional Information: Exposure Control Plan for Bloodborne Pathogens; attachment 12: 55-58. l http://intranet.unchealthcare.org/hospitaldepartments/infection/ policies/Ecpbbp.pdf http://intranet.unchealthcare.org/hospitaldepartments/infection/ policies/Ecpbbp.pdf

27. Other Communicable Diseases with Risk of Occupational Exposure l Tuberculosis l Varicella zoster l Pertussis l Influenza l Meningococcal Meningitis l Parvo Virus-B19

28. UNC OHS EVALUATIONS, 2007-08 Disease2007 Index Cases 2007 Staff Screened 2007 Infected 2008 Index Cases 2008 Staff Screened 2008 Infected Tuberculosis 9 3814140 Pertussis 4 1105190 Varicella 1 00000 Zoster 3 00000 Syphilis 5 90690 N. meningitidis 1 4903160 Hepatitis B 2 20220 Hepatitis C 27 039 1 HIV 12 0010 0 All blood269 0314 1

29. Health Care Associated Infections (HAIs)

30. Impact of HAIs 2002 data from CDC National Nosocomial Infections Surveillance Systems l Estimated number of HAIs: 1.7 million l Estimated number of deaths associated with the HAI:98,987 Pneumonia:35,967 Bloodstream:30,665 Urinary tract:13,088 Surgical site: 8,205 Other sites:11,062 Klevens RM. Public Health Rep. 2007, 122(2):160-6

31. Economic Costs of HAIs l Overall annual direct medical costs range from $28.4 to $33.8 billion (adjusted to 2007 dollars). Scott DR, CDC, March 2009 http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf

32. COST ESTIMATES FOR SPECIFIC HEALTHCARE-ASSOCIATED INFECTIONS HAI typeWeight-Adjusted Cost per HAI Mean + SE Range of Published Estimates of Cost per HAI VAP25,072 + 4,1328,682-31,316 BSI23,242 + 5,1846,908-37,260 SSI10,443 + 3,2492,527-29,367 CA-UTI758 + 41728-810 Anderson DJ, et al. ICHE 2007;28:767-773 (2005 dollars)

33. UNC HOSPITALS SELECTED HAIs AND ESTIMATED COST HAI typeUNC Cases, 2008Estimated Cost VAP822,055,904 BSI2315,368,902 SSI3353,498,405 CA-UTI339 256,962 Total98711,180,173 Total cost estimated by multiplying number of cases at UNC Hospitals by mean cost derived from Duke meta-analysis

34. What is the most effective and simplest method to protect your health and to help prevent HAIs?

37. UNC Hospitals Intensive Care Units: Hand Hygiene Compliance (%), 2003-2008

38. Hand Hygiene: Methods l Soap and water Hand washing with antimicrobial soap (e.g.CHG) and water for 15 seconds l Alcohol-based handrubs (e.g. Alcare) when… Hands are not visibly soiled, or Hand washing facilities are not available in patient rooms l Use soap and water when… Patient known or suspected to have C. difficile disease or norovirus infection (alcohol not effective against spores or nonenveloped viruses)

39. Indications for Handwashing and Hand Antisepsis l Before having direct contact with patients. l Before donning sterile gloves for sterile/aseptic procedures (e.g., central venous catheter placement) l After glove removal l After patient contact l After contact with a contaminated instrument or surface - Artificial nails and nail extenders are prohibited for direct patient care providers.

41. In Review l Infections can be transmitted in the hospital setting via contact, droplet, or airborne spread l Adherence to Isolation Precautions prevents transmission of disease to you and to other persons l Appropriate use of PPE and safe handling of sharp devices can reduce your risk of exposure to bloodborne pathogens l Hand hygiene reduces the risk of transmission of pathogenic organisms l Questions related to infection prevention and control: contact Hospital Epidemiology @ 6-1638 and after hours on pager 216-6652

42. Thank You! “I don't see the glass as half-empty or half-full. I see it as a glass somebody else has already put their lousy germs on.” Maxine