- 1. Principles of Infection ControlandPersonal Protective
EquipmentMay, 2007
2. Learning Objectives Demonstrate knowledge of the principles
ofinfection control Recognize gaps in infection
controlinfrastructure Recognize ways to address gaps in
infectioncontrol infrastructure in different situations Demonstrate
proper selection and use ofpersonal protective equipment 3. Session
Overview Disease transmission Introduction to personal
protectiveequipment (PPE) How to use PPE Demonstration Infection
control precautions In health care facilities In the community 4.
Routes of DiseaseTransmission 5. Chain of Infection+Quantity
ofpathogenVirulence Route oftransmissionSensitivehostPort 6. Routes
of Transmission Respiratory Cough Sneeze Fecal-oral Feces
contaminate food, environment, orhands Vector-borne Transmitted by
insects 7. Routes of TransmissionContactDirect Contact Host comes
intocontact with reservoir Kissing, skin-to-skincontact,
sexualintercourse Contact with soil orvegetationIndirect Contact
Disease is carried fromreservoir to host Contaminated
surfaces(fomites)Examples: 8. Routes of TransmissionDropletLarge
droplets within ~1 meter (3 feet)transmit infection via: Coughing,
sneezing, talking Medical proceduresExamples: Diphtheria Pertussis
(Whooping Cough) Meningococcal meningitis 9. Routes of
TransmissionAirborne (droplet nuclei)Very small particles of
evaporateddroplets or dust with infectious agentmay Remain in air
for a long time Travel farther than droplets Become aerosolized
during proceduresExamples: Tuberculosis Measles (Rubeola) 10.
Transmission of Influenza VirusesSeasonalInfluenza inHumansCurrent
AvianInfluenza in HumansDroplet most likelyroutepossibleAirborne
possible atclose distancespossible at closedistancesContact
possible Most likely(bird to human), andpossible (human tohuman)
11. Infection Control MethodsandPersonal Protective Equipment 12.
Hand WashingMethod Wet hands with clean (not hot)water Apply soap
Rub hands together for about20 seconds Rinse with clean water Dry
with disposable towel orair dry Use towel to turn off faucet 13.
Alcohol-based Hand Rubs Effective if hands not visibly soiled More
costly than soap & waterMethod Apply appropriate (3ml) amount
topalms Rub hands together, covering allsurfaces until dry 14.
Personal Protective Equipment(PPE) When used properlycan protect
youfrom exposure toinfectious agents Know what type ofPPE is
necessaryfor the duties youperform and use itcorrectly 15. Types of
PPE Gloves Gowns Masks Boots (for agricultural settings, not used
forhuman healthcare) Eye protection 16. Types of PPEGloves
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
PPEGowns Fully cover torso Have long sleeves Fit snuggly at the
wrist 18. Types of PPE Surgical masks Cotton, paper Protect against
body fluids and largeparticles Particulate respirators (N95) Fit
testing essential Protect against small droplets andother airborne
particles Alternative materials (barrier) Tissues, clothMasks and
Respirators: Barriers and Filtration 19. Types of PPEParticulate
Respirators Three types: disposable, reusable, poweredair 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 PPEBoots(non-hospital
settings) Eye Protection Face shields Goggles 21. PPE Supplies
Maintain adequate, accessible supplies Creative alternatives
(studies not done toasses effectiveness) Mask: tissue, scarf Gown:
laboratory coat, scrubs 22. Working with Limited Resources Avoid
reuse of disposable PPE items Consider reuse of some disposable
itemsonly as an urgent, temporary solution Reuse only if no obvious
soiling ordamage When prioritizing PPE purchase Masks Gloves Eye
protection 23. Infection Control Precautions 24. Precaution
LevelsAll levels require hand hygiene StandardTransmission based
precautions: Contact Droplet Airborne 25. Standard Precautions
Prevent the transmission ofcommon infectious agents Hand washing
key Assume infectious agent couldbe present in the patients Blood
Body fluids, secretions, excretions Non-intact skin Mucous
membranes 26. PPE for Standard PrecautionsWear: Gloves Gowns
EyeProtectionand / or MaskIf: Touching Respiratory secretions
Contaminated items or surfaces Blood & body fluids Soiling
clothes with patient bodyfluids, secretions, or excretions
Procedures are likely to generatesplashes / sprays of blood,
bodyfluids, secretions, excretions 27. Contact PrecautionsTaken 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 patientcontact 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 forContact 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 bylarge droplets from Sneezing Coughing Talking
Examples Neisseria meningitidis Pertussis Seasonal influenza 31.
Droplet PrecautionsTaken 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 ofpatient Limit patient movement within
facility Patient wears mask when outside of room 32. Airborne
PrecautionsTaken in addition to Standard Precautions Prevent spread
of infection through inhalableairborne particles Examples
Tuberculosis Measles Varicella Variola 33. Airborne Precautions Use
for confirmed or suspected avianinfluenza cases 34. Airborne
Precautions for AvianInfluenza 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 HEPAfiltration Patient to wear a surgical mask
if outside ofthe isolation room 35. Negative Pressure Isolation
Room 36. Natural VentilationCohorting Room1 meter 37.
Aerosol-generating Procedures(Example; Endotracheal intubation) N95
particulate respirator If not available, wear tight fitting
surgical maskand face shield Eye protection Gloves and hand washing
Gown and waterproof apron Isolation room with negative pressure,
ifavailable Hair cover optional 38. Choosing the AppropriatePPE 39.
Avian Influenza Currently not easily transmitted humanto human
Routes of transmission to humans notknown, cannot rule-out any
routes Current transmission from poultry tohuman or human to human
for H5N1requires very close contact 40. Interviewing -
AsymptomaticExposed Persons and Contacts Low-risk activity Routine
use of PPE not recommended Maintain 3 feet distance between
interviewerand interviewee Use proper hand hygiene May use hand
sanitizer (at least 60% alcohol) ifhands not visibly soiled 41.
Interviewing - SymptomaticExposed Persons Higher risk activity PPE
recommended in community andhealthcare facility Contact precautions
Droplet precautions N95 respirator In healthcare facility, person
should beplaced in airborne isolation room Maintain a distance >
3 feet if possible 42. Specimen Collection ExposedPersons and Birds
High-risk aerosol-generating procedure PPE recommended Gloves Gown
Goggles or face-shield N95 or better respirator 43. Avian
InfluenzaInfection Control inHealth Care Facilities 44. Influenza
TransmissionEffective Infection ControlPrevents TransmissionFrom
... Patients to health careworkers Patients to patients Patients to
family membersproviding care 45. Droplet precautionsDroplet
precautionsAvian Influenza PrecautionsAvian Influenza
PrecautionsStandard precautionsStandard precautionsAirborne
PrecautionsAirborne Precautions 46. Precautions for Suspected
orConfirmed 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 anoutside area where no
people are located Place patients in rooms alone Alternative:
cohort patients away from otherpatient care areas with beds > 3
feet apart Avoid placement in rooms with stagnantair and poor
airflow/ventilation 47. Precautions for Suspected orConfirmed Cases
of Influenza A(H5N1) Limit number of health care workers,
familymembers and visitors Designate experienced staff to provide
care Limit designated staff to avian influenzapatient care Teach
family and visitors to use PPE 48. Precautions for Suspected
orConfirmed 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 orconfirmed cases that have
completed isolation for atleast 7 days,and who are no longer
symptomatic, maynot be considered a source of exposure to others.
49. Precautions for CollectingSpecimens Notify laboratory in
advance Health care worker collecting specimenshould wear full
barrier PPE Place specimen in leak-proof bag Hand deliver, if
possible Label specimen clearly as suspected avianinfluenza 50.
PatientAcute influenza symptom +travel to AI country in 10daysTest
for influenza A/H5Confirmed Influenza A/H5Maintain required
infection control precautionsAdults and adolescents > 12 years:
Continue for 10 days after resolution offever unless case is
ruled-out through confirmatory laboratory methodsInfection
ControlPrecautionSurgical mask for patient, userespiratory
hygieneIsolation room, use of PPEApply all infection control
precautionsDifferentdiagnosisRe-evaluatethe
precautionmeasuresPrecautions for Suspected or Confirmed Cases 51.
Environmental Decontamination Cleaning MUST precede decontamination
Disinfectant ineffective if organic matter ispresent Use mechanical
force Scrubbing Brushing Flush with water 52. Environmental
Decontamination:Disinfecting Household bleach(diluted) Quaternary
ammoniacompounds Chlorine compounds(Chloramin B, Presept) Alcohol
Isopropyl 70% orethyl alcohol 60% Peroxygen compounds Phenolic
disinfectants Germicides with atuberculocidal claim onlabel Others
53. Using Bleach Solutions First clean organic material
fromsurfaces or items Wipe nonporous surfaces with spongeor wet
cloth Allow to dry Use fresh diluted bleach daily! 54. Waste
Disposal Use Standard Precautions Gloves and hand washing Gown +
Eye protection Avoid aerosolization Prevent spills and leaks Double
bag if outside of bag is contaminated Incineration is usually the
preferred method 55. Managing Linens and Laundry Use Standard
Precautions Gloves and hand hygiene Gown Mask Avoid aerosolization
do not shake Fold or roll heavily soiled laundry Remove large
amounts of solid waste first Place soiled laundry into bag in
patient room Wash with normal detergent 56. Avian Influenza
InfectionControl in the Community 57. Preventing Transmissionin the
Community Respiratoryetiquette Cover nose / mouthwhen coughing
orsneezing Hand washing! 58. Avian Influenza and Food Heat poultry
meat to > 70C to kill the avian influenzavirus Consumption of
any raw / undercooked poultryingredients is risky Runny eggs Meat
with red juice Uncooked duck blood Separate raw meat from cooked or
ready-to-eat foodsto avoid cross-contamination Wash hands before
and after preparing food 59. Patients Cared for at Home Potential
for transmission Must educate family caregivers Fever / symptom
monitoring Infection control measures Hand washing Use of available
material as PPE 60. Patients Cared for at Home Handle laundry with
gloves; do not shake toprevent aerosolization Use disposable or
dedicated dishes, utensils Decontaminate the home environment
Frequent cleaning before disinfection 61. Autopsy Precautions
forInfluenza A (H5N1) Follow normal PPE procedures forautopsies
Anyone handling a corpse should followstandard precautions for
blood and bodyfluids 62. Application of Infection ControlActivities
during anInvestigation 63. Location Influences Actions Medical
facilities Homes Farms Markets Rural versus Urban areas 64.
Anticipate ExposuresContact with. . . Infected individuals
Individuals suspected to be infected Potentially contaminated
substances Potentially contaminated surfaces /items High-risk
procedures Animals 65. Assess Existing InfectionControl
Infrastructure Policies and procedures Authority Human resources
Financial resources Engineering resources 66. Assess Existing
InfectionControl Infrastructure Do policies describe PPE for health
careworkers? Are procedures in place for patient roomcleaning? Are
there negative air pressure rooms? Will you need to promote
respiratory andhand hygiene in the community? 67. Assessing
Infection ControlNeeds During an Investigation 68. Overview
Components of infection controlinfrastructure Infection control in
healthcare facilities Infection control in the community 69.
Components ofInfection Control Infrastructure Policies Procedures
Authority Human resources Financial resources Engineeringresources
70. AssessingInfection Control InfrastructureExample: cleaning
patient rooms Policies When to clean, what to clean Procedures
Cleaning products, order of surfaces to clean Authority Enforcing
policies and procedures 71. AssessingInfection Control
InfrastructureExample: 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) 72. Sustainability Evaluate infection
control knowledge Evaluate infection control procedures Develop a
sustainable program Encourage routine practice Build local capacity
73. Sustainability Example Hospital outside a large city Has basic
infection control program You notice healthcare personnel Recapping
needles Not wearing eye protection when doing invasiveprocedures
Help staff develop appropriate policies andprocedures 74. Authority
Communication with variousadministrative levels Policies may
already exist National Regional Local Adapt to the facility you are
working in 75. How to Put on and RemovePersonal Protective
Equipment 76. Sequence for Donning PPE1. Hand hygiene2. Gown3. N95
Particulate respirator Perform seal check1. Hair cover2. Goggles or
face shield3. Gloves 77. 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 78.
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 79. 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 collapseExhale check for leakage
around face 80. Eye and Face Protection Limited human to
humantransmission of H5N1 hasoccurred to date Position goggles over
eyes andsecure to the head using the earpieces or headband Position
face shield over face andsecure on brow with headband Adjust to fit
comfortably 81. Gloves Don gloves last Select correct type and size
Insert hands into gloves Extend gloves over gown cuffs 82. 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 83.
Duration of PPE UseSurgical Masks (if N95 not available) Wear once
and discard Discard if moistN95 Particulate Respirators May use
just one with cohorted patientsEye Protection May wash, disinfect,
reuse 84. Sequence for Removing PPERemove in anteroom when
possible1. Gloves2. Hand hygiene3. Gown (and apron, if worn)4.
Goggles5. Mask6. Cap (if worn)7. Hand hygiene 85. Removing Gloves
(1) Grasp outside edge near wrist Peel away from hand, turningglove
inside-out Hold in opposite gloved hand 86. Removing Gloves (2)
Slide ungloved fingerunder the wrist of theremaining glove Peel off
from inside,creating a bag for bothgloves Discard 87. Removing A
Gown1. Unfasten ties2. Peel gown away from neck and shoulder3. Turn
contaminated outside toward the inside4. Fold or roll into a
bundle5. Discard 88. Removing Goggles orA Face Shield Grasp ear or
headpieces with unglovedhands Lift away from face Place in
designatedreceptacle fordisinfecting ordisposal 89. Removing a Mask
Lift the bottom elasticover your head first Then lift off the
topelastic Discard Dont touch front ofmask 90. If You MUST Reuse
PPE.. Use during one shift and for one patient Discard at the end
of each shiftGOWN Hang gown with outside facing inMASK OR
RESPIRATORS Put the mask into the sealable bag May touch the front
of the mask, but washhands immediately after removing 91. Hand
Washing Between PPE item removal, if handsbecome visibly
contaminated Immediately after removing all PPE Use soap and water
or an alcohol-based hand rub 92. Summary Influenza transmission
occurs mainly throughrespiratory 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 toprevent contamination of wearers and environments
Guidelines for using PPE and infection controlmeasures for avian
influenza in humans should bepracticed until they are routine 93.
GlossaryDecontamination - The removal of harmful substancessuch as
chemicals, harmful bacteria, or otherorganisms, from exposed
individuals, rooms, andfurnishings in buildings or in the
outsideenvironment.Disease transmission - The process of the spread
of adisease agent through a populationInfection control - Measures
practiced by health carepersonnel in health care facilities to
prevent thespread of infectious agentsPersonal protective equipment
- Specialized clothingor equipment worn by a worker for protect
from ahazard 94. References and Resources Avian influenza,
including influenza A (H5N1), in humans: WHOinterim infection
control guideline for health care facilitiesRevised 24 April
2006.http://www.who.int/csr/disease/avian_influenza/guidelines/infectioncontrol1
Practical Guidelines for Infection Control in Health Care
Facilities.SEARO Regional Publication No. 41; WPRO Regional
Publication.2004.http://w3.whosea.org/LinkFiles/Update_on_SEA_Earthquake_and_Tsunam
US Centers for Disease Control and Prevention. Cover YourCough
http://www.cdc.gov/flu/protect/covercough.htm Elizabeth A. Bolyard,
et al. Centers for Disease Control andPrevention. Guideline for
infection control in health care
personnel,1998.http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/InfectControl98.pdf
