Infection Prevention and Control of Pandemic- and

Epidemic-Prone Respiratory Diseases in Health Care

WHO Interim Guidelines

Infection Prevention and Control of Pandemic- and

Epidemic-Prone Respiratory Diseases in Health Care

WHO Interim Guidelines

Carmem Lúcia Pessoa-Silva, MD, PhD

pessoasilvacl@who.intInfection Control in Health Care

Biorisk Reduction for Dangerous Pathogens (BDP)

Department of Epidemic and Pandemic Response (EPR)

Communicable Disease Surveillance and Response Cluster (CDS)

TB Infection Control Global Consultation

22-23 October, Geneva, Switzerland

Objectives of New GuidelinesObjectives of New Guidelines

� Update

� Threat of pandemics

� Reduce spread in healthcare settings

� Avoid healthcare settings to amplify outbreaks

� International Health Regulations (2005)

WHO Recommended Steps in Guideline DevelopmentWHO Recommended Steps in Guideline Development

Not startedMake recommendations on dissemination strategy

In progressTest the guidelines through pilot evaluations

In progressDefine strength of recommendations

�Interim version of the guidelines

�External peer review

�WHO Internal review

�Draft guidelines

�Develop evidence-based recommendations

�Review the evidence available

�Undertake a systematic search for evidence

�Definition of guideline development group

�Definition of guideline WHO steering group

�Define the specific issues to be addressed by the guidelines

Action takenWHO recommended steps in guideline development

Development of the WHO Guidelines

Acknowledgements

Development of the WHO Guidelines

Acknowledgements• M Birmingham

• M Bell

• DM Cardo

• M Chamberland

• Y Chartier

• P Ching

• G Dziekan

• A Estrela

• P Formenty

• K Fukuda

• P Gully,

• K Harriman

• F Hayden

• S Hill

• S Hugonnet

• WR Jarvis

• D Legros

• Y Li

• M Libel

• JC Martines

• ZA Memish

• S Mortier

• C Murphy

• F Otaiza

• U Panisset

• S Paton

• CL Pessoa-Silva

• N Previsani

• S Resnik

• G Rodier

• VD Rosenthal

• C Roth

• MJ Ryan

• S Salmon

• WH Seto

• N Shindo

• G Thomson

• TKF Wang

• S Wilburn

• R Williams

• M Weber

Editors

� CL Pessoa-Silva & WH Seto

Writing committee

� P Ching, K Harriman, Y Li, CL Pessoa-Silva,

WH Seto, TKF Wang

Guideline steering group

� DM Cardo, C Murphy, F Otaiza, S Paton, CL

Pessoa-Silva, C Roth, WH Seto

ContentsContents

� Introduction: Scope of the guidelines & Main IC strategies

� Infection prevention and control recommendations

� Environmental ventilation for respiratory infections

� Preparedness planning for ARD epidemics

� Annexes

ScopeScope

� Acute febrile infectious respiratory syndrome

– Focus on epidemic- and pandemic-prone diseases

� Acute respiratory disease of potential concern

– International Health Regulation (2005)

• SARS

• New influenza subtype

• New organisms

• Plague

• MDR TB

ScopeScope

� Acute febrile infectious respiratory syndrome

– Focus on epidemic- and pandemic-prone diseases

� Acute respiratory disease of potential concern

– International Health Regulation (2005)

• SARS

• New influenza subtype

• New organism

• Plague

• MDR TB

GUIDELINES FOR THE PREVENTION OF TUBERCULOSIS IN

HEALTH CARE FACILITIES IN RESOURCE-LIMITED SETTINGS, 1999

Guiding PrinciplesGuiding Principles

� Strategies to promote IC measures

– Sustainability

– Multimodal interventions

– Promotion of safety institutional climate

� Risk assessment and management

– Modes of transmission

– Source

– Environment

– Procedure

– Resources

� Minimal evidence-based standards for safe health care

Risk ManagementRisk Management

� Goal: reduce the risk

� Means:

– Source controls

• Cough etiquette and respiratory hygiene

– Administrative controls

• Construction of infection control infrastructure

• Early detection, isolation, treatment and report

– Engineering controls

• Patient placement

• Environmental ventilation

– Personal protective equipment (PPE)

Source Control: Cough Etiquette & HygieneSource Control: Cough Etiquette & Hygiene

Macau, China, 2003. Photo: C Murphy.

Infection Control PracticesInfection Control Practices

� Engineering Controls

– Environmental ventilation (air exchanges)

� Administrative Controls

– IC programme, policies, procedures

– Early recognition, treatment, contention and reporting

– Triage, organization of work

� Personal Protective Equipment

Strength of measure

Scientific Working Meeting on Occupational Influenza

Prevention and Control in Health Care Settings

Ontario, Canada, October 26 – 27, 2006.

Engineering ControlsEngineering Controls

� Reduce the concentration of infectious aerosols in the air

– Improve quality of ventilation

– Particularly relevant during aerosol-generating events

� Reduce the presence of contaminated surfaces and items

– cleaning and disinfection of contaminated surfaces and items

� Appropriate use of PPE can further reduce the risk of

infection, but it is dependant on several factors

– availability, training, adequate staff

– AND human behaviour.

The quality of ventilation has been pointed as a major

factor in determining the risk of exposure.Fennelly K, Nardell E. The relative efficacy of respirators and room ventilation in preventing

occupational tuberculosis. Infect Control Hosp Epidemiol. 1998;19(10):754-759.

Patient PlacementPatient Placement

� Type of room

– Airborne precaution room

– Adequately ventilated single room

� Cohorting

� Adequate spatial separation of patients suspected to have

the same clinical syndrome but diagnosis not yet identified

Designs of Airborne Precautions Rooms (1)Designs of Airborne Precautions Rooms (1)

� Naturally ventilated

– Open door and windows to allow airflow across the room

– Corridor adequately ventilated

Corridor

Isolation room

Toilet

Toilet exhaust

Corridor

Isolation room

Toilet

Toilet exhaust

Corridor

Isolation room

Toilet

Toilet exhaust

Corridor

Anteroom

Isolation room

Toilet

Floor level exhaust

Diffuser

Toilet exhaust

Transfer grille

� Mechanically ventilated

– Sealed room

– Negative pressure

Designs of Airborne Precautions Rooms (2)Designs of Airborne Precautions Rooms (2)

Types of Room for Patient PlacementTypes of Room for Patient Placement

YESNOControlled airflow

direction

YESYESMechanically or

naturally ventilated

YESYESVentilation rate ≥12 air

changes per hour

Airborne precaution

room

Adequately ventilated

room

Need for control of air flow direction?

Environmental Ventilation

Next Steps

Environmental Ventilation

Next Steps

� Development of guidelines on the use of natural ventilation

� Coordination: – Y. Chartier (Water, Sanitation and Health)

– CL Pessoa da Silva

� Partners– WHO

• TB/HIV and Drug Resistance (THD)

• Occupational and Environmental Health (OEH)

• Water, Sanitation and Health (WSH)

• Biorisk Reduction for Dangerous Pathogens (BDP)

– External Partners

• University of Hong Kong, Hong Kong SAR China

• Queen Mary Hospital, Hong Kong SAR China

Personal Protective EquipmentRationale

Personal Protective EquipmentRationale

� RISK ASSESSMENT

� Level of resources

� Early confirmation of diagnosis

� Use of filtering face piece respirators

– particularly in high risk situations for droplet nuclei

– Respirators Must Fit Properly