Infection Control Aspects of Influenza

Infection Control Aspects of Infection Control Aspects of Influenza Influenza

Chariya Sangsajja, M.D.Chariya Sangsajja, M.D.

BIDI, DDC, MOPHBIDI, DDC, MOPH

October 2011October 2011

Large respiratory droplet: distance<,=6 ft.Large respiratory droplet: distance<,=6 ft. Contact with large respiratory dropletContact with large respiratory droplet Airborne transmission over longer Airborne transmission over longer

distances has not been documenteddistances has not been documented

Human-to-Human Human-to-Human Transmission of Transmission of Influenza(1)Influenza(1)

Human-to-Human Human-to-Human Transmission of Influenza (2)Transmission of Influenza (2)

Smaller droplet nuclei at close-range Smaller droplet nuclei at close-range exposureexposure ?, may be important under ?, may be important under special condition; e.g. aerosol- producing special condition; e.g. aerosol- producing proceduresprocedures

All respiratory secretions and bodily All respiratory secretions and bodily fluidsfluids, including diarrheal stools are , including diarrheal stools are considered to be potentially infectiousconsidered to be potentially infectious

Administrative controlsAdministrative controlsEnvironmental/ engineering Environmental/ engineering

controlscontrolsPersonal protective equiPersonal protective equipmentspments

WHO :CWHO :Categories of Infection ategories of Infection Prevention and ControlsPrevention and Controls

US CDC: Fundamental Elements US CDC: Fundamental Elements to Prevent Influenza to Prevent Influenza

Transmission (1)Transmission (1) Seasonal Influenza vaccineSeasonal Influenza vaccine Respiratory hygiene and cough Respiratory hygiene and cough

etiquetteetiquetteAppropriate management of ill Appropriate management of ill

HCWsHCWs

US CDC: Fundamental Elements US CDC: Fundamental Elements to Prevent Influenza to Prevent Influenza

Transmission (2)Transmission (2)

Adherence to IC precautions for Adherence to IC precautions for all patient-care activities and all patient-care activities and aerosol-generating proceduresaerosol-generating procedures

Implementing environmental and Implementing environmental and engineering IC measuresengineering IC measures

Administrative Control Strategies Administrative Control Strategies (1)(1)

: Hospital Policy & Plan: Hospital Policy & Plan: : Monitor influenza activitiesMonitor influenza activities:: Clinical and IC practices Clinical and IC practices

guidelinesguidelines:: Education, training and monitoringEducation, training and monitoring: : Minimize potential exposuresMinimize potential exposures

Hospital PreparednessHospital Preparedness

Isolation Isolation RoomRoom

Training

ExerciseExercise

Clinical Clinical Practice Practice

GuidelinesGuidelines

Hand Hygiene Training Program

Minimize Potential ExposuresMinimize Potential Exposures

During periods of increased influenza During periods of increased influenza activity, minimizing OPD and ER activity, minimizing OPD and ER visits for visits for patients with mild ILI who are patients with mild ILI who are not at increased risk for complications not at increased risk for complications from influenzafrom influenza

Set up Set up Hotline CenterHotline Center Visitors screening for ILI symptomsVisitors screening for ILI symptoms

Administrative Control Administrative Control Strategies Strategies (2)(2)

: Implementing respiratory hygiene & : Implementing respiratory hygiene & cough etiquette programs cough etiquette programs

:Triage system, alerting sign :Triage system, alerting sign managing patient flowmanaging patient flow

:Provide facemask, alcohol hand-:Provide facemask, alcohol hand-rub at facility access pointrub at facility access point

:Provide space and separate area :Provide space and separate area for ILI patientsfor ILI patients

Infection Control Infection Control RecommendationsRecommendations

Standard precautionsStandard precautions: hand hygiene, : hand hygiene, glovesgloves

: Droplet precautions: Droplet precautions Respiratory hygiene/cough eRespiratory hygiene/cough etiquettetiquette Use cautions when performing Use cautions when performing

aerosol-generating proceduresaerosol-generating procedures

Respiratory Hygiene / Cough Respiratory Hygiene / Cough EtiquetteEtiquette

Apply to all patients with respiratory illnessApply to all patients with respiratory illness Posting visual alertsPosting visual alerts Source control measuresSource control measures Early recognition, separation and isolationEarly recognition, separation and isolation Droplet precautionsDroplet precautions Hand HygieneHand Hygiene Waste managementWaste management

Alerting Poster

Droplet precautionby using mask

1

2

3Steps to take off the surgical mask

Sink at patient waiting area

Posting visual alerts

Early recognition and

early implementation of

IC practices

Screening site Screening site

แยกจุ�ดคั�ดกรองมี ระยะห่�างจุากผู้��ป่�วย

>3 ฟุ�ต

แยกจุ�ดคั�ดกรองมี ระยะห่�างจุากผู้��ป่�วย

>3 ฟุ�ต

การเคัลื่��อนย�ายผู้��ป่�วย

การแยกผู้��ป่�วย ILI ที่ � OPD

ห่�องตรวจุโรคัไข้�ห่ว�ดให่ญ่�ห่�องตรวจุโรคัไข้�ห่ว�ดให่ญ่�


ห่�องสั�งเกตอาการไข้�ห่�องสั�งเกตอาการไข้�ห่ว�ดให่ญ่�ห่ว�ดให่ญ่�

Portable X-RayPortable X-Ray

การแยกผู้��ป่�วยที่ �ห่�องฉุ�กเฉุ(น

Administrative Controls Strategies(3)Administrative Controls Strategies(3)

Isolation ward/roomIsolation ward/roomLimiting the numberLimiting the number of persons in of persons in

present in patient roompresent in patient roomScreening personnel and visitorsScreening personnel and visitorsPatients and visitors Patients and visitors

recommendationsrecommendations

30

Patient PlacementPatient Placement

Single room Single room : confirmed case, : confirmed case, suspected case ,suspected case ,

Cohort ward Cohort ward : confirmed cases : confirmed cases AIIRAIIR: patients who need : patients who need

mechanical ventilationmechanical ventilation

Single RoomSingle Room

Patient Placement

Cohort Ward

AIIRAIIR

Bamras 34 04/21/23

Airborne Infection Isolation Room

Cohort WardCohort Ward

Patient recommendationsPatient recommendations

Hand hygieneHand hygienePersonal hygiene Personal hygiene surgical masksurgical mask Post discharge Post discharge

recommendationsrecommendations

Family Members/Visitors Family Members/Visitors RecommendationsRecommendations

Visitor Limiting Visitor Limiting Visitor Screening : ILI, high Visitor Screening : ILI, high

risk grouprisk group PPE PPE Hand Hygiene Hand Hygiene

Monitor and Manage Ill HCWs(1)Monitor and Manage Ill HCWs(1)

Screening for ILI before they Screening for ILI before they come on duty, register formcome on duty, register form

HCWs ILI surveillance system, HCWs ILI surveillance system, self monitoring form, self-self monitoring form, self-reporting and isolatingreporting and isolating

Develop sick leave policies for Develop sick leave policies for HCWsHCWs


Stop patient-care activities, Stop patient-care activities, don a don a facemask, promptly notify ICNfacemask, promptly notify ICN

Keeping personnel with mild ILI Keeping personnel with mild ILI at home to reduce the risk of at home to reduce the risk of spreading influenzaspreading influenza

HCWHCW ILI Monitoring FormILI Monitoring Form

Day1Day1 Day2Day2 Day3Day3 Day4Day4 Day5Day5

Date…………Date………….. Date…………Date………….. Date…………Date………….. Date…………Date………….. Date…………Date…………..

AM temp……AM temp…… AM temp……AM temp…… AM temp……AM temp…… AM temp……AM temp…… AM temp………AM temp………

PM temp………PM temp……… PM temp………PM temp……… PM temp………PM temp……… PM temp……PM temp…… PM temp………PM temp………

ILI symptoms:ILI symptoms:No…....Yes…No…....Yes…




ILI symptoms:ILI symptoms:No…....Yes……No…....Yes……

Day6Day6 Day7Day7 Day8Day8 Day9Day9 Day10Day10

Date…………Date………….. Date…………Date………….. Date…………Date………….. Date…………Date………….. Date…………Date…………..

AM temp……AM temp…… AM temp……AM temp…… AM temp……AM temp…… AM temp……AM temp…… AM temp………AM temp………

PM temp………PM temp……… PM temp………PM temp……… PM temp………PM temp……… PM temp……PM temp…… PM temp………PM temp………





ILI symptoms:ILI symptoms:No…....Yes……No…....Yes……


Exclude from work until 24 hours after Exclude from work until 24 hours after they no longer feverthey no longer fever

Considered for temporary Considered for temporary reassignment or exclusion from work reassignment or exclusion from work for 7 days from symptoms onset or for 7 days from symptoms onset or until the resolution of symptoms until the resolution of symptoms whichever is longer whichever is longer

Engineering Controls(1)Engineering Controls(1) Separate triage areas, installing Separate triage areas, installing

partitionspartitions Using local exhaust ventilationUsing local exhaust ventilation for for

aerosol generating procedures or aerosol generating procedures or perform in AIIRperform in AIIR

Using hood/Bio-safety cabinet in Using hood/Bio-safety cabinet in laboratorylaboratory

Aerosol-generating Aerosol-generating procedures produce large & procedures produce large &

small particle aerosolssmall particle aerosols BronchoscopyBronchoscopy

Sputum inductionSputum induction

ET intubation and ET intubation and

extubation extubation

CPR CPR

Open suctioningOpen suctioning

of airwaysof airways

AutopsiesAutopsies

Non-invasive Non-invasive

positive pressure positive pressure

ventilationventilation

NP swab/aspirationNP swab/aspiration

Aerosolized Aerosolized

medicationmedication

High-frequency High-frequency


การเก)บสั(�งสั�งตรวจุระบบที่างเด(นห่ายใจุการเก)บสั(�งสั�งตรวจุระบบที่างเด(นห่ายใจุ


47

Bio-safety Cabinet

Engineering ControlsEngineering Controls

Using closed suctioning systemsUsing closed suctioning systems Using high efficiency particulate Using high efficiency particulate

filters on mechanical and bag filters on mechanical and bag ventilatorsventilators

Ensuring effective ventilation and Ensuring effective ventilation and thorough environmentalthorough environmental surface surface hygienehygiene

Closed circuit suctioning system

Bacterial / virus HEPA Bacterial / virus HEPA filterfilter

Personal Protective Equipments Personal Protective Equipments (PPE)(PPE)

SuppliesSupplies TrainingTraining

ProperProper PPEPPE MonitoringMonitoring

PPE: Seasonal and Pandemic PPE: Seasonal and Pandemic Flu 2009Flu 2009

Surgical maskSurgical mask

N-95 mask, GogglesN-95 mask, Goggles:: Aerosol- Aerosol-generatinggenerating

proceduresprocedures GOWNGOWN GLOVESGLOVES

Aerosol-generating Aerosol-generating procedures produce large & procedures produce large &

small particle aerosolssmall particle aerosols BronchoscopyBronchoscopy

Sputum inductionSputum induction

ET intubation and ET intubation and

extubation extubation

CPR CPR

Open suctioningOpen suctioning

of airwaysof airways

AutopsiesAutopsies

Non-invasive Non-invasive

positive pressure positive pressure


NP swab/aspirationNP swab/aspiration

Aerosolized Aerosolized

medicationmedication

High-frequency High-frequency


Research on Influenza ICResearch on Influenza IC

PPE: N-95 mask vs surgical maskPPE: N-95 mask vs surgical mask

:Unpublished multiple hospital study :Unpublished multiple hospital study in Chinain China

:N-95 provided 75% protection :N-95 provided 75% protection against lab-confirmed fluagainst lab-confirmed flu

:N-95 were 42% more effective than :N-95 were 42% more effective than surgical mask over allsurgical mask over all

Research on Influenza ICResearch on Influenza IC

Household influenza transmission: Household influenza transmission: Cowling B.,et alCowling B.,et al

: HH+alcohol hand rub vs.: HH+alcohol hand rub vs.

HH+facemask vs. control gr.HH+facemask vs. control gr.

: Substantial and significant benefits : Substantial and significant benefits of facemask and HH if implement of facemask and HH if implement within 36 hours of index case ILI within 36 hours of index case ILI onsetonset

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Infection Control Aspects of Influenza