Infection Prevention and Control for Epidemic- and Pandemic-Prone Acute Respiratory Diseases

Influenza Training Package Learning Objectives Describe basic infection-control principles. Discuss core infection-control measures in health-care settings.

Influenza Training Package Presentation Overview Basic infection control principles Core infection control measures used in health care settings

Influenza Training Package Basic Infection Control Principles

Influenza Training Package Aim of Infection Control Basic infection control measures reduce risk of transmission of pathogens from a known or unknown source

Influenza Training Package + Quantity of pathogen Virulence Routes of transmission Susceptible host Portal of entry into host Chain of Infection

Influenza Training Package Routes of Transmission Contact: Infections spread by direct or indirect contact with patients or the patient-care environment (e.g., shigellosis, viral hemorrhagic fevers) Droplet: Infections spread by large droplets generated by coughs, sneezes, etc. (e.g., Neisseria meningitidis, pertussis) Airborne (droplet nuclei): Infections spread by particles that remain infectious while suspended in the air (TB, measles, varicella, and variola)

Influenza Training Package Breaking the Chain of Infection Source control measures -Cough etiquette, cleaning, disinfection Modes of transmission -Contact: hand hygiene -Droplet: distance from source >1 m -Airborne: ventilation -Vector: bednets Portal of entry into the host -Adding barriers, e.g., PPE Host -Strengthen host defences, e.g., vaccination

Influenza Training Package Seasonal Influenza in Humans SARS and Current Avian Influenza in Humans Droplet most likely routemost likely route (SARS) possible (AI) Airborne possible during aerosol generating procedures Contact possiblemost likely route (SARS) H5N1: (bird to human), and possible (human to human) Transmission of Epidemic- and Pandemic-Prone Acute Respiratory Diseases

Influenza Training Package Core Infection Control Measures in Health Care Settings

Influenza Training Package ●Early recognition and reporting ●Infection control precautions ●Hand hygiene: alcohol-based hand rub, hand washing ●PPE: gloves, gowns, masks/respirators, eye protection Core Infection Control Measures in Health Care Settings (1)

Influenza Training Package Core Infection Control Measures in Health Care Settings (2) ●Patient accommodation ●Environmental cleaning and waste disposal ●Occupational health management WHO

Influenza Training Package Prevention is Primary CDC

Influenza Training Package Early Recognition in Health Care Facilities Health care facility staff must quickly identify and separate potential sources of infection from susceptible hosts

Influenza Training Package How to identify rapidly Rapid identification of Patients with Epidemic- or Pandemic- Prone Acute Respiratory Diseases: Clinical indications –Severe acute febrile respiratory illness (e.g., fever > 38°C, cough, shortness of breath) –Exposure history consistent with ARD of potential concern Epidemiological indications –History of travel to area affected by ARDs –Possible occupational exposure –Unprotected contact with ARDs patient(s)

Influenza Training Package Infection Control Precautions Standard precautions –Should be applied for ALL patients Transmission-based precautions* –Contact –Droplet –Airborne *Transmission-based precautions are often used empirically, according to the clinical syndrome and the likely etiological agent

Influenza Training Package Standard Precautions Hand hygiene Respiratory hygiene/cough etiquette Use of personal protective equipment (PPE) Prevention of needle sticks/sharps injuries Cleaning and disinfection of the environment and equipment

Influenza Training Package Droplet Precautions Protection against respiratory pathogens transmitted by large droplets In addition to Standard Precautions: –Use a medical mask when < 1 m of patient –Maintain a distance ≥ 1 meter between infectious patient and others –Place patient in a single room or cohort with similar patients –Limit patient movement

Influenza Training Package Contact Precautions Protection against contact with large droplets In addition to Standard Precautions: –Use non-sterile, clean, disposable gloves, gown, apron (only if gown is not impermeable) –Use disposable or dedicated reusable equipment (which must be cleaned and disinfected before use on other patients) –Limit patient contact with non-infected persons –Place patient in a single room or cohort with similar patients

Influenza Training Package Airborne Precautions Protection against inhalation of tiny infectious droplet nuclei In addition to Standard Precautions: –Use particulate respirator –Place the patient in adequately ventilated room (≥ 12 air changes per hour) –Limit patient movement Use airborne precautions for performance of any aerosol-generating procedures associated with pathogen transmission

Influenza Training Package Hand Hygiene Hand hygiene should be performed: –before and after any direct contact with a patient –after contact with blood, body fluids, secretions and excretions –after contact with items contaminated with blood, body fluids, secretions and excretions, including respiratory secretions Use alcohol-based hand rub or wash hands with soap and water –Wash hands if visibly soiled

Influenza Training Package Respiratory Hygiene and Cough Etiquette Part of standard precautions Education of health care workers, patients and visitors Source control measures (e.g., cover cough to prevent dissemination of infectious droplets) Hand hygiene Spatial separation (> 1 meter) of persons with acute febrile respiratory symptoms

Personal Protective Equipment Courtesy of K. Harriman

Influenza Training Package Types of PPE Used in Healthcare Settings Gloves – protect hands Gowns/aprons – protect skin and/or clothing Masks and respirators– protect mouth/nose –Respirators – protect respiratory tract from airborne infectious agents Goggles – protect eyes Face shields – protect face, mouth, nose, and eyes

Influenza Training Package PPE for Standard Precautions: Based on Risk Assessment IF direct contact with blood & body fluids, secretions, excretions, mucous membranes, non-intact skin –Gloves –Gown IF there is the risk of spills onto the body and/or face –Gloves –Gown –Face protection (mask plus eye protection goggle or visor; face shield)

Influenza Training Package PPE for Transmission-Based Precautions  Used in addition to Standard Precautions Contact Precautions –Gloves –Gown Droplet Precautions –Medical mask Airborne Precautions –Particulate respirator +

Influenza Training Package Masks and Respirators: Barriers and Filtration Surgical masks –Protect against body fluids and large particles Particulate respirators (e.g., N95) –Protect against small particles and other airborne particles Alternative materials (barriers) –Tissues, cloth

Influenza Training Package HHGlovesGownMedical Mask Particulate Respirator Eye Protection Entry to isolation room/area, but no anticipated patient contact Y Risk Asst N Close contact (< 1 meter) with infected patient in or out of isolation room/area Y YYYNY Performance of aerosol- generating procedure on patient YYYNYY PPE for Persons Providing Care for Patients with Acute Febrile Respiratory Illness, Including Patients with Suspected or Confirmed AI Infection

Influenza Training Package PPE for Interviewing Exposed Persons and Contacts of ARDs Patients Asymptomatic exposed persons and contacts ( low-risk) –Routine use of PPE not recommended –Maintain 1 meter distance between interviewer and interviewee –Use proper hand hygiene Symptomatic exposed persons (higher-risk) –PPE recommended in community and health care facility: Contact and Droplet Precautions –In health care facility, person should be placed in adequately ventilated room (≥ 12 air changes per hour), if possible –Maintain a distance of > 1 meter, if possible

Influenza Training Package PPE for Specimen Collection – Exposed Persons Collecting respiratory specimens is a high-risk, aerosol-generating procedure PPE recommended –Gloves –Gown –Goggles or face shield –N95 or higher level respirator CDC

Influenza Training Package ●Isolate patients with droplet or airborne spread diseases from other patients ●Separate wards, areas, or establish rooms for infectious patients where isolation facilities do not exist ●Only those patients with epidemiological and clinical information suggestive of a similar diagnosis should share rooms ●Separate patients by at least 1 meter Patient Accommodation

Influenza Training Package 1 meter Patient accommodation: Natural Ventilation Room

Influenza Training Package Duration of IC measures for Avian and Pandemic Influenza Adults and adolescents > 12 years of age – from time of admission until 7 days after symptoms resolved Infants and children ≤ 12 years of age – from time of admission until 21 days after symptoms resolved For immunocompromised patients, pathogen shedding may be protracted

Influenza Training Package Environmental cleaning: Use appropriate procedures for the routine cleaning and disinfection of environmental and other frequently touched surfaces Waste disposal: Treat waste contaminated with blood, bodily fluids, secretions and excretions as clinical waste, in accordance with local regulations Environmental Cleaning and Waste Disposal WHO

Influenza Training Package 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

Influenza Training Package Autopsy Precautions for Influenza A (H5N1) Follow standard PPE procedures for autopsies Anyone handling a corpse should follow standard precautions for blood and body fluids

Influenza Training Package Occupational Health Management During an Outbreak Monitor staff who work with patients with an infectious disease of potential concern for symptoms Screen for symptoms of influenza-like illness among staff reporting for duty (fever, cough) WHO

Influenza Training Package Implementation of Core Infection Control Measures During Rapid Containment Early recognition and reporting Infection control precautions Hand hygiene PPE: gloves, gowns, masks/respirators, eye protection Patient accommodation Environmental cleaning and waste disposal Occupational health management

Influenza Training Package Hospital Preparedness: Key Points Apply standard precautions routinely in all health-care settings Place all patients (suspected or confirmed with an infectious ARD) in a room or area separate from other patients Practice both standard and droplet precautions when caring for patients with infectious ARD

Important Components for HC Facility Infection Prevention and Control Program Available supplies and equipment (PPE, disinfectants) Policies and guidelines for procedures Ongoing educational programs for healthcare facility staff Process for monitoring staff health to identify and to prevent staff-to-patient and patient-to-staff spread of infection Jamaica IC Guidelines

Influenza Training Package Infection Control for ARD in Heath Care Settings Symptoms acute ILI Investigation for ARD of potential concern Confirmed ARD of potential concern Single room adequately ventilated (≥ 12 air changes per hour), if possible Standard and droplet precautions Different diagnosis Reassess precautions + Risk Factor Report to Public Health Authorities WHO Single room adequately ventilated, if possible Patient Infection control precautions

Influenza Training Package Environmental Decontamination Cleaning MUST precede decontamination Disinfectant ineffective if organic matter is present Use mechanical force –Scrubbing –Brushing –Flush with water

Influenza Training Package Environmental Decontamination: Disinfecting Household bleach (diluted) Quaternary ammonia compounds Chlorine compounds (Chloramin B, Presept) Alcohol –Isopropyl 70% or ethyl alcohol 60% Peroxygen compounds Phenolic disinfectants Germicides with a tuberculocidal claim on label Others

Influenza Training Package Using Bleach Solutions First clean organic material from surfaces or items Wipe nonporous surfaces with sponge or wet cloth –Allow to dry Use fresh diluted bleach daily!