mandatory by lanyuehua


									 Mandatory program for
hospital professional staff

 Update infection control on SARS
 Management of Norovirus outbreak

                        Infection Control Team
                        26 November 2003
    Standard Precautions &
Transmission Based Precautions
1970 first CDC isolation recommendation

1983 CDC guideline for prevention and control of
   nosocomial infections
  Strict isolation, respiratory isolation, enteric precautions,
      contact isolation, tuberculosis(AFB) isolation, drainage
      / secretion precautions, and blood / body fluid

1987 Universal precautions ( Universal blood and
   body fluid precautions ) - UP
   Body substance isolation ( BSI )

1996 New CDC isolation guideline – Standard
   precautions ( combines UP & BSI )
    Guideline for Isolation
Precautions in hospitals - CDC
Two tiers of precautions
 Standard Precautions
 Transmission Based Precautions
  - Airborne
  - Droplet
  - Contact
    Standard Precautions

Apply to all patients regardless of
 diagnosis or known infection status.

Applicable to blood, all body fluids,
 secretions, and excretions, whether
 they contain visible blood or not
 ( except sweat ).
   Fundamentals of Standard Precautions
Hand washing
  Clean, non-sterile gloves when touching blood, body fluids,
  secretions, excretions and contaminated items.
Mask, eye protection, face shield
  Protect mucous membrane of eyes, nose and mouth if
  activities that are likely to generate splashes or spray of
  blood, body fluid, secretion and excretion.
  Clean, non-sterile gown to prevent soiling of clothing.
Patient care equipment
  Reusable equipment should be cleaned and reprocessed
  appropriately before and after use on patient.
Environmental control
  Adequate routine cleaning, disinfection of environmental
  surfaces, equipment and frequently touched surface.
  Handle, transport and process of soiled linen with care.
Prevent sharp injuries
  Never recap used needle, bend or break the needle.
  Single-handed technique or mechanical device if recapping
  Use mouth pieces, resuscitation bag or other ventilation
  devices as alternative to mouth-to-mouth resuscitation method.
Patient placement
  Place in private room if likely to contaminate the environment.
  E.g. poor hygiene.
  Routine daily cleaning. Airing of room or delay in admitting next
  patient is not needed.
        Airborne Precautions
For patients known or suspected to be
 infected with microorganisms
 transmitted by air borne droplet nuclei
 ( small-particle residue ie. 5 um or
 smaller in size )
 e.g. measles ( rubeola ), varicella
 ( chicken pox ) including disseminated
 zoster, TB.
 Airborne Precautions
 In addition to Standard Precautions
1. Patient placement
   Private room
   ~ negative pressure in relation to surrounding area.
   ~ 6-12 air changes per hour.
   ~ appropriate discharge of air outdoors or high-
       efficiency filtration of air if recirculate.
       ( HEPA )
   ~ Door kept closed.
   Anteroom – extra measure, no adequate data
   regarding the need.
2. Respiratory protection
 Wear respiratory protection when entering the room
    of patient with known or suspected TB – N95
    particulate respirator.
 Susceptible persons should not enter room of
    patient known or suspected to have measles or
    chicken pox.
 Persons immuned need not wear respiratory

3. Patient transport
 Limit movement. Minimize patient dispersal of
    droplet nuclei by wearing a surgical mask.
Prevention of Airborne Transmission
N95 respirator tested by HA:
regular size (3M-1860R, 3M-8210);
small size (3M-1860S, 3M- 9210,
Gerson brand model 2735S, and
Kimberly Clark ‘duckbill’ models

                                    Aerosol (Cough)
                                    Generating Procedure:
                                    •Negative Pressure
         Droplet precautions
For patient known or suspected to be
  infected with microorganisms
  transmitted by large- particle droplets
  ( > 5 um in diameter ) that can be
  generated by patient during coughing,
  sneezing or talking, or performance of
Transmission via close contact within 3 ft.
e.g. meningococcal meningitis, influenza,
  parvovirus B19, rubella, mumps.
 Droplet precautions
 In addition to Standard precautions
1.   Patient placement
     If private room or cohorting is not possible,
     place at least 3 ft. from other patients.
2.   Mask
     When working within 3 ft. of patient.
3.   Patient transport
     Minimize dispersal of droplet by wearing a
        Contact Precautions

For patients known or suspected to be
  infected or colonized with epidemio-
  logically important microorganisms that
  can be transmitted by direct or indirect
e.g. G.I, respiratory, skin or wound
  infection with multi-resistant bacteria.
Contact Precautions
In addition to Standard Precautions

1.   Patient placement
     If private room or cohorting not
     achievable, consider the epidemiology of
     the microorganism and patient population.
2.   Gloves and handwashing
     Wear gloves when enter the room and
     remove before leaving patient
     Handwashing after gloves removed.
3.   Gown
     Remove gown before leaving patient’s environment.

4.   Patient transport
     Minimize risk of contamination of environment
     surface or equipment.

5.   Patient care equipment
     When possible, dedicate use of non-critical patient-
     care equipment to a single patient.
     For reuse of common equipment,clean and disinfect
     before use on another patient.
Faecal Oral Transmission

Areas requiring special attention:
•Handling bed pans
•Flushing of toilets
•Clean up Spillage
•Specimens Handling
•Clean up Spillage
•Specimens Handling
               Standard             Contact             Droplet            Airborne
               Precautions          Precautions         Precautions        Precautions
Indications    All patients         Faecal-oral,        Droplets           Droplet nuclei, 1-5
                                    fomite, contact     (>5  in size)      in size

Handwashing    After contact bld,   Wash with
               BF, Sec, Exc, &      antiseptics upon
               cont. items          gloves removal

Gloves         For contact bld,     When enter the
               BF, Sec, Exc, &      room
               cont. items

Mask, Eye      Procedure                                Mask within 3      N95 upon entering
               splashes of bld,                         feet of patient    the room
protection/    bf, sec & exc
Face Shield,   likely
Environment    Routine

Private room   Patients with        optional            If NA, cohorting   Negative pressure,
               poor hygiene                                                6-12 ACH

Others                              Dedicated use of    Surgical mask      Surgical mask for
                                    non-critical item   for patients       patients during
                                                        during transport   transport
Hand washing
       Your hand is . . .

 A Source of undesired microorganisms
  (multiplying in and being shed from
 Main microbial vector of spread of
                 Transient                     Resident
                 (noncolonizing or             (colonizing flora)
                 contaminating flora)

Isolated from    Skin from most of people      Skin from most of people

Present          Not persistently but can be   Persistently
                 readily trans. by hand

Multiplication   Unable to multiply            Multiply on the upper
on the skin      (usually do not survive for   regions of the hair follicle
                 very long time)
Removed by       Easily removed by             Difficult by normal technique
mechanical       handwashing for 1 min. by
means            soap & water

e.g.             MRSA, Ps. aureginosa,         Staph. spp, other Gm –ve
                 Acine. spp., Salmonella       bacteria on moist skin
                 spp, E. coli. etc
            Therefore . . .

   Effective handwashing is the single
    most important infection control
    measure to protect patients in clinical
    areas from hospital acquired and cross-
                Hand washing
Objective :
1. Prevent hand-borne infection
2. Remove dirt, organic material and majority of
    transient flora.
3. by unmedicated detergent and water.
Factors affecting proper handwashing
1. Availability of handwashing facilities :
    basin, water tap, ( water flow, temp.)
    detergent dispenser, towel.
2. Compliance : lack of time
   Infectious lesions must be healed before hands regarded
    as safe.
            IC practice: Handwashing
          A matter of Motivation and Convenience ?

                                      •   frequent
                                      •   consistent
Setting         Year
                         compliance   •   after gloves removal
Medical Wards     June                •   antiseptics if indicated
HK                2003
ICU               1999     36%
                  1994     32%
ICU               1992     40%
ICU               1990     32%
All Wards         1983     45%
    Effective hand washing

CDC & HICPAC recommendation:
 Soaps (medicated / unmedicated) &
  water should be used if hands are
  visibly soiled
 If no visible dirt, use of waterless,
  alcohol-based hand rub for routine
 presurgical hand antisepsis, either
  methods are suitable

                  HICPAC: Hospital Infection Control Practices Advisory Committee
                Time taken
     of     =
Handwashing   + Agents use

               + Technique
                       Agents use
Interrupting transmission of
      Types of Handwashing

1. Social      2. Hygienic hand   3. Surgical hand
   handwashing    disinfection    disinfection
                                  (Surgical scrub)

 A. Hygienic hand wash      B. Hygienic hand rub
      1. Social handwashing

Why     Maintainthe hands socially clean
        Remove transient flora

How     Thorough    wash +
        a bar or liquid soap

When All routine tasks within general wards
  2. Hygienic hand disinfection
  (hygienic hand wash & hand rub)
Why      To remove majority of transient flora and part
         of resident flora by skin antiseptic

How      A thorough or defined wash for 15-30 sec
  Wash   with an antiseptic soap or detergent e.g.
         idiophors, chlorhexidine gluconate, triclosan
  Rub    Alternatively, apply an alcoholic hand-rub to
         disinfect clean hands
When     1. During outbreaks
         2. In high risk areas
         3. When contact with infectious materials
         4. Before procedures & after leaving
              isolation room
… cont’d (Hygienic hand wash)
1. Wet hands first with water
2. Apply soap/ antiseptic lotions
3. Rub hands together vigorously ~
4. Rinse with water
5. Dry thoroughly with disposable
6. Use towel to turn off the faucet.
7. Avoid using hot water
   (increase risk of dermatitis)
    … cont’d (Hygienic hand rub)
 Rubbing small portions ( 3-
  5 ml ) of antiseptic with all
  areas of hands & fingers to
  be covered, till hands dry.
 Alcoholic rubs well suited
  for hygienic hand
  disinfection :
  1. Antimicrobial
  performance is excellent.
  2. No wash basin
    … cont’d
    (Hygienic hand wash Vs Hand rub)
    A recent study conducted in Switzerland confirms the
    effectiveness of hand rub:        Lancet 2000; 356: 1307-12

   Handrub solution (alcohol-based 0.5% chlorhexidine gluconate
    and skin emollients) were distributed to all wards,
   Holders were mounted on all beds to facilitate access,
   HCWs were encouraged to carry a bottle in their pocket,

  Overall nosocomial infection decreased (16.9% in 1994 to 9.9% in
  MRSA rates decreased (2.16 to 0.93 per 10,000 patient-days)
  Handwashing compliance increased to 48-66%.
… cont’d
(Hygienic hand wash Vs Hand rub)
comparison with normal handwashing:
                           Handwashing w/wo              Alcoholic Handrub
Activity                  Bacterial killing effective   Bacterial killing effective

Time required                      2 mins                        30 secs

Cost                                Low                           Low

Risk of recontamination              Yes                           No

Accessibility by sink                Yes                           No

Compliance                          Low                         48 – 66%

Paper towel required?                Yes                           No

Application                    For all setting            Except visible soil
Point to note :
Skin dryness & irritation -
    by applying lotions & creams  irritant contact dermatitis due to
     handwashing or hand antisepsis
Nail polish –
    No artificial fingernails or extenders when having direct contact with pts
     at high risk (e.g. ICU, O.T.)
    Keep natural nails tips short (<1/4-inch long)
Glove use -
    Do not wear same glove for > one pt
    Change glove during pt care if moving from contaminated site to clean
     body site.
    Handwashing still require after removal of glove because
     contamination by small, undetected holes on gloves
Wearing of jewellery –
    Should be limited
Topping up of antiseptics –
    Do not add soap to a partially empty soap dispenser.
      bacterial contamination of soap. (strongly recommended)
    Update for
prevention of SARS
                Guidelines &

Facilities &
 Supplies                               Review
                Effective                 &
                Infection Control       Update

Communication             Enforcement
      &                        &
   Training                   Drill
           SARS: Prevention Strategies
  Intelligence           Hospital level

  Case               Infection
                                         HCW            Visitors
 Detection            Control

                 • Patient Triage
•Alert System                        • SARS Alert     • No visit in
                 • Standard          • Health         HR areas
•High Index
                   Precautions for     surveillance   •Limit &
of suspicion
                   ALL patients      • Influenza      Register in
•Lab. Dx         • Procedure &         Vaccination    non-HR
•Reporting to      Risk related      • Training &     •Mask if
HAHO & DH          PPEs                Drill          symptomatic
SARS: Mode              of transmission
   Contact secretions and excretions
    – Sources: fomites, patients BABF, Droplets
 Droplets and aerosols
    – Portal of entry: Eye, mouth
    – Portal of Entry: Respiratory tract
    – Sources: Aerosols generated by nebuliser,
 Special Attentions to:
    – Environment decontamination, esp. after spillage
    – Patient specimens handling
SARS Guideline on PPE    effective August 1, 2003

                               Conditions in High Risk Areas

                  No Patient      Direct      Splashing    Aerosol Gen
                   contact       Contact     Procedures     procedure

Mask (Surgical)      +              +            +
Mask (N95)                          +            +             +
Linen/Dp Gown        +              +            +             +
Face/Eye Shield                     +            +             +
Gloves                                           +             +
Goggles                                                        +

Cap/Shoe cover
SARS Guideline on PPE    effective August 1, 2003(continued)

                           Conditions in Non-High Risk Areas

                  No Patient     Direct     Splashing   Aerosol Gen
                   contact      Contact    Procedures    procedure

Mask (Surgical)      +            +            +               +
Mask (N95)                                                     +
Linen/Dp Gown                                  +               +
Face/Eye Shield                                +               +
Gloves                                         +               +
Dp Cap
Notes on Practices

• Handwashing is most important
• Use alcohol-based hand rub as alternative
• Do not touch mask or face (esp. eyes, nose &
  mouth) without 1st washing hands thoroughly
• Gloves must be changed after procedure and
  between patients.
• No wash gloves & double gloves
• Wash immediately and thoroughly if contaminated
  by patient’s body fluid or excretions
• N95:
  • Should be fit checked every time when used.
  • Cautions when reuse
Notes on Practices ( cont.)

• Barrier-man is NOT recommended
• Mask for patients and Visitors with respiratory
• No visitors in High Risk areas
• Limit and register visitors in other areas
• Precautions in performing high risk procedures
• Portering high risk patients with PPE and
  disinfection after use
    Staff Infectious Sickness Surveillance
Sick staff profile at Paediatrics department on 24/9/03
                                                                                    no. of
 Workplace name
        Staff Rank Resp.Inf. Fever G.I.Inf.               Attend      S ick Date    leave    Remarks:
            CHEUNG WAN SZE No
                       Cough,                             GP           24/09/2003        1
            LEUNG HOI YEE
               RN                  No  Diarrhoea          GP            24/09/2003     1
            LEUNG WING YAN 37.2c - 37.5c
               RN      Cough,                             GP                           2
                                                                   24/9/2003 - 25/9/2003 Call back
                       running                                                           to AED
                       nose,                                                             RS clinic
                       SOB due
                       to asthma
            HUIFamily YIN MANDY
                SUK MedSore        Yes                             2003/9/23-2003/9/24 2 Call back
                       throat,                                                           to AED
                       muscle                                                            RS clinic
            TANG SAUHeadache, No
               MO       SHEK                                           24/09/2003        1
                       sore throat
             HA Outbreak Response Plan
   Outbreak: An increase of infection above the normal level, for
    that period and in that place.

     Alert                 Conditions                             Actions
               Abnormal pattern in Community/Hosp.        outbreak investigation
               Guidelines in place                        local measures
    GREEN      Local actions are adequate e.g. Scabies    CCE/HCE in command
              outbreak, ILI in OAH                         HAHO & DH notified

              Abnormal pattern with territory-wide     Alert Duty Microbiologist
              implications/ HA response is needed e.g. & chairman of HA CCID
    YELLOW    H5N1 avian Flu                            HA Director in command
                                                        HCE liaise DH on control

              Outbreak has widespread territory           CE in command
      RED     wide implications e.g. SARS Alert, re-       HA Central Command
              emergence of SARS                           Committee activated
Management of Norovirus
The virus
 Family Caliciviridae
 Genus: Noroviruses
    – 4 genotypes
   Other names:
    – Norwalk-like viruses (NLV), after the strain
      responsible for an outbreak of GE infection in a
      school in Norwalk, Ohio, USA in 1968
    – Small Round Structured Viruses (SRSV).
   Survives freezing, temperatures as high as
    60ºC, up to 10 ppm chlorine
The virus

Norwalk virus (left and middle) and an unspecified calicivirus (right), bar = 100 nm.
Electron Micrograph by C Büchen-Osmond, ICTVdB Management, Columbia University,
Biosphere 2 Center, Oracle, AZ, USA. Image reconstructions of Norwalk virus (middle, top)
by Dr. B.V.Venkataram Prasad's Lab in the W.M. Keck Center for Computational Biology at
Baylor College of Medicine. and capsid protein reconstruction (middle, bottom) by VIPER
Management of Norovirus Outbreak
  All age groups are susceptible.
  The disease usually occurs as
   epidemics in winter (winter vomiting
  Outbreaks in nursing homes,
   restaurants, cruise ships and schools.
Recent outbreaks in November 2003:
   5-17 Nov:    Sacred Heart Cannosian School
                 (277/1835 students)
   10-14 Nov:   ESF-QBS (51/732 students;
                 0/60 staff)
   11-12 Nov:   PWH-7C ward (6 of 34
                 inpatients, 0/20 staff)
   14-16 Nov:   DDU, CMC (16/64 inmates;
                 4/30 staff)
   12-18 Nov:   TKO, HKSPC-SWSM Day Centre
                 (27/112 children; 0/16 staff)
Route & mode of transmission
   Foodborne disease –
     contaminated food or drink by food handler or at
      source which usually are shellfish e.g. oyster
   Person to person
     faecal-oral route
     aerosolization of vomitus (especially in institutes
      such as nursing homes or day care centres)
   Contact of contaminated environment
     patient environment / swimming pool or fomite
   The infective dose can be less than 100
   Aerosolization of vomitus leading to
    extensive environmental contamination by
    droplets, resulting in secondary spread
    among contacts is common.
   Shedding begins with onset of symptoms
   Shedding might continue for 2 weeks after
          Clinical features
   Incubation period: 12 - 50 hours.
   Presenting symptoms:
      Acute onset
      Vomiting
      Watery non-bloody diarrhoea, with abdominal cramp
      Nausea
      Low grade Fever may be present.
   Dehydration may occur in the young elderly.
   Symptoms last for 1-3 days with no chronic
   Outbreak suggestive of viral origin
    (Kaplan’s criteria)
    – Illness duration 12-60 hrs.
    – Incubation period 24-48 hrs.
    – >50% people with vomiting
    – No bacterial agents found.
   RT-PCR on specimens of:
    – Stool
    – Vomitus
    – Environmental samples
 Electron microscopy: insensitive.
 Culture and serology: Not available.
           Preventive Measures

   Heighten vigilance on Gastroenteritis
    – Information of community outbreak from
    – Cluster of GE should be reported to HAHO
      and Regional Office of DH
    – Fact sheet on Norovirus should be widely
      promulgated to hospital staff.
    – Briefing sessions for frontline staff
           Preventive Measures

   Clinical Awareness on Gastroenteritis
    – Compatible CF, patients from institutes,
      OAH or school clusters
    – Inform ICT
    – Laboratory diagnosis for enteric
      pathogens, and vomitus/stool for
      Norovirus PCR by GVU-DH
          Preventive Measures
   Enhance infection control measures
    – Isolate suspected cases
    – Ensure a stringent infection control;
    – Hand washing is the most important
    – Extensive disinfection (Na hypocholorite
      1:49 dilution) of environment and objects;
    – Visitors should adopt similar precautions
         Preventive Measures

   Wards with hospital acquired gastroenteritis
    outbreak should
    – stop all admissions and discharges
    – surveillance on both staff and patients for 3
      days from the date of onset of last patient
              Preventive Measures

   Ensure provision of appropriate PPE to
    – gloves, disposal gowns, and surgical masks in
      direct contact with patients' vomitus or excreta;
    – During the cleansing of vomitus or excreta, put
      on face shield;
    – Caring patients with on-going vomiting attack,
      put on face shield to prevent inoculation of
      droplets onto mucosal surfaces.
            High Risk Areas
 AED, Paediatrics, Medical, Long-stay
 Additional measures:
    – Bag for anticipated vomiting;
    – Increase frequency and intensity of routine
    – Early reporting of vomiting among staff
    – Strict hygienic measures in food and potable
      water handling

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