5 infection control 110309

TRAINING ON OUTBREAK INVESTIGATION

TOPIC 4

INFECTION CONTROL

DRAFT Version

DRAFT Version

During outbreak investigation

TOPIC 4

INFECTION CONTROL

DRAFT Version

At the end of the session, the participants will be able to: Explain the importance of promoting culture of safety Identify common situations during an outbreak investigation when the

investigator is likely to be exposed to sources of infection Describe standard precautions and transmission-based precautions Explain the uses of different types of personal protective equipment (PPE) Demonstrate hand washing, putting on and removing PPE and particulate

respiratory seal check Identify challenges in the use of PPE

Below is the summary table of recommended activities for the topic Infection control, their objectives and suggested timing in the training.

LEARNING OBJECTIVES

RECOMMENDED ACTIVITIES

Table 5—1. Summary of recommended activities

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Activity Number

Title Objective Timing

Before During After

1 Skills Station (should have all the posters available)

To practice participants on donning of PPE, hand hygiene, disinfection, chlorine solution preparation, par-ticulate respirator seal check, etc.

+++

+++

+++

2 Droplet vs Aerosol To show difference between droplet and aerosol

+++ ++

3 Mime-Precaution To enumerate safety precaution components

+++ + +++

4 Match the mask To identify appropriate mask for specific transmission

++ +++ ++

5 Video on Donning PPE and hand hygiene

To demonstrate wearing and taking off PPE and hand hygiene

++ +++ ++

DRAFT Version

During an outbreak investigation, it is important that staff/investigators try their best to prevent self from being infected by patients or other possible sources. This topic is about protecting you and your staff from infections caused by dangerous pathogens and its immediate environment. Standard precautions require that health workers in the field assume that the blood and the body substances of all patients are potential sources of infection, regardless of the diagnosis, or presumed infectious status. Additional precautions are needed for diseases transmitted by air, droplets and through contact.

A culture of Safety Improving worker safety requires an organization-wide commitment to creating, implementing, evaluating and maintaining effective and current safety practices – a culture of safety. Establishing an effective culture of safety also requires that both personal safety and safety of others are responsibilities inherent to both the managers and the staff. This means respecting and adhering to the standards and protocols, being aware of personal safety and safety of others by providing immediate feedback or correcting incorrect behaviour positively.

Risk of infection during an outbreak During an outbreak, staff can be infected in many ways. More notably are the following situations when staff are the most at risk:

a. needle stick injury during specimen collection and other procedures b. breach in the use of PPE – not using PPE, improperly fitted PPE or re-

using single-use PPE c. from aerosol-generating procedures d. being exposed to an asymptomatic but infected patient

Standard Precaution Standard precautions are precautionary measures that help limit infections to health workers, patients and relatives. Experiences from previous outbreaks have shown that further disease transmissions e.g., nosocomial transmission, could

SUMMARY CONTENTS

In hospital setting, recapping of needles after taking blood samples is the most common cause of needle stick injury.

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have been prevented if basic level of infection control precautions are followed. Treating all patients with the “standard” precautions involves work practices that are essential to provide a high level of protection to patients, health care workers, relatives, etc. These are:

Hand hygiene Respiratory hygiene and cough etiquette – which are added to standard

precautions to control transmission of respiratory infections if a patient has respiratory symptoms.

Use of personal protective equipment (PPE) based on risk assessment to avoid direct contact with patient's blood, body fluids, secretions and non-intact skin

Prevention of needle sticks/sharps injuries and Cleaning and disinfection of the environment and equipment

Transmission-based precaution For certain transmissible or highly pathogenic infections, transmission-based precautions are used IN ADDITION to standard precautions. These are:

a. Contact precaution, b. Droplet precaution and, c. Airborne precautions

Standard precautions should be: in PLACE ALL the time – whether or not there is

recognized outbreak practiced for ALL PATIENTS – regardless of diagnosis

Since the infecting agent may not be known at the time of admission to a health care facility, transmission-based precautions are used empirically, according to the clinical syndrome and the likely aetiologic agent (based on a risk assessment), and then modified when the pathogen is identified or stopped if a transmissible infectious disease etiology is ruled out.

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Table 5—2. Transmission-based precautions, organisms implicated and recommended PPE.

Personal Protective Equipment (PPE) Personal protective equipment or PPE is designed to act as a barrier to hazardous agents encountered by health workers in the hospital or while conducting outbreak investigation. Personal protective equipment reduces, but does not completely eliminate, the risk of acquiring an infection. It is important that it is used effectively, correctly and at all times where contact with blood and body fluids of patients may occur.

Personal Protective Equipments (PPE) are comprised of:

Transmission - based

Precautions Transmission Example

Organisms Commonly implicated

Recommended PPE

Contact Direct – indirect contact with patient/ environment

shigellosis, Ebola hemorrhagic fever, MRSA

Gloves, gowns

Droplet Cough, sneeze Neisseria meningitidis, pertussis, pneumonias, diptheria, influ-enza, mumps

Surgical mask, goggles + standard precaution

Airborne Particle suspended in the air (<5μ)

TB, measles, varicella, and vari-ola

N 95, goggles + standard precau-tion

Staff must also be aware that use of personal protective equipment does not replace the need to follow basic infection control measures such as hand hygiene.

MEDICAL MASK GOWN PROTECTIVE EYEWEAR GLOVES

Figure 5—1. Personal protective equipment (PPE)

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Items that are not PPE include caps for hair which function more for staff comfort and closed footwear or boots. Boots are used only to avoid accidents and sharp objects.

How to’s The accompanying PowerPoint presentation on Infection Control provides us with steps on the following:

a. Wearing and taking off PPE b. Particulate respirator seal check c. Hand-rub with alcohol d. Hand washing with soap and water

Hand Hygiene Hand washing is the simplest and most effective way of preventing the transmission of infection. Hand washing should be performed during these circumstances:

Table 5—3. When to perform hand hygiene

Availability of alcohol-based hand rubs is critical in promoting effective hand hygiene practices especially in setting without access to running water. This approach has led to increased compliance in hand hygiene and decreased health care-associated infection.

Immediately Before Between After

Upon arriving at work

Direct contact with patient

Procedures on the same pa-tient where soiling of hands is

likely

Contact with patient

Putting on gloves for clinical and invasive procedures

Removal of gloves

Preparing handling, serving, or eating food

Removal of other personal protective equipment

Leaving work

Contact with blood, body flu-ids, secretions, excretions, wounds exudates, contami-

nated items Contact with items/surfaces

known or likely to be contami-nated

Personal body functions such as using the toilet, and wiping

or blowing one's nose

Wash hands with soap and water when visibly dirty or soiled with blood or other body fluids, or if exposure to potential spore-forming organisms is strongly suspected or proven or after using the restroom. Preferably use an alcohol-based hand rub for routine hand antisepsis.

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Challenges in using PPE and strategies to improve safety PPE is one of the vital components of a system of safety controls and preventive measures in health facilities or in the field. Recent studies have shown that despite expert recommendations and high risk conditions, health care workers tend to use PPE less. Below are some of the challenges in PPE use. Studies were conducted in a hospital setting although the findings can also be noted in field setting:

Too busy or no time to wear PPE Health staff do not consider themselves high risk in contracting the

disease Patient did not appear high risk Interference with skills Discomfort Perception that precautions are ineffective Availability of supply and ready access to it Cost of the PPE Community/patient perception e.g., alien looking, creates fear

Strategies to improve safety (after Goldfrank, 2008)

Leadership and commitment to safety Emphasis on education and training Improving feedback and enforcement Clarify relevant work practices

Activity 1 – Skills Station Objectives:

To practice participants on donning of PPE, hand hygiene, disinfection, chlorine solution preparation, particulate respirator seal check, etc.

Estimated Time

Throughout the session. Participants can go and try to practice during breaks, lunch time, etc

Materials (see Annex B page 8 –31) 1. PPEs, particulate respirator mask, soap and water, alcohol hand rub,

chlorine solution 2. Posters showcasing steps in wearing and taking off PPE, particulate

respirator seal check, hand washing, alcohol hand rub, chlorine solution preparation

DETAILS OF RECOMMENDED ACTIVITIES

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3. Containers for water, soap, water receiver (when performing hand washing, etc.)

Process

1. Provide stations (desks) for each topics: PPE, respirator seal check, hand washing, chlorine solution

2. Train organizing team member or participant on specific skills and allow them to oversee skills practice by participants.

3. Participants can practice several times. (Note: In case of limited supplies of PPE, participants maybe requested to keep one e.g., mask and share others e.g., gown for practice purpose with clear explanation that this should not be the case in actual investigation.)

Activity 2 – Droplet vs Aerosol Objectives

To show difference between droplet and aerosol

Estimated Time 5 minutes

Materials

1. Video clip on aerosol vs droplet production 2. LCD/ DVD player

Process

1. Run the video clip on aerosol and droplet 2. Let patient discuss when aerosol and droplets are generated. This can be

followed by discussion on example of disease with transmitted through aerosol or droplet as well as the PPE to use.

Activity 3 – Mime Precaution Objectives

To enumerate safety precaution components


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Figure 5—2. Skills station set-up

DRAFT Version

Materials Small pieces of paper to draw group who will perform the activity Process 1. In a small piece of paper, write Silent Movie Actors and leave the other pieces

blank. The group who picked the paper with Silent Movie Actors on it will perform the activity

2. Ask the participants to guess what standard precaution is being acted out by the silent movie actors

3. Write down the standard precautions correctly guessed. 4. Encourage participants to create mnemonics or any easy-to-remember action

to illustrate standard precautions.

Activity 4 – Match the Mask Objectives

To identify appropriate mask for specific transmission


Materials (see Annex B page 8 –32) 1. Slides containing scenario and question whether mask is needed and what

particular mask 2. LCD/ Computer 3. Score sheet Process 1. Divide the group into four. Flash the scenario and ask the group to discuss and

provide the answer. Allow time for the group to give reason to their answers 2. Score correct answers on displayed score sheet. 3. The group with the most correct answer wins.

Standard Precautions Hand hygiene Respiratory hygiene and cough etiquette have been

added to standard precautions to control transmis-sion of respiratory infections.

Use of personal protective equipment (PPE) based on risk assessment to avoid direct contact with patient's blood, body fluids, secretions and non-intact skin

Prevention of needle sticks/sharps injuries and Cleaning and disinfection of the environment and equip-

ment

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Activity 5 – Video on donning PPE and performing hand hygiene Objectives

To demonstrate a) wearing and taking off PPE and b) hand hygiene Estimated Time

15 minutes Materials

1. Video clips on a) wearing and taking off PPE and b) performing hand hygiene

2. LCD/ DVD player Process

1. Run the video clips 2. Allow discussion on variations in wearing and taking off PPE and draw

conclusions/ summary.

Goldfrank, L.R., Liverman, C.T., eds. Preparing for an influenza pandemic: personal protective equipment for healthcare workers. Washington, D.C., The National Academies Press, 2008 Infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in health care. Interim Guidelines. Geneva, World Health Organization, 2007 (WHO/CDS/EPR/2007.6) Laboratory biosafety manual. 3rd ed. Geneva, World Health Organization. 2004. (WHO/CDS/CSR/LYO/2004.11) WHO Guidelines in hand hygiene in health care (Advanced Draft): A summary. Geneva. World Health Organization, 2005 (WHO/EIP/SPO/QPS/05.2)

REFERENCES

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DRAFT Version

NOTE: The following pages contain transcripts of the presentations included in this topic. The embedded transcripts aim to assist facilitators in explaining the content of the slides. The slides and transcripts (slide notes) can be modified and adapted based on facilitator’s objectives and needs of the trainees. “Karaoke-type” presentation (directly reading the contents of the slides and transcripts) is strongly discouraged.

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THOUGHTS, COMMENTS, NEW GAMES AND VARIATIONS

DRAFT Version

SLIDE 1

SEARO – CSR Training on Outbreak InvestigationE P I D E M I C A L E R T A N D R E S P O N S ESEARO –CSR Training on Outbreak Investigation

Infection ControlA good epidemiologist is a safe epidemiologist

Infection control During an outbreak investigation, it is important that staff/investigators try their best to prevent self from being infected by patients or other possible sources. This presentation is about protecting you and your staff from infections caused by dangerous pathogens. Standard precautions require that health workers in the field assume that the blood and the body substances of all patients are potential sources of infection, regardless of the diagnosis, or presumed infec-tious status. Additional precautions are needed for diseases transmit-ted by air, droplets and through contact. In the field, it is important that maximum protection is provided to staff. Most of the time, staff are faced to work in resource limited set-tings. It may happen that discrepancies exist between what is ideal and what can be achieved/ provided in terms of staff protection. Aside from limited resources, there might be cases whereby wearing bulky items may limit movement hence further increase danger and lead to a situation where a breach of methods is more likely to occur.

SLIDE 2

Name of Presentation SEARO – CSR Training on Outbreak InvestigationE P I D E M I C A L E R T A N D R E S P O N S E

Infection ControlSEARO –CSR Training on Outbreak Investigation

Learning Objectives

• At the end of the session, the participants will be able to:– Explain the importance of promoting culture of safety

– Identify common situations during an outbreak investigation when the investigator is likely to be exposed to sources of infection

– Describe standard precautions and transmission-based precautions

– Explain the uses of different types of personal protective equipment (PPE)

– Demonstrate putting on and removing PPE– Demonstrate hand washing

Learning objectives At the end of the session, the participants will be able to: Explain the importance of promoting culture of safety Identify common situations during an outbreak investigation

when the investigator is likely to be exposed to sources of infec-tion

Describe standard precautions and transmission-based precau-tions

Explain the uses of different types of personal protective equip-ment (PPE)

Demonstrate putting on and removing PPE Demonstrate hand washing

SLIDE 3



A Culture of Safety

• Follow standard protocols

• Always be aware of your safety

• Change incorrect behavior in a positive way

A culture of safety In infection control, for overall safety, it is important to ensure the following: Follow organizational protocols, standard guidelines should be

regularly practiced. Awareness of staff/ health workers on safety measures (attitude)

as well as the organization’s commitment to safety Commitment of the team leader to identify, correct and change

erroneous behavior of staff and co-workers to minimize and avoid risk of infection

INFECTION CONTROL Transcript

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SLIDE 4



Raise Awareness!

• Stop and think• Assess the risk• Prepare appropriate

precautionary measures

• Use PPE• Don’t expose yourself or your

staff to danger!

Raise awareness Before going to the field, staff should be able to reflect on the impor-tance of safety culture/ behaviour/ attitude. This means: Collect as much information as possible regarding the possible

situation (or infection, if this is known) you are to deal with. This includes consideration of staff vaccination status in relation to the kind of disease to be investigated.

Assess the risk Prepare appropriate precautionary measures before moving self/

staff for investigation/ sample collection Use personal protective equipment Strike a balance between the overall benefit of the action and the

safety of self/staff. Do not expose yourself or your staff to unnec-essary danger.

SLIDE 5



Risk of infection when assisting in an outbreak

Staff may become infected because of: – needle stick injury– breach in the use of PPE – during an aerosol-generating

procedure – before a patient is recognised as

infectious

Risk of infection when assisting in an outbreak During an outbreak, staff can be infected from the following: Injuries by needle stick during specimen collection. This occurs

most commonly when trying to RECAP the needles after taking blood samples.

Use of PPE that has not been properly fitted e.g., gloves, masks. Staff should wear PPE that is appropriate for the degree of pa-tient contact and the type of infection (if this is known). All person-nel who may need to use an N-95 respirator (face mask) should be trained and fit-tested in use. Most PPE should not be re-used.

Failure to perform hand hygiene From aerosol-generating procedures e.g., intubation, suctioning,

nebulisation, cough-inducing procedures e.g. in SARS clusters identified in Toronto, Hong Kong, Singapore and Hanoi (http://www2a.cdc.gov/PHTN/webcast/SARSII/Chiarello5-8.pdf)

An infected patient who is not recognized as an infection risk (for example, a person who is not yet manifesting signs and symp-toms)

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Standard Precaution

SHOULD be:• IN PLACE ALL of the time

– Whether or not there is a recognized outbreak

• PRACTICED for ALL patients– Regardless of diagnosis

Standard precautions limit health care worker’s contact with secretions, skin lesions, mucus membranes, blood and other body fluids.

Standard precautions Standard precautions should be followed routinely for all types of pa-tient contact that may involve exposure to blood or body fluids irre-spective of whether or not there is a recognized infectious risk or out-break. Standard precautions are used for all patients regardless of their diag-noses to ensure protection of the health care worker and the patient.

DRAFT Version

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Standard Precaution

• Standard Precautions include– Hand hygiene

– Respiratory hygiene and cough etiquette – Use of personal protective equipment (PPE)

– Prevention of needle sticks/sharps injuries– Cleaning and disinfection of the environment and

equipment

Standard precautions Treating all patients by applying standard precaution measures involve work practices that are essential to provide a high level of protection to patients, health care workers and visitors. These are:

Hand hygiene

Respiratory hygiene and cough etiquette – which are added to standard precautions to control transmission of respiratory infec-tions if a patient has respiratory symptoms.

Use of personal protective equipment (PPE) based on risk as-sessment to avoid direct contact with patient's blood, body fluids, secretions and non-intact skin

Prevention of needle sticks/sharps injuries and

Cleaning and disinfection of the environment and equipment

SLIDE 8



Transmission-based Precautions

• USED for certain transmissible or highly pathogenic infections

• Contact, droplet, and airborne precautions each aim to block different routes of transmission

• USED in addition to standard precautions

Transmission-based precautions For certain transmissible or highly pathogenic infections, transmission-based precautions are used in addition to standard precautions. Con-tact, droplet, and airborne precautions are meant to prevent exposure to pathogens contracted through these means. Since the infecting agent may not be known at the time of admission to a health care facility, transmission-based precautions are used empirically, according to the clinical syndrome and the likely aeti-ologic agent (based on a risk assessment), and then modified when the pathogen is identified or stopped if a transmissible infectious dis-ease etiology is ruled out. It’s important to note that these guidelines are for clinical patient care and investigation in the field. Procedures in the laboratory or autopsy suite, etc. where mechanical generation of fine aerosols might occur, require different types or degrees of protection.

SLIDE 9



Transmission-Based Precautions

TB, measles, varicella, and variola

Neisseria meningitidis, pertussis, pneumonias, diptheria, influenza, mumps

shigellosis, Ebola hemorrhagic fever, MRSA

Organisms

commonly

implicated

N 95, goggles + standard precaution

Particle suspended in the air (<5μ)

Airborne

Surgical mask, goggles + standard precaution

Cough, sneezeDroplet

Gloves, gownsDirect – indirect contact with patient/ environment

Contact

Recommended PPE

ExampleTransmission

Transmission-based precautions Contact: Diseases which are transmitted by this route include MRSA, enteric infections and most skin infections. Gloves and gowns must be worn and contaminated surfaces cleaned Apply for infections that are spread through direct or indirect contact with patients or patient-care environment (e.g., shigellosis, Ebola hem-orrhagic fever, MRSA). Droplet: droplets are usually generated from the infected person dur-ing coughing, sneezing, talking or when health care workers undertake procedures such as tracheal suctioning. Wear surgical mask and gog-gles in addition to standard precautions. Apply for infections spread by large droplets generated by coughs, sneezes, etc. (e.g., Neisseria meningitidis, pertussis, pneumonias, diptheria, influenza, mumps). Airborne: Airborne transmission when particles < 5 micron in size are disseminated into the air. These particles can remain suspended into the air for long periods of time, especially when bounded to dust parti-cles. Use mask N95 and goggles in addition to standard precautions Apply for infections spread by particles <5μ that remain infectious and suspended into the air (TB, measles, varicella, and variola).

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Personal Protective Equipment

Personal protective equipment (PPE) PPEs are comprised of:

gloves

gowns

eye protection

medical masks

Items that are not PPE:

Caps for the hair – only for the comfort of HCWs

Closed footwear – only to avoid accidents with sharp objects

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Personal Protective Equipment

• Reduces but does NOT completely eliminate the risk of acquiring infection

• Important that it is used

– Effectively

– Correctly– At all times

• DOES NOT replace basic infection control measures like HAND HYGIENE.

where contact with blood and body fluids may occur

Personal protective equipment (PPE) Personal protective equipment reduces but does not completely elimi-nate the risk of acquiring an infection. it is important that it is used effectively, correctly and at all times where contact with blood and body fluids of patients may occur. Staff must also be aware that use of personal protective equipment does not replace the need to follow basic infection control measures such as hand hygiene.

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Putting on PPE (if all is needed)

Wash hands

Wash hands

Putting on PPE There has been much discussion regarding the order of putting on and taking off personal protective equipment. The order for putting on personal protective equipment is not important, what is important is the staff’s knowledge on how contamination while wearing PPE be prevented. The following sequence is an example of one of the order when full personal protective equipment is worn: 1. Wash hands. 2. Wear scrub suit or old set of thin clothes before entering the

designated changing room or area (optional) 3. Put the gown on. 4. If required, wear boots /or shoe covers with trousers tucked

inside. (optional) 5. Wash hands. 6. Put the cap on. 7. Put the mask on. 8. Wear an impermeable apron if necessary. (optional) 9. Wear protective eye wear/ goggles. 10. Wash hands and dry them. 11. Wear gloves with gown sleeve cuff tucked into glove.

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Taking off PPE

Taking off PPE The order in which personal protective equipment is removed is not as important as the principle behind choosing such an order. The key principle is that when removing personal protective equipment the wearer should avoid contact with blood, body fluids, secretions, excre-tions and other contaminants. When hands become contaminated they should be washed or decontaminated with 70% alcohol solution. An example of how to remove personal protective equipment is given. 1. Using gloved hands, untie the gown string if tied in front and

remove shoe covers. 2. Remove gown and apron, without contaminating clothing under-

neath. Touch only inside of gown and apron while removing. Place in appropriate disposal bag.

3. Remove gloves (fingers under cuff of second glove to avoid contact between skin and outside of gloves) and discard in an appropriate manner.

4. Wash hands. 5. Remove cap. 6. Remove eye protection from behind. Put eye protection in a

separate container for reprocessing 7. Remove mask from behind 8. Wash hands up to elbows thoroughly with soap and water, dry

or decontaminate in 70% alcohol before leaving facility.

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PPE Materials

GlovesDifferent kinds of gloves

– Household gloves– Clean gloves (protect

yourself) – Sterile gloves (also protect

the patient from infection –use for sterile sites)

Do’s – Work from clean to dirty– Avoid “touch contamination”

• Eyes, mouth, nose, surfaces– Change gloves between

patients

PPE materials: Gloves First we will discuss gloves. Gloves protect the user against contami-nation with infectious material, but it is important to realize that gloves may become sources of contamination if they are not used properly. There are different kinds of gloves that are used for different pur-poses. Thick rubber gloves may be used for cleaning or household purposes in a patient’s room. Clean gloves can be used for general contact in the room or with the patient, while sterile gloves should be used when collecting specimens or conducting any type of medical procedure on the patient. Here are some “do’s” of glove use: Work from clean to dirty. This is a basic principle of infection control. In the context of working with possible or confirmed avian influenza patients, it refers to touching clean body sites or surfaces before you touch dirty or heavily contaminated areas. Limit opportunities for “touch contamination” - protect yourself, others and environmental surfaces. An example of “touch contami-nation” is when someone wearing gloves touches his or her face or adjusts glasses with gloves that have been in contact with a patient. Touch contamination can potentially expose a person to infectious agents. Think about environmental surfaces, too, and avoid unneces-sarily touching them with contaminated gloves. Surfaces such as light switches and door and cabinet knobs can become contaminated if touched by soiled gloves. Change gloves as needed, if this is possible. If gloves become torn or heavily soiled and additional patient care tasks must be performed, then change the gloves before starting the next task. Always change gloves after use on each patient, and discard them in the nearest appropriate receptacle. Patient care gloves should never be washed and used again. Washing gloves does not necessarily make them safe for reuse; it may not be possible to eliminate all microorganisms and washing can make the gloves more prone to tearing or leaking.

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SLIDE 15



PPE Materials: Gowns

Gowns

• Fully cover torso

• Have long sleeves

• Fit snuggly at the wrist

PPE materials: Gowns Gowns are generally the preferred PPE for clothing, but aprons occa-sionally are used where limited contamination is anticipated. If con-tamination of the arms can be anticipated, a gown should be se-lected. Gowns should fully cover the torso, fit comfortably over the body, and have long sleeves that fit snuggly at the wrist.

SLIDE 16



PPE Materials: MasksMasks and Respirators: Barriers and Filtration

• Surgical masks– Cotton, paper

• Particulate respirators (N95)– Fit testing essential

• Alternative materials (barrier)– Tissues, cloth

PPE materials: Masks Masks are another type of PPE. Wear masks that fully cover your nose and mouth to prevent fluid penetration. Masks should fit snugly, so ones with a flexible nose piece and that can be secured to the head with string ties or elastic are preferable. Respirators that filter the air before it is inhaled have been designed to protect the respiratory tract from airborne transmission of infectious agents. A commonly used respirator in healthcare settings is the N95 particulate respirator. The device has a sub-micron filter capable of excluding particles that are less than 5 microns in diameter. Prior to use, respirators should be fit tested for the appropriate size. And you should always check your respirator before use to make sure it has a proper seal. If surgical masks and respirators are not available, other materials such as tissues and cloth may be used to cover the nose and mouth. While the efficacy of these materials has not been scientifically evalu-ated, they are probably better than no mouth covering at all.

SLIDE 17



Performing a particulate respirator seal check

Performing a particulate respirator seal check The slide presents step-wise manner in performing a particulate res-pirator seal check.

SLIDE 18



PPE Materials

Eye Protection– Face shields– Goggles

PPE materials: Goggles Eye protection is important. Goggles provide barrier protection for the eyes. Personal prescription lenses do not provide optimal eye protec-tion and should not be used as a substitute for goggles. Goggles should fit snuggly over and around the eyes or personal prescription lenses. You can use a face shield as a substitute to wearing a mask or goggles. The face shield should cover the forehead, extend below the chin, and wrap around the side of the face.

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SLIDE 19



Ensure you have everything you require before starting a task

Ensure that no mucosal surface is exposed

Check PPE is being correctly put on ( mirror / observer)

Avoid self contamination while using the PPE

Do not touch face, mask, eye wear etc

Avoid self contamination on removal of the PPE

Remember where you could be contaminated

Avoid contamination of others

Avoid contamination of the environment

Dispose of PPE immediately and safely

Pointers on how to safely use PPEPPE does not provide 100 % protection

Pointers on how to safely use PPE Personal protective equipment reduces but does not completely elimi-nate the risk of acquiring an infection. it is important that it is used effectively, correctly and at all times, where contact with blood and body fluids of patients may occur. Staff must also be aware that use of personal protective equipment does not replace the need to follow basic infection control measures such as hand hygiene.

SLIDE 20



Hand hygiene – when to perform

Immediately– Upon arriving at work

Before– Direct contact with patient

– Putting on gloves for clinical and invasive procedures (e.g. administering intravascular injections, intravenous injections)

– Preparing handling, serving, or eating food

– Leaving work

Hand hygiene – when to perform Hand washing is the simplest and most effective way of preventing the transmission of infection. Hand washing should be performed during these circumstances: Immediately

Upon arriving at work

Before

Direct contact with patient

Putting on gloves for clinical and invasive procedures (e.g. ad-ministering intravascular injections, intravenous injections)

Preparing handling, serving, or eating food

Leaving work

SLIDE 21



Hand hygiene – when to perform

Between– Procedures on the same patient where soiling of hands is likely

After– Contact with patient

– Removal of gloves

– Removal of other personal protective equipment– Contact with blood, body fluids, secretions, excretions, wounds

exudates, contaminated items– Contact with items/surfaces known or likely to be contaminated

– Personal body functions such as using the toilet, and wiping or blowing one's nose

Hand hygiene – when to perform (continuation) Between

Procedures on the same patient where soiling of hands is likely After

Contact with patient

Removal of gloves

Removal of other personal protective equipment

Contact with blood, body fluids, secretions, excretions, wounds exudates, contaminated items

Contact with items/surfaces known or likely to be contaminated

Personal body functions such as using the toilet, and wiping or blowing one's nose

SLIDE 22



How to hand rub with alcohol-based formulation

Hand hygiene – how to hand rub with alcohol-based formulation The slide provides a step-wise manner in performing hand rub with alcohol-based formulation. An alcohol-based hand product should be used if hands are NOT visibly soiled or contaminated and when access to soap and water are not available at the moment.

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SLIDE 23



How to perform hand washing

Hand hygiene – how to hand wash The slide provides a step-wise manner in performing hand washing with soap and water. Hands that are visibly dirty or contaminated with body fluids should be washed with soap and water.

SLIDE 24



Typical parts missed

Typical parts missed Washing hands should be done properly so as to ensure that no major parts are missed. Typical parts missed are shown in the slides when hand washing is not done properly.

SLIDE 25



PPE Use: Challenges

• Reasons for not wearing PPE:– Too busy or no time– Do not consider themselves high risk– Can tell which patients are high risk– Interference with skills, dexterity,

communicating– Physical discomfort– Perception that precautions are ineffective

PPE use: Challenges PPE is one of the vital components of a system of safety controls and preventive measures in health facilities or in the field. Recent studies have shown that despite expert recommendations and high risk conditions, health care workers tend to use PPE less. Below are some of the challenges in PPE use. Studies were con-ducted in a hospital setting although may apply in the field setting:

Too busy or no time to wear PPE

Health staff do not consider themselves high risk in contract-ing the disease

Patient did not appear high risk. Some staff even expressed that they can tell which patient are high risk

Interference with skills particularly dexterity, communicating, health worker – patient relationship and in recognizing people

Physical discomfort

Perception that precautions are ineffective

SLIDE 26



PPE Use: Challenges

• Reasons for not wearing PPE:– Availability of supply and ready access to it– Cost of the PPE– Community/patient perception e.g., some staff

are careful not to upset patient

PPE use: Challenges (continuation) Below are some of the challenges in PPE use. Studies were con-ducted in a hospital setting although may apply in the field setting (continuation)

Availability of supply and ready access to it

Cost of the PPE

Community/patient perception - alien looking, creates fear, some staff are careful not to upset patient - pressure from community as they do not want to be handled by “ghosts” - a case during Ebola outbreak in recent period

DRAFT Version

SLIDE 27



Strategies for improving safety

• Leadership and commitment to safety

• Emphasis on education and training– Risk perception

• Improving feedback and enforcement• Clarify relevant work practices

Strategies for improving safety Promoting culture of safety necessitate strong management leader-ship and commitment. This includes providing opportunity to enhance understanding of staff in the importance of safety adherence. This can be done through continued education and training, improving feed-back and enforcement of safety procedures among staff.

SLIDE 28



Be Alert / vigilant

• A – Be Alert• B – Use Barrier protection• C – Clean and Disinfect• D – Dispose of waste• E – Evaluate and Feed back

Be alert/ vigilant Finally infection control can be summarized as ABCDE: A – Be Alert – be conscious of your environment and the situation you

are in B – Use Barrier protection – use appropriate PPE/ immunization if

necessary C – Clean and Disinfect – perform hand hygiene all the time D – Dispose of waste – dispose waste properly E – Evaluate and Feed back – review infection control measures and

further improve

5-19

SEARO CSR Subunit in Bangkok Permanent Secretary Building No. 3, 4th Floor

Ministry of Public Health, Tiwanon Road Nonthaburi 11000 Thailand

Telephone No.: +66 2 580 7534 to 35

Facsimile: +66 2 580 7537 Email Address: [email protected] Website: www.searo.who.int/csrsubunitbkk

5 infection control 110309

Documents

use of ppe

donning of ppe

donning ppe

worker safety

effective culture of

safety precaution components

aware of personal safety

outbreak investigation