ElementI ProfessionalResponsibilityfor InfectionControl

LearningObjectives
1.Describebenefitstopatients,andhealthcareworkersofadheringto scientificallyacceptedprinciplesandpracticesofinfectioncontrol. 2.Describetheprofessionalsresponsibilitytoadheretothesepractices, andtheconsequencesoffailingtocomply 3.Describetheprofessionalsresponsibilitytomonitorinfectioncontrol practicesofpersonsforwhomhe/sheisresponsible.

Definitions:
Universalprecautions(standardprecautions):theseare precautionsapplicabletoallpatients,includinguseof barriers,suchasgloves,gowns,masks,and/orprotective eyewear,andproperdisposalofsharps,topreventskinand mucousmembraneexposuretobloodbornepathogensandall othermoistandpotentiallyinfectiousbodysubstances. Standard ofCare:establishedcriteriafortheperformanceof individualsinsimilarcircumstances. OSHA:OccupationalSafetyandHealthAdministration,a branchoftheU.S.DepartmentofLabor.

I.Standardsofcareininfectioncontrol
A. PreventionofBloodborneDiseases:
Evidencesuggeststhatthetransmissionofhuman anddentalproceduresispreventablethrough thestrictadherencetogoodinfectioncontrol practices. Standard Precautions:decreasetheopportunityfor bloodexposuresamonghealthcareworkersand patients,andhavebecomethestandardofcare inallheathcaresettingssince1985.

I.Standardsofcareininfectioncontrol
B.Otherstandardsofcareforinfectioncontrolinclude: 1.Practicestopreventspreadofairbornediseases.(e.g.tb,measles ,chickenpox,smallpox,severeacuterespiratorysyndrome; 2.Practices,suchashandhygiene,aseptictechnique,anduseof barriermethods,especiallygloves,topreventspreadofmost bacterialinfections(e.g.staph,andstrep)andsomeviruses(herpes, coldviruses,CMV)inhealthsettings; 3.Appropriatecleaning,disinfection,andsterilizationofmedical devicesandequipment;and 4.Occupationalhealthpracticesforpreventionandcontrolof communicablediseasesinhealthcareworkers(e.g.TBskintesting andimmunizationsagainsthepatitisB,measles,andrubella).

II.Standardsofprofessionalconductas theyapplytoinfectioncontrol
A. MandatedNYStateandFederalstandardof professionalconduct.
1. NewYorkState:1992legislationformallyestablished acceptedinfectioncontrolpracticesasstandardsof professionalconduct. 2. NYStateDepartmentofHealthandNYState DepartmentofEducationrequirethatalllicensed healthcareprofessionalsinNYmustcomplete mandatorycourseworkininfectioncontrolbefore7 11994andeveryfouryearsforstatelicensingor registrationofnonphysicians.

II.Standardsofprofessionalconductas theyapplytoinfectioncontrol
B.Implicationsofprofessionalconductstandards
1.Allhealthcareprofessionalsbearresponsibilitytoadhere toinfectioncontrolstandards. 2.Allhealthcareprofessionalshavearesonsiblity tomonitor thepracticesofotherstoassuresafetyofallpatientsand personnel. 3.Consequencesoffailuretofollowacceptedstandardsof infectioncontrolinclude: a.subjectingself,coworkers,and/orpatientstoincreased riskofcommunicabledisease. b.subjectingoneselftochargesofunprofessional conduct.

II.Standardsofprofessionalconductas theyapplytoinfectioncontrol
Consequencesoffailurecontinued
1.Mechanismsforreportingunprofessionalconduct:patients, familymembersorcoworkers/employerscanfilechargestothe NYStateDepartmentofHealth(OfficeofHealthSystems, OHSM) 2.investigationofthecomplaintiscarriedoutbythehospital, employerorOHSM 3.Possibleoutcomes,dependingontheseverityofmisconduct, include:
Disciplinaryaction Revocationofprofessionallicense Professionalliability:failuretoadheretostandardofcarecanbe groundsfor

ElementII
Transmissionandcontrolofinfectioninhealth caresettings Learningobjectives
Describehowpathogenicorganismsmaybe spreadinhealthcaresettings Identifythefactorswhichinfluencetheoutcome ofanexposure Liststrategiesforpreventionoftransmissionof pathogenicorganisms Describehowinfectioncontrolconceptsare appliedinprofessionalpractice.

Transmissionandcontrolofinfectioninhealthcaresettings

Definitions
Pathogenorinfectiousagent:amicroorganismcapableofcausingdisease Transmission:anymechanismapathogenisspreadbyasourcetoahost Reservoir:anyperson,animalinsect,plantorsubstanceinwhichan infectiousagentnormallylivesandmultiplies,andwhereitreproduces itselfinsuchamanneritcanbetransmittedtoahost Susceptiblehost:apersonorother,lackingeffectiveresistanceto particularinfectiousagent Commonvehicle:contaminatedmaterial,productthatservesasan intermediatebywhichaninfectiousagentistransported Nosocomial infection:anyinfectionwhichisacquiredinahealthcare setting,manifestationofillnessmyoccurduringorafterhospital discharge Incubationperiod:timebetweenexposureandonsetofdisease Colonization:presenceofinfectiousagentwithoutcausingillness Carrier:personwhoiscolonizedorinfectedbyagentforextendedtime, oftenwithoutsymptoms,andmaytransmitinfectiontoothers

I.Transmissionofinfections
A. Thechainofinfection:
Thepatternofspreadofinfection.Thischainrequiresa pathogen,asourceorreservoir,amodeof transmission,asusceptiblehost,andaportofentry. Manyinfectionsarespreadfrompersonperson includinginfluenza,measles,chickenpox,tb,colds,strep throat,staph,HIV,hepatitis,typhoid,and gastroenteritis,othersareenvironmenttopersonsuch asLegionnairesDisease,Anthrax,andfungalinfections

I.Transmissionofinfections
B.Presenceofpathogen:
1.Bacteria:examplesarestaph,strep,Ecoli,TB. 2.Viruses:examplesareinfluenza,coldviruses,measles,mumps, varicella,smallpox,hepatitisandHIV 3.Fungi:includeyeasts(e.g.candida)andmolds(e.g.Aspergillus). 4.Parasites:includeprotozoa,(e.g.malaria,toxoplasmosis, pneumocystis,)worms,andinsects,(e.g.liceandscabies) 5.Prions:includeKuru (shiveringdisease)CJD(madcowdisease) GermanStrausslerScheinker (GSS),fatalfamilialinsomnia(FFI)and atypicaldementias(prion dementiaw/ospongiformdisease. 6.pathogensvaryintheirillnesscausingpotential,dependingon virulence,survivaloutsidethehost.Mutationsallow microorganismstobecomemorevirulent,todevelopresistanceto antimicrobialdrugs,andtoavoidnormalhostdefenses.

I.Transmissionofinfections
C.Reservoirsinclude:
1.Animate a.people patientsandheathcareworkers infectedorcolonizedpersons Illpersonsorasymptomaticcarriers b.insectsoranimals 2.Inanimate a.Environment,water,food,soil,sinks,medical equipment.

I.Transmissionofinfections
D.Portalsofexit:routesandmechanismsbywhichpathogensexitthebody 1.Coughing,sneezing,respiratory,oralsecretions 2.drainingskinlesionsorwounds. 3.feces 4.urine 5.drainageofbloodandotherbodyfluids

I.Transmissionofinfections
E.Modesbywhichpathogensaretransmitted: 1.Contactwithaninfectedperson. a.directcontactwithpersonortheirbloodsecretions. b.indirectcontact,handlingofcontaminatedobjectsinenvironment c.largedroplet,closerangeexposuretodroplets 2.Airborne:infectionsacquiredbyinhalationofaerosolscomposedof smallinfectiousparticles 3.Commonvehicle:contaminatedfood,water,medication,intravenous fluidorotherproductwhichtransmitsinfectionto2ormorepersons. 4.Vectorborne:transmissionviaaninsectoranimalcarrier F.PortalsofEntry:routesandmechanismsbywhichpathogensare introduced: 1.Entrysites:nonintactskin,mucousmembranes,GI,respiratory,etc 2.Mechanisms:viaingestion,inhalation,vascularaccess,surgical incisions,etc.

I.Transmissionofinfections
G.Factorswhichinfluencetheoutcomeofanexposure:
1.Hostsusceptibility:Immunityfrompastinfectiondecreasessusceptibility. Impairmentofhostdefensesincreasessusceptibility.Impairmentofdefenseis mediatedbyalterationin: a.Naturalbarrierstoinfection b.Immunesystem c.Presenceofaforeignbody/invasivedevice 2.Agentfactors a.Infectivity b.Pathogenicity theabilityofanagenttocausediseaseina susceptiblehost c.Virulenceofthepathogen,invasiveness,abilitytocausedisease. d.Inoculum size:amountoftheinfectiousagentintheexposure e.Routeofexposure:someroutesmorelikelytocauseinfection f.Durationofexposure 3.Contaminationfactors a.Contaminationofenvironment b.Contaminationofequipment

II.Preventionstrategies BreakingtheChainofTransmission
A. Considerallpatientstobepotentially infectedwithabloodbornepathogen B. Fororganismsotherthanbloodborne pathogens.
1.Recognize,diagnose,andtreatpersonswith transmissibledisease 2.eliminateorcontrolinanimatereservoirsof pathogenicorganisms

II.Preventionstrategies BreakingtheChainofTransmission
C.Interruptroutesoftransmission:
1.HandHygieneisthesinglemostimportantmeansofpreventingspreadofinfection. a.washingwithantimicrobialsoapforminimumof15seconds,withrunning wateranduseoffriction. 2.Useofbarriers:gloves,masks,goggles 3.Sterilizationanddisinfectionofpatientcareequipment 4.Isolationorcohorting : a.standardprecautionssynthesizeUniversalandbodysubstanceisolationand applytoallpatientsreceivingcare b.transmissionbasedisolationprecautions: 1.Contactprecautions 2.Dropletprecautions 3.Airborneprecautions 4.Isolationprecautioncategoriesmaybecombinedformultipleroute diseases

II.Preventionstrategies BreakingtheChainofTransmission
C.Interruptroutesoftransmission 5.Environmentalpractices a.handwashing b.ventilation c.wastemanagement d.linenandlaundrymanagement 6.Engineeringcontrols:safercontrols(ex:needlelessIVtubingaccesssystem) 7.Workpracticecontrols:modificationintechniques(ex:norecappingneedles) D.Protectionofthehost 1.Vaccination:personnel:immunityagainstmeaslesandrubella,recommendedagainst hepatitisB.Influenzavaccineadvised 2.Pre/postexposureprophylaxix:apreventivetreatmentafterexposuretoinfectiousagent 3.Protectskinfrombreakdown 4.Avoidunnecessaryuseofexcessivedurationofplacementofintravenouslines,bladder, catheters,andotherinvasivedevices E.Trainingandeducationofhealthcareworkers

ElementIII
UseofEngineeringandworkpracticecontrolsto reducetheopportunityforpatientandhealthcare workerexposure
Learningobjectives: Defineengineeringcontrolsandworkpracticecontrols Identifyahierarchyofexposurepreventionstrategies Describespecificpracticesandsettingswhichincreasethe opportunityforexposureofhealthcareworkersand patientstoinfectiousmaterial Identifywhereengineeringorworkpracticecontrolscan beutilized

ElementIII
UseofEngineeringandworkpracticecontrolsto reducetheopportunityforpatientandhealthcare workerexposure Definitions: Engineeringcontrolsuseofequipment,devicesthat removehazard Workpracticecontrols:arealterationsinperformance ofataskinsuchamannerastoreduce/eliminate likelihoodofexposure Personalprotectiveequipment:gloves,gowns,masks, goggles

ElementIII UseofEngineeringandworkpracticecontrolstoreducethe opportunityforpatientandhealthcareworkerexposure

1. Highriskpracticesandprocedures:circumstances andpracticeswhichincreaseopportunitiesfor exposuretobloodborne andcontactpathogens A. Percutaneous exposures=exposuresthat occurthroughtheskin 1. Injuryoccursbyhandling,disassembly, disposaloforreprocessingofneedlesand sharps 2. Precedures inwhichthereisopportunity forinjury, a.Examle:blindsuturing b.Using nondominat handnexttoasharp

ElementIII UseofEngineeringandworkpracticecontrolstoreducethe opportunityforpatientandhealthcareworkerexposure

B.Mucousmembraneornonintactskinexposure(exposurethrough eyes,mouth,nose,cuts,rashes,dermatitis) A.directcontactwithbloodorbodyfluid B.sprays/splashesofbloodorbodyfluid C.Parenteralexposure:mayoccurbyinjectionwithinfectiousmaterial a.infusionofcontaminatedbloodproducts b.transplantationofcontaminatedorgansortissue

ElementIII UseofEngineeringandworkpracticecontrolstoreducethe opportunityforpatientandhealthcareworkerexposure

2.Evaluation/surveillanceofexposureincidents A. Identifywhoisatrisk a. Directcareproviders/Patients/family/visitors B. Identifythedevicescausingexposure a. Needles,scalpels,lancets,etc C. Deviceswithhigherdiseasetransmissionrate a.Suchashollowboreneedles D. Deviceswithhigherinjuryrate a. Recoileffectfrombutterflyphlebotomyneedles E. Identifyareasorsettingswhereexposuresareoccurring. a. Patientroom b. Operatingroom c. Treatmentroom d. Physiciansroom F. Circumstancesbywhichexposuresareoccurring a. Recapping b. Transferringbodyfluidbetweencontainers c. Failingtoproperlydisposeofusedneedles d. Failuretoactivatetheengineeredsafetydevice

ElementIII UseofEngineeringandworkpracticecontrolstoreducethe opportunityforpatientandhealthcareworkerexposure

3.Engineeringcontrolswhicheliminateorisolatethehazard: A.Usesaferdeviceswheneverpossibletopreventsharpinjuries: a.Passive(i.e.,automatic)safetyfeaturesarepreferred b.Providemechanismtosafelycoverthesharpimmediatelyafter use c.Integratesafetydevicesratherthanaccessorydevices d.Provideeducationandtrainingontheuseofsaferdevices e.Eliminatethetraditional,nonsafetyalternative B.Punctureresistant,durable,leakproofcontainersfordisposaland transportofneedlesandothersharps. a.Containersmustberedincolororlabeledbiohazard b.containersmustberemovedbeforeoverfilled C.Splattershieldsonmedicalequipment,biosafety cabinetforlabprocedures

ElementIII UseofEngineeringandworkpracticecontrolstoreducethe opportunityforpatientandhealthcareworkerexposure

4.Workpracticecontrolstoeliminateorreducethelikelihoodofexposuretopotentially infectiousmaterial A.Generalpractices 1.Washhands 2.Avoidunnecessaryuseofneedlesandsharps 3.Usespecialcareinhandlinganddisposalofsharps donotrecapneedles oruse onehandedrecappingtechnique insurgery,dentistry,oremergencies,passsharpsusinganareaorbasinor trayasa safezone onlydisassemblesharpequipmentusingforcepsorotherdevices alwaysdisposeofsharpsyouhaveused watchoutforoverfilledsharpcontainers 4.Modifyprocedurestoavoidinjury 5.Promptlycleanbloodandbodyfluidspills wearglovesanduseapproveddisinfectant discardcontaminatedmaterialsinbiohazardcontainer laundrycontainerforcontaminatedlaundry 6.Donoteat,drink,smoke,applycosmeticsorhandlecontactlensesinworkarea

ElementIII UseofEngineeringandworkpracticecontrolsto reducetheopportunityforpatientandhealthcare workerexposure

5.Preventionandcontrolofairbornepathogens A.Circumstanceswhichincreaseopportunitiesforexposureinclude: 1.Inadequateventilation 2.Lackofsourcecontrol 3.Failuretoinstituterespiratoryprecautionsforknown/suspected TBcases B.Unrecognizedcases 1.FailuretoconsiderthediagnosisofTBorotherairbornedisease, resultingindelayedrecognition,isolation,andtreatmentofcases 2.TransmissiontoHCWSandotherpatientsmayfollow C.Engineeringcontrolsforpreventionofairbornetransmission 1.Appropriateairexchange(numberofcompleteairreplacements perhour)

ElementIII UseofEngineeringandworkpracticecontrolstoreducetheopportunityfor patientandhealthcareworkerexposure

1.AppropriateAirexchange continued a. Aminimumof6airexchangesperhourarerequiredinroomshousing patientswithknoworsuspectedTBorotherairbornediseases;high ratesofairexchangeremovecontaminatedairmorequicklyanddilute concentrationofairborneorganismswithfreshair b. Airfromtheseroomsmustbeexhaustedtotheoutside,or appropriatelyfiltered(HEPAfiltration) 2.Negativepressurerooms:specialisolationroomswhichhaveairpressure belowthecorridorairpressure,causingairtoflowfromthecorridorinto theroom,andlimitingflowofcontaminatedairoutintothecorridor.Doors totheseroomsmustbekeptclosed.PatientswithactivepulmonaryTB shouldbeisolatedinnegativepressurerooms. 3.HEPAfilters:highefficiency airfiltersremoveinfectiousparticles 4.Ultraviolet(UV)lightsareasupplementalmeasureforcontrolofairborne pathogens

ElementIII UseofEngineeringandworkpracticecontrolstoreducetheopportunityfor patientandhealthcareworkerexposure

D.Sourcecontrol 1.EarlyIdentification 2.Teachsource 3.possiblyinfectiouspatientsshouldbetriagedearlyandisolated 4.closedoorsonidentified/suspectedpatients 5.PerformstaffPPDsurveillance 6.Providepatient/familyedu E.PersonalProtectiveEquipment(masks,respirators)seeelementIV F.Specialconsiderations 1.Operatingsuitesmusthavepositiveairpressure,therefore a.Electiveproceduresshouldbepostponeduntilpatientisnoninfectious b.Forproceduresunabletobepostponedcontactyourfacilitys infectionscontroldepartment

ElementIII UseofEngineeringandworkpracticecontrolstoreducetheopportunityfor patientandhealthcareworkerexposure F.Specialconsiderations 2.ProceduresassociatedwithaerosoltransmissionofextrapulmonaryTB 3.Potentiallyinfectiouspatientsmustwearasurgicalmaskduring transportation

ElementIV
Selectionanduseofbarriersandpersonalprotectiveequipment Learningobjectives Describethecircumstanceswhichrequiretheuseofbarriers andpersonalprotectiveequipment(PPE)toprevent patientandhealthcareworker(HCW)contactwith potentiallyinfectiousmaterial IdentifyspecificbarriersandPPEforpatientandHCW protection

ElementIV
Selectionanduseofbarriersandpersonalprotectiveequipment
Definitions: PersonalProtectiveEquipment(PPE):specializedclothingor equipmentwornbyahealthcareworkerforprotectionagainsta hazard Barrier:anobjectthatseparatesapersonfromahazard

TypesofPPEandbarriersandcriteriaforselection

ElementIV
Selectionanduseofbarriersandpersonalprotectiveequipment
TypesofPPEandbarriersandcriteriaforselection
A.Gloves: 1.whentobeworn:glovesmustbewornforallanticipatedhandcontactwith: blood,bodyfluids,excretions,mucousmembranes,nonintactskin.Duringall invasiveproceduresandallvascularaccessprocedures,includingphlebotomies andIVinsertion 2.Sterileandnonsterilegloves: a.sterileglovesarerequiredtopreventtransmissionofinfectionfromHCW topatientinsurgeryandinotherproceduresassociatedwithhighriskofinfection b.Nonsterileglovesareusedtoreducetransmissionofinfectionwhen sterilityisnotrequiredorwheresteriletechniquedoesnotneedsterilegloves 3.Glovematerial: a.Vinylorlatexglovesareusedformostmedical,dental,andlabprocedures discussedabove,doubleglovingorpunctureresistantlinerscanbeusedto decreaseriskofpercutaneous injurytoblood/bodyfluids

ElementIV Selectionanduseofbarriersandpersonalprotectiveequipment
3.Glovematerial b.Rubberutilityglovesareusedforheavydutyhousekeepingchores.They maybedecontaminatedandreusedunlesstheyarecracked,peelingor punctured. c.Hypoallergenicgloves,gloveliners,andpowderlessglovesareavailable B.Covergarb=protectiveattiretopreventcontaminationofskin,mucous membranes,workclothes,andundergarments.(Regularworkclothes, uniforms,andsurgicalscrubsarenotconsideredprotectiveattire.) 1. Typesofcovergarb: a. Gowns (withsleeves)areworn: Insurgeryandobstetrics, Whensplashing,spraying,spatteringofblood/bodyfluidsis anticipated,or Whenblood/bodyfluidcontaminationofarmsisanticipated. b. Aprons (nosleeves)maybewornforlesserdegreesofexposure. c. Laboratorycoatsareworninlaboratorysetting.

ElementIV Selectionanduseofbarriersandpersonalprotectiveequipment
2.Permeabilitycharacteristics: a. Impervious =fluidswillnotpassthrough b. Fluidresistant=fluidswillnotreadilypassthrough c. Permeable =easilypenetratedbyfluids

3.Choiceofgownoraprondependsonthelevelofbloodorbodyfluid exposureanticipated.Fluidresistantgownsaresuitableformost situations;extrafluidresistantsleevescanbewornoveragown,and/or animperviousaproncanbewornunderagown,toimproveprotection againstsoakthroughduringprolongedorhighbloodlosssurgical procedures.Imperviousgownsmaybepreferableforprocedureswith thehighestriskofbloodexposure.Imperviousgownsmaybeless comfortablesincethematerialdoesnotbreathewell.

ElementIV Selectionanduseofbarriersandpersonalprotectiveequipment
C.Masks 1. Typesofmasks a. SurgicalMask:purposeistoprotectthepatientbypreventing dischargeofcontaminatednasalandoralsecretionsfromthe wearerduringaprocedure,andtherebyreduceriskofwound infection. b. Maskstoprotectthewearer:
Protectwearersnose/mouthfromexposuretosplatteredorsplashedbloodor bodyfluids.Standardsurgicalmasksareappropriateforthispurpose. Maskstoprotectwearerfrominhalationofairborneaerosolizedinfectious particles(e.g.,TB,influenza,andmeasles).

MasksforprotectionagainstorganismsspreadviatheairborneroutesuchasTB, Chickenpox,andincludeN95respirators,alsocalledParticulateRespirators,and HEPAfilterrespiratorsindispsable andreusabletypes. N95respiratorsmust filteroutparticlesassmallas1microninsizewithatleast 95%efficiency,and allownomorethan10%leakageofairaroundthemask. HEPAfiltersprovide thehighestleveloffilteringability(0.3micronsizewith99.7%efficiency). PoweredairpurifyingagainstTB.N95respirators,HEPArespiratorsandPAPRs areacceptedbyOSHAforprotectionoftheweareragainstairborneorganisms.

ElementIV Selectionanduseofbarriersandpersonalprotectiveequipment
2.Characteristicsofmasks: a. Filtrationcharacteristicsofthematerial:surgicalmasksmayeffectively blockdischargeoflargedropletsintotheair,butthematerialisnotan effectivefiltertopreventinhalationofverysmall,aerosolizedparticles characteristicofTBandairborneviraldiseases.N95andHEPArespirators provideincreasedlevelsoffiltration.Awetmaskisnolongereffective. b. Faceseal: atightsealaroundtheedgesofaparticulaterespiratoris essentialtoitseffectiveness.Ifloosefitting,contaminatedairisdrawnin aroundtheedgesofthemaskwitheachinhalation,insteadoftheair beingdrawnthroughthefilter.Acceptableprotectionrequiresthatface sealleakagebenomorethan10%.SeeRespiratorFit testingand Training(sectionIII.A.3)

ElementIV Selectionanduseofbarriersandpersonalprotectiveequipment D.Fieldshieldsprotecteyes,nose,andmouthfromexposuretobloodor bodyfluidsviasplash,splatter,ofspray.Protectionagainstairborne pathogensrequirestheadditionofanappropriatemask. E. Eyeprotection(goggles,safetyglasses,offaceshield)shouldbeworn duringallmajorsurgicalproceduresandwheneversplashes/spraysof bloodofbodyfluidmaybegenerated.Ordinaryglassesarenot acceptableunlessasolidsideshieldisaddedtotheeyewear. F. Shoecovers,legcovers,boots,andheadcoversareappropriateattire wheneverheavyexposuretoblood/bodyfluidsisanticipated,usuallyin surgery.Mostsuchsituationsinvolvesurgicalproceduresinwhichcapsor hoodsarealreadyrequiredforsterility.Shoe/legandheadcoversshould beremovedordiscardedbeforeleavingtheroom. G. Otherbarriers,suchaswounddressings,reducetheriskofexposureto blood/bodyfluids.

ElementIV Selectionanduseofbarriersandpersonalprotectiveequipment
SelectionofPPE/barriersbasedonanticipatedexposureofHCW. 1.Contactwithminimalbleedingordrainage:useglovesplusgownor apron. 2.Thepossibilityofblood/bodyfluidsplashes,sprays,splattersexists: usegloves,fluidresistantgown,mask,andeyeprotectionorfaceshield (forexample:insurgery,obstetrics,anddentistry). 3.Contactwithlargevolumebleedingordrainage(likelytosoakthrough):use theabove,(Selectvinylornitrilegloves)withfluidresistantgown,and addshowcovers,legcovers,and/orboots;considerimperviousgown. 4.Largedropletvs.airborne(aerosol)pathogen:afaceshield,orsurgical maskpluseyeprotection,willprotectagainstinoculationoflarge dropletsorsplatterintomouth,nose,andeyes.Optimalprotection againstairbornedisease(e.g.,TB)requiresaparticulaterespirator. A.

ElementIV Selectionanduseofbarriersandpersonalprotectiveequipment
II.ChoiceofPPDandbarriersisbasedonreasonablyanticipatedexposureof theHCWandontheneedforpatientprotection: B.SelectionofPPE/Barriersbasedonneedforpatientprotection: 1.SelectsterilebarriersandPPEforinvasiveprocedures 2.Selectsurgicalmasksforpreventionofdropletcontaminationof patientswounds.Mostparticulaterespiratorswillalsopreventdroplet contaminationfromHCWtopatient. 3.HCWswithskinlesionsornailinfectionsmustweardressingsand/or glovestoprotectpatientsfromexposuretoHCWsblood/bodyfluid

ElementIV Selectionanduseofbarriersandpersonalprotectiveequipment
III.ProperandeffectiveuseofPPEandbarriers A.Properfit 1.Gloves:tosmallmaytear,toolargeareclumsy. 2.Gowns:shouldcoverskinandclothes 3.Mask:mustfitsnuglyaroundmouthandnose,withmetalband moldedacrossbridgeofnose,andstrapsortiesinplace.Whenwearinga N95particulaterespiratormask,afitcheckshouldbedoneafterapplying themaskandbeforegoingintheroom.
Note:RespiratorFittestingandtraining:HCWswhocareforpatientswithknoworsuspected infectiousTBareevaluatedforabilitytowearaparticulaterespirator(N95maskorHEPA mask),fittestedwiththedesignatedmask,andeducatedregardingTBtransmissionand precautions.Successfulfittestingrequiresthatfacesealleakagebenomorethan10%. HCWswhohavenotbeenfittestedandtrainedfortheappropriaterespiratordonotenter roomsbeingusedforTBisolation.Poweredairpurigying particulaterespirators(PAPRs)are analternativeforrespiratoryprotectionofpersonswhohavenotorcannotbefittested successfullywithanN95maskbutpropertrainingforitsusemustoccur.

ElementIV Selectionanduseofbarriersandpersonalprotectiveequipment B.Integrityofbarrier:checkforholes,tears,anddamagebeforeuse. 1.Inspectglovesfortearsorholesbeforeuse.Replaceglovesassoonas practicalifdamagedduringuse.Glovesneedtobechangedbetween patientsandduringcareofthesamepatientifgoingfromadirtytoclean task(e.g.fromperformingperineal caretocheckinganIVsite). 2.Masksshouldbereplacedifdamagedorwet. C.Disposablevs.reusablebarriersandPPE: 1.Disposableitemsshouldnotbereused. 2.Reusableitemsmustbeproperlycleanedandreprocessedbeforereuse 3.Surgicalmasksarereplacedaftereachuse,anddiscardedpromptly betweenpatients.Particulaterespirators(N95andHEPArespirators)are oftenusedforlongerperiodsoftime,butmebereplacedifdamaged, soiled,orwet. 4.AllPPE,whetherdisposableorreusable,mustberemovedbefore leavingthepatientroomorworkarea,andhandsmustbesanitized.

ElementIV Selectionanduseofbarriersandpersonalprotectiveequipment D.PotentialforcrosscontaminationifPPEisnotchangedbetweenpatients. 1.Gloves,gowns,aprons,andsurgicalmasksmustbechangedbetween patientcontacts.Neverwearthesamegloves,gowns,etc. 2.Handsmustbesanitizedafterglovesareremoved.Glovesdonot completelypreventpenetrationofbacteriaandviruses,andthemoist environmentinsideaglovecanpromotegrowthofbacteriaontheskin. E.UnderandoverutilizationofbarriersandPPE: 1.UnderutilizationplacesHCWsandpatientsatunnecessaryrisk. 2.Over utilizationwastesresources,mayintimidatepatients,andmay interferewithpatientcare. F.ThepropersequenceforputtingonandremovingPPEisasfollows: Http://www.cdc.gov/handhygiene/download/hand_hygiene_supplement.ppt

ElementIV Selectionanduseofbarriersandpersonalprotectiveequipment

IV.Dentistanddentalhygienists: see(CDC)

ElementV Principlesandpracticesforcleaning,disinfection,andsterilization LearningObjectives: Recognizetheimportanceofthecorrectapplicationofreprocessing methodsofassuringthesafetyandintegrityofpatientcare equipment. Identifytheindividualsprofessionalresponsibilityformaintaininga safepatientcareenvironment. Recognizestrategiesforeffectiveprecleaning,chemicaldisinfection, andsterilizationofinstrumentsanddevices.

ElementV Principlesandpracticesforcleaning,disinfection,andsterilization

Definitions:
Cleaning:theremovalofallforeignmaterialfromobjects. Contamination:thepresenceofmicroorganismsoninanimateobjects orinsubstances. Decontamination:theprocessofremovingdiseaseproducing microorganismsandrenderingtheobjectsafeforhandling. Disinfection:aprocessthatresultsintheeliminationofmanyorall pathogenicmicroorganismsoninanimateobjects,withtheexception ofbacterialendospores. Highleveldisinfection:killsbacteria,Mycobacteria (TB),mostfungi, andmostviruses.Doesnotkillresistantbacterialspores. Intermediateleveldisinfection:killsbacteria,some fungi,some viruses.Willnotkillbacterialsporesandislessactiveagainstsome gramnegativerods(e.g.Pseudomonas)andMycobacteria. Sterilization:Aprocessthatcompletelyeliminatesallformsof microbiallife.

ElementV Principlesandpracticesforcleaning,disinfection,andsterilization
I. GeneralInformation: A. Cleaning,disinfection,andsterilizationplayanimportantroleinpreventionof infectionsrelatedtoexogenousintroductionofmicroorganisms. B. Themajorriskfrombreaksininfectioncontrolpracticeistopatients. 1. Infectionsmayoccuratanybodysizewhenmedicalsuppliesorequipmentare contaminated. 2. Theinfectionpotentialisgreatestwheninvasiveproceduresareperformed. C. Additionalriskexistsforpersonnelwhomaybecomecolonized/infectedduring processingofequipment. D. Everyhealthcaresettingshouldestablishpoliciesforthedisposaland/or reprocessingofsupplies,toinclude: 1. Procedureforreprocessingreusableequipmentorsuppliesappropriateforeach typeofmaterialanditsintendeduseinptcare. 2. Workflowpatternsfromsoiled/contaminatedtoclean/sterileareas. 3. Procedureforreceivingandstoringclean/sterilesuppliesandtoprovidedfor rotationtoavoidoutdatingofsupplies. 4. Proceduresforrecallofproductsfromcommercialsuppliersandfrominhouse preparation.

ElementV Principlesandpracticesforcleaning,disinfection,andsterilization I.GeneralInformation E.Everyhealthcaresettingshoulddevelopmonitoringsystems,to include: 1.Monitoringofthesterilizationprocesswithresultsrecordedina permanentlogorrecord. 2.recallofitemsifmonitorsindicatesterilizationisnotcomplete. 3.Criteriaforsterilityassurance shelflifethelengthoftimetheitemisconsideredsterile Eventrelatedsterilitysterilityofapackagedependsonthe packagingmaterialused,thenumberoftimesitishandledandthe conditionsofstorage 4.thehealthcareprofessionalisresponsibleforcheckingsupplies basedonshelflifeoreventrelatedsterility.

ElementV Principlesandpracticesforcleaning,disinfection,andsterilization

II.Evidenceofdiseasetransmissionbycontaminatedequipmentiswell documented A.Examples: 1.Vascularaccessdevices(IVcannulas,arterialpressure monitors,cardiacandvascularprostheses,AVshuntsfor hemodialysis)contaminationofdevicesattimeofinsertion,or subsequentcontamination,mayresultinbloodstreaminfection, siteofentryinfection,orremoteinfection. 2.Genitourinarytractdevices:contaminatedurinarydrainage systemsorcystoscopes cancausenosocomial urinarytractinfection andsubsequentbloodstreaminfection. 3.Respiratorytractdevices:contaminatedfluidnebulizers, ventilators,orbronchoscopesmaycausenosocomial pneumonia.

ElementV Principlesandpracticesforcleaning,disinfection,andsterilization
II.Evidenceofdiseasetransmissionbycontaminatedequipmentiswell documented: B.Factorsthathavecontributedtocontaminationinreportedcasesinclude: 1.Inadequatecleaning.Examples:Inadequatelycleanedcommodes contributingtotransmissionofclostridiumdifficile colitis;inadequatecleanup ofbloodspillscontributingtotransmissionofhepatitisB. 2.Inadequatedisinfection/sterilizationprocesses.Example:inadequately sterilizedinstrumentsincreasingpostoperativewoundinfectionrates. 3.Contaminationofdisinfectantorrinsesolution.Example:Pseudomonas contaminateddisinfectantcausingcontaminationofbronchoscopes;C. difficilecontaminatedendoscopes. 4.Reuseofdisposableequipment.Example.Reuseofdisposableplatformson glucometers linkedwithtransmissionofHepatitisB. 5.Failuretoreprocessordisposeofequipmentbetweenpatients.Example: transmissionofS.aureus,hepatitisBandnumerousotherpathogens.

ElementV Principlesandpracticesforcleaning,disinfection,andsterilization III.Pointsinreprocessingorhandlingwherebreaksininfectioncontrol practicescancompromisetheintegrityofequipmentordevices. A.GeneralPrinciplesofCleaning: 1.Soilprotectsmicrobesfromcontactwithlethalagentsandmay directlyinactivatetheseagents. 2.Physicalcleaningeliminateslargenumbersoforganisms associatedwithgrosssoil. 3.Soundcleaningpractices,inadditiontotheiraestheticbenefits, reducethemicrobialloadonenvironmentalsurfaces. 4.Manufacturersrecommendationsforoperationofcleaning equipmentanduseofcleaningsuppliesmustbefollowedcarefully.

ElementV Principlesandpracticesforcleaning,disinfection,andsterilization III.Pointsinreprocessingorhandlingwherebreaksininfectioncontrol practicescancompromisetheintegrityofequipmentordevices. B.Handlingandcleaningcontaminateditems,e.g.: 1.Presoakinginstrumentsvs.immediatetransporttoacentral reprocessingarea.Presoakingindetergentdisinfectantsolutionis preferredwhendelaysinreprocessingareunavoidable. 2.Thoroughnessofinternalandexternalphysicalcleaningisvitalto theprocess.Adequatedisinfectioncannotbeachievedwithoutfirst completingthoroughcleaningandrinsingoftheitem,sinceorganicdebris andresidualdetergentmayinactivatethedisinfectant.Morecomplex equipmentcreatesopportunitiesforbreaksinthisprocess. C.Choiceofreprocessingmethodshouldbebasedonthe: 1.Intendeduseoftheequipmentordevice, 2.desiredlevelofantimicrobialactivityand 3.manufacturersrecommendationsforreprocessing.

ElementV Principlesandpracticesforcleaning,disinfection,andsterilization
III.Pointsinreprocessingorhandlingwherebreaksininfectioncontrolpractices cancompromisetheintegrityofequipmentordevices. D.ReprocessingandReuse . 1.Definitions a.singleusedisposablesingleusedevicethatisintented tobeusedonone patientduringasingleprocedure. b.openedunusedsingleusedevice adisposablesingleusedevicewhose sterilityhasbeenbreachedorcompromisedorwhosesterilepackagewas openedbutwhichhasnotbeenusedonapatient c.reprocessingincludesalloperationsperformedtorenderacontaminated reusablereusable orsingleusedevicepatientready.Stepsmayinclude cleaning,testing,repackaging,disinfectionandsterilization. d.resterilization repeatedapplicationofaterminalprocessdesignedto removeordestroyallviableformsofmicrobiallife,includingbacterialspores. e.reuse:repeateduseofmultipleusesofanymedicaldevice,including devicesintendedforreuseorsingleusewithreprocessing

ElementV Principlesandpracticesforcleaning,disinfection,andsterilization
III.Pointsinreprocessingorhandlingwherebreaksininfectioncontrolpracticescan compromisetheintegrityofequipmentordevices. f.Disposabledevices:Medicaldevicesthatarerequiredtobesterileandare suppliedbythemanufacturersasforsingleuseonly.Awiderangeof itemsusedfordiagnosisandtreatmentaremarketedasdisposable devicessuchassyringestocardiacpacemakers. g.Endotoxin:ahighmolecularweightcomplexassociatedwiththeouter membraneofgramnegativebacteria.Endotoxins arepyrogenic and increasecapillarypermeabilityregardlessofthespeciesofbacteria. h.Originalequipmentmanufacturers(OEM)thecompanythatoriginally manufacturesadevicepriortoitsfirstuse i. outsourcing:theprocessinhealthcarefacilitiesofcontracting reprocessingactivitiestoacompanythatspecializesinresterilization j.pyrogen:afeverproducingsubstance k.reposable:recommendedpracticesforendoscopyandminimallyinvasive surgeryfromtheassociationofperioperative registerednurses(AORN) definesareposable deviceasaninstrumentwithacombinationof reusableanddisposablecomponents l.Reusabledevices:intendedtobeusedandreprocessedmanytimes

Table1:EquipmentReprocessing Guidelines
Riskof Infection
Critical

UsageofMedical Device
Entersnormallysterile tissueorvascularsystem

ExamplesofMedicalDevices
surgicalinstruments,cardiaccatheters;implants; pertinentcomponentsofheartlungoxygenators, bloodcomponentofhemodialyzers;laparoscopes; arthroscopes;bronchoscopes noninvasiveflexibleandrigidfiberoptic endoscopes,endotrachealtubes;anesthesia breathingcircuits;cystoscopes crutches;bedboards;bloodpressurecuffs

ProceduretoUseBefore EachUse

Sterilize
sterilizeiffeasibleoratleast highleveldisinfection

SemiCritical

contactsintactmuscous membranes,doesnot ordinarilypenetrate bodysurface doesnotordinarilytouch thepatientortouches onlyintactskin

NonCritical

intermediatetolowlevel disinfection

Note: The CDC recommends that scopes be sterilized, if feasible, and if sterilization is not feasible, high level disinfection should be utilized. There is currently no data to prove that sterilization of scopes reduces the risk of infection as compared to proper cleaning and high level disinfection. However, since there is also no data to prove that proper cleaning and high level disinfection eliminates the potential for cross-contamination, sterilization following cleaning is the preferred method.

ElementV
IV.Effectivenessofthedisinfectionprocessisdependentonthreefactors: Selectionanduseofdisinfectingproducts Monitoringactivityofdisinfectants,and Postdisinfectionhandlingandstorageoftheequipmentordevice

A.

Generalprinciplesregardinguseofanychemicaldisinfectantinclude:
1. 2. 3. 4. 5. 6. Readthelabelforactivityanduseinstructions Allitemsmustbethoroughlycleanedbeforedisinfecting. Allitemsmustbethoroughlyrinsedanddriedafterdisinfecting.Caremustbetaken nottorecontaminatetheitems. Onlysurfacesindirectcontactwiththesolutionwillbedisinfected(instrumentsmust beopened,disassembled,andcompletelysubmergedtoavoiddilutingthesolution toinactivelevels. Itemsshouldbedrybeforesubmergingtoavoiddilutingthesolutiontoinactive levels. Disinfectantsaredesignedforinanimateobjectsandaredamagingtotheskin.Gloves shouldalwaysbeworntoprotectthehands.Gogglesmaybeadvisabletoprotect eyesfromsplashes.Generally,themoreeffectiveagainstmicrobes,themoretoxicto humans. Disinfectantsshouldbeusedinwellventilatedrooms.

7.

V.Sterilization
A. Typesofsterilizationmethods
1.Heat a.Steam
Steam continuestobethemethodofchoiceforsterilizationofheatallmoisturestableitems.TheCDCGuidelineforHandwashingand HospitalEnvironmentalControlstatesthatsteamsterilizationshouldbeusedunlesstheobjecttobesterilizedwillbedamaged byhigh pressureormoistureorisotherwiseinappropriateforsteamsterilization. Flashsterilization istheprocessofsterilizingitemsthatareneededforimmediateuse.Thisprocessalsorequirestheuseofsaturated steam.Thisprocessdestroysmostvegetativebacteriaandvirusesifthebioburdenislowandnoormatterisevident.Flashsterilization shouldnotbeusedasaroutinesterilizationprocessbecauseofitsminimaltime,temperatureandperrequirenments;thelackof biologicalindicatorsappropriateforrapidsterilization;theabsenseofprotectivepackaging,andthepossibilityofcontaminationduring transport.Implantableitemsshouldnotbeflashsterilized.

b.DryHeat
Thisprocesshasbeenusedforthesterilizationofglass,instrumentsofglass,instrumentsandotheritemsthatcannotbesterilizedbysteamsterilization. However,itisconsideredalessefficientprocessthatmoistheat.Furthermore,theparametersfordryheataredifficultto determineandtheprocessis quitelengthy.

2.Gas
a. b. c. ETOisacolorlessgasthatishighlyreactivewithotherchemicals.TheETOcycleinvolvespreconditioningandhumidification,gas introduction,exposure,evaluationandairwashes.Theprocess,excludingaerationtime,isapproximately2to3hours.ETOpenetrates materialsand,therefore,mechanicalaerationisneededtoremovethetoxicETOresidue. Formaldehydecanbeusdasadisinfectant(liquidform)orasterilant(gasform).Itisprimarilyusedfordecontaminationofbiological safetycabinets,highefficiencyparticulatefilterunits. Peroxidegasplasma: newlowtemperaturesterilizationmethod Utilizeshydrogenperoxideinvaporphaseandlowtemperaturegasplasma Peraceticacidgasplasma: process(Plazlyte)clearedforuseonselectedinstrumentswithoutsmalllumens. canformatoxicsaltwhensterilizationmaterialsinteractwithcopper,brassorzinc Vaporphasehydrogenperoxide: usesadeepvacuumtopull30%liquidhydrogenperoxidefromadisposablecartridgethroughaheated vaporizer.

d. e.

3.ChemicalSterilants:
Glutaraldehyde Hydrogenperoxide Peraceticacid Peraceticacidwithhydrogenperoxide

4.OtherMethods:
a. b. c. Chlorinedioxide Filtration Ozone

Table2:SummaryofChemicalSterilantsUsedPrimarilyasHigh LevelDisinfectants
AGENT
Glutaraldehyde (>=2.0%)

ADVANTAGES
Goodcompatibility Fairlyinexpensive

DISADVANTAGES
Respiratoryirritant;cancoagulate bloodandfixtissuestosurfaces Activationrequired Slowmycobacterialactivity Compatibilityconcernwithbrass, copper,zincandnickelsilverplating Cancauseseriouseyedamage Yes

CLEAREDBY FDA?

Hydrogenperoxide (7.5%)

Noactivationrequired Mayfacilitateremovaloforganismsandorganic material Nospecificdisposalnecessary Compatiblewithmetals,plastics,andelastomers Noodor Doesnotcoagulatebloodorfixtissuesto surfaces InactivatesCryptosporidium Broadspectrum Rapidactivity Environmentfriendlybyproducts

Yes

Peraceticacid(0.2%)

Cancorrodecopper,brass,bronze, plainsteelandgalvanizediron Unstablewhendiluted Cancauseseriouseyeandskin damage

Yes

Agent
Peraceticacidwithhydrogen peroxide(0.8%,1%)

Advantages
Noactivation MildOdor

Disadvantages
Someconcernsaboutcompatibilitywithlead, brass,copper,andzinc(bothcosmeticand functional) Limitedclinicaluse

ClearedbyFDA?
Yes

B.
1. 2.

Sterilizationmonitoringsystems aremeanttoassurethatequipmentanddeviceslabeledsterilearein factsterile.Suchsystemstakeoneoftwoforms:productcontrolorprocesscontrol.

Productcontrol =sterilitytesting;useofbiologicalindicators(i.e.sporesamplesplacedinsterilizertodocument sterilization) Productcontrol =assessingthesterilizationprocess;e.g.:
a. b. Mechanicalindicators(time/temperaturecharts&pressuregauges); Chemicalindicatorsoftemperature/humidity.

C.
1.

Poststerilizationhandlingandstorageproceduresareimportanttopreventcontamination:
Providesterilestorageinprocedureareas(closedcabinets,wrappers)toavoid:
a. b. c. Contaminationfrompatientsecretionsorbodyfluids Handcontaminationbyemployeesobtainingextrasupplies,and Contaminationfromsuppliesbeingreturnedtostockafteruse.

2.

Storepackagestopreventdisruptionofpackageintegrity:
a. b. c. Coveredstoragetopreventmoisturedamage, Keepstorageoffthefloor,and Protectfrominsectsandotherpests.

3. 4. 5. 6.

Rotatestocktoavoiduseofoutdatedsupplies. Designateseparateareaformixingofmedicationsorsolutions. Refrigerateproductsaccordingtomanufacturersrequirements. Appropriatestorageconditionsforsterilepacksinclude:

limitedaccesstostorageareaand/orclosedcabinets, cleansuppliesshouldbestoredseparatelyfromsterilesupplies, areamustbeclean,dry,dustfree,lintfree, temperature1822C(65 72F), relativehumidity3550%

7.

Checkpackageintegrity:
isthepackagefreeoftears,dampness,excessivedust,andgrosssoil? Isthereachemicalindicatorontheoutsideofthepackage? Hastheexpirationdatebeenreachedorpassed? Ifheatsealed,hasthesealbeenmaintained?

III.Recognizingpotentialsourcesofcrosscontaminationinthehealthcareenvironment
A. Identificationofsurfacesorequipmentrequiringbetweenpatientcleaning:
1.Allitemshavingcontactwithmucousmembranesmustbecleanedanddisinfectedbetweenpatientuses.Example: reusablethermometers. 2.Itemshavingcontactwithintactskin,suchasbloodpressurecuffsandstethoscopes,needperiodiccleaning. 3.Anyenvironmentalsurface,equipment,ordevicecontaminatedwithbloodorboyfluidsshouldbecleanedanddisinfectedimmediately.

B.

Identificationofpracticeswhichcontributetotouchcontaminationandthepotentialforcrosscontamination:
1.Cleananddirtyworkareasshouldbeseparatedtoreducecrosscontaminationofsupplies. 2.Environmental(e.g.,commodescontaminatedwithfecesmaybeavehicleforspreadofC.difficle betweenpatients). 3.Glovesmustberemovedandhandswashedaftertouchingcontaminatedsurfacesorequipment(e.g.,urinarycollectiondevices,bedpans, dressing).

V.Appropriatelevelsofknowledgeofdisinfection/sterilizationmethodsandagentsarebasedontheareaof professionalpracticeandscopeofresponsibility
A. Knowledgeexpectationsofhealthprofessionalswhopracticeinorganizationswheretheresponsibilityforhandling,cleaning andreprocessingequipmentordevicesisdesignatedtoanotherdepartmentshouldinclude:
1.Basicconceptsandprinciplesofcleaning,disinfection,andsterilizationdescribedabove. 2.Appropriateapplicationofsafepracticesforhandlingdevicesandequipmentinthespecificareaofprofessionalpractice(e.g.,ophthalmology, dentistry)

B.

Knowledgeexpectationsofindividualswhohaveprimaryorsupervisoryresponsibilitiesforequipmentordevicereprocessing shouldinclude:
1.Coreconceptsandprinciplesofcleaning,disinfection,andsterilizationdescribedabove. 2.Detailedinformationonthefollowing: a.propertiesandusesofchemicaldisinfectants b.methodsforachievingsterilization c.sterilizationequipmentandpackagingdevices methodsformonitoringsterilizationprocessesandcurrentrecommendationsformonitoringfrequency AdditionalreferencesforpersonsresponsibleforSterilization/Disinfectionprocedures: Guidelinesforinfectioncontrolindentalhealthcaresettings2003 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217al.htm Guidelinesforenvironmentalinfectioncontrolinhealthcarefacilities2003 http://www.cdc.govncidod/dhqp/glenvironinfection.htm

ElementVI
PREVENTIONANDCONTROLOFINFECTIOUSANDCOMMUNICABLEDISEASESINHEALTHCAREWORKERS

LearningObjective
Listoccupationalhealthstrategiesforprotectinghealthcareworkers(HCWs)andpatients; ListnonspecificdiseasefindingswhichshouldpromptevaluationofHCWs; IdentifyoccupationalhealthstrategiesforpreventingHIV,hepititisB(HBV),hepititisC(HCV)andtuberculosis (TB)inhealthcareworkers; IdentifyresourcesforevaluationofHCWsinfectedwithHIV,HBV,and/orHCV Infectiousdisease: aclinicallymanifestdiseaseresultingfrominfection. CommunicableDisease: anillnessduetoaspecificinfectousagentwhichisacquiredthroughtransmissionof thatagentfromaninfectedperson,animal,orinanimatereservoirtoasusceptiblehost. Occupationalhealthstrategies: asappliedtoinfectioncontrol,asetofactivitiesintendedtoassess,prevent, andcontrolinfectionsandcommunicablediseasesinHCWs.

Definitions

I.Overviewofoccupationalhealthstrategiesforinfectioncontrol
A.Goalsofoccupationalhealthstrategies:
1. PreventdiseasetransmissionfromHCWstopatientsandstaff ProtectsusceptibleHCWsfrominfrectiousorcommunicablediseases. Preemployment: reviewofoverallhealthandimmunizationstatus,TBtesting(PPD)beforeemployment(2stepifnodocumentationof negativePPDwithinpastyear),chestxrayandmedicalassessmentforPPDpositiveemployees,administrationofnecessaryvaccinations (i.e.rubella,rubeola,varicella,andtetanus/diphtheria). Periodic(annual)healthassessments: reviewofoverallhealthstatusandassessmentforpossiblecommunicablediseaseexposure,PPD skintestfornegativeemployees,medicalassessmentandscreeningforsigns/symptomsofTBactivation(i.e.fever,chills,nightsweats, fatigue,anorexia,andcough)forPPDpositiveemployees. Immunization/screeningprogramsaretargetedatseveraldiseases:
a. b. c. Tuberculosis(TB): atleast annualtuberculinskintesting(PPD)isrequired;moreoftenforhighriskpositions. HepititisB(HBV):HBVvaccinationishighlyrecommended;mustbeofferedatnochargetoallHCWswhoseworkinvolvesriskofexposureto blood/bodyfluids. Rubeola(measles):documentationofimmunity(2dosesofvaccineorahistoryofillness)isrequiredofallHCWbornin1957 or later.

B.StrategiestoassessHCWsfordiseaserisks:

2.

ElementVI
I.Overviewofoccupationalhealthstrategiesforinfectioncontrol
A.Goalsofoccupationalhealthstrategies:
1. PreventdiseasetransmissionfromHCWstopatientsandstaff ProtectsusceptibleHCWsfrominfrectiousorcommunicablediseases. Preemployment: reviewofoverallhealthandimmunizationstatus,TBtesting(PPD)beforeemployment (2stepifnodocumentationofnegativePPDwithinpastyear),chestxrayandmedicalassessmentforPPD positiveemployees,administrationofnecessaryvaccinations(i.e.rubella,rubeola,varicella,and tetanus/diphtheria). Periodic(annual)healthassessments: reviewofoverallhealthstatusandassessmentforpossible communicablediseaseexposure,PPDskintestfornegativeemployees,medicalassessmentandscreening forsigns/symptomsofTBactivation(i.e.fever,chills,nightsweats,fatigue,anorexia,andcough)forPPD positiveemployees. Immunization/screeningprogramsaretargetedatseveraldiseases:
a. b. c. d. e. f. g. h. Tuberculosis(TB): atleast annualtuberculinskintesting(PPD)isrequired;moreoftenforhighriskpositions. HepititisB(HBV):HBVvaccinationishighlyrecommended;mustbeofferedatnochargetoallHCWswhoseworkinvolves riskofexposuretoblood/bodyfluids. Rubeola(measles):documentationofimmunity(2dosesofvaccineorahistoryofillness)isrequiredofallHCWbornin 1957orlater. Rubella(germanmeasles)documentationofimmunity(1doseofvaccineorapositiveserologictest)isrequiredofall HCWs Mumps:screeningforhistoryofillness(and/orabloodtesttoconfirmimmunityorsusceptibility)isoftenperformed; vaccinationisrecommendedforsusceptibleHCWs. Varicella(chickenpox):screeningforhistoryofillness(and/orabloodtesttoconfirmimmunityorsusceptibility)isoften done;vaccinationishighlyrecommendedforsusceptibleHCWs. Influenza:annualinfluenzavaccinationishighlyrecommendedforallHCWs;vaccinationisrequiredtobeofferedtoall employeesinlongtermcarefacilities,homecare,adultdaycareprogramsetc. Pneumovax:vaccinationisrequiredtobeofferedtoallemployeesinlongtermcarefacilities,homecare,adultdaycare programsetc.;itishighlyrecommendedforanyoneatriskasidentifiedinACIPguidelines. SomeoftheabovescreeningsandimmunizationsarerequiredbyNYStateorFederalmandates;othersarehighly recommended.ImmunitytorubeolaandrubellaarerequiredbytheNYStateDepartmentofHealth.OfferinghepititisB vaccineatnochargeisrequiredbytheUSDepartmentofLabor(OSHA)PeriodicTBscreening(PPD)isrequiredbyboth theNYStateDepartmentofHealthandOSHA.

B.StrategiestoassessHCWsfordiseaserisks:

2.

ElementVI
2. EvaluationofacuteorincubatingillnessesinHCWs: a. HCWsexhibitinganyofthesesymptomsshouldbepromptlyevaluatedforfitnesstowork(i.e.,risk oftransmittingtopatients,staff,visitors): Fever,chills Cough,sputumproduction Sorethroat Exanthema(rash),vesicles Skinlesions,weepingdermatitis Drainingwounds,sores Diarrheaorvomiting Eyeinfectionordrainage b. Postexposureevaluation:susceptibleHCWswhohavebeenexposedtothefollowingdiseasesshould alsobeevaluated: Tuberculosis Varicella(chickenpoxorherpeszoster,shingles) Rubeola Rubella Pertussis(whoopingcough) Mumps Meningococcalinfection(closecontact) Scabies ParvovirusB19(fifthdisease) Example:ifaHCWisexposedtoapersonalfamilymemberorpatientwithactiveTB,theHCW mustbeevaluatedforsymptomsofactiveTBandtestedforTBinfection(PPDskintest).If infectionispresent,achestxrayisperformedandtreatmentisbegun. c. ManagementofillorexposedHCWswithacuteorincubatingcommunicabledisease.Goalisto preventpotentialtransmissiontosusceptiblepatientsandstaff 1) Limitcontactwithsusceptiblepatientsandstaff.Example:temporaryjobreassignment. 2) FurloughfromworkuntilHCWisnolongerinfectiousorriskofcontractinginfection(post exposure)haspassed. Example:asusceptible(nonimmune)HCWwhohasbeenexposedtochickenpoxisusually furloughedfromworkbeginningthe10th daythroughthe21st dayafterexposure(the incubationperiodforchickenpox). 3) Treatmentasneeded.Examples: HCWwithactivepulmonarytuberculosisistreatedwithmultipleantituberculosisdrugs,and mayreturntoworkaftersymptomshaveresolvedandsputumsmearsshowclearingofTB.