Assessment of health care workers knowledge, attitude and Practice

towards infection control in labor rooms in Khartoum state

hospitals-2009

Authors:
Nuha Mohammed HajAli
MCP, University of Khartoum

Prof. Al Amin Ibrahim ELNeama

University of Khartoum-Faculty of Pharmacy
Department of Pharmaceutics

Abstract:
Objectives: The purpose of the study was to assess health care workers knowledge, attitude and
practice towards infection control in labor rooms in Khartoum state hospitals.
Methods: Descriptive cross-sectional facility based study. Self-administered questionnaire was
used to to assess health care workers knowledge, attitude and practice towards infection control.
Results: After a month of data collection the coverage reached 78%, in other word I had covered
14 hospitals out of 18 (1 specialized, 7 central, and 6 rural hospitals). Also I have found that the
midwives have the highest degree of knowledge and practice of infection control precautions.
Conclusion: The good infection control practice is acquired by experience over years of work.

Introduction:
Nosocomial infections (NIs) are infections which result from treatment in a hospital or a
healthcare service unit, but secondary to the patient's original condition. Infections are
considered nosocomial if they first appear 48 hours or more after hospital admission or after
discharge. This also includes occupational infections among staff of the facility (Benenson
1995.). NIs are also commonly known by the terms health care-associated and hospital-acquired
infections (HAIs). The most common type of NIs are surgical wound infections, respiratory
infections, genitourinary infections, as well as gastrointestinal infections.
The emergence of life-threatening infections such as severe acute respiratory syndrome (SARS)
and re-emerging infectious diseases like plague and tuberculosis have highlighted the need for
efficient infection control programs in all health care settings and capacity building for health
care workers so they can implement them. A breach in infection control practices facilitates
transmission of infection from patients to health care workers, other patients and attendants. It is
therefore important for all health care workers, patients, their family members, friends and close
contacts to adhere to the infection control guidelines strictly. It is also imperative for health care
administrators to ensure implementation of the infection control program in health care facilities
(WHO, 2004). The responsible health authority should develop a national (or regional) program
to support hospitals in reducing the risk of health-care-associated HAIs or nosocomial infections
NIs.

Rationale:
Women in labor rooms are exposed to invasive devices and/or procedures that are known to pose
significant infection risk. Although the duration of contact with the facilities is generally brief,
the infection risk associated with care in labor rooms is probably quite high. But fortunately,
most nosocomial infections in these settings are largely preventable by the combination of
simple good hygienic practice and appropriate decontamination of instruments (WHO 2004).
Nosocomial infections, such as endometritis, postoperative pelvic infection, urinary tract
infections, neonatal sepsis, etc, are serious complications in normal vaginal delivery. The
incidence of postoperative infections approaches 38%. The third most common nosocomial
infection is surgical site infection includes obstetrics and gynecological sources (Faro and Faro
2008). The infection control program was known to be simple, low-cost, low technology
intervention to reduce substantially the incidence of septicemias and mortality (Darmstadt et al
2005.)
So this study was conducted to evaluate the situation of infection control practices in labor rooms
in the hospitals of Khartoum states Ministry of Health, in order to determine the level of
adherence of hospitals and health care workers to infection control guidelines and to measure the
extent of pharmacists participation in infection control programs. Also to evaluate health care
workers knowledge and attitude towards infection control programs.

Objectives:

To assess health care workers knowledge, attitude and practice towards infection control.

Materials and methods:

Study design:

Descriptive cross-sectional facility based study.

Study area:

The research was conducted in Khartoum state Public hospitals. Khartoum state is the
national capital of Sudan. It is of 20.140km areas, situated in the centre of Sudan.
According to 2008 census its population is 5.274.325. Public hospitals Khartoum state's
Ministry of Health are in List of KMoH hospitals.

Study population:

The study population comprised the hospital pharmacists.

Data Collection Tools & Techniques:

Questionnaire was used to evaluate the knowledge, attitudes and practices of medical
personnel towards infection control guidelines.

Inclusion criteria:

All health workers who have regular, clinical contact with patients in the labour rooms,
this includes staff such as physicians, medical officers, house officers, and midwives in
hospitals that have labor rooms, at the time of data collection (from Sunday to Thursday
between 9:00 am and 2:00 pm).

Sample size & sampling technique:

Total coverage.

Data analysis:

Statistical analysis was done by the Statistical Package for Social Sciences (SPSS 17.0)
program and Microsoft excel program (2007).

Results:
Response rate:
After a month of data collection the coverage reached 78%, in other word I had covered 14
hospitals out of 18 (1 specialized, 7 central, and 6 rural hospital).
Figure (1): Response rate

22%
covered hospitals

78%

not covered hospitals

Knowledge and Attitudes of Medical Personnel on Standard Precautions of

Infection Control:
Gender:
The number of respondent to this questionnaire is 50, 26% male and 74% female.
Figure (2): Gender within respondents
26%
male

74%

female

Years of work:
40% of the respondents work for five years or less, 16% work for 10 years or less, and 44% work
more than 10 years.
Figure (3): Years of work with in respondents

40%

44%

5 years
10 years

16%
>10 years

Medical occupation:
10% of the respondents are registrars, 16% are medical officers, 18% are house officers, and
56% are midwives.
Figure (4): Medical occupation within respondents
10%
16%

registrars
medical officers

56%
18%

house officers
midwives

Medical occupation VS I change gloves between tasks/procedures on the same patient to

prevent cross-contamination between different body sites:
66% of respondents change gloves every time between tasks to prevent cross-contamination
from whom midwives are 27 out of 28, compared to registrars 2 out of 5, medical officers 3 out
of 8, house officers 1 out of 9.
Table (1): Medical occupation VS I change gloves between tasks/procedures on the same
patient to prevent cross-contamination between different body sites.
I change gloves between tasks/procedures on the
same patient to prevent cross-contamination between
different body sites
every time
sometimes
never
medical occupation

Total

registrar

medical officer
house officer

3
1

5
5

0
3

8
9

27

28

33

13

50

midwife
Total

Figure (5): Medical occupation VS I change gloves between tasks/procedures on the same
patient to prevent cross-contamination between different body sites.

Medical occupation VS I wash/decontaminate hands before handling an invasive device

(regardless of whether or not gloves are used) for patient care:
74% of respondents wash or decontaminate hands every time before handling an invasive device
(regardless of whether or not gloves are used) for patient care from whom midwives are 27 out
of 28, compared to registrars 2 out of 5, medical officers 5 out of 8, house officers 3 out of 9.
Table (2): Medical occupation VS I wash/decontaminate hands before handling an invasive
device (regardless of whether or not gloves are used) for patient care
I wash/decontaminate hands before handling an
invasive device (regardless of whether or not gloves
are used) for patient care
every time
medical occupation

sometimes

never

Total

registrar
medical officer

2
5

3
3

0
0

5
8

house officer

27
37

0
8

1
5

28
50

midwife
Total

Figure (6): Medical occupation VS I wash/decontaminate hands before handling an

invasive device (regardless of whether or not gloves are used) for patient care

Medical occupation VS I wear a surgical mask to protect nose and mouth during
procedures and activities that are likely to generate splashes or sprays of blood and body
fluids:
48% of respondents wear a surgical mask every time to protect nose and mouth during
procedures and activities that are likely to generate splashes or sprays of blood and body fluids
from whom midwives are 16 out of 28, compared to registrars 2 out of 5, medical officers 4 out
of 8, house officers 2 out of 9.
Table (3): Medical occupation VS I wear a surgical mask to protect nose and mouth during
procedures and activities that are likely to generate splashes or sprays of blood and body
fluids.
I wear a surgical mask to protect nose and mouth
during procedures and activities that are likely to
generate splashes or sprays of blood and body fluids
every time
sometimes
never
medical occupation

Total

registrar

medical officer
house officer

4
2

3
2

1
5

8
9

16

28

24

17

50

midwife
Total

Figure (7): Medical occupation VS I wear a surgical mask to protect nose and mouth
during procedures and activities that are likely to generate splashes or sprays of blood and
body fluids.

10

Medical occupation VS I wear a gown during procedures that are likely to generate
splashes or sprays of blood and body fluids:
72% of respondents wear gown every time during procedures that are likely to generate splashes
or sprays of blood and body fluids from whom midwives are 26 out of 28, compared to registrars
2 out of 5, medical officers 6 out of 8, house officers 2 out of 9.
Table (4): Medical occupation VS I wear a gown during procedures that are likely to
generate splashes or sprays of blood and body fluids.
I wear a gown during procedures that are likely
to generate splashes or sprays of blood and body
fluids
every time
sometimes
never
medical occupation registrar
2
3
0
medical officer
6
2
0
house officer
2
4
3
midwife
26
2
0
Total
36
11
3

Total

Figure (8): Medical occupation VS I wear a gown during procedures that are likely to
generate splashes or sprays of blood and body fluids.

11

5
8
9
28
50

Medical occupation VS I place used disposable syringes and needles, scalpel blades and
other sharp items in a puncture-resistant container with a lid.
62% of respondents every time place used disposable syringes and needles, scalpel blades and
other sharp items in a puncture-resistant container with a lid from whom midwives are 24 out of
28, compared to registrars 2 out of 5, medical officers 2 out of 8, house officers 3 out of 9.
Table (5): Medical occupation VS I place used disposable syringes and needles, scalpel
blades and other sharp items in a puncture-resistant container with a lid.
I place used disposable syringes and needles, scalpel blades and
other sharp items in a puncture-resistant container with a lid
every time
medical occupation registrar
medical officer
house officer
midwife
Total

sometimes

never

Total

3
24

3
3

2
1

1
0

9
28

31

15

50

Figure ( 9): Medical occupation VS I place used disposable syringes and needles, scalpel
blades and other sharp items in a puncture-resistant container with a lid.

12

Medical occupation VS I recap or bend needles:

62% respondents every time recap or bend needles from whom midwives are 22 out of 28,
compared to registrars 3 out of 5, medical officers 4 out of 8, house officers 2 out of 9. This have
negative impact.
Table (6): Medical occupation VS I recap or bend needles.
I recap or bend needles
every time
medical occupation

sometimes

never

Total

registrar

medical officer

house officer

22

28

31

14

50

midwife
Total

Figure (10): Medical occupation VS I recap or bend needles.

13

Medical occupation VS I use a plain soap, antimicrobial agent or waterless antiseptic agent
to wash my hands after removing gloves:
56% respondents every time use a plain soap, antimicrobial agent or waterless antiseptic agent to
wash my hands after removing gloves from whom midwives are 24 out of 28, compared to
registrars 0 out of 5, medical officers 2 out of 8, house officers 2 out of 9.
Table (7): Medical occupation VS I use a plain soap, antimicrobial agent or waterless
antiseptic agent to wash my hands after removing gloves.
I use a plain soap, antimicrobial
agent or waterless antiseptic agent
to wash my hands after removing
gloves
every time
medical occupation

sometimes

Total

registrar

medical officer

house officer

24

28

28

22

50

midwife
Total

Figure (11): Medical occupation VS I use a plain soap, antimicrobial agent or waterless
antiseptic agent to wash my hands after removing gloves.

14

Medical occupation VS Containers should be disposed of when they are three-quarters full:
58% respondents thought containers should be disposed of when they are three-quarters full from
whom midwives are 11 out of 28, compared to registrars 4 out of 5, medical officers 7 out of 8,
house officers 7 out of 9. These have negative impact
Table (8): Medical occupation VS Containers should be disposed of when they are threequarters full.
Containers should be disposed of
when they are three-quarters full
yes
medical occupation

no

Total

registrar

medical officer

house officer

11

17

28

29

21

50

midwife
Total

Figure (12): Medical occupation VS Containers should be disposed of when they are threequarters full.

15

Medical occupation VS

had received previous formal training on infection control

precautions:
58% respondents had received previous formal training on infection control precautions from
whom midwives are 18 out of 28, compared to registrars 3 out of 5, medical officers 5 out of 8,
house officers 3 out of 9. These have negative impact
Table (9): Medical occupation VS I had received previous formal training on infection
control precautions.
I had received previous formal
training on infection control
precautions
yes
medical occupation

no

Total

registrar
medical officer

3
5

2
3

5
8

house officer

18
29

10
21

28
50

midwife
Total

Figure (13): Medical occupation VS I had received previous formal training on infection
control precautions.

16

Discussion:
The time of data collection affects the percentage of coverage. Since its conducted in the
rainy season some hospitals were not accessible. Treating all patients in the health care
facility with the same basic level of standard precautions involves work practices that are
essential to provide a high level of protection to patients, health care workers and visitors
(WHO 2004). Preventive measures are applied in most of the hospitals, but there are some
problems. Hand washing facilities and techniques are available in all hospitals, but in
(85.7%) of hospitals bar soaps were put in non perforated soap racks which may form a
suitable media for bacterial growth and a source of infection. Another study at Khartoum
Nourth teaching hospitals showed that the practices of healthcare personnel about rinsing
and keeping hands above the level of the waist during scrubbing were practiced properly
(Hassan and Hassan 2007).
Although there is a risk of wound infections in the labor rooms for both mother and baby,
the midwives and doctors did not wear surgical latex gloves and wear examination gloves
which give the least protection. . A fresh pair of sterile gloves should be worn for each
procedure. It has been traditional teaching that gloves should be changed promptly if
punctured (Eckesley and Williamson1990). Also it has been found that some healthcare
personnel in these facilities use double gloves for more protection, this in agreement with
Patterson et al who demonstrated that double gloving may be uncomfortable, reduce manual
dexterity and tactile sensitivity but it provides increased protection from penetration of
needle stick injuries (Patterson et al 1998). Also randomized studies within various surgical
specialties have shown that wearing two pairs of gloves decreases leaks by 3-9 fold in water
permeability tests, when compared with wearing one pair of gloves (Doyle et al 1992).

17

There is good level knowledge regarding sharps and/or spillages but there is greater
problems in waste disposal, in (21.7%) of hospitals sharp boxes are disposed when full,
and were not disposed with minimal handling. A separate study reported a varied
compliance rate regarding universal precautions among hospital physicians in United States:
glove use: 94%; disposal of sharps: 92%, wearing protective clothing: 55%; not recapping
needles: 56% (Michalsen et al 1997).
In the area of knowledge and attitudes of medical personnel on standard precautions of
infection control it has been found that the higher degree of adherence is among the
midwives and this may be due to the longer period of experience in labor rooms and the
inclusion of infection control program in their basic medical education syllabus. This
disagreed with the results of pretest examination of knowledge, attitude, and practice of
healthcare personnel at Khartoum North Teaching Hospital which showed poor knowledge
about the use of protective barriers such as gowns, gloves, head covers, and masks.
Numerous studies done by different authors in different countries showed that continuous
education, policy, guidelines and monitoring system would improve the knowledge, attitude
and practices of healthcare personnel in maintaining sterile surgical field (Hassan and
Hassan 2007).
It can be concluded that the good infection control practice is acquired by experience over
years of work.

18

Limitations:
The short time and difficulties in the accessibility to some hospitals limits the total coverage of
all hospitals, and the localized area of study, labor room, has special conditions, this will limit
the extrapolation of results.
Also the special and stressful environment of work in labor rooms limits the number of
respondents to the questionnaire of the knowledge and attitude of medical personnel; this
rendered carrying of inferential statistics and also limits generalization of study findings.

19

Conclusions:

Although there is regulation controls the implementation of infection control program

there is a gap between the availability of the regulations and the adherence of health
organization to it.

There are problems in some areas in the application of preventive measures especially in
the field of waste disposal and personal protective equipments.

The absence of screening and immunization policies put the healthcare personnel in a
greater hazard of infectious diseases.

The good infection control practice is acquired by experience over years of work.

20

Recommendations:

Additional concern should be given to the labor rooms to improve the work environment
since it handles hot cases area and sometimes it works as emergency room where the
females are subjected to invasive procedures with higher risk of infection.

Further studies are essential in the evaluation of the situation of infection control in
different areas in hospitals.

Additional concern should be given to the availability of clear guidelines which must be
introduced to all healthcare personnel.

More intensive and regular training programs to all health care workers must be included
in the plans of quality control in all hospital.

Additional concern should be given to the availability and quality of personal protective
equipments.

Regular inspection and follow-up from the ministry of health guarantees good infection
control practices.

21

Acknowledgment:
I would like to thank the man who gave me his time and knowledge, my supervisor Prof. Al
Amin Ibrahim ElNeama for his keen supervision, precious advices, kind help and support to
accomplish this research. Also I would like to thank Dr. Abdullahi Nour Hassan (Faculty of
Medicine - Elzaem Elazhary University) for his help and advices in every step of this study. My
thanks extended to Dr. Hatim Hassan Deif Allah (Faculty of Business AdministrationUmdurman Alahlya University) for his greatest help in statistical and technical processing of this
research. Also Im grateful to the Technical and Ethical Research Committee- Ministry of health
Khartoum State for their efforts in guiding me to the best way to perform this study. My
appreciations to all who gave me a hand or light a candle in my way to complete this research.

22

Abbreviations:
HAIs

Healthcare-Associated/Hospital-Acquired Infections

HCFs

Healthcare Facilities

HCW

Healthcare workers

ICC

Infection Control Committee

KMoH

Khartoum State's Ministry of Health

MRSA

Methicillin-resistant Staphylococcus aureus

NIs

Nosocomial Infections

NSIs

Needle Stick Injuries

PPE

Personal Protective Equipment

SARS

Severe Acute Respiratory Syndrome

RSV

Respiratory Syncytial Virus

23

References:
1. Abdullahi N Hassan and Moawia A Hassan. Knowledge, attitude, and practice of
healthcare personnel about sterilization and disinfection at Khartoum North Teaching
Hospital, Hospital report 2007.
2. Alvarado CJ. 2000. The Science of Hand Hygiene: A Self-Study Monograph. University
of Wisconsin Medical School and Sci-Health Communications.
3. American Society of Health-System Pharmacists. ASHP statement on the pharmacists
role in infection control. Am J Health-Syst Pharm. 1998; 55:17246. Available from :
http://www.ashp.org/DocLibrary/BestPractices/InfectionControl.aspx (accessed on 24

June 2009).
4. Ami S. Patel, Mary Beth White-Comstock, Diane Woolard, Joseph F. Perz. Infection
Control Practices in Assisted Living Facilities: A Response to Hepatitis B Virus Infection
Outbreaks Infection Control and Hospital Epidemiology March 2009, vol. 30, no. 3.
5. Benenson AS. Control of communicable diseases manual, 16th edition. Washington,
American Public Health Association, 1995.
6. Berger SA, Kramer M, Nagar H, Finklestein A, Frimmerman A, Miller HI. Effect of
surgical mask position on bacterial contamination of the operative field. J Hosp Infect
1993; 23: 51-4 26
7. Constance Faro, Sebastian Faro .Postoperative pelvic infections. www. theclinic.com.
infectious disease clinics of North America. Volume 22, issue 4. December 2008.
8. Dalin MG, Danielson JS, Sinclair Eh. Infection control practices at the Singapore General
Hospital: from a Swedish point of view. Ann Acad Med Singapore, 2008 Oct:
37(10);897-9
9. Daly A D, M P Nxumalo, R J Biellik. An assessment of safe injection practices in health
facilities in Swaziland. 2004, SAMJ vol. 94, no3, pp. 194-197.
10. Darmstadt GL, Nawshad Uddin Ahmed MA, Alam MA, Khatum M, Black RE,
Santosham M. Infection control practices reduce nosocomial infections and mortality of
preterm infants in Bangladish. (Randomized controlled trial). May 2005.

11. David Greenwood, Richard C. B. Slack, John F. Medical Microbiology, A guide to

microbial infections: Pathogenesis, Immunity, Laboratory Diagnosis and Control.

FRCPE.14th edition, Churchill Livingstone 1992.

24

12. Dever, GEA, Improving Outcomes in Public Health Practice, Strategy and Methods.
Aspen Publishers, 1997 p10).
13. Dodds RD, Guy,PJ, Peacock AM, Duffy SR, Barker SG, Thomas MH. Surgical glove
perforation. Br J Surg 1988; 75: 966-8.
14. Donskey CJ. The role of the intestinal tract as a reservoir and source for transmission of
nosocomial pathogens. Clin Infect Dis 2004;39(2):219-26.
15. Doyle PM, Alvi S, Johanson R. The effectiveness of double gloving in obstetrics and
gynaecology. Br J Obstet Gynaecol 1992; 99: 83-4
16. Eckesley JRT, Williamson DM. Glove punctures in an orthopaedic trauma unit. Br J
Accident Surg 1990; 21: 177-8
17. Emori TG and RP Gaynes. 1993. An overview of nosocomial infections, including the
role of the clinical laboratory. Clin Microbiol Rev 6(4): 428442.
18. Finnegan LP, Sheffield J, Sanghvi H, Anker M. Infectious diseases and maternal
morbidity and mortality [conference summary]. Emerg Infect Dis [serial on the Internet].
2004

November.

Available

from:

http://www.cdc.gov/ncidod/EID/vol10no11/04-

0624_05.htm. (accessed on 14 March 2009)

19. Fisher, Reddy VR, Williams FM, Link Y, Thacker JG, Edlich RF. Biochemical
performance of latex and non-latex double glove systems, J Biomed Meter Research
1999; 48: 797-806
20. Gala CL, Hall CB, Schnabel KC, et al. The use of eye-nose goggles to control
nosocomial respiratory syncytial virus infection. Jama 1986;256(19):2706-8.
21. Guidance for Industry and FDA Staff - Surgical Masks - Premarket Notification [510(k)]
Submissions;

Guidance

for

Industry

and

FDA.

http://www.fda.gov/cdrh/ode/guidance/094.html
22. Guilherme H.C. Furtado, Solange L. Santana, Ana Paula Coutinho, Luciana B. Perdiz,
Srgio B. Wey and Eduardo A.S. Medeiros. Compliance with Handwashing at Two
Intensive Care Units in So Paulo. The Brazilian Journal of Infectious Diseases 2006;
10(1):33-35.
23. Hall CB. Nosocomial respiratory syncytial virus infections: the "Cold War" has not
ended. Clin Infect Dis 2000;31(2):590-6.

25

24. Health and Safety Commission. Control of Substances Hazardous to Health Regulations
Biological Agents Approved Code of Practice. HSE Books, Sudbury, UK.1999
25. Health Canada, Laboratory Centre for Disease Control Bureau of Infectious Diseases
Nosocomial and Occupational Infections Infection Control Guidelines, Hand Washing,
Cleaning, Disinfection and Sterilization in Health Care, December 1998, Volume 24S8,
10.
26. ICS

UK.

Infection

control

manual,

Cleaning

of

Instruments

http://www.infectioncontrolservices.co.uk/dental_decontamination_cleaning_instruments
.htm. October 2006. (accessed on 1st. September. 2009)
27. Kermode M. Unsafe injections in low-income country health settings: need for injection
safety promotion to prevent the spread of blood-borne viruses. Health Promot Int 2004,
19(1):95-103
28. Lee JJ, Marvin JA, Heimbach DM, Grube BJ, Engrav LH. Infection control in a burn
center. J Burn Care Rehabil 1990;11(6):575-80.
29. Lt A Gupta, Brig AC Anand, Lt Col SK Chumber, Wg Cdr VK Sashindran, SR Patrikar.
Impact of protective foot wear on floor and air contamination of intensive care units.
MJAFI 2007; 63: 334-336.
30. Lynch P et al. 1997. Infection Prevention with Limited Resources. ETNA
Communications: Chicago.
31. Malik Abdo, Mashaer B. Omer, and Hatim Z. A.ElBary. Guidelines for hospital acquired
infection control programs, Fedral Ministry of Health, Sudan.2005.
32. Mayon-White RT et al. 1988. An international survey of the prevalence of hospitalacquired infection. J Hosp Infect 11(Suppl A): 4348.
33. McLure HA, Tallboys CA, Yentis SM, Azadian BS. Surgical face masks and downward
disposal of bacteria, Anaesthesia 1998; 53: 624-6
34. Michalsen A, Delclos GL, Felknor SA, Davidson AL, Johnson PC, Vesley D, Murphy
LR, Kelen GD, Gershon RR. Compliance with universal precautions among physicians. J
Occup Environ Med 1997, 39(2):130-137.
35. Mitchell NJ, Hunt S. Surgical face masks in modern operating rooms - a costly and
unnecessary ritual? J Hosp Infect 1991; 18: 239-42

26

36. Naveed Z Janjua, Mahreen Razaq, Subhash Chandir, Shafquat Rozi and Bushra
Mahmood. Poor knowledge predictor of nonadherence to universal precautions for
blood borne pathogens at first level care facilities in Pakistan BMC Infectious Diseases
2007, 7:81
37. Nevin Kuzu, Fadime .zer, Semra Aydemir, Ata Nevzat Yalcin, Mehmet Zencir,
COMPLIANCE WITH HAND HYGIENE AND GLOVE USE IN A UNIVERSITYAFFILIATED

HOSPITAL

INFECTION

CONTROL

AND

HOSPITAL

EPIDEMIOLOGY March 2005.

38. Orr NW. Is a mask necessary in the operating theatre? Ann R Coll Surg Eng 1981; 63:
390-2
39. OSHA. OSHA. Department of Labor: Occupational Safety and Health Administration.
Occupational exposure to bloodborne pathogens: Final rule. 29 CFR Part 1910:1030
Federal Register 1991;56:64003-64182 Revised 2001 CFR 66 2001:5317-25.
40. Patterson JM, Novak CB, Mackinnon SE, Patterson CA. Surgeons concern and practices
of protection against blood-borne pathogens American Surgery 1998; 228: 266-72
41. Potential

confounding

in

evaluating

infection

control

in

hospital

setting.

http://igitur_archive.library.uu.nl/match/2006 (accessed on 24 June 2009)

42. R. Douglas Scott II. The Direct Medical costs of Healthcare-Associated Infections in U.S.
Hospitals

and

the

Benefits

of

Prevention.

March

2009.

Available

from:

http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf .

43. RICPRAC Rural Infection Control Practice Group - Infection Prevention & Control
Manual, 2nd Edition 2005 Medical Equipment Cleaning, Disinfection & Sterilisation
Guidelines.
44. Robert Gaynes, Chesley Richards, et al. Feeding Back Surveillance Data To Prevent
Hospital-Acquired Infections, National Nosocomial Infections Surveillance (NNIS)
System Hospitals Centers for Disease Control and Prevention, Atlanta, Georgia, USA
Vol.

7,

No.2,

MarchApril

2001.

Available

from:

http://www.cdc.gov/ncidod/eid/vol7no2/pdfs/gaynes.pdf (accessed on 15 August 2009)

45. Taravella MJ, Weinberg A, May M, Stepp P. Live virus survives excimer laser ablation.
Ophthalmology 1999; 106: 1498-9.

27

46. Tikhomirov E. 1987. WHO programme for the control of hospital infections.

Chemiotherapia 6(3): 148151.Tunevall TG. Postoperative wound infections and surgical face
masks in a controlled study. World J Surg 1991; 15: 383-8

47. WHO World Alliance for Patient Safety In collaboration with: Genevas University
Hospitals, Switzerland. GLOBAL PATIENT SAFETY CHALLENGE, 2005 - 2006.
http://www.who.int/patientsafety/events/05/GPSC_Launch_ENGLISH_FINAL.pdf

(accessed on 14 march 2009)

48. WHO. Guidelines on Hand Hygiene in Health Care (Advanced Draft): A Summary 2005
(Accessed

on

Feb

14,

2009

from

http://whqlibdoc.who.int/hq/2005/who_eip_spoqps_05.2.pdf).

49. William A. Rutala, David J. Weber. Guideline for Disinfection and Sterilization in
Healthcare Facilities. Healthcare Infection Control Practices Advisory Committee

(HIPAC) 2008.
50. William R. Jarvis, Infection Control and Changing Health-Care Delivery Systems.
MarchApril2001.

Available

from:

http://www.cdc.gov/ncidod/eid/vol7no2/pdfs/jarvis.pdf.

51. World Health Organization 2004.Practical Guidelines for Infection Control in Health
Care Facilities. Regional Office for Western Pacific, Manila. Regional Office for South-

East Asia, New Delhi.

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