What do you know about IPC?

IPC is integral to the safe delivery of health care. It is important to implement IPC programmes and how they protect
patients and health-care providers (HCP). 

Defining healthcare-associated infections

Healthcare-associated Infections (HAIs), an infection occurring in a patient during the process of care in a
health-care facility which was not present or incubating at the time of admission. This includes infections
acquired in the hospital but appearing after discharge, and also occupational infections among staff, are
infections that occur during the process of care that were not present or incubating at the time of
admission. Microorganisms are found in many places, including air, soil, water, and our bodies. Some of them are
helpful, but others can be harmful and cause infections.

In low- and middle-income countries, the burden of HAIs is high. Surveillance data suggest HAI prevalence is 2—3
times higher in low-income settings than in high-income settings. Vulnerable patients, such as those in intensive
care units and those with invasive devices, are at a higher risk of developing an HAI. HAIs contribute to
increased morbidity and mortality, length of stay, and healthcare costs.

Modern healthcare uses many types of invasive devices and procedures to treat patients and help them recover.
Infections can be associated with the devices used in medical procedures, such as catheters and
ventilators. These HAIs include central line-associated bloodstream infections, catheter-associated urinary
tract infections, and ventilator-associated pneumonia. Surgical site infections can also occur.

An effective IPC programme at a healthcare facility is essential for preventing and reducing HAIs and
antibiotic resistance, and in preparing for, managing, and preventing infectious disease outbreaks.

How diseases are transmitted

To reduce the risk of harmful microorganisms, you must understand how different HAIs can spread.
Microorganisms are found in air, soil, water, and in our bodies. Some microorganisms are helpful, others can be
harmful and cause infections.

The diagram below represents the chain of infection. For an infection to spread, all steps in the chain must
occur. The key to stopping the spread of infection is to break at least one link in the chain.
In a healthcare setting, the chain of infection refers to the numerous opportunities for pathogens to spread among
patients, HCP, and the environment. Effective IPC aims to break the chain.
Infectious Agent
An infectious agent or microorganism, such as a virus, bacteria, or other microbe, that is capable of
causing infection.

Reservoir
The reservoir is where microorganisms can be found. This can be a person (patient or HCP) or the
environment. The healthcare environment contains diverse microorganisms. Environmental reservoirs include dry
surfaces (bed rails and medical equipment), wet surfaces (faucets, sinks, and ventilators), indwelling medical
devices (catheters and IV lines), and the environment around the patient.

Portal of Exit
Microorganisms must exit their reservoir to spread. For example, when someone coughs, microorganisms leave
the reservoir (the person) through the respiratory tract. Portals of exit can include breaks in skin, mucous
membranes (eyes, nose, and mouth), hands, blood, and the gastrointestinal and urinary tracts (as feces,
vomit, and urine). Portals of exit can also be splashes from emesis (vomiting) patients or an exposed needle
in an open sharps container.
Mode of Transmission
Microorganisms need a way to move (spread) from the portal of exit to the portal of entry. In other words,
they need a way to get from point A to point B. Microorganisms usually depend on people, the environment, and
medical equipment to move in healthcare settings.

Modes of transmission include:

 Direct
o Direct contact
o Droplet spread
 Indirect
o Airborne
o Contaminated equipment
In direct transmission, an infectious agent is transferred from a reservoir to a susceptible host by direct
contact or droplet spread.
 Direct contact refers mainly to skin-to-skin contact, but it can also refer to contact with soiled
surfaces.
 Droplet spread refers to spray with relatively large, short-range aerosols produced by sneezing,
coughing, or even talking.
Indirect transmission refers to the transfer of an infectious agent from a reservoir to a host via suspended air
particles and inanimate objects or equipment.
 Airborne transmission refers to infectious agents being carried over long distances through the
air. Airborne particles include material that has settled on surfaces and become resuspended by air
currents, as well as infectious particles blown from the soil by the wind. In contrast to droplets that fall to
the ground within a few feet, airborne infectious agents can remain suspended in the air for long periods
of time and can be blown over great distances.
 Contaminated items that can indirectly transmit infectious agents include food, water, biological
products (blood), and fomites (inanimate objects such as bedding, surgical instruments, shared
equipment such as x-ray and dialysis equipment).

Portal of Entry
IV catheters (and other devices) and surgical incisions can provide entryways for microorganisms to gain access
to a susceptible host.

Mucous membranes (eyes, nose, and mouth) are an entryway for microorganisms spread by direct contact,
sprays, and splashes. When healthcare personnel wear masks or face shields, this prevents microorganisms from
coming in contact with the eyes, nose, or mouth.

Breaks in the skin, such as a puncture caused by a sharps injury, can also be an entryway. Notice that portals of
entry can also serve as portals of exit and reservoirs for harmful microorganisms.

Susceptible Host
The final link in the chain is the susceptible host. When patients receive medical treatment, the following factors
can increase susceptibility to infection:
  Patients who have underlying medical conditions such as diabetes, cancer, and organ transplantation
are at increased risk for infection. These illnesses often decrease the immune system’s ability to fight
infection.
 Certain medications, such as antibiotics, steroids, and some chemotherapy medications, increase the
risk of some types of infections.
 Medical devices and procedures, such as urinary catheters, tubes, and surgery, increase risk of
infection by providing additional ways for microorganisms to enter the body.

Understanding the chain of infections—infectious agents, reservoirs, modes of transmission, portals of entry and
exit, and susceptible hosts—enables us to develop IPC measures to break the chain of infection.

Standard and transmission-based precautions

Standard and Transmission-Based Precautions are core IPC practices that healthcare personnel use to reduce
transmission of microorganisms in all healthcare settings.

Standard Precautions aim to protect both HCP and patients from infectious agents—they are required in all
healthcare settings. Standard Precautions are recommended for care of all patients in any healthcare setting,
regardless of their suspected or confirmed diagnosis.

Standard precautions include:

 Hand hygiene
 Environmental cleaning
 Injection and medication safety
 Risk assessment with appropriate use of personal protective equipment (PPE)
 Reprocessing of reusable medical equipment
 Waste management
 Respiratory hygiene/cough etiquette

Transmission-Based Precautions are used in addition to Standard Precautions for patients who are
suspected or confirmed to be infected or colonized with certain pathogens for which the mode of
transmission is known.

Transmission-based Precautions include:

 Contact
 Droplet
 Airborne

The type of precaution assigned to a patient will depend on the mode of transmission of the suspected or confirmed
pathogen.

The importance of recognizing risk

Risk recognition is a skill that every clinician and individual working in healthcare should be able to perform for
both themselves and their patients: identifying sources of infection, or actions that can lead to infection. It
relies on an understanding of why IPC is implemented, and not just memorization of what is needed. Risk
recognition is a broad approach to IPC that includes both direct patient care and consideration of the
surrounding environment.

All clinicians and healthcare personnel should constantly assess risk related to their activities. Real-time
awareness enables immediate action to reduce or eliminate risk. A more formal assessment can be performed
to assess and reduce risk related to environmental surfaces, new devices, or procedures, or factors related to
physical layout and furnishings in the patient care area.

Questions to Consider Action to Take

Decision 1: Do I need protection for what I am I must follow Standard Precautions because there is a risk that I
about to do because there is a risk of might expose myself to an infection that is transmitted via this route,
exposure to blood and body fluids, mucous or expose the patient to my microorganisms.
Decision 2: Do I need protection for what I am I must alert someone about the patient showing symptoms so that a
about to do because the patient has diagnosis can be made, and I must determine what precautions to
undiagnosed symptoms of infection? perform to protect others and myself.
Decision 3: What are the facility standards for I must follow Transmission-based Precautions indicated for this
a patient that has an identified infection? infection to protect others and myself.

The hierarchy of controls

When risk has been recognized, do you know how to control it? The hierarchy of controls helps healthcare
personnel determine the most reliable controls to reduce the risk from hazards during healthcare
delivery. The image below represents this hierarchy: the most reliable methods do not rely on human behavior
or memory. The best control is elimination or substitution of a hazard. When elimination or substitution
are not possible, engineering controls can reduce potential exposure to hazards. Administrative controls
and use of PPE at the bottom of the hierarchy require HCP to take specific actions to reduce the risk—
they do not control the hazard itself.
Elimination and substitution
Remove the hazard or substitute it with something with less risk. These methods are the most effective at
reducing hazards; however, this tends to be the most difficult to implement. This is especially true if the risk is
associated with an existing process.

Examples:
 Elimination: Using a suitable alternative instead of an injection
 Substitution: Using blunt-tip suture needles instead of sharp-tip needles

Engineering controls
This control method is designed to isolate healthcare personnel from hazards. Examples:
 Prevent sharps injury by using safety-engineered syringes, needle shields, and sharps containers that
prevent emptying.
 Use ventilation systems (e.g., negative-pressure room: pulling air from the hallway to the patient room
and venting directly outside) that prevent airborne pathogens from leaving isolation room and exposing
others in the hallway.

Administrative controls
These controls reduce risk by providing protocols and procedures for tasks. This type of control relies on people
adhering to administrative rules.

Examples:
 Implementing contact precautions—for example, use of a single room, and of gloves and gowns—stops
the spread of potential pathogens.
 A facility’s written IPC plans inform HCP of protocols.
 Education and training requirements for HCP enforce protocols.
 Screening assessment rapidly identifies infectious disease risk.

Personal protective equipment

PPE—gloves, gowns, surgical masks, respirators, eye protection, and other specialized clothing—plays an
important role in IPC but requires consistent and correct use. It’s the least reliable control method because it
does not control the hazard itself but relies on human decision-making and performance—meaning there is
potential for human error.

IPC Programmes
An IPC programme is a systematic, defined way to prevent HAIs and AMR and prepare for, manage, and
prevent infectious disease outbreaks. An IPC programme is a horizontal programme, which means that it affects
every aspect of patient care and is applicable in all patient care settings, from wound treatment to complex, invasive
surgery. (A vertical program, like one for TB, deals with only a single disease.)

IPC professionals at healthcare facilities

Ideally, an IPC professional leads and oversees the development, implementation, coordination, and evaluation of
the IPC programme. The number of IPC professionals per facility depends on the acuity (acuity, used here to refer
to nursing care workload, is the complexity of care required for an individual patient or group of patients) and
complexity of the patient population. Greater acuity (severity of illness) and complexity will require more dedicated
IPC staff.

For facilities with limited or no IPC staffing, consider using a stepwise approach to implement IPC activities. As a
starting point, a nurse or doctor might spend 1—2 days per week on IPC activities. Nurses on wards can be
assigned to help expand the reach of IPC throughout the facility (i.e., link nurses or IPC champions). This approach
can help build an IPC team while also increasing IPC awareness throughout a facility.

The core components of IPC programmes

In 2016, the World Health Organization (WHO) released guidelines defining the elements of an effective IPC
programme. Known as the Core Components of IPC Programs, they serve as a roadmap for how IPC can
prevent harm caused by HAIs and AMR. These components should be implemented together—all of them
are required to build an effective IPC program. You will learn more about the core components and how to
implement them in a later module.

The core components include:

1. IPC programme
2. IPC guidelines
3. IPC education and training
4. HAI Surveillance
5. Multimodal strategy
6. Monitoring/audit of IPC practices, and feedback
7. Workload, staffing, and bed occupancy
8. Built environment, materials, and equipment for IPC at the facility level

Implementing an IPC programme

“Implementation” is another way to refer to the day-to-day activities of IPC. Implementation is a process,
not an event, and does not happen overnight.

There are many ways to implement an IPC programme. Each method depends on a strategy—a plan worked
out in advance—to be effective. This can look different from one facility to another, depending on national,
regional, or facility-level considerations. Implementing IPC also requires the support of key stakeholders and partner
organizations. Each IPC professional or team works collaboratively to determine the best way to implement IPC.

At a minimum, the IPC programme must clearly define roles and responsibilities, demonstrate administrative
support, outline oversight and accountability, and ensure resources are provided.
A WHO implementation manual and a range of tools and resources have been developed for IPC staff in healthcare
facilities. You can find links in the Resources section. For more on this, see the WHO core components and
multimodal strategy module.

Multimodal Strategy
Implementation of IPC policies and practices is more likely to be successful with a multimodal strategy
(using more than one method).

Let us look at an example of how to use a multimodal strategy in IPC.

Imagine that you are an IPC focal person and you notice that a significant number of injections in the medical ward
are not being administered safely. Your first course of action might be to assess barriers to performing safe
injections. Based on this, there might be a need to train relevant staff on how to perform safe injections. Training is
an administrative control (in the hierarchy of controls), but it is only one activity, or strategy, that will influence
implementation of this new practice.

So once training is complete, you decide to routinely observe staff, making sure to provide feedback (strategy No.
2). Then you could post job aids about safe injection practices in areas of the clinic where staff give injections
(strategy No. 3). Purchasing safety-engineered syringes that reduce personal injury and prevent needle recapping
would be strategy No. 4. These four activities combined—training, observation/feedback, posters/visual
reminders, and purchasing safety-engineered syringes—constitute a multimodal strategy and give you a
greater chance of successful implementation.

Summary
In this module, you have learned that HAIs are caused by microorganisms that can spread from person to person
via direct or indirect contact. The chain of infection describes how infection and disease are spread. HCP should
always use risk recognition to identify and reduce risk during healthcare activities. Facilities can make systematic
and behavioral changes to reduce these risks. The hierarchy of controls describes these changes and specifies
methods that reduce risk with varying degrees of reliability. The WHO core components and CDC core IPC
practices help development and implementation of an effective IPC program.

Resources
Implementation resources for Core Components of IPC Programs
Hierarchy of Controls, National Institute for Occupational Safety and Health, Centers for Disease Control and
Prevention
Performing a Risk Assessment related to routine practices and additional precautions, Public Health Ontario
Chain of Infection, Introduction to Epidemiology; Principles of Epidemiology in Public Health Practice, Third Edition.
Centers for Disease Control and Prevention