RGUHS- ECHO India online training/education for COVID -19 Awareness

COVID- 19 INFECTION
PREVENTION AND CONTROL
Mrs Asha
Vijayan . MSN
Senior Nursing
Officer
Infection Control
NIMHANS
Infection Prevention and Control (IPC) for
COVID-19
• IPC is a major challenge for healthcare systems around the world.
There is an important opportunity to reduce avoidable morbidity and
mortality through improvements to IPC during the COVID -19
pandemic
CDC RECOMMENDATIONS
• Additional infection prevention and control practices along with
standard practices as a part of routine healthcare delivery to all
patients.
• Apply to all patients, not just those with suspected or confirmed
SARS-CoV-2
• Facilities should develop policies and procedures to ensure
recommendations are appropriately applied in their setting (e.g.,
emergency department, home healthcare delivery).
Components of IPC –COVID 19
• Universal masking
• Early identification and isolation of patients with suspected disease
• Appropriate personal protective equipment (PPE) when caring for
patients with COVID-19
• Environmental disinfection
• Safe disposal and management of COVID waste
Universal use of masks 
•  Universal masking is required for all patients, visitors, and HCWs in
the health care setting.
• The goal of universal masking is to reduce transmission of SARS-CoV-2
from unsuspected virus carriers .
• Symptom screening alone is insufficient to identify individuals with
COVID-19 since pre symptomatic and asymptomatic transmission can
occur .
Patient and visitors
• All patients and visitors should bring or be given well-fitting masks for
universal source control .
For patients, once they are in an appropriate room (eg, single room
with the door closed for patients with suspected COVID-19), they can
usually remove their mask. However, patients should be instructed to
replace their masks when HCWs enter their room.
• If the patient cannot don the mask themselves, it is important the
HCW wear a face shield or goggles in addition to a mask. A face shield
or goggles provide additional protection in the event that a patient
cannot or will not wear a mask
An experimental study by the United States Centres for Disease Control and Prevention (CDC) suggested even
greater protection to the wearer from adjusting the fit of a surgical mask using mask extenders, knotting the ear
loops, or tucking in the side folds to reduce gaps around the mask.
Measures for all patients, visitors, and
personnel
Screening prior to and upon entry into the health care facility
• Patients – Patients should be screened for clinical manifestations
consistent with COVID-19 (eg, fever, cough, myalgias, sore throat,
dyspnea, anosmia/hyposmia) prior to entry into a health care facility
• All patients should also be screened for symptoms of COVID-19 upon
entry into a health care setting.
Screening..
• Efforts should be made to place patients with suspected COVID-19
into private rooms as soon as possible.
• If an examination room is not immediately available, such patients
should not wait among other patients.
• In this setting, it may be reasonable to have patients wait in a
personal vehicle or in a well-ventilated space
where patients can be separated by at least six feet.
• Patients without symptoms should also be questioned about any
unprotected exposures to a person with COVID-19 within the last 14
days.
• Patients who have had close contact with someone with suspected or
confirmed COVID-19 may need to quarantine.
• Some institutions quarantine all patients who live in settings where
there is an increased risk of SARS-CoV-2 transmission (Containment
Zone ), even if the patient did not have a known exposure
• Visitors – During the COVID-19 pandemic, most hospitals have
restricted visitors in the health care setting.
OR
• visitors should also be screened for exposure to and symptoms of
COVID-19; those with evidence of infection or a known exposure in
the last 14 days should not be allowed to enter the health care
setting, even if they had SARS-CoV-2 infection within the last 90 days
or have been fully vaccinated with one of the available COVID-19
vaccines.
• Health care workers – Screening health care workers (HCWs) entering
the health care setting depends upon the institution's policies.
• HCWs should monitor themselves for fever and other symptoms of
COVID-19 and stay home if they are ill . They should then contact
occupational health for additional guidance
• HCWs should also be educated about the need to report all known or
possible unprotected exposures to COVID-19
(both in the community and at work) to occupational health services
so they can determine the need for work restrictions, self-quarantine,
and testing.
Hand hygiene
• Hand hygiene should be performed immediately before and after
contact with the face masks, including cloth masks. Masks should be
changed if they become soiled, damp, or difficult to breathe through.
• Cloth masks should be laundered regularly (eg, daily and when soiled)
Patients with suspected or confirmed COVID-19
• Approach for most patients —  Infection control precautions should
be used for all patients with suspected or confirmed COVID-19.

• Type of room — Patients should be placed in a well-ventilated single-

occupancy room with a closed door and dedicated bathroom .When
this is not possible, patients with confirmed COVID-19
can be housed together.

• Patients with confirmed COVID-19 should

 not be in a positive-pressure room
• An airborne infection isolation room (AII; ie, a single-patient,
negative-pressure room) should be prioritized for patients undergoing
aerosol-generating procedures.
• Type of PPE — All HCWs who enter the room of a patient with
suspected or confirmed COVID-19 should wear personal protective
equipment (PPE) to reduce the risk of exposure.
• Standard PPE for patients with suspected or confirmed COVID-19
includes the use of a gown, gloves, a respirator or medical mask, and
eye or face protection:
• Gown and gloves – Isolation gowns and non-sterile gloves should be put on upon
entry into the patient room or area. Some institutions require double gloving for
HCWs caring for patients with suspected or confirmed COVID-19 to reduce the risk of
skin contamination when doffing.
• On COVID-19 units, gowns do not need to be routinely changed between patients
unless the gown is soiled or the patient requires additional contact precautions (eg,
for a drug-resistant organism), in which case a new gown should be used. However,
gowns and gloves should not be worn into common spaces (eg, workstations).
• Caregivers should perform hand hygiene after removing and before putting on gloves.
• Respirator or medical mask – A respirator (eg, N95 or other
respirators that offer a higher level of protection) should be worn
instead of a medical mask (eg, surgical mask) during aerosol-
generating procedures and certain types of environmental cleaning. If
the respirator has an exhalation valve or vent, a medical mask should
be placed on top of it for source control

• (There are limited data comparing the use of respirators or medical masks when caring for patients with suspected or confirmed COVID-19 )
• However, other experts feel that medical masks (when combined with other PPE including face shields and hand hygiene) are sufficient during non-aerosol-
generating care, since droplet transmission is the main mode of transmission, and available data from patients with SARS-CoV-2 or other viral respiratory infections
suggest that N95 respirators offer no clear benefit over medical masks during routine care
• Eye or face protection – For eye or face protection, goggles or a face
shield that covers the front and sides of the face should be used in
conjunction with a respirator or medical mask, as discussed above;
glasses are not sufficient. However, if a powered air-purifying
respirator (PAPR) is used, additional eye protection is not needed.

• When caring for patients with suspected or confirmed COVID-19, we prefer that HCWs wear a full face
shield, rather than goggles or a surgical mask with an attached eye shield, whenever possible. A full face
shield provides eye protection and a double layer of protection for the nose and mouth. It also prevents
contamination of the respirator or mask. Full face shields may be reused as long as they can be adequately
cleaned with an approved disinfectant
MASK

PAPR N95
• Some institutions also require hair and shoe covers for providers
when caring for patients with COVID-19 outside of the operating
room setting (eg, on a dedicated COVID-19 ward or intensive care
unit).
• However, there are insufficient data to make these practices mandatory for routine care. As an example,
reports suggest that SARS-CoV-2 RNA can be widely distributed on surfaces, such as floors, particularly in the
intensive care unit, and can be found on shoes after intubation but whether this reflects infectious virus
remains unknown.
Sequence of Donning and Doffing
• HCWs should pay special attention to the appropriate sequence of
putting on and taking off PPE and the use of hand hygiene to avoid
contamination. 
• Errors in removal of PPE are common, even by trained clinicians, and
are associated with contamination of HCWs with pathogens . This can
result in indirect (secondary) transmission.
• In a Cochrane review that evaluated methods to increase compliance with donning and doffing of PPE, several interventions
appeared to have some benefit in preventing contamination, including the use of CDC protocols and face-to-face training .
Some institutions have trained PPE observers to provide additional safety during PPE donning and doffing; however, it is
unclear whether the presence of trained PPE observers on COVID-19 wards reduces HCW infections related to indirect
transmission events.
• Transporting patients outside the room — Patients with confirmed or
suspected COVID-19 should wear a medical mask if being transported
out of the room (eg,for studies that cannot be performed in the
room). If a portable tent system with high-efficiency particulate air
(HEPA) filtration is used to transport patients with COVID-19, the
patient does not need to wear a mask, but HCWs transporting the
patient should wear PPE
Aerosol-generating procedures/treatments
In patients with COVID-19, aerosol-generating procedures and treatments should be avoided when possible to reduce the potential risk of
transmission to HCWs.

Bronchoscopy (including mini bronchoalveolar lavage)

Cardiopulmonary resuscitation

Colonoscopy

Filter changes on the ventilator

High-flow oxygen

Manual ventilation before intubation

Nasal endoscopy

Noninvasive ventilation

Open suctioning of airways

Tracheal intubation and extubation

Tracheotomy

Upper endoscopy (including transesophageal echocardiogram)

Swallowing evaluation

Chest physiotherapy

Nebulizer treatments
• Aerosol-generating treatments –inhaled medications should be
administered by metered-dose inhaler when feasible, rather than
through a nebulizer, to avoid the risk of aerosolization
• If is not possible, appropriate PPE for HCWs includes use of N95 or
other respirators (eg, a powered air-purifying respirator [PAPR]) that
offer a higher level of protection .
• Other precautions include eye protection (eg, goggles or a face shield
that covers the front and sides of the face), gloves, and a gown.
Aerosol-generating procedures should take place in an airborne
infection isolation room (AII) whenever possible.
HCWs and other personnel (eg, environmental services,
maintenance) should not enter the room without appropriate PPE
(eg, gown, gloves, respirator, eye protection)
• Specimen collection for respiratory viral pathogens — single-
occupancy room with the door closed, and visitors should not be
present during specimen collection..
• Use N95 or higher level respirator (or medical mask if a respirator is
not available), eye protection (eg, face shield or goggles), gloves, and
a gown
Isolation and quarantine
• Patients who have had an exposure to COVID-19 — Some patients
who require hospitalization for a reason unrelated to COVID-19 may
have developing symptoms
• All symptomatic patients should be treated as if they have COVID-19,
pending additional evaluation.
• Who requires quarantine – Most patients who have had close contact
with someone with suspected or confirmed COVID-19 need to
quarantine
• Approach to quarantine –Apply all infection control precautions
similar to those used for patients with suspected disease
• However, such patients should not be cohorted or share a room with
patients who have COVID-19.
• If PPE is limited, a medical mask (eg, surgical mask) can be used
instead of an N95 respiraN95 respirators must be used for all aerosol-
generating procedures.or for routine care.
• Duration of quarantine – Infection control precautions specific for
COVID-19 should be used for the duration of their quarantine, which
is 14 days after their last contact with the infected patient.
Optimizing the supply of PPE
Strategies include:
• Cancelling non-urgent procedures or visits that would warrant use of PPE
and favouring home care rather than hospitalization when appropriate.
• Increasing the use of telehealth services for outpatients, when appropriate.
• Limiting movement outside the patient's room, prioritizing the use of
certain PPE for the highest risk situations (eg, aerosol-generating
procedures), and designating entire units within a facility to care for known
or suspected patients with COVID-19 (ie, cohorting).
• Minimizing face-to-face encounters with the patient
• Utilizing alternatives to N95s, such as PAPRs
Extended or limited reuse of PPE
• Extended or limited reuse of PPE is reasonable in certain situations.

• As an example, some hospitals encourage users to disinfect, store,

and reuse face shields unless they become visibly soiled or no longer
fit.

(When a face shield is used for repeated encounters with different patients, the provider should not touch
or remove the face shield between patient encounters. The provider should perform hand hygiene before
removing the face shield, and the face shield should be disinfected with an Environmental Protection
Agency (EPA)-registered product and stored in a clean container.)
Extended or limited reuse of PPE
• Similarly, the same medical mask can be used for repeated close
contact encounters with several different patients (assuming it is not
visibly damaged or soiled) .
• When this strategy is used, the provider should not touch or remove
the mask between patient encounters, since the outside surface is
presumably contaminated.
• If the provider does touch the mask, they must immediately perform
hand hygiene. The CDC suggests that masks can be used for 8 to 12
hours , whereas the WHO states medical masks can be used for up to
six hours when caring for a cohort of patients with COVID-19 .
Extended use of N95 respirators
• Discard N95 respirators following use during aerosol generating
procedures.
• Discard N95 respirators contaminated with blood, respiratory or nasal
secretions, or other bodily fluids from patients.
• Discard N95 respirators following close contact with, or exit from, the
care area of any patient co-infected with an infectious disease
requiring contact precautions.
• Consider use of a cleanable face shield (preferred) over an N95
respirator and/or other steps (e.g., masking patients, use of
engineering controls) to reduce surface contamination.
Extended or limited reuse of PPE
• Perform hand hygiene with soap and water or an alcohol-based hand
sanitizer before and after touching or adjusting the respirator (if
necessary for comfort or to maintain fit).
• Extended use alone is unlikely to degrade respiratory protection.
However, healthcare facilities should develop clearly written
procedures
Decontamination of PPE for reuse —
• Decontamination of personal protective equipment (PPE) for reuse, such as select
face shields and N95 respirators, has been done in many medical centres during
the COVID-19 pandemic when supplies have been critically low (crisis standards
• If crisis capacity strategies are needed to conserve supplies of PPE in the setting
of shortages, the CDC and WHO have highlighted several methods for
decontamination of respirators]. These include:
• Ultraviolet light 
• Hydrogen peroxide vapour
• Moist heat
Environmental disinfection

• Many hospitals have implemented enhanced environmental cleaning and

disinfection ( once in 4 hrs)protocols for rooms used by patients with known
or suspected COVID-19 and for areas used by HCWs caring for such patients
to prevent secondary transmission from fomites.

• Appropriate disinfectant should be selected ( Eg. Sodium hypochlorite 0.5-

1%).
Environmental disinfection
• Staffs should be trained to conduct the cleaning in appropriate PPE .

• Workers should be fit tested and trained to wear N95 respirators and
face shields (or PAPRs)

• Can use droplet and contact precautions, plus eye protection (surgical
mask, face shield or goggles, gown, and gloves) when cleaning areas
used by HCWs who are caring for COVID-19 patients.
List and Preparation of Disinfectant
Disinfectant concentrations Dilution protocol

Hypochlorite1% Readily available in

Hypochlorite0.5% 1Lt of1%hypochlorite +1Lt water

Hypochlorite0.1% 100mlof 1%hypochlorite+ 900 ml water

Bacillocid1% 10mlin 1Lt

Bacillocid0.5% 5mlin 1Lt

Bacillocid0.25% 2.5mlin 1Lt

Addressing barriers to use of PPE
• Despite the benefits of PPE in reducing transmission of COVID-19,
adherence to practices, such as prolonged use of masks, respirators,
and face shields, can be difficult since PPE can be burdensome and
uncomfortable to use .
• mask fit and/or washing their eyeglasses with soap and water to avoid
fogging
Bio medical waste management
• Keep separate colour- coded bins /bags / containers
• Use a dedicated collection bin labeled as “COVID-19” to store COVID-
19 waste and keep separately in temporary storage room prior to
handing over to authorised staff of CBWTF.
• As precaution double layered bags (using 2 bags) should be used for
collection of waste from COVID-19 isolation wards so as to ensure
adequate strength and no-leaks
• The (inner and outer) surface of containers/bins/trolleys used for
storage of COVID-19 waste should be disinfected with 1% sodium
hypochlorite solution daily
INFECTION CONTROL IN THE HOME
SETTING
• Isolation at home — Outpatients with suspected or confirmed COVID-19
(including those awaiting test results) should stay at home and try to separate
themselves from other people and animals in the household
• They should also avoid having visitors enter the home.
• Patients should wear a face mask if they must be in the same room (or vehicle) as
other people for source control.
INFECTION CONTROL IN THE HOME
SETTING
• Caregivers and those sharing a living space with individuals with
known or suspected COVID-19 should also wear a mask when in the
same room (or vehicle) as the patient .
• When medical masks are not available, household contacts should use
a non-medical mask (eg, cloth mask). and the combination of the
patient and caregiver wearing a mask may be synergistic
INFECTION CONTROL IN THE HOME
SETTING
• Educating caregivers on how to carefully put on and take off PPE.
• As an example, caregivers should first remove and dispose of gloves, and then
immediately clean their hands with soap and water or alcohol-based hand
sanitizer. After that, the mask should be removed, and the caregiver should again
perform hand hygiene.
Other measures …
•Limiting the number of caregivers.
•Having patients use a separate bedroom and bathroom, if available.
•Minimizing patients' exposure to shared spaces and ensuring shared spaces
in the home have good air flow, such as an air conditioner or an opened
window.
•When sharing spaces cannot be avoided, patients and caregivers should try
to remain six feet (two meters) apart, if possible, and face masks should be
used.
Other measures
• Ensuring caregivers perform hand hygiene after any type of contact
with patients or their immediate environment. In addition, caregivers
should wear gloves when touching the patient's blood, stool, or body
fluids, such as saliva, sputum, nasal mucus, vomit, and urine
Other measures
• Instructing family members to avoid sharing dishes, drinking glasses,
cups, eating utensils, towels, bedding, or other items with the patient.
After the patient uses these items, they should be washed thoroughly;
disposable gloves should be worn when handling these items. In
addition, thermometers should not be shared, or should be thoroughly
disinfected before use by other household members.
• Avoid unmasked time together such as during eating or drinking
Other measures..

Disinfection — Cleaning and disinfection of frequently touched

surfaces is also important. For disinfection, diluted household bleach
solutions, alcohol solutions with at least 70% alcohol, and most
common Environmental Protection Agency-registered household
disinfectants are thought to be effective
Discontinuation of precautions

• Non-test-based and test-based strategies can be used to inform when infection

control precautions should be discontinued in patients with COVID-19

• For most patients, a non-test-based strategy is preferred; however, the ultimate

choice depends upon the patient population and the severity of disease.

• Non-test-based strategies allow for discontinuation of precautions based on

improvement in symptoms and/or specific time intervals,

Discontinuation of precautions

• Test-based strategies typically require two negative reverse-

transcription polymerase chain reaction (RT-PCR) tests for severe

acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on

sequential respiratory specimens collected ≥24 hours apart. .

Discontinuation of precautions

I. At least 10 days have passed since symptoms first appeared AND

II. At least one day (24 hours) has passed since resolution of fever
without the use of fever-reducing medications AND 
III. There is improvement in symptoms (eg, cough, shortness of breath)
IV. Once infection control precautions/home isolation are discontinued,
patients should still continue to follow public health
Recommendations for wearing masks
ADDITIONAL CONSIDERATIONS
• Those who require quarantine should be excluded from work for 14 days whenever possible,
• Differences in return-to-work policies may vary among individual institutions, and the CDC
states alternatives to the 14-day quarantine can be considered to mitigate staffing shortages .
• As an example, for asymptomatic HCWs, the duration of quarantine may be reduced to 10
days, or to 7 days provided the individual has a negative nucleic acid amplification test
(NAAT) or antigen SARS-CoV-2 test within 48 hours of the planned end of quarantine.
• When the duration of quarantine is reduced, HCWs should be monitored closely for
symptoms and wear a medical mask for source control through day 14 since there may be an
increased risk of transmission, as described above
Preventing infection in the community
•  Several strategies have been implemented to reduce the risk of SARS-
CoV-2 transmission in the community.
• These include social distancing, the use of facemasks, and frequent
hand washing.
Protect yourself and others from COVID-19

• If COVID-19 is spreading in your community, stay safe by taking some

simple precautions, such as physical distancing, wearing a mask,
keeping rooms well ventilated, avoiding crowds, cleaning your hands,
and coughing into a bent elbow or tissue. Check local advice where
you live and work. Do it all!
• Vaccination
What to do to keep yourself and others
safe from COVID-19
• Maintain at least a 1-metre distance between yourself and others to
reduce your risk of infection when they cough, sneeze or speak.
Maintain an even greater distance between yourself and others when
indoors..
• Make wearing a mask a normal part of being around other people. 
• The appropriate use, storage and cleaning or disposal are essential
to make masks as effective as possible.
How to make your environment safer
• Avoid the 3Cs: spaces that are closed, crowded or involve close
contact.
• Outbreaks have been reported in restaurants, choir practices, fitness classes,
nightclubs, offices and places of worship where people have gathered, often
in crowded indoor settings where they talk loudly, shout, breathe heavily or
sing.
• The risks of getting COVID-19 are higher in crowded and inadequately
ventilated spaces where infected people spend long periods of time together
in close proximity. These environments are where the virus appears to spread
by respiratory droplets or aerosols more efficiently, so taking precautions is
even more important.
• Meet people outside. 
• Outdoor gatherings are safer than indoor ones, particularly if indoor
spaces are small and without outdoor air coming in.

• Avoid crowded or indoor settings but if you can’t, then take

precautions:

Open a window. Increase the amount of ‘natural ventilation’ when indoors

Don’t forget the basics of good hygiene

• Regularly and thoroughly clean your hands with an alcohol-based

hand rub or wash them with soap and water. This eliminates germs
including viruses that may be on your hands.
• Avoid touching your eyes, nose and mouth. Hands touch many
surfaces and can pick up viruses. Once contaminated, hands can
transfer the virus to your eyes, nose or mouth. From there, the virus
can enter your body and infect you.
• Cover your mouth and nose with your bent elbow or tissue when
you cough or sneeze. Then dispose of the used tissue immediately
into a closed bin and wash your hands. By following good ‘respiratory
hygiene’, you protect the people around you from viruses, which
cause colds, flu and COVID-19.
• Clean and disinfect surfaces frequently especially those which are
regularly touched, such as door handles, faucets and phone screens.
References.....
• World Health Organization. Director-General's remarks at the media briefing on 2019-nCoV on 11
February 2020. http://www.who.int/dg/speeches/detail/who-director-general-s-remarks-at-the-
media-briefing-on-2019-ncov-on-11-february-2020 (Accessed on February 12, 2020).
• Centers for Disease Control and Prevention. 2019 Novel coronavirus, Wuhan, China. Information
for Healthcare Professionals. https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html (Ac-
cessed on February 14, 2020).
• World Health Organization. Novel Coronavirus (2019-nCoV) technical guidance. https://
www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance (Accessed on
February 14, 2020).
• Gorbalenya AE, Baker SC, Baric RS, et al. Severe acute respiratory syndrome-related coronavirus:
The species and its viruses – a statement of the Coronavirus Study Group. bioRxiv 2020. https://
www.biorxiv.org/content/10.1101/2020.02.07.937862v1 (Accessed on February 12, 2020).
• Zhu N, Zhang D, Wang W, et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019.
N
Engl J Med 2020; 382:727.