Avian Influenza

1. Avian Influenza Infection control and Isolation M – Hajiabdolbaghi. Tehran university .Medical Sciences مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

2. In an era of emerging and re-emerging communicable diseases, basic infection control precautionsare the cornerstone of the approach to prevent transmission of communicable diseases in health-care facilities. Facilitating compliancewith these basic precautions should beemphasizedin all health-care facilities at all times. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

3. transmission of human influenza viruses occurs through multiple routes including large droplets, direct and indirect contact, and droplet nuclei. observational studies suggest that droplet transmission is the major mode of transmission in that setting مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

4. Standard anddroplet precautionsshould be the minimum level of precautions to be used in all health-care facilitieswhen providing care for patients with acute febrile respiratory illness,regardless of whether AI infection is suspected. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

5. The most critical elements of these precautions includefacial protection(nose, mouth, and eyes if sprays/splashes of secretions are anticipated) andhand hygieneand these precautions should be prioritized . مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

6. HA Infection Control Plan for Avian Influenza • Respiratory hygiene and cough etiquette • Standard precautions • Contact precautions • Droplet precautions 5. Eye protection 6. Airborne precautions مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

7. Cover the nose/mouth when coughing or sneezing Perform hand hygiene if contact respiratory secretions and contaminated objects Put on a surgical mask Recommendation for all individuals with respiratory symptoms Respiratory hygiene and cough etiquette • Use tissue paper to contain respiratory secretions and dispose in the waste receptacle مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

8. Universal Respiratory Hygiene/Cough Etiquette Strategy • Encourage patients to alert staff • Give patients surgical masks • Provide hand hygiene product • designate areas in waiting room for symptomatic patients • Encourage triage personnel to wear surgical mask during respiratory season • Use droplet precautions for all patients with suspected pneumonia until diagnosis is defined مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

9. Respiratory hygiene/cough etiquette for all health-care facilities • a) Persons with respiratory infection should be educated to: • Cover their mouth and nosewith a tissue when coughing and dispose of used tissue in • waste containers; • Use a mask if coughing, when a mask is available and can be tolerated; • Perform hand hygiene(use an alcohol-based hand rub or wash hands with soap and • water) after contact with respiratory secretions; and • · Stand or sit at least 1 metre(3 feet) from other persons, if possible. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

10. Isolation precautions for suspected or confirmed AI-infected patients Hand hygiene Patient placement PPE Isolation Precautions Patient Transport Decontamination Linen & laundry Waste Management مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

11. Perform hand hygiene: Before and after patient contact After removing gloves or any other PPE item After touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn Perform hand hygiene after touching surgical mask/ N 95 respirator or before touching the face Hand hygiene مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

12. Hand hygiene, which includes hand washing withsoap and waterand the use ofalcohol-based hand rubsiscritical to prevent possible self-inoculationof thenose, mouth, and conjunctivaand thetransfer of microorganisms to the environment or to other patients by contaminated hands. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

13. Hands should be washed with soap, either plain or antimicrobial, and waterwhen visibly soiled or contaminated with proteinaceous material. The use of analcohol-based hand rubforroutinehand antisepsis is recommended in the health-care setting for all other clinical situations. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

14. Ethyl alcoholhas greater activity against viruses than isopropyl alcohol, and therefore ethyl alcohol-based hand disinfection products may bepreferredover isopropyl alcohol products in settings wheretransmission of AI is likely. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

15. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

16. When expose to blood, body fluids, secretions, excretions, mucous membranes and non-intact skin, and contaminateditems Perform hand hygiene immediately after glove removal PPE - Gloves • Change gloves when heavily contaminated • Disposable glove should not be reused مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

17. 1.When splashes or sprays of blood and body fluids, secretions and excretions to skin and working clothesare likely 2.contact with patient, environmental surfaces or patient items PPE - Gown 3.Select an appropriate gown for the procedure Long-sleeved gown, fluid-resistant or a waterproof apron should be worn over the gown مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

18. PPE – Respiratory & eye protection Surgical masks and eye protection: -When splashes or sprays of blood and body fluid, secretions and excretions are likely and for all aerosol-generating procedures - Droplet precautions N95 Respirator • Airborne isolation precautions Change PPE promptly if heavily contaminated during the procedure مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

19. Types of protective masks • Surgical masks • Easily available and commonly used for routine surgical and examination procedures • High-filtration respiratory mask • Special microstructure filter disc to flush out particles bigger than 0.3 micron. These masks are further classified:• oil proof• oil resistant• not resistant to oil • The more a mask is resistant to oil, the better it is • The masks have numbers beside them that indicate their filtration efficiency. For example, a N95 mask has 95% efficiency in filtering out particles greater than 0.3micron under normal rate of respiration. • The next generation of masks are called Nanomasks. These boast of latest technologies like 2H filtration and nanotechnology, which are capable of blocking particles as small as 0.027micron. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

20. Air Purifying Respirators –N95 (filter) مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

21. Powered Air Purifying Respirators (PAPR) – Hooded (versus face-piece) مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

22. Surgical and procedure masks • Wear masks once and then discard • Change masks when they become moist • Do not leave masksdangling around the neck • Aftertouching or discarding a used mask, perform hand hygiene مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

23. Strategy ofPatient Placement • Isolate suspected or confirmed cases in a negative pressure isolation room (≥12 air changesper hour • When single rooms are fully occupied • Cohort patients with same confirmed diagnosis in same cubicles, maintaining a minimum of 1 metre distance from each other • Confirmed and suspected cases should be nursed in separate cubicle مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

24. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

25. Preparation of the isolation room/area • Appropriate infection control precautionssignage on the door. • Placea recording sheet at the entrance. • All HCWs and visitors entering the isolation room/area shouldprint their names(contact information) on the recording sheet · • Remove allnonessential furniture. • furniture should beeasy to clean. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

26. Doors must be kept closed • To facilitate cleaning, and to reduce virus aerosolization via vacuuming, inuncarpeted rooms/areas,. • · When possible, isolation rooms should have theirown hand washing sink, toilet, and bath facilities. • · The number of persons entering the isolation room should belimited to the minimum number necessary forpatient care and support. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

27. Preparation of the isolation room/area • Stock the sink area with suitable supplies for hand washing, as well as with alcohol based hand rub near point of care and room door • Place appropriate waste bags in a bin. If possible use a touch-free bin • Place a puncture-proof container for sharps inside the isolation room. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

28. Preparation of the isolation room/area • Keep the patient’s personalbelongings to a minimum. andall items necessary for attending to personal hygiene within thepatient’s reach. • Non-critical patient-care equipment(e.g. stethoscope,thermometer, blood pressure cuff, sphygmomanometer) should be dedicated to the patient, • If it is not possible should be thoroughly cleaned anddisinfected prior to use. • Set up a trolley outside the door to hold PPE. • A checklistmay be useful to ensure that • all equipment is available مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

29. Atelephone or other method of communicationshould be set up in the isolation room to enable patient or family members/visitors to communicate with HCWs tominimize the necessity for HCWs to enter the room. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

30. Transport of Suspected or confirmed patient • Limit patient transport unless clinically indicated • Encourage patients to wear surgical mask if no contraindication • Informthe receiving service/department of concern beforehand • Clean / disinfect transport vehicles after use مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

31. Decontamination - Patient Care Items • Dedicated non-critical patient care items for suspected and confirmed cases • Clean and disinfect reusable equipment before used on other patients. • Use 1,000 ppm of hypochlorite solution (i.e. add 1 part of 5.25% hypochlorite in 99 parts of water) to disinfect non-critical items • Use 70% alcohol on metallic surfaces • Reusable respiratory equipment should undergo high level disinfection before reused on other patients مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

32. Decontamination - Environmental Control Disinfect isolation and procedure rooms after use by a high risk patient • Clean and disinfect the environment regularly • Contaminated area(and If blood spills occur )should be disinfected by one part of hypochlorite solution add in 99 parts of waterfor non-metallic and 70% alcohol for metallic items. • the blood should be removed by disposable material soaked with one part of hypochlorite solution add in 4 parts of water before further cleaning and disinfection مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

33. Survival of influenza in the inanimate environment and on skin -         24 – 48 hr. or hard, non porous surfaces -         8 – 12 hr. on cloth, paper, tissue -         5 min. or hand -         in water 22ºc → 4 days, 0ºc → 30 days -         at 60ºc for 30 mintues -         inactivated by 70% alcohol and by Chlorine WHO. Interim Infection Control Guidelines for Healthcare Facilities for HPAI : http://www.WPRO.WHO.int/avian/docs/IC_Guidelines_for_HPAI.pdf مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

34. Survival of Influenza Virus on Surfaces* • (WHO) recommends that environmental surfaces be cleaned by : • disinfectants such as Sodium hypochloride 1% in-use dilution, 5% solution to be diluted 1:5 in clean water for materials contaminated with blood and body fluids; • bleaching powder 7 gram/liter with 70% available chlorine for toilets and bathrooms; and • 70% alcohol for smooth surfaces, tabletops and other surfaces where bleach cannot be used. • Environmental cleaning must be done on a daily basis. Source: World Health Organization. Highly pathogenic avian influenza (HPAI) Interim infection control guidelines for health care facilities. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

35. Environmental cleaning and disinfection • Cleaning MUST precede disinfection. • AI virus is inactivated by a range of disinfectants, including: • phenolic disinfectants • quaternary ammonia compounds • peroxygen compounds • sodium hypochlorite (household bleach) o alcohol • other germicides with a tuberculocidal claim on the label مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

36. Alcohol • effective.(e.g. rubber stoppers of multiple-dose medication vials, and thermometers) and occasionally external surfaces of equipment (e.g. stethoscopes and ventilators). • flammable, its use as a surface disinfectant should be limited • . Alcohol may also causediscoloration, swelling, hardening, and cracking of rubber and certain plastics after prolongedand repeated use. • also result in health-care worker injury. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

37. Sodium hypochlorite (bleach) • Strong and effective • Readily inactivated in the presence of organic material heat and light. • From 10–60 min • Available at a low cost, • Irritates mucous membranes, the skin and the airway,, and • Reacts readily with other chemicals مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

38. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

39. Linen and laundry management • Proper handling of soiled linen: • Avoid sorting • Minimum agitation and shaking • Well pack soiled linen to prevent leakage • Wear appropriate PPE when handling soiled linen • Clean linen should be transported and stored separately to prevent recontamination مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

40. All waste generated from room/ area housing suspected or confirmed avian influenza patients should be treated as clinical waste Biohazard labeling Wear appropriate PPE when handling clinical waste Waste Management مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

41. Principles of precautions for high-risk procedures • In high risk patients • Limit indications of use • Limit extent of procedure • Limit number of persons involved • Use recommended PPE مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

42. Control measures for high-risk procedures (cont) Specific CDC recommendations: • Limit aerosol-generating procedures to those medically necessary & perform them in negative pressure isolation room • Most experienced staff • Minimal # of staff in room • N95 or higher level respirator (such as PAPR) مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

43. Examples of aerosol-generating procedures include: • Endotracheal intubation; • Bronchoscopy; • Airway suctioning; • Tracheostomy care; • Chest physiotherapy; • Nasopharyngeal aspiration; • Positive pressure ventilation via face mask (e.g. BiPAP, CPAP) ; • High-frequency oscillatory ventilation; • Resuscitation manoeuvres; • Postmortem excision of lung tissue. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

44. In countries with AI infections in animals or humans مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

45. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

46. مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

47. Infection control measures in A&E and clinic • Follow Respiratory Hygiene and Cough Etiquette precautions • Triage: Fever, Travel history,Occupational exposure, Contact history and Cluster of persons with fever and pneumonia symptoms. • Designated areas for suspected patients while waiting for referral and arrange speedy consultation and management • Wear appropriate PPE • Environment and equipment cleaningand disinfection مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

48. Patient discharge • If the patient is discharged while possibly still infectious, family members should be educated in personal hygiene and infection control measures (e.g. hand hygiene • and the use of a surgical or procedure mask by a patient who is still coughing). • Family members should be educated to avoid poultry and other animals that have been ill, • and to self-monitor their health status · Terminal cleaning of the patient room should be performed after patient discharge مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

49. Infection Control for Outreach staff Cardiac Life Support: • Avoid direct mucosal exposure, e.g. mouth to mouth resuscitation • Use alternative ventilation device: e.g. resuscitation bags, pocket masks • Wear appropriate PPE مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا

50. Handling of dead bodywith known Avian Influenza • Implement standard precautions when caring for the deceased patients • Wear appropriate PPE when handling dead body • Ensure proper covering and packing to prevent leaking • Attach warning tag indicating risk category 2 (Yellow label) on outside of the body bag • Cremation is not mandatory مرکز مدیریت بیماریها اداره بیماریهای قابل پیشگیری با واکسن واحد آنفلوآنزا