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Infection Control of Aerosol Transmissible Diseases

Infection Control of Aerosol Transmissible Diseases. Overview. Transmission of Communicable Diseases Principles of Infection Control Application to Aerosol Transmissible Diseases (ATDs) Interactive exercises Resources in packet. The Chain Model of Communicable Diseases. Infectious agent

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Infection Control of Aerosol Transmissible Diseases

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  1. Infection Control ofAerosol Transmissible Diseases

  2. Overview • Transmission of Communicable Diseases • Principles of Infection Control • Application to Aerosol Transmissible Diseases (ATDs) • Interactive exercises • Resources in packet

  3. The Chain Model of Communicable Diseases • Infectious agent • Reservoirs and/or sources • Portals of exit • Modes of transmission • Portals of entry • Susceptible hosts

  4. The Chain Model of Communicable Diseases • Infectious agent • Reservoirs and/or sources • human • animal • Environment • Portal(s) of exit: • Respiratory tract • GI tract • Genital/urinary tract • Breaks in skin

  5. The Chain Model of Communicable Diseases • Modes of transmission • Direct contact • Indirect contact • Portals of entry • Susceptible hosts

  6. Modes of Transmission • Direct Transmission • Direct Contact • Droplet • Indirect Transmission • Vehicle-borne • Vector-borne • Airborne • Vertical transmission (mother to infant)

  7. Infectious Aerosols Department of Medical Microbiology, Edinburgh University

  8. Transmission of Infections by Respiratory Aerosols • Droplets: land directly on mucosal lining of nose, mouth, eyes of nearby persons or can be inhaled. • Highest exposures within 3-6 feet. • Airborne: aerosols become smaller by evaporation; small aerosols (≤ 10 microns) remain suspended for longer periods, if inhaled travel deep into the lungs. • Contact: Aerosols/ secretions contaminate nearby surface. Touch surfaces can infect self or others. Relative contribution of three routes varies with agent.

  9. Modes of Transmission viaInfectious Respiratory Secretions • Airborne: tuberculosis, measles, varicella, smallpox, SARS, avian influenza • Droplet: meningococcal meningitis, rubella, pertussis, common cold, SARS, influenza* • Indirect contact: (fomite) RSV, SARS *Influenza traditionally droplet, increasing evidence for airborne component

  10. Infection Control in aHealth Care SettingReview

  11. Infection Control in a Health Care Setting • Basic principles • Standard precautions • Transmission-based precautions • Seasonal influenza in health care settings • Vaccination of HCWs • TB screening of HCWs • Proper donning and doffing • Choose your PPE

  12. Basic Principles • All body fluids are potentially infectious (except sweat) • blood and blood-tinged fluids including open-wounds • stool, urine, vomit, respiratory secretions, saliva, semen, vaginal secretions, breast milk, other body fluids such as pericardial and synovial fluids • Minimize exposure to potentially infectious body fluids • Infection control measures designed to “break the chain” of transmission

  13. Standard Precautions in Health Care Settings • Appropriate hand hygiene • Barrier protective equipment: • if splash, splatter, or sprays can be reasonably anticipated • choose appropriate PPE as needed: gloves, gown, mask, eye protection (face shield, goggles) • Proper use and handling of patient care equipment

  14. Standard Precautions in Health Care Settings • Proper environmental cleaning and disinfection • Proper Handling of Linen • Adherence to Bloodborne Pathogens Standards • Proper patient placement • Respiratory Hygiene/Cough Etiquette • Safe injection practices

  15. Expanded Isolation Precautions:Transmission-based Standards • When standard precautions are not enough • Additional measures based on mode of transmission • Contact Precautions • Droplet Precautions • Airborne Precautions

  16. Transmission-Based Precautions: Contact Precautions • For known or suspected infections that represent an increased risk of spread by direct or indirect contact with the patient or the patient’s environment

  17. Transmission-Based Precautions: Contact Precautions • Personal Protective Equipment • Gown & Gloves for all patient interactions • Don PPE on entry, discard before exiting room.(in addition to Standard Precautions) • Examples: MRSA, C difficile, Norovirus, other GI pathogens, RSV, antibiotic-resistant pathogens

  18. Transmission-Based Precautions: Droplet Precautions • Single room preferred, no special ventilation • Patient: Mask if transport necessary. Instruct on respiratory hygiene/cough etiquette • HCWs wear surgical or procedure mask within 6 feet of patient. Eye protection if splash, spray anticipated (in addition to Standard Precautions)

  19. Transmission-Based Precautions: Airborne Precautions • Airborne Infection Isolation Room (AIIR) if available • Patient: Mask if transport necessary (as tolerated). • Health care workers (HCWs): • N95 respirator prior to entry into room, discarded after exit. • Higher level respirators for aerosol-gen procedure. Careful attention to proper putting on & taking off (don/doff) respirator, including seal check. • Hand hygiene before & afterdon/doff. • Alert others if need to transfer (in addition to Standard Precautions)

  20. Seasonal Influenza in Healthcare Settings • CDC and CDPH guidelines updated 2010 • Multi-faceted approach • Flu vaccine for HCWs • Implementation of respiratory hygiene and cough etiquette • HCWs with ILI stay home • Source Control

  21. Seasonal Influenza in Healthcare Settings: Isolation Precautions • Droplet precautions for all patients with suspect influenza (ILI) • ILI Temp >37.8 C (100 F) plus new cough or sore throat • Ideally, place patients in single room • Surgical mask for close patient contact • Employer may allow N95 during routine care as option • Patient should be transported with surgical mask.

  22. Seasonal Influenza in Healthcare Settings: Isolation Precautions • For aerosol-generating procedures: N95 respirator + standard precautions (gown, gloves, goggles for spray/splash) • Aerosol generated procedures • Sputum induction, bronchoscopy, elective intubation and extubation, autopsies • CPR, emergent intubation, open suctioning of airways

  23. Vaccination of HCWs • Protect patients, protect yourself and other HCWs • CDC recommends • Measles, mumps, rubella (MMR): vaccinate unless documentation of immunity or previous vaccination • Varicella: vaccinate unless documentation of immunity or previous vaccination • Tdap • Yearly influenza vaccination • Hepatitis B: vaccinate unless documentation of previous vaccination

  24. Vaccination of HCWs • Cal/OSHA ATD & Bloodborne Pathogen Standard • Employer must offer to those who are not vaccinated or immune: • MMR and varicella vaccination • Tdap • Seasonal influenza vaccination • Hepatitis B vaccination • No cost to employee • Employer must maintain on file: records of immunity, vaccine, or declinations

  25. Tuberculosis Screeningfor Health Care Workers • Title 22 and Cal/OSHA ATD Standard • TB screening at hire and then annually for all licensed healthcare facilities in CA (e.g., acute care hospitals, skilled nursing facilities, primary care clinics)

  26. Sequence for Donning PPE • Gown • Mask or Respirator www.cdc.gov/ncidod/dhqp/ppe.html

  27. Sequence for Donning PPE • Goggles/Face Shield • Gloves www.cdc.gov/ncidod/dhqp/ppe.html

  28. Sequence for Removal of PPE • Gloves www.cdc.gov/ncidod/dhqp/ppe.html

  29. Sequence for Removal of PPE • Goggles/Face Shield www.cdc.gov/ncidod/dhqp/ppe.html

  30. Sequence for Removal of PPE • Gown www.cdc.gov/ncidod/dhqp/ppe.html

  31. Sequence for Removal of PPE • Mask or Respirator www.cdc.gov/ncidod/dhqp/ppe.html

  32. What Type of PPE Would You Wear? • Giving a bed bath? • Generally none • Suctioning oral secretions? • Gloves and mask/goggles or a face shield – sometimes gown www.cdc.gov/ncidod/dhqp/ppe.html

  33. What Type of PPE Would You Wear? • Transporting a patient in a wheel chair? • Generally none required • Responding to an emergency where blood is spurting? • Gloves, fluid-resistant gown, mask/goggles www.cdc.gov/ncidod/dhqp/ppe.html

  34. What Type of PPE Would You Wear? • Taking vital signs • Generally none • Drawing blood from a vein? • Gloves www.cdc.gov/ncidod/dhqp/ppe.html

  35. What Type of PPE Would You Wear? • Cleaning an incontinent patient with diarrhea? • Gown, gloves • Taking vitals on a patient with suspect TB? • N95 respirator www.cdc.gov/ncidod/dhqp/ppe.html

  36. Controlling the Spread of Aerosol Transmissible Diseases in Health Care Settings Breaking the Chain

  37. Health care and public safety settings • Unique challenges for control of ATDs • Diversity of job titles and duties • Unique “business” of caring for the ill • Societal behaviors related to caregiving • Exotic and unique exposures • Suspension of usual self protection behaviors • Emphasis on confidentiality

  38. Aerosol Transmissible Diseases in Health Care and Public Safety Settings • Droplet • Meningococcal meningitis • Pertussis • Mumps • Rubella (German measles) • Strep pharyngitis • Influenza • Airborne • Tuberculosis • Varicella (chickenpox) • Measles • SARS • Avian influenza • Smallpox • Influenza

  39. Elimination of Potential Exposures Administrative Controls Hierarchy of Infection Prevention and Control Measures Protects most people Engineering Controls PPE Protects only the wearer

  40. Hierarchy of Control Technologies • Goal is to reduce exposures to a hazard • Order in which these elements are selected to control exposure is important • Elimination of Potential Exposures • Engineering controls • Administrative and work practice controls • Personal protective equipment/apparel

  41. Elimination of Potential Exposures • Example: patients with mild influenza like illness stay home

  42. Engineering Controls • Physically separates the employee from the hazard • Does not require employee compliance to be effective • Examples: • physical barriers at triage • airborne infection isolation room for patients with known or suspect airborne infectious diseases

  43. Administrative Controls/ Workplace Practices • Policies, procedures, and programs that minimize intensity or duration of exposure • Examples: • signs on door of an airborne isolation room • triage, mask symptomatic patient • provide tissues/ masks/hand sanitizer to public • Standard procedures/ behaviors in caring for patients e.g. hand hygiene, HCW vaccination • Only as good as enforcement

  44. Personal Protective Equipment • Lowest level of hierarchy - requires employee compliance for efficacy • Means higher elements of hierarchy fail to adequately protect employee • May involve use of gowns, gloves, eye/splash protection or respirators • Last line of defense

  45. Face Masks vs. N95 Respirators • Loose fitting, not designed to filter out small aerosols • Place on coughing patient (source control) • HCW should wear mask to • protect patient during certain procedures (e.g., surgery, LP) • protect HCW • droplet precautions • Mask + goggles for anticipated spray/splash • Tight fitting respirator, designed to filter the air • Protects the wearer • HCW should wear when concerned about transmission by airborne route

  46. Reasons for Respiratory Protection • Engineering controls not feasible or sufficient • Employees must wear N95 respirators (or higher level of protection) in the following circumstances • Entering a room with patient with suspect or confirmed airborne infectious disease • When performing high-hazard (aerosol-generating) procedures on persons with suspect/confirmed airborne infectious disease or influenza • When emergency response employees/others must transport in a closed vehicle, a patient with suspect/confirmed airborne infectious disease

  47. Aerosol-Generating Procedures • Sputum induction, bronchoscopy, elective intubation and extubation, autopsies • CPR emergent intubation, open suctioning of airways

  48. What you should do when you hear Ah-choo! • Likely communicable? • airborne vs. droplet ? • Choose appropriate source control and PPE • Reportable Disease? Contact local health department. Some require immediate action • Title 17 reporting requirement

  49. Aerosol Transmissible DiseasesBreaking the Chain • Source control • stay home, isolate or separate mask patient • Respiratory hygiene, cough etiquette • Hand hygiene • HCW protection • Vaccinate • Droplet – Mask • Airborne- N95 respirator

  50. References • CDC • 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings http://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html • Guideline for Hand Hygiene in Health-Care SettingsMMWR 2002; vol. 51, no. RR-16 http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf

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