Cross Contamination and Infection Control

Presented by: Onnicah D. Matuka

National Health Laboratory Services

National Institute for Occupational Health

PO Box 4788, Johannesburg, 2000, RSA

Practice No.: 5200296

Switchboard: + 27 (0) 11 712 6400

Website: http://www.nhls.ac.za

http://www.nioh.ac.za

DoL Shopsteward Workshop (KZN): 10 November 2015

ENVIRONMENT

Equipment, Reservoirs, surfaces

Waste, laundry, waiting areas

Work procedures

HUMAN

Patients

Visitors

WORKERS

Medical HEALTH EFFECTS

Contact, droplet, airborne

Biological Agent, Route

Indirect Exposure

Direct Exposure

Indirect Exposure

HOW CONTAMINATION OCCURS? 2

Skin

Respiratory

tract

Gastro-

intestinal

tract

Mode of transmission

Vector

Ingestion

Inhalation

Contact

Site of entry

Needlesticks

TRANSMISSION ROUTES 3

Basic measures of IC (i.e. standard precautions)

Education and training of HCWs

Protection of HCWs (i.e. Immunization)

Identification of hazards and minimizing the risks

Routine practices (e.g. aseptic techniques)

NB. Must include support staff (cleaners, waste, laundry, porters)

INFECTION CONTROL PROGRAMME 4

Contact with blood and body fluids

HIV, Hepatitis B and Hepatitis C

Workers are at high risk of exposure

Sharps injuries (needles &scalpels)

Splashes (eyes and mouth)

Prevention: Hand hygiene & safety engineered devices

Don’t recap needles after use

Use sharp containers

BLOODBORNE PATHOGENS 5

Waste management

Segregate waste (sharps & boxes)

Sharps containers readily available

Don’t compress garbage bags by hand

Hold waste bags away from body

Transport waste in a dedicated trolley

Store waste in areas with restricted access

PREVENTION OF BLOODBORNE DISEASES 6

Pathogen Mode of Transmission Targeted prevention measure

Tuberculosis Airborne Airborne isolation, screening of contacts & HCWs, Respirators use, ventilation

MRSA Contact Contact precautions, enhanced cleaning, Chlorhexidine use in certain settings

C. Difficile Contact Contact precautions, hand hygiene, antimicrobial stewardship, enhanced cleaning, spores elimination

Mumps Droplet, contact (D&InD) Vaccination and droplet precautions

SARS & MERS Droplet, contact, airborne? Contact and airborne isolation

Chickenpox/ varicella Airborne, contact (blisters ) Vaccination, early identification, airborne and contact isolation, avoid contact with rash

Measles /rubella Airborne Vaccination, early identification, airborne isolation, contact tracing, and quarantine

Norovirus contact(D&InD) Contact precautions, enhanced cleaning, and gloves for food handlers

Pertussis /Bordetella Droplet Vaccination, droplet isolation, and post exposure prophylaxis

Other: Influenza, malaria, scabies, Enterococcus (VRE), Ebola, Klebsiella, Pseudomonas , fungi Branch-Elliman et al., 2015

KEY PATHOGENS AND PREVENTION MEASURES 7

Ebola virus is contagious

Direct Contact (blood and body fluids)

Splashes and cuts

Indirect with contaminated objects

Symptoms (2-21 d; onset 8-10d)

Fever, severe headache, fatigue,

muscle pain, abdominal pain,

vomiting, diarrhea, weakness and

unexplained hemorrhage

VIRAL HAEMORRHAGIC FEVERS (VHF) 8

EBOLA OUTBREAK IN WEST AFRICA 2014/15

Country Cases Deaths

Guinea 186 94

Liberia 372 184

Sierra Leone 303 221 ICOH Newsletter v13, no 1, May 2015

Public and Occupational health problem

2nd highest infection rate - 22 high burden states

9th highest annual incidence rate (834/100 000)

Prevention and Control

TUBERCULOSIS IN SA 10

Detection & case isolation

HCWs must wear respirators

Install Ventilation

36% samples MTB +

50% Drs & 23% nurses

87.5% No masks BUT

contact with patients

and trained on PPE

GP provincial mapping:

42% UVGI not working

Red flag study: future

collaborations

TUBERCULOSIS: ENVIRONMENTAL EXPOSURE 11

Detection

Elimination

Administrative Engineering

&

Environmental

PPE

&

Hand hygiene

12

FUNDAMENTAL PILLARS OF INFECTION PREVENTION

Public awareness campaigns or media attention

Screening for possible exposure (e.g. travel)

Identify key symptoms at healthcare facility

Diagnostic testing for “flagged” cases

Isolate suspicious cases

Notify the laboratory and authorities (IP)

Detection | Elimination

CASE DETECTION AND IDENTIFICATION

Policies and procedures to prevent transmission of MOs within the HC facility

Safe working practices to minimize the risk of exposure

Safe Disposal and Disinfection

Specific Emergency procedures (spills & incidences)

Administrative

Screening of high risk areas and Isolation

Vaccination is effective for Infection control

ADMINISTRATIVE PROCEDURES

Handle laundry carefully, hidden sharps may be present

Isolate contaminated laundry and bag separately

Place wet laundry in leak-proof bags

Label and Colour code contaminated laundry bags

Send directly to laundry, DO NOT rinse or sort in patient areas

Minimize agitation to avoid aerosolization of microbes

HANDLING CONTAMINATED LAUNDRY 15

Restrict access to the area

Wear PPE and gather the needed tools

Wipe up and dispose visible material

Decontaminate using fresh disinfectant (2% Jik-10min)

Clean and decontaminate all equipment

CLEANING UP SPILLS 16

HVAC systems

HEPA filters

Negative pressure

Dilution rate (6-12 ACH)

Install in risky areas (RA)

Isolation rooms and waiting areas

Critical care, operating rooms and transplant rooms

PPE must be worn (airborne precaution) Engineering | Environmental

Isolation rooms: prevent airborne pathogens transmission

Natural ventilation is superior to mechanical

Natural ventilation have more than Double ACH

Patients have low risk of TB acquisition after exposure

Natural ventilation is cost effective than mechanical

Haiti : 2 open air hospitals reduce respiratory infections

UVGI lamps or fixtures

Kimmelman, 2014

Escombe et al, 2007

VENTILATION: NATURAL VS MECHANICAL 18

Photograph courtesy: CSIR

Lack of maintenance

Poor installations

Effectiveness

Inferior designs

Dose Rec: 20 mW/m³ Photograph courtesy: CSIR

UVGI FIXTURES 19

Supplier Fixture

MTB reduction after 60 min UVGI

% MTB Survival % Effectiveness

A 40 60 B 27 73 C 19 81 D 18 82 E 18 82 F 8 92 G 7 93 H 0 100 I 0 100 J 0 100 K 0 100

EFFICACY OF UVGI IN TEST ROOM 20

Water systems, cooling towers, showers

L. pneumophila

Pneumonia and Pontiac fever (“flu-like”)

Prevention Strategy

Water system maintenance ( Temp. & ClO2)

PPE (respirators) not a feasible measure of prevention – Mitigation is Environmental

Engineering | Environmental

LEGIONELLA OUTBREAKS

MERS survive up to 2 days

Calciviruses (e.g. norovirus)

Resistant to standard disinfectants

Transferred to food (at least 7d)

Prevention Strategy

MDR- H202 vapour (Pasaretti et al., 2013)

C.dificille H202 deep cleaning

(Best et al., 2014)

ENVIRONMENTAL PERSISTENT AGENTS 22

GOWNS and GLOVES

Pathogens transmitted by contact

Skin protection -blood & body fluids

GOGGLES: Eye splashes, Blood splatter

RESPIRATORS AND MASKS:

Reduce risk of inhaling or spreading aerosols

Other: Aprons, boots, hair and shoe covers PPE | Hand hygiene

PERSONAL PROTECTIVE EQUIPMENT 23

PEOPLE vs. PPE in PRACTICE 24

Which one is the best respiratory protection?

Surgical mask

Respirator

• Surgical masks offer only partial protection

• Protect patient and environment (airborne droplets)

• No seal, Inadequate fit, possible leaks

25

• Respirators offer better protection

• Protect the worker from inhaling TB droplets

• Forms a tight seal around the face preventing leaks

CORRECT TYPE

26

Fit testing can be qualitative or quantitative

Contact NIOH Occupational Hygiene Department

Several sizes &

models Fit test

prior to use Changes

that affect fit

Fit test periodically

26 CORRECT FIT

Hold -cupped

hand Nose piece at

the fingertips Head straps

hang loosely in front.

Place over nose, mouth & chin.

Pull and rest the top strap over the top back of your head, above ears

Pull & place the bottom strap around your neck, below ears.

Use both hands fingertips fit the nose piece to your nose by pushing inward, adjust to fit

Using 1 hand will likely result in less effective respirator fit.

+ve pressure check: exhale sharply, no leaks to face

-ve pressure check: inhale deeply (should

depress slightly)

Seal check: Cover with both hands.

Re adjust, DONT use until passed.

To remove, hold with 1 gloved hand

With the other hand, pull the bottom strap over your head, then pull the top strap off.

Dispose of it as a bio-hazardous waste.

Perform Fit Check

27 27 RESPIRATOR: TRAIN THE USER

Low cost and highly effective

Wash contaminated hands with soap and water

Before leaving work area Before and after patient care and between patients After handling blood and contaminated items Before eating and after using the bathroom Immediately after removing gloves

Hand sanitation (Alcohol rubs or Gemstar etc.)

not effective for some organisms e.g. C.dificille

28 28 HAND HYGIENE

29 29 SAFE WORK PRACTICES: HAND HYGIENE

30 30 SAFE WORK PRACTICES: GLOVE REMOVAL

SURVEYS OBSERVATIONS AND INTERVIEWS

Isolation not always possible due to lack of space

Lack of PPE supply or non compliance

Inappropriate masks used in risky areas

Staff don’t adhere to best practices despite being

trained

Engineering controls not functional or not maintained

Costs implications (N95, UVGI service, fit testing)

PERCEPTIONS

Overworked staff-decreased compliance-increase

infections

31 31 CHALLENGES FOR IMPLEMENTATION OF IP

PREVENTION IS BETTER THAN CURE

THANK YOU

onnicah.matuka@nioh.nhls.ac.za

Direct line: 011 712 6487

Switchboard: 011 712 6400