NATIONAL INFECTION PREVENTION AND CONTROL (IPC)

REFERENCE MANUAL FOR HEALTH CARE SERVICE

PROVIDERS AND MANAGERS

VOLUME 1: GENERAL INFECTION PREVENTION AND CONTROL

(IPC)

THIRD EDITION
OCTOBER 2019
FOREWORD

In Ethiopia, effort is being made to improve the quality healthcare service provision to citizens.
Among multitude of initiatives currently underway, the protection of patients and healthcare workers
from infections and reducing antimicrobial resistance in health facilities has been given
particular attention by the Federal Ministry of Health. It is known that infection prevention and
control (IPC) is a critical component of quality health services. In this respect, the Ministry is
scaling-up its activities related to health facility related infection prevention and will make use of
all opportunities to strengthen ongoing activities directed to it. As in many of its programs, the
undertakings of the Ministry pertaining to this special goal largely depends on the current scientific
evidence to establish optimal infection prevention and control practices or processes in health
facilities.

Although Healthcare Acquired Infections global estimates are not yet available, by integrating data
form published studies, there is clear evidence that hundreds or millions of patients are affected every
year worldwide, with the burden of disease in low and middle income countries.

The situation tends to persist causing a real threat to healthcare providers and community at large and
at times demand additional cost to the patient in particular and the healthcare system in general.
Furthermore, with an inadequate practice of infection prevention and control, healthcare providers
and patients would be at an increased risk of acquiring serious infections like HIV, HBV, HCV,
Ebola and other emerging and re-emerging bacterial or viral infections not to mention Anti-Microbial
Resistant Microbial (AMR) Infection including Multi-Drug Resistant TB. Fortunately, most
nosocomial infections in healthcare facilities can be prevented with readily available, relatively
inexpensive and simple strategies.

In Ethiopia, where many health care settings are resource constrained, the control of the risk of
acquiring nosocomial infections is a very challenging. For the control measure or practice to kick
into action, material, human power, training, policy, guideline, IPC program would certainly
be necessary. Infection Prevention and Control (IPC) in healthcare settings is therefore, a broad
and cross-cutting component of healthcare which involves every aspect of patient care, food hygiene,
housekeeping, laundry service, healthcare waste management and many more.

This Infection Prevention and Control reference manual is intended to primarily serve
healthcare providers and managers. This manual is believed to aid the target users by way of

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providing clear guidance in the provisions of standard Infection Prevention and Control in
their respective setups. The material is developed by way of incorporating both indigenous
experiences and internationally acclaimed standardized recommendations. It is composed of
innovative and evidence based methods widely in use all over the world to reduce the incidence of
nosocomial infections and the entailing overhead cost of an Infection Prevention and Control
program. It is also anticipated that health bureaus, program managers, other stakeholders and interest
groups would benefit from consulting this reference manual which embodies a wide spectrum of
issues pertaining to prevent and control infections in different healthcare facilities. Finally, I wish to
extend my heartfelt gratitude to all individuals and institutions that have contributed to the realization
of this Revised Reference Manual.

Lia Tadesse,M.D,MHA
State Minister

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ACKNOWLEDGEMENTS
The Federal Ministry of Health acknowledges the commitment and technical support of the
National Infection Prevention and Control (IPC) Advisory Technical Working Group (ATWG)
members and key contributors along with their organizations who made the revision of this
reference manual a reality.
The Ministry of Health would like to specially thank W H O , Jhpiego and I C A P for their
technical support in the third edition of the Reference Manual. Furthermore, the Ministry of
Health would also like to extend its gratitude to USAID MTaPS programfor providing financial
support to print this document.

National Infection Prevention and Control (IPC) Advisory Technical Working

Group (ATWG) Members and Key Contributors:
Mr. Molla Godif Federal MOH, Clinical Service Directorate Chair
Dr.Fahmi Ahmed WHO Country office Secretary
Abebe Shume Jhpiego-Ethiopia Member
Mr. Arone Mebrhatu EPHI-PHEM Member
Dr.Ashenafi Negash ICAP-Ethiopia Member
Mr. Wondayehu Wube Federal MOH Member
Mr.Tewodros Fantahun USAID MTaPS program Member
Mr.Addisalem Bogale St.Paul‘s hospital Millennium Medical college Member
Mr.Feyisa Regassa Tikur Anbessa Specialized Hospital Member
Sr. Nishit Enyew ICAP-Ethiopia Member
The FMOH would also like to thank the following individuals and their organization
for the contribution they made on this manual:
Habtamu Milkias FMoH, Health Service Quality Directorate
DR. Michael Oji WHO County Office, Consultant
Dr. Yibeltal Mokenen FMoH, Clinical Service Directorate
Mr. Mesfin Bekele FMoH, Disease Prevention and Control Directorate
Dr. Negash Seyoum, Jhpiego-Ethiopia
Mrs. Redda WHO Country office, Consultant
Mr. Masresha Addis Ababa University
Mr. Sisay Endale Transform PHCU
Ato Wondwosen Maternity Foundation
Mr Zinar Nebi JSI - L.10k
Dr. Mulugeta Dessalegn ALERT Hospital
Dr. Ruparelia Chandrakant Jhpiego International
Mrs. Gezashign Denekew FMOH,Clinical Service Directorate

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TABLE OF CONTENTS

CONTENTS
FOREWORD ............................................................................................................................ 2
ACKNOWLEDGEMENTS .......................................................................................................... 4
TABLE OF CONTENTS .............................................................................................................. 5
LIST OF TABLES ......................................................................................................................... 7
LIST OF FIGURES ....................................................................................................................... 9
LIST OF ACRONYMS ............................................................................................................... 11
CHAPTER 1: INTRODUCTION TO INFECTION PREVENTION AND CONTROL
(IPC) ............................................................................................................................ 2
CHAPTER 2: BASIC MICROBIOLOGY FOR IPC .............................................................. 18
CHAPTER 3: STANDARD AND TRANSMISSION-BASED PRECAUTIONS .................. 42
CHAPTER 4: HAND HYGIENE ............................................................................................... 56
CHAPTER 5: PERSONAL PROTECTIVE EQUIPMENT (PPE) ........................................ 78
CHAPTER 6: SHARPS AND INJECTION SAFETY ........................................................... 112
CHAPTER 7: DECONTAMINATION AND REPROCESSING OF MEDICAL
DEVICES (INSTRUMENT PROCESSING) .......................................................................... 138
CHAPTER 8: PROCESSING REUSABLE TEXTILES AND LAUNDRY SERVICES ... 205
CHAPTER 9: ENVIRONMENTAL CLEANING IN HEALTH CARE SETTING ........... 219
CHAPTER 10: HEALTHCARE WASTE MANAGEMENT ............................................... 236
CHAPTER 11: FOOD AND WATER SAFETY .................................................................... 268
CHAPTER 12: FACILITY DESIGN AND PATIENT FLOW ............................................. 283
CHAPTER 13: INFECTION PREVENTION AND CONTROL ASPECTS OF
OCCUPATIONAL HEALTH IN HEALTH CARE SETTINGS ....................................... 298
CHAPTER 14: CLIENT EDUCATION ON INFECTION PREVENTION AND
CONTROL (IPC) ...................................................................................................................... 331
REFERENCES ........................................................................................................................ 341
APPENDIX ........................................................................................................................ 362
Appendix 4A: Sample Hand Hygiene Observation Form: World Health Organization ........ 362
Appendix 4B Sample Hand Hygiene Observation Form Modified for Room Entry and Exit 365
Infection Prevention and Control (IPC) Reference Manual ,Volume 1
 Appendix 4C: Implementation of a Multimodal Hand Hygiene Improvement Strategy........ 366
Appendix13A: Initial Management of a Person Reporting Exposure to Potentially Infectious
Body Fluids .............................................................................................................................. 371
Appendix 13B: Summary of Steps in Clinical Management of HIV Post- Exposure Prophylaxis
.................................................................................................................................................. 372
Appendix 13C: Facilitating Informed Patient Decision Making For HIV Post- Exposure
Prophylaxis .............................................................................................................................. 374
Appendix 13D: Pediatrics PEP Doses ..................................................................................... 375
Appendix 13E: Post Exposure Prophylaxis Follow up Card Legend ...................................... 376
Appendix 13F: Post Exposure Prophylaxis Follow up Card Legend (Cont‘d…) ................... 377
Appendix 13G: Post Exposure Prophylaxis Follow up Card Legend (Cont‘d…) ................... 378
Appendix 13H: Occupational and Non-Occupational HIV Post Exposure Prophylaxis Register
.................................................................................................................................................. 379
Appendix 13I: Occupational and Non-Occupational HIV Post Exposure Prophylaxis Registers
(Continued…) .......................................................................................................................... 380
Appendix 13 J: PEP Facility Assessment Form ...................................................................... 381
Appendix 13K: Checklist for PEP at Site Level PEP Service Delivery .................................. 383
Appendix 13L: Risk and Work Restriction for Health Care Workers Exposed to or Infected With
Infectious Diseases of Importance in Health Care Settings ..................................................... 384
Appendix13M: Decision Making Tools for PEP ..................................................................... 396

Infection Prevention and Control (IPC) Reference Manual ,Volume 1

LIST OF TABLES
Table 1.0-1 WHO Core Components of IPC ................................................................................................................. 5

Table 2.0-1 Basic Features of Micro-Organisms and Implications for Health Care ............................................... 21

Table 2.0-2 Background of the Common Organisms That Cause Infection of Body Systems ................................ 40

Table 3.0-1 Empiric use of Transmission –Based Precaution (based on sign and symptoms) for isolation of
patient in hospital ............................................................................................................................................ 54

Table 4.0-1 WHO‟s Five Recommended Moments for Hand Hygiene ..................................................................... 60

Table 4.0-2 Hand Hygiene Observation Methods ....................................................................................................... 71

Table 4.0-3 Advantages and Disadvantages of Various Hand Hygiene Monitoring Approaches ........................... 72

Table 4.0-4 Minimum Criteria for Implementation ................................................................................................... 77

Table 5.0-1 How Personal Protective Equipment Blocks the Spread of Microorganisms ...................................... 82

Table 5.0-2 Types and Uses of PPE .............................................................................................................................. 84

Table 5.0-3Advantages and Disadvantages of Different Types of Non-Sterile Gloves ............................................ 95

Table 6.0-1Conditions Causing Risks to Community, Patients/Clients and Providers ......................................... 115

Table 6.0-2 Proportion of Infections and Total Burden of Disease Caused by Unsafe Injection.......................... 117

Table 6.0-3Types of Injection Devices: Advantages and Disadvantages ................................................................. 126

Table 7.0-1 Spaulding‟s Risk Classification and Level of Processing ..................................................................... 141

Table 7.0-2 Effectiveness of Methods of Processing Instruments ............................................................................ 155

Table 7.0-3 Liquid Chemicals Used for Sterilization ................................................................................................ 192

Table 7.0-4 Preparing and Using Chemical Disinfectants ........................................................................................ 199

Table 7.0-5 Guidelines for Processing Instruments, Surgical Gloves and Other Items......................................... 200

Table 7.0-6 Guidelines for Processing Instruments, Surgical Gloves and Other Items (Continued…) ............... 201

Table 7.0-7 Guidelines for Processing Instruments, Surgical Gloves and Other Items (Continued…) ............... 202

Table 7.0-8 Guidelines for Processing Instruments, Surgical Gloves and Other Items (Continued…) ............... 203

Table 7.0-9 Guidelines for Processing Instruments, Surgical Gloves and Other Items (Continued…) ............... 204

Table 8.0-1 Recommended PPE for Processing Textiles .......................................................................................... 208

Table 8.0-2vGuidelines for Processing Textile and Personal Protective Equipment (PPE) .................................. 218

Table 10.0-1 Categories of Waste Generated by Health Care Facilities ................................................................. 240

Infection Prevention and Control (IPC) Reference Manual ,Volume 1

Table 10.0-2 Health Care Wastes from Different Sources in a Health Care Facility ............................................ 241

Table 10.0-3 WHO‟s Recommendation for Waste Segregation ............................................................................... 245

Table 10.0-4 Methods for Treating Health Care Waste ........................................................................................... 250

Table 11.0-1 National standard for drinking water .................................................................................................. 276

Table 11.0-2 Sample Volume and Transportation Condition .................................................................................. 278

Table 11.0-3 Sample De-chlorination ......................................................................................................................... 279

Table 11.0-4 Minimum sampling frequency for drinking water in distribution system. ...................................... 280

Table 13.0-1 Occupational Health Activities for Newly Employed HCWs ............................................................. 304

Table 13.0-2 Occupational Health Activities for all HCWs ..................................................................................... 305

Table 13.0-3 Facility-Wide Activities ......................................................................................................................... 306

Table 13.0-4 WHO-Recommended Immunizations for HCWs ............................................................................... 306

Table 13.0-5 Occupational Health Activities for Management of Job-Related Illnesses and Exposures ............. 308

Table 13.0-6 Infectious Agents of Concern for Pregnant HCWs According to the Risk of Transmission
Associated with Providing Health Care Services and Available Preventive Measures ........................... 311

Table 13.0-7 Management of Occupational Exposure to Common Infections for Pregnant Staff Members ...... 312

Table 13.0-8 Recommended HIV Post Exposure Prophylaxes (PEP) for Percutaneous Injuries ......................... 318

Table 13.0-9 Recommended HIV Post Exposure Prophylaxes for Mucous Membrane Exposures and Non-intact
Skin Exposures .............................................................................................................................................. 318

Table 13.0-10 Considerations of nPEP According to the type of risk exposure ..................................................... 321

Table 13.0-11 Recommended Post-Exposure Prophylaxis for Exposure to Hepatitis B Virus ............................. 321

Table 13.0-12 HIV Exposure Risk and Type of Exposure ....................................................................................... 323

Table 13.0-13Determinant for Post-Exposure Prophylaxis for Occupational Exposure to HBV ......................... 325

Infection Prevention and Control (IPC) Reference Manual ,Volume 1

LIST OF FIGURES

Figure 1.0-1 The Infection Chain ................................................................................................................................... 8

Figure 1.0-2.Transmissions of HBV and HIV from Patients to Healthcare Workers ............................................. 11

Figure 1.0-3. Breaking the chain of Infection .............................................................................................................. 13

Figure 2.0-1. Structure of a Bacterial Cell ................................................................................................................... 23

Figure 2.0-2. Clonal Morphology of Bacteria .............................................................................................................. 24

Figure 2.0-3 Shapes and Groupings of Bacteria ......................................................................................................... 24

Figure 2.0-4. Bacterial Classification by Staining Properties .................................................................................... 26

Figure 2.0-5 Transmission Electron Micrograph of the Ebola Virus........................................................................ 27

Figure 2.0-6 Candida albicans ...................................................................................................................................... 29

Figure 2.0-7 Plasmodium falciparum, Malaria Parasite ............................................................................................ 30

Figure 2.0-8: Microorganisms That Cause the Four HAIs of Global Public Health Interest ................................ 37

Figure 4.0-1. The Steps for Routine Hand Washing (How to Properly Wash Your Hands) .................................. 62

Figure 4.0-2 WHO Recommendation on How to Perform Hand Hygiene with ABHR ........................................... 65

Figure 4.0-3. Five Steps of the Hand Hygiene Improvement Strategy ...................................................................... 75

Figure 5.0-1 Surgical Head Coverings ......................................................................................................................... 85

Figure 5.0-2. Different types of Eye Protection Equipment‟s .................................................................................... 87

Figure 5.0-3. Putting on Eye Protection ....................................................................................................................... 87

Figure 5.0-4. Taking off Eye Protection ....................................................................................................................... 88

Figure 5.0-5. Types of Masks ........................................................................................................................................ 89

Figure 5.0-6. Coverall Suit ............................................................................................................................................ 92

Figure 5.0-7. A and B. Putting on and Removing an Isolation Gown Respectively ................................................. 93

Figure 5.0-8. The Glove Pyramid – to aid decision making on when to wear (and not wear) gloves ..................... 97

Figure 5.0-9. How to don and remove examination gloves ....................................................................................... 101

Figure 5.0-10. How to wear (don) sterile gloves ........................................................................................................ 102

Figure 5.0-11. How to remove (doff) sterile gloves.................................................................................................... 102

Figure 5.0-12. Cutting the Four Fingers off a Glove................................................................................................. 104

Infection Prevention and Control (IPC) Reference Manual ,Volume 1

Figure 6.0-1.Unsafe Injection Practices and Disease Transmission ........................................................................ 118

Figure 6.0-2: Right Ways to Give Safe Injection...................................................................................................... 121

Figure 6.0-3. One Handed Recap Method ................................................................................................................. 124

Figure 6.0-4. ONE and ONLY Campaign ................................................................................................................. 127

Figure 6.0-8. Breaking Open an Ampoule ................................................................................................................. 132

Figure 6.0-6. Withdrawing Medication Using an Auto-Disable Syringe ................................................................ 134

Figure 6.0-7. Standard Safety Box ............................................................................................................................. 135

Figure 7.0-1. Work flow for instrument processing and other medical devices ..................................................... 142

Figure 7.0-2. Typical Wrapping Techniques ............................................................................................................. 163

Figure 7.0-3. Steamer Used for HLD ......................................................................................................................... 169

Figure 7.0-4. Simplified Diagram of a Gravity Displacement Steam Sterilizer ..................................................... 176

Figure 7.0-5. Loading Steam Sterilizer ...................................................................................................................... 183

Figure 7.0-6. Non-Electric Gravity Displacement Steam Sterilizer......................................................................... 187

Figure 9.0-1 Frequently Touched Surfaces in an Examination Room .................................................................... 222

Figure 10.0-1 Hazardous Waste Symbols for Health Care Facilities ...................................................................... 246

Figure 10.0-2:Practical Classification of Hospital Wastes and Methods of Disposal............................................. 252

Figure 10.0-3. Diagram of an Autoclave .................................................................................................................... 261

Figure 10.0-4. Standard Components of a Small-Scale Incinerator ........................................................................ 264

Figure0-9. Plan for a Small Burial Pit ....................................................................................................................... 266

Figure 10.0-6. Placenta Pit Plan ................................................................................................................................. 267

Figure 12.0-1. a and b Floor Plans for Instrument Cleaning, High-Level Disinfecting and Sterilizing Areas
in a Clinic and Larger Facility ..................................................................................................................... 287

Figure 12.0-2. Floor Plan for a Central Supply Department in a Hospital ............................................................ 294

Infection Prevention and Control (IPC) Reference Manual ,Volume 1

LIST OF ACRONYMS

AMR Anti-Microbial Resistance

3TC Lamivudine
AIDS Acquired Immunio Deficiency Syndrome
ARC AIDS Resource Center
ART MDT Anti-Retroviral Treatment Multi-Disciplinary Team
ARV Antiretroviral
AZT Zidovudine
BPMH Best Possible Medication History
BSI Body Substance Isolation
BSL Bio-Safety Level
CDC Centers for Disease Control and Prevention
DHHS Department of health and human service
DMPA Depot Mediroxy Progesteron Acetate
EFV Efavirenez
EPI Expanded Program of Immunization
HAART Highly Active Anti-Retroviral Treatment
HAIs Healthcare Associated/Acquired Infections
HBe Ag Hepatitis B envelope Antigen
HBs Ag Hepatitis B surface Antigen
HBV Hepatitis B virus
HCF Health-Care Facility
HCP Health-Care Provider
HCP Health-Care Providers
HCV Hepatitis C Virus
HCW Health-Care Worker
HCWM Health-Care Waste Management
HIV Human Immunodeficiency Virus
HLD High Level Disinfection
IAIS Intra-Amniotic Infection Syndrome
IP Infection Prevention
IPC Infection Prevention and Control
IUD Intra-Uterine Device
LASA Look-Alike and Sound Alike
Lpr/r Lopinavir/ritonavir
MDR TB Multi-Drug Resistant Tuberculosis
MDT Multi-Disciplinary Team
MoH Ministry of Health
MRN Medical Record Number
MSDs Material Safety Data Sheets
nPEP Non Occupationnel Post Exposure Prophylaxies
NVP Nevirapine

Infection Prevention and Control (IPC) Reference Manual ,Volume 1

OHSO Occupational Health and Safety Officer
PEP Post-Exposure Prophylaxis
PLWHA People Living With HIV/AIDS
PMTCT Prevention of Mother-to-Child Transmission
PPE Personal Protective Equipment
ppm Parts Per Million
PS Patient Safety
QUAT Quaternary Ammonium Compound
RNA Ribonucleic Acid
SHIV Simian Human Immunodeficiency Virus
SIV Simian Immunodeficiency Virus
SSI Surgical Site Infection
SUD Single-Use Device
TB Tuberculosis
TDF Tenofovir
TST Time, Steam, Temperature
TTI Transfusion Transmissible Infection
UP Universal Precautions
VVM Vaccine Vial Monitor
WHO World Health Organization

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RATIONALE OF THE MANUAL
Since the publication of Infection Prevention Guideline in 2003 and the of the first edition of
National Infection Prevention and Patient Safety Guideline in 2011 and the second edition in
2012, considerable progress has been exhibited in understanding and implementing evidence
based IPC practices in healthcare facilities. However, the recommended evidence based
practices, keeps on modifying globally due to incoming scientific findings. In connection with
that, it was observed that the existing national Infection Prevention and Patient Safety (IPPS)
guideline lack updated information and is inadequate on some important topics. On top of this,
the existing guideline comprises two vast but interrelated programs (Infection Prevention and
Patient Safety). This surely calls for separating Infection Prevention and Control (IPC) from
Patient Safety (PS) and updating the guideline and designing a comprehensive Infection
Prevention and control (IPC) Reference Manual for Healthcare Facilities in Ethiopia which will
give an in depth information on IPC. Furthermore, it will be used in line with the existing
guidelines like the Ethiopian Hospital Service Transformation Guidelines (EHSTG), T he
National Healthcare Waste Management Guideline and other similar documents.

To that effect, great efforts have been put to come up with up-to-date information and practical
interventions in the area of serious concerns. In this regard, all of the chapters incorporated in
IPC have been revised. Furthermore, additional topics like: Anti-Microbial Resistance (AMR),
Prevention of common Healthcare Associated/Acquired Infections (HAIs), IPC in outbreak
Management, Basic Surveillance and Biostatistics, Basic Microbiology and IPC in Special
Setting and other issues have been included as well. This manual purports primarily to provide
the practitioners with the most appropriate recommendations in the activities of IPC putting
more emphasis to practices and procedures that could be applicable in the country.

As a document meant for macro level functions, the manual is divided in two Volumes (Volume
I deals with General IPC and Volume II deals with, more of advanced IPC and Special
Settings), it principally serves as a standardized IPC Reference Manual for healthcare providers
and managers in all government, private and non-governmental healthcare delivery systems. As
an informative, relevant and user-friendly material, it would also be of a considerable resource to
health educators, trainers, public health and medical officials. Moreover, it also serves for pre-
service education, group-based training or on the job learning.

Cognizant of this, the Federal Ministry of Health revitalized the national IPC Advisory Technical
Working Group (ATWG) in 2019 under the Medical Services General Directorate. The group
consequently identified the IPC gaps and took the initiative to review the existing IP and PS
related documents and developed this IPC manual

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CHAPTER 1: INTRODUCTION TO INFECTION PREVENTION AND
CONTROL (IPC)
Key Topics

Goal of Infection Prevention and Control (IPC)

WHO core components of Infection Prevention and Control
The Infection Chain or Cycle and Breaking the Chain of Infection
Introduction to Healthcare Associated Infections (HAIs)
Background of Standard and Transmission Based Precaution
Background of Clean and Asepsis Techniques
Definition of Key Terms

Micro-Organisms - A microorganism is any living organism like bacteria, protozoa, or even

fungi that cannot be seen with the naked eye. Microorganisms can only be viewed through a
microscope.

Colonization - the presence of pathogenic (illness or disease causing) organisms in a person

or animal in abundance (i.e. they can be detected by cultures or other tests) usually without
causing symptoms or clinical findings (i.e. they do not invade tissues, cause cellular changes
or cause damages).In other words, it is the appearance or increased number of a particular
invasive bacterial species in the resident micro flora.

Colonized Persons - can be a major source of transfer of pathogens to other persons. For
instance, Neisseria meningitides colonizes nasal cavity and oropharynx with or without
causing subsequent infections. Entameba histolytica can colonize the large bowel without
any harm to the host but are often shade in the stool as infectious cysts which may cause
dysentery.

Infection - is an invasion and multiplication of microorganisms in body tissues which may

clinically be apparent or result in local cellular injury due to competitive metabolism, toxins,
intracellular replication or antigen antibody response.

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Disease - is any deviation from being healthy or interruption of the normal structure or
function of any body part, organ, or system manifested by a characteristic set of symptoms
and signs whose etiology, pathology, and prognosis may be known or unknown.

Infectious microorganisms- are microorganisms capable of producing disease in the

appropriate hosts. They are also called infectious agents, pathogens or pathogenic agents
interchangeably in this manual.

Healthcare Associated Infections (HAIs) - is a term used interchangeably with ―healthcare

facility acquired infection‖ or ―healthcare associated infections (HAIs)‖ and is defined as
infections acquired during the course of healthcare interventions, which was not present or
incubating at the time of admission.

Infection Prevention and Control (IPC) - refers to scientifically sound practices aimed at
preventing harm caused by infection to patients, health workers and the community. It is a
systematic effort or process of placing barriers between a susceptible host (person lacking
effective natural or acquired protection) and infectious agents. Infection Prevention and
Control is used interchangeably with Infection Prevention in this manual.

Protective Barriers - are physical, mechanical or chemical processes that help to prevent the
spread of infectious agents from person to person (patient, healthcare client or health
workers) and/or equipment, instruments and environmental surfaces to people.

Antimicrobial Resistance (AMR) - is the ability of a microorganism to resist the effects of

an antimicrobial agent using various resistance mechanisms. Antimicrobial resistance occurs
when microorganisms such as bacteria, viruses, fungi, and parasites develop ways to avoid
the effects of medications used to treat infections (such as antibiotics, antivirals, and
antifungals) and pass these changes on to their offspring or in some cases to other bacteria
via plasmids.

BACKGROUND

Infection Prevention and Control is essential for the delivery of safe and quality healthcare
services. Infections remain a major health threat globally, and could affect anyone.
Healthcare workers have a critical role to play in the prevention and control of infection at all
levels of care and the nature of their work increases their chances of acquiring or transmitting

3
infectious agents. In healthcare settings the risk for infection is usually high due factors such
as the presence of a wide range of infectious agents (including resistant strains) from various
sources, weakened immunity of patients, invasive and other high risk procedures. Health
care-associated infections are the most frequent adverse events in health care delivery
systems worldwide. They are a major cause of preventable diseases, deaths, and higher health
care costs. Application of evidence-based IPC practices at all healthcare settings is key; the
rest of this chapter will introduce readers to basic principles of Infection Prevention and
Control with the aim of laying the foundation for the chapters in the rest of the manual

Goal of Infection Prevention and Control

The goal of Infection Prevention and Control is to make healthcare facilities safe for all,
including patients, clinical and non-clinical staff of healthcare facilities, and the community

WHO Core Components of Infection Prevention and Control

Effective implementation of IPC practices in health care facilities require that appropriate
strategic interventions to be put in place. WHO has provided guidance on core components
for Infection Prevention and Control (IPC) interventions which are summarized in the table
below in Table 1.0.1
A comprehensive and effective approach to IPC consists of establishing IPC programs with
strong links to other national programs, for example, those addressing quality and safety and
AMR. The presence of an IPC program is a necessary, but not a sufficient condition to
achieve safe and high quality health care. In addition, at the facility level, an adequate built
environment (including the necessary infrastructure, materials and equipment, appropriate
inpatient service, adequate human resources or staffing and workload) represents the
foundation enabling the implementation of all other core components and the achievement of
safe practices. These two prerequisites, that is, an IPC well organized and established
program and an adequate built environment and IP supplies, support the effective
implementation of IPC guidelines, training and education, program monitoring, audit,
feedback and surveillance. Implementation success in each of these areas also depends on the
adoption of a multimodal approach, that is, a strategy consisting of several elements

4
implemented in an integrated way with the aim of improving an outcome and changing
behavior.

It comprises the following eight core components. The first six are particularly relevant for
the national level, while all 8 components apply to health care facilities.

Table 1.0-1 WHO Core Components of IPC

S. Component Recommendation
No.
1 IPC programs An IPC and PS program with a dedicated, trained team should be
in place in each acute health care facility for the purpose of
preventing HAI and combating AMR through IPC good
practices.

Stand-alone, active national IPC programs with clearly defined

objectives, functions and activities for the purpose of preventing
HAI and combating AMR through IPC good practices should
be established. National IPC programs should be linked to other
relevant national programs and professional organizations.
2 Evidence-based Evidence-based guidelines should be developed and
guidelines implemented for the purpose of reducing HAI and AMR.

Education and training of the relevant health care workers on

guideline recommendations and monitoring of adherence with
guideline recommendations should be undertaken to achieve
successful implementation.
3 Education and At the facility level, IPC education should be in place for all
training health care workers by utilizing team and task based strategies
that are participatory and include bedside and simulation
training to reduce the risk of HAI and AMR.

The national IPC program should support education and

training of the health workforce as one of its core functions.

5
4 Health care- Facility-based HAI surveillance should be performed to guide
associated IPC interventions and detect outbreaks, including AMR
infection (HAI) surveillance with timely feedback of results to health care
surveillance workers and stakeholders and through national networks.

National HAI surveillance programs and networks that include

mechanisms for timely data feedback and with the potential to
be used for benchmarking purposes should be established to
reduce HAI and AMR.
5 Multimodal At the facility level, IPC activities should be implemented using
strategies multimodal strategies to improve practices and reduce HAI and
AMR.

National IPC programs should coordinate and facilitate the

implementation of IPC activities through multimodal strategies
at the national or sub-national level.
6 Monitoring and Regular monitoring/audit and timely feedback of health care
audit of IPC practices should be undertaken according to IPC standards to
practices and prevent and control HAIs and AMR at the health care facility
feedback level. Feed-back should be provided to all audited persons and
relevant staff.

A national IPC monitoring and evaluation program should be

established to assess the extent to which standards are being met
and activities are being performed according to the program‘s
goals and objectives. Hand hygiene monitoring with feedback
should be considered as a key performance indicator at national
level.
7 Workload, In order to reduce the risk of HAI and the spread of AMR, the
staffing and bed following should be addressed:
occupancy (for (1) Bed occupancy should not exceed the standard capacity of
facility level) the facility;

6
 (2) Health care worker staffing levels should be adequately
assigned according to patient workload.
8 Built At the facility level, patient care activities should be undertaken
environment, in a clean and/or hygienic environment that facilitates practices
materials and related to the prevention and control of HAI, as well as AMR,
equipment for including all elements around the WASH infrastructure and
IPC (for facility services and the availability of appropriate IPC materials and
level) equipment.

At the facility level, materials and equipment to perform

appropriate hand hygiene should be readily available at the
point of care.
From World Health Organization (2016). Guidelines on core components of infection
prevention and control programmes at the national and acute health care facility level.
World Health Organization

The Infection Chain / Cycle

All humans are susceptible to infections due to some bacteria and most of the viral agents
and other infectious agents, these disease-causing organisms are also called pathogens. The
number (dose) of organisms necessary to produce infection in a susceptible host varies with
the location. All of us touch materials which contain some organisms every day but suffer
from no infection because organisms coming into contact with the intact skin are unlikely to
cause such risk. Nonetheless, when these organisms come into contact with mucous
membranes or non-intact skin, the chance of risk of infection correspondingly increases.
Infection risk increases greatly when organisms come into contact with normally sterile body
sites. In such cases, the introduction of only few organisms may produce disease.

Health workers have a responsibility to prevent and control infections, including Healthcare
Associated Infections (HAIs), however it is essential to understand the how infections spread,
to apply appropriate preventive measures. For infectious agents to successfully survive and
spread, certain factors or conditions must be present; these are illustrated as the components
or elements of the Chain of Infection If any of the links or components of the chain is absent

7
or removed, an infection cannot occur, this interruption of the ―chain‖ is commonly referred
to as ―breaking the chain of infection‖. These concepts are illustrated below.

F
igure 1.0-1 The Infection Chain

Key Elements of the Chain Infection

The following elements are required in sequential order, for an infection to occur and spread
as shown by the Chain of Infection illustration;

1. Infectious Agent- These are disease-causing organisms including bacteria, virus,

fungus, parasites etc.

2. Reservoir: Reservoir of an agent is the habitat in which an infectious agent normally

lives, grows, and multiplies. Reservoirs include humans, animals, and the
environment. The reservoir may or may not be the source from which an agent is
transferred to a host. For example, the reservoir of Clostridium botulinum is soil, but
the source of most botulism infections is improperly canned food containing C.

8
 botulinum spores. Many of the common infectious diseases have human reservoirs.
Diseases which are transmitted from person to person without intermediaries include
the sexually transmitted diseases, measles, mumps, streptococcal infection, most
respiratory pathogens, and many others. Smallpox was eradicated after the last human
case was identified and isolated because humans were the only reservoir for the
smallpox virus. Two types of human reservoir exist:

 Persons with symptomatic illness

 Carriers: Persons who are not experiencing symptoms of an infection but are
capable of transmitting the pathogen to others. The different types of carriers
are;

 Asymptomatic or passive carriers: Those who have never been ill from the
infection

 Incubatory carriers: Those who are in the incubation period of the disease

 Convalescent carriers: Those who have recovered from the infection

 Chronic carriers: Those which remain as reservoirs for the disease causing
agents for as long as years after they had the infection.

3. Portal of Exit - This is a gateway through which the agent leaves the host or
reservoir. However, the agent must have the right environment for its survival until it
gets an entry to infect another person/animal. For example, the bacteria that cause
tuberculosis can survive in sputum for weeks, but fortunately could be killed by
sunlight within few hours.

4. Mode of Transmission - an agent which exits and develops in its natural reservoir,
can be transmitted in numerous ways to a susceptible host and get portal of entry.
These modes of transmission are classified as:

 Direct Transmission - refers to an immediate transfer of the agent from a

reservoir to a susceptible host through direct contact or droplet.

9
  Direct Contact - occurs through kissing, skin-to-skin contact, and sexual
intercourse.

Direct contact refers also to contact with soil or vegetation harboring

infectious organisms. Infections such as mononucleosis (―kissing disease‖)
and gonorrhea are contracted from direct contact to an infected person.
Likewise, Hookworm infection is acquired through direct contact with
contaminated soil.

 Droplet Spread - refers to a spray of a relatively large, short-range germ

laden aerosols produced by sneezing and/or coughing (or even talking) of
infected people. Droplet Spread is classified as direct because transmission
is by direct spray over a few feet, before the droplets fall to the ground.

 Indirect Transmission - an agent is carried from a reservoir to the

susceptible host by suspended air particles or by animate (vector) or inanimate
(vehicle) intermediaries.

o Airborne
o Vehicle-borne
o Vector borne
o Mechanical
o Biologic
This manual deals primarily with preventing the spread of infectious diseases taking
place in healthcare facilities from contacts with sources like air (airborne and
droplets), blood or body fluids and contaminated foods or articles.

5. Portal of Entry - is the gate way through which an infectious agent enters in to the
susceptible host. These portals of entry could be mouth, nose, skin etc.

6. New / Susceptible Host - is an organism (human or animal) which is liable to take up

infectious agents/pathogens and harbors them. People are exposed to disease-causing
agents every day but do not always get sick. An infectious agent/pathogen getting
access or inhabiting in the host does not necessarily lead to infection or initiate illness
due to the body‘s natural defense mechanisms and the immune system is normally at

10
 work to fight back against the invading agent. However, organisms which get access
to a new host and reproduce there cause colonization which may later increase the
likelihood of development of infections. The other reason why people do not get
sick could be because of previous exposition to it through artificial or natural
immunity (e.g. vaccinated for it or previously had the disease).

For example:

The following figure illustrates the steps in the transmission of Hepatitis B Virus (HBV)
and Human Immunodeficiency Virus (HIV) from infected persons (e.g. a family planning
client or pregnant woman attending an antenatal clinic) or patients getting treated in
healthcare institutions. This spread of infection from viruses occurs when the staffs (physician,
nurse or cleaning personnel) are exposed to the blood or body fluids of an infected person
(e.g. needle stick injury).

Figure 1.0-2.Transmissions of HBV and HIV from Patients to Healthcare Workers

11
Breaking the Chain of Infection

Understanding the Chain of Infection or Transmission Cycle of specific infectious diseases is

important if healthcare workers are to:

 Prevent transmission of microorganisms from patient to patient, from patient to

the provider or vice versa during medical and surgical procedures;
 Teach others on the factors required for transmission to occur and most importantly.
 Teach others on how to break the disease transmission cycle;

Preventing the spread of infectious agents or proper infection prevention and control practice
requires breaking the chain of infection by removing one or more of the conditions necessary
for transmission of the diseases from the host, reservoir to the susceptible host through
practices which;

 Reduce the number of microorganisms present ( e.g. hand washing, cleaning of

instruments)
 Kill, inhibit or inactivate microorganisms (e.g. hand washing with a waterless
alcohol preparation, decontamination of patient care items);
 Create barriers to prevent infectious agents from spreading (e.g. wearing gloves
or personal protective equipment); or
 Reduce or eliminate risky practices (e.g. by using hands-free technique in the
operation room, using gloves and disposable syringes etc)
 Make sure that people, especially healthcare workers, are immune or vaccinated.

The figure below illustrates how to break or interrupt the Chain of Infection through IPC
practices.

12
Figure 1.0-3. Breaking the chain of Infection

Failure to apply infection prevention and control measures in healthcare settings can increase
the risk for Healthcare Associated Infections.

13
Healthcare Associated Infections (HAIs)

Healthcare Associated Infection (HAI) was previously known as Hospital Acquired Infection
and Nosocomial Infection. An infection is called ―healthcare-associated‖ if it is acquired
during the course of healthcare intervention for other conditions, regardless of where the
interventions are provided.

OR Infections acquired while a patients is under hospital (or any other health facility) care
which are not present or incubating at time of admission. It is a time related criterion which
refers to infections occurring more than 48 hours after admission. This situation, therefore, is
inclusive of infections acquired in the hospital but appear after discharge and occupational
infections among the staff of the facility as well.

HAIs may also occur;

 Up to 48 hours after the episode of care

 Up to 3 days after discharge
 Up to 30 days after an operation
 Up to 1 year after an operation with an implant

Note that patients and healthcare workers are at risk of acquiring HAIs.

HAIs may be endogenous (from self) where the infectious agents is from patient like the
normal flora which causes disease as a result of gaining access into another part of the body
where it is not normally found, for example organism from the colon entering the urinary
tract and causing Urinary Tract Infection.

HAIs may also be exogenous (from others or cross infection). This involves acquiring
infection from an external source; for example a patient or health worker, through
contaminated hands, or contaminated patient care items or the environment.

Some of the most common HAIs are; Urinary Tract Infections, Blood Stream Infections,
Surgical Site Infections and Pneumonia

14
Infection prevention practices are crucial for reducing the risk for any type of HAI with
application of an understanding of the chain of infection or transmission cycle. Two sets of
practices for Infection prevention are; Standard Precautions and Transmission-Based
Precautions

Background of Standard and Transmission Based Precaution

Infection prevention and control practices include, Standard and Transmission-based

Precautions.

Standard Precautions: These practices are designed for use in caring for all people-both
clients and patients attending healthcare facilities (first level precautions). These apply to
blood, all body fluids, secretions and excretions (except sweat), non-intact skin and
mucous membranes. Since no one really knows what organisms do clients or patients have, it
is necessary that standard precautions be used all the time.

Transmission-Based Precautions: The second level precaution is intended for use in

patients known or highly suspected of being infected or colonized with pathogens transmitted
by:

 Air (tuberculosis, chicken pox, measles, etc)

 Droplet ( flu, mumps and rubella); or
 Contact (hepatitis A or E and other enteric pathogens, herpes simplex and skin or
eye infections).

If there is any impending development of an infectious process in a patient without known

diagnosis, implementing Transmission-Based Precautions should be based on the patient‘s
signs and symptoms (empirical basis) up until a definitive diagnosis is made.

In all cases (whether they are being used alone or in combination), Transmission-
Based Precautions must be used in conjunction with the Standard Precautions.

15
Background of Clean and Asepsis Techniques

Aseptic technique means using practices and procedures to prevent contamination from
pathogens. It involves applying the strictest rules to minimize the risk of infection. Healthcare
workers use aseptic technique in surgery rooms, clinics, outpatient care centers, and other
health care settings.

Antisepsis is the process of reducing the number of microorganisms on skin, mucous

membranes, or other body tissue by applying an antimicrobial (antiseptic) agent.

The goal of the aseptic technique is to eliminate germs entirely. The goal of the clean
technique is to reduce the number of germs whenever possible.

Clean techniques are important for all healthcare providers and their patients because they
prevent infections every day.

Examples of clean techniques include washing hands and putting on clean gloves when needed.
Healthcare providers keep a patient‘s surroundings as clean as possible, but they aren‘t using
sterile items or aseptic technique.

Asepsis and aseptic techniques are the combination of efforts made to prevent entry of
microorganisms into any area of the body where they are likely to cause infection. The goal of
asepsis is to reduce to a safe level, or eliminate, the number of microorganisms on both animate
(living) surfaces (skin and mucous membranes) and inanimate objects (surgical instruments and
other items).

Keeping the environment as clean as possible is always important in preventing infections.

However, some situations call for aseptic technique while others call for clean techniques.

Asepsis Risk reduction of Contamination

Surgical Antiseptic Aseptic Technique Clean Technique

Technique

16
Summary

In summary, the goal of infection prevention and control is to make health care facilities a
safer place and WHO‘s components of infection prevention and control is an integral part of
this guideline. Understanding each step of infection chain or cycle is a one step forward in
prevention and control of HAI‘s. Always Apply Standard Precaution and Transmission based
precaution as appropriate. Infection prevention and patient safety activates are every body‘s
responsibility. And each and every one of us have a responsibility to implement IPC and PS
activates in our health care facilities.

17
CHAPTER 2: BASIC MICROBIOLOGY FOR IPC
Key Topics

Basic Features of Microorganisms

Classifications and Identification Of Microorganisms
How Microorganisms Cause Disease
Common Techniques for Identifying Microorganisms
Characteristics of Microorganisms of Interest for Infection Prevention and Control (IPC)

Definition of Key Terms

Antibody is a microscopic structure, called an immunoglobulin, produced by the immune

system, which is the system that defends the body from infection. Antibodies can be found in
the blood and other body fluids.

Antigens are foreign molecules such as toxins, viruses, or bacteria that stimulate the body‘s
immune system to produce antibodies.

Antimicrobial resistance Antimicrobial resistance occurs when microorganisms such as

bacteria, viruses, fungi, and parasites develop ways to avoid the effects of medications used to
treat infections (such as antibiotics, antivirals, and antifungals) and pass these changes on to
their off-spring or in some cases to other bacteria via plasmids. Mechanisms can include
production of substances that inactivate the drug, an alteration in cell structure that prevents
the drug from binding with the cell, or the ability to pump the drug out of the cell. Resistance
develops by changes in existing genes or by acquisition of new genes (such as from plasmids).

Antimicrobial susceptibility testing (AST) measures the activity of one or more

antimicrobial agents against a microorganism isolated from a sample to determine potential
susceptibility or resistance to antimicrobials. It helps the prescriber to determine which
antimicrobial will be most successful in treating a patient with a specific infection. The type
and extent of the AST conducted depend on the organism isolated, the source of the culture
(body site), available antimicrobial agents, and typical susceptibility patterns.

18
Colonization is the establishment of a site of pathogen reproduction in or on a host individual
that does not necessarily result in clinical symptoms or findings. A colonized individual may
transmit the colonizing pathogens to their immediate surroundings and other individuals.

Colony (bacterial colony) is a cluster of identical microorganisms growing on the surface of or

within a solid medium, presumably cultured from a single cell.

DNA, deoxyribonucleic acid, is the hereditary material for all living organisms; it contains the
instructions that make each type of living creature unique. DNA is the substance in the genes
that is organized into the chromosomes in the cells, determines particular characteristics, and
allows these characteristics to be passed from parents to offspring.

Endogenous infection is caused by organisms normally present within an individual‘s body

(normal flora or colonizing organisms).

Exogenous infection is caused by organisms from a source outside of the individual‘s body.

Infection is the condition resulting from an invasion and multiplication of microorganisms—

such as bacteria, viruses, and fungi—that are not normally present within the body. An
infection may cause no symptoms (subclinical infection) or it may cause symptoms (clinical
infection).Normal flora/commensal bacteria are microorganisms (usually bacteria and fungi)
that are naturally present in and on healthy people (e.g., on the skin or in the gut, or
reproductive or respiratory tract).
Opportunistic infection is an infection caused by a microorganism that under normal
circumstances does not cause disease but becomes pathogenic when the body‘s immune
system is impaired and unable to fight off infection, or antibiotic therapy allows for
overgrowth of some microorganisms (such as yeast in the gastrointestinal and reproductive
tracts).

Plasmids are genetic structures in a cell, typically a small, circular DNA strand in the
cytoplasm of a bacterium or protozoan independent of the chromosomes. They are relevant for
IPC as they enable antimicrobial resistance to pass from one genus of bacteria to another.

Polymerase chain reaction (PCR) is a type of molecular test in which genetic material
(DNA/RNA) is extracted from the sample and through complex techniques is duplicated or

19
amplified until there is a large enough amounts to test the DNA, RNA, or protein sequences
and identify specific microorganisms.

RNA, ribonucleic acid, is present in all living cells and many viruses. RNA molecules are
involved in protein synthesis and sometimes in the transmission of genetic information.

Species: refers to the taxonomic/biological classification system of microorganism; all species

have a two-part name, called a binomial (e.g., Staphylococcus aureus). The first name is the
generic name— genus—(e.g., Staphylococcus), the second name is the species (e.g., aureus),
based on structural and biochemical characteristics. A species can have different strains and
subgroups that can cause different diseases. Some organisms of medical interest are classified
below the species level, based on their characteristics (e.g., Escherichia coli O157:H7, a strain
that produces Shiga-like toxin).

Staining is a technique that uses dyes to color the cell wall of bacteria to quickly identify it in
a broad group of bacteria. Staining methods involve fixing bacteria cells to a glass slide and
then staining and washing them with a dye and alcohol. The differing characteristics of a
microorganism‘s cell wall cause the stain to be retained in the cell or not, resulting in color
changes. For example, Gram stain is used to differentiate bacteria into two groups, gram
positive and gram negative; acid-fast stain is used to identify Mycobacterium tuberculosis.

Strain is a variation in members of the same bacterial species. For treatment and
epidemiology, it may be helpful for clinical laboratories to distinguish between strains in the
same species. For example, some strains of E. coli are harmless and play an important role in
the human intestinal tract, but other strains can cause diarrhea. Tests such as PCR can identify
strains.

BACKGROUND

A basic knowledge of the microscopic organisms that commonly cause infections and the
methods used by the clinical laboratory to identify and examine them is important in the day-
to-day work of the IPC team. Understanding the features and behavior of the microorganisms
that are causing infections in a health care facility, in particular health care-associated
infections (HAIs), can help the IPC team choose the most effective prevention strategy. It will

20
also help IPC focal persons to more effectively convince health care workers (HCWs) of the
need for basic IPC strategies such as hand hygiene, Standard Precautions, Transmission-Based
Precautions, cleaning, and disinfection. Understanding the methods used in the clinical
laboratory can also assist the IPC team in making sure that the best-quality samples are taken
so that the microorganisms that are causing infection can be identified.
Basic Features of Microorganisms
The basic features that microorganisms of medical interest share can help hospital staff,
patients, and families understand the importance of IPC. These features include:

Table 2.0-1 Basic Features of Micro-Organisms and Implications for Health Care

Biological Characteristic Implications for Healthcare

feature
Microscopic Microorganisms can be Even a microscopic crack or space in equipment (such as
size: seen only with a an intravenous [IV] line or endoscope) can contain
microscope. numerous microorganisms that can be passed to a patient.

Rapid rate of If conditions are If even just a few microorganisms enter a vulnerable
reproduction favorable, patient under the right conditions, they have the potential
microorganisms can to cause serious infection within a short period of time.
multiply quickly.
Tendency to Microorganisms can Staff, patients, and families in health care facilities can
spread from spread through air spread microorganisms from one place to another and
one place to currents, people‘s hands, from one patient to another via their hands or equipment.
another: or equipment. Methods to remove microorganisms from hands, medical
equipment, and surfaces in facilities (hand washing,
cleaning, disinfection, and sterilization) must be
performed carefully, consistently, and thoroughly.
Ability to Some microorganisms HCWs must carefully follow instructions for removing
resist can survive harsh microorganisms from hands, medical equipment, and
eradication conditions (heat, cold, surfaces in facilities (hand washing, cleaning,
dryness, and chemicals). disinfection, and sterilization). (APIC 2014b)

21
Classification and Identification of Microorganisms

Microorganisms that HCWs and IPC staff may encounter in health care settings include
bacteria, fungi, parasites, and viruses.

The names of bacteria, viruses, fungi, and parasites follow the naming convention of the
biological classification system. Their names contain two terms and are written in italic letters.
The first term is the genus name; the second term is the species name. For example, for
Staphylococcus aureus, the genus name is Staphylococcus, the species is aureus.

After the first use of the full name in a text, the genus is abbreviated with the first letter;
Staphylococcus aureus is written as S. aureus.

The genus name can be used alone (e.g., Staphylococci) but the species (e.g., aureus) cannot
be used alone because a genus includes other species; Staphylococcus includes Staphylococcus
epidermidis and Staphylococcus haemolyticus.

The singular form of ―species‖ is abbreviated as ―sp.‖ and the plural as ―spp.‖ When used with
a genus, spp. is a short way of saying that something applies to many species within a genus,
but may not apply to all species within that genus.

Viruses are named by their family/subfamily, genera, and species. For example, influenza
virus is from the family Orthomyxoviridae, in general Influenza A, B, and C. There are several
subtypes of Influenza A, for example H1N1, H1N2, and H3N1.

It is common practice to name viruses based on the disease they cause. For example, the virus
that causes acquired immunodeficiency syndrome was named Human Immunodeficiency
Virus (HIV).

Bacteria
Characteristics

Bacteria are single-cell organisms (see Figure 2.0.1) with a well-defined cell wall that
maintains the shape of the cell and protects an underlying structure called the plasma
membrane, which surrounds and encloses the contents of the cell including:
 Cytoplasm, which contains the other cell contents

22
  Ribosomes, which produce proteins for cell function
 Genetic material, which is composed of a bacterial chromosome made of double-
stranded DNA that is essential for cell function and replication. Some bacteria also
have plasmids, which contain other DNA molecules that are not necessary for cell
replication and that carry genes for antibiotic resistance and production of toxins and
enzymes.
Some bacteria also have appendages on the outside of the cell that help the cell move (flagella)
or help the cell attach to surfaces or other cells (fimbriae and pili). (APIC 2014b)

Figure 2.0-1. Structure of a Bacterial Cell

Source: By Mariana Ruiz Villarreal, LadyofHats, via Wikimedia Commons.
https://commons.wikimedia.org/wiki/File:Average_prokaryote_cell-_en.svg.

Bacteria reproduce by cell division; a cell divides into two identical cells. When artificially
grown on an appropriate culture medium, new cells form groups of the same species and strain
of bacteria, called colonies, which may be seen with the naked eye.

Significance for Healthcare

Bacteria are the most common causes of HAIs (WHO 2002) and thus it is helpful for HCWs as
well as the IPC team to know the key characteristics of bacteria commonly seen in health care
facilities.

23
Laboratory Methods of Identification

Colonies of bacteria can be identified without a microscope by their appearance (known as

clonal morphology) on the nutrient gel used to grow them. Colonies of bacteria differ in color,
size, form, elevation, texture and margin (See figure below).

Figure 2.0-2. Clonal Morphology of Bacteria Source: By Macedo [CC BY-SA 4.0], via Wikimedia
Commons. https://commons.wikimedia.org/wiki/File%3AColony_morphology.svg.

Morphology (forms and structure) of bacteria cells is used to identify and classify different
groups of bacteria. Given the small size of these microorganisms, they can be viewed and
recognized only under a microscope, based on their size, shape, and how they are grouped
together. Figure 2.0.3 shows some of the different shapes and groupings of bacteria that can be
seen under the microscope.
Coccus: Staphylococcus aureus
Rods (bacilli): E. coli, K. pneumoniae
Spiral: Treponema pallidum pertenue

Figure 2.0-3 Shapes and Groupings of Bacteria Source: Mariana Ruiz LadyofHats, via Wikimedia Commons.
https://www.commons.wikimedia.org/wiki/File%3ABacterial_morphology_diagram.svg.

24
Staining of the cell walls with different dyes is also used to identify and classify bacteria
(see Figure 2.0.4). Gram stain is widely used in clinical laboratories to differentiate bacteria
into two groups, gram positive and gram negative. Nearly all clinically relevant bacteria fall
into one of these two groups based on whether or not their cell walls retain Gram stain.
Another clinically relevant group of bacteria are acid-fast bacilli (AFB). Gram stain quickly
determines a broad group of bacteria, which can be important for choosing the appropriate
antibiotic to treat the infection and for determining the need for isolation of the patient. For
example, gram-negative diplococci in cerebrospinal fluid suggest meningococcal meningitis,
and gram-positive cocci suggest staphylococci as the cause of infection. AFB-positive rods
suggest Mycobacterium spp., which may be tuberculosis (TB). (APIC 2014b)

Gram stain can also help the IPC team focus and guide IPC activities. For example, gram-
positive bacteria include S. aureus, which commonly colonizes the skin and nose of staff and
patients. S. aureus is often resistant to antibiotics and can cause serious infections in the lungs,
bones, and heart and can also result in sepsis.

25
 Figure 2.0-4. Bacterial Classification by Staining Properties
Source: Lowy F. Bacterial Classification, Structure and Function.
http://www.columbia.edu/itc/hs/medical/pathophys/id/2009/introNotes.pdf.

Gram-negative bacteria include Enterobacteriaceae (e.g., Escherichia coli, Klebsiella spp.,

Serratia spp.) that commonly cause serious infections, particularly when medical devices are
used (such as urinary catheters and IV lines), and are often resistant to antibiotics and colonize
patients in hospitals. Other gram-negative organisms (Pseudomonas spp. and Acinetobacter
spp.) live in damp and wet areas of facilities, are difficult to eradicate from the environment,
and cause HAIs.

Growth characteristics, including growth rate, composition of the air, nutrients, and
temperature in which bacterial colonies grow, are used to identify bacteria. Bacteria can be
divided into groups according to:
 Oxygen requirements: ―Aerobic‖ bacteria require oxygen to grow; ―anaerobic‖
bacteria grow in the absence of oxygen. Aerobic bacteria are more likely to be found
on the surface of the body. The presence of anaerobic bacteria (e.g., Bacteroides
fragilis and Clostridium perfringens) can indicate a source from a deep wound, the gut,
or vagina. Bacteria can be strict (obligate) anaerobes, which die in the presence of
oxygen, or facultative anaerobes, which can survive with or without oxygen. (APIC
2014b)
 Fermentation of carbohydrates: Lactose fermenting bacteria are typically gram
negative. For example, Enterobacter spp. are lactose fermenting and Pseudomonas
spp. and Proteus spp. are non-lactose fermenting.
 Presence of specific enzymes:

26
 o Catalase test differentiates streptococci (negative) from staphylococci
(positive).
o Coagulase test differentiates S. aureus (positive) from other staphylococci such
as S. epidermidis (negative). (APIC 2012; APIC 2014b)

Viruses
Characteristics

Viruses are microorganisms that are smaller than bacteria and consist of genetic material,
which can be either DNA or RNA, surrounded by a protein coat and, in some viruses, by a
membranous envelope. Viruses do not have many of the cell structures found in bacteria and
fungi and are able to multiply only within the living cells of a host (see Figure 3-5.) They
attach to receptors on the host cell (such as a respiratory tract cell), enter the cell, and use the
cell to replicate. The offspring are then released from the host cell.

Viruses are classified based on:

 The type of substance that makes up their central core—DNA (e.g., herpesvirus,
cytomegalovirus) or RNA (e.g., HIV, measles, Ebola, SARS, hepatitis C, and polio)
 The number of strands in the core—double-stranded (e.g., rotavirus) or single-stranded
 The presence or absence of a membrane-like envelope surrounding them—enveloped
(herpesvirus, chicken pox virus, influenza viruses, and Ebola virus) and non-enveloped
viruses (adenovirus, poliovirus)

(APIC 2014b)

Figure 2.0-5 Transmission Electron Micrograph of the Ebola Virus Credit: CDC/Cynthia Goldsmith, #1832.

27
Implications for Healthcare

Many viruses can be transmitted in the health care environment and often cause HAIs and
outbreaks. Bloodborne viruses, such as HIV and hepatitis B and C, can be spread from patient
to patient during transfusions, dialysis, injections, and endoscopy. Viruses such as influenza
and respiratory syncytial virus (RSV) can be spread from patient to patient by respiratory fluid
droplets during crowding or sharing of respiratory equipment, or on contaminated hands.
Others viruses such as measles and varicella quickly spread to patients on air currents.
Rotaviruses and enteroviruses infect the gastrointestinal tract and are transmitted by hand-to-
mouth contact due to poor hand hygiene and inadequate cleaning. (WHO 2002).

The presence or absence of a virus envelope has significance for cleaning and disinfection.
Enveloped viruses (e.g., herpes, HIV, Ebola) are easier to kill with disinfectants than non-
enveloped viruses (e.g., norovirus, rotavirus, adenovirus, and poliovirus). Cleaning products
should be evaluated for their ability to kill both enveloped and non-enveloped viruses. (Rutala
et al., 2008).

Laboratory Methods of Identification

Most virus identification methods are out of the scope of many clinical laboratories in limited-
resource settings but may be available in reference laboratories. Examples of some tests
commonly used to detect the presence of virus are:
 Enzyme-linked immunosorbent assay (ELISA) for detecting antibodies against HIV,
RSV, rotavirus, and hepatitis B
 Polymerase chain reaction (PCR) for DNA and RNA detection of HIV, HPV, and
many others viruses
 Papanicolaou (Pap) smears for the effect of human papillomavirus on squamous cells
lining the cervix, (APIC 2014b)

Fungi
Characteristics

Fungi are typically slightly larger than bacteria and can be divided into yeasts and molds based
on their appearance:

28
  Yeasts are single-celled, microscopic, and form smooth, creamy colonies in culture
(see Figure 2.0.6).
 Molds consist of long, branching filaments of cells called hyphae. A tangled mass of
hyphae visible to the naked eye is a mycelium and can be various colors (black, white,
or green),(APIC 2014b)

Figure 2.0-6 Candida albicans

Credit: By Graham Colm (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0) or
GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons.

Significance for Healthcare

While fungi can cause infection in humans (e.g., Candida albicans), most are opportunistic
pathogens that cause infections (which can be severe) in those who are on extended antibiotic
treatment or are immunosuppressed (C. albicans, Aspergillus spp., Cryptococcus neoformans,
Cryptosporidium). A species of yeast, Candida auris, with a propensity to spread in hospitals
and resistant to multiple antifungals, is emerging globally. Molds such as Aspergillus spp.,
which originate in dust and soil can become airborne and infect vulnerable patients during
hospital renovation or construction if precautions are not taken. (APIC 2014b; WHO 2002)

29
Laboratory methods of identification

Like bacteria, fungi can also form colonies. Fungi are mainly identified using direct
examination under the microscope of physical characteristics of the mold, such as shape, color,
staining, and the root-like structures; they are also identified through culture and non-culture
tests. (APIC 2014b).

Parasites
Characteristics
Parasites range from single-cell protozoan parasites (Giardia spp. and Plasmodium spp.) to
large worms (e.g., hookworm) and insects (Sarcoptes scabiei, the scabies parasite). Some
parasites can live inside the cell (intracellular), such as the parasite that causes malaria
(Plasmodium spp.) (See Figure 2.0.7). Others (such as scabies, mites, and lice) live on the
outside of the body, on the skin. Most protozoan parasites exist in two different forms:
 The trophozoite stage—the feeding stage during which the parasite produces effects in
the host
 The cyst stage—the dormant stage, when most protozoan parasites are transmitted

Figure 2.0-7 Plasmodium falciparum, Malaria Parasite Credit: CDC/Dr. Mae Melvin.

30
Common Parasitic Infections

Health care-associated parasitic infestations include scabies, lice, and myiasis (maggots).
Water- or foodborne parasite infestations—such as amoebiasis (caused by Entamoeba
histolytica) or cryptosporidiosis (caused by Cryptosporidium parvum)—mainly occur in
community settings but can also spread within hospitals.

31
Significance for Health Care

Some parasites can spread from person to person in health care facilities. Giardia lamblia is
easily transmitted from person to person through poor hand hygiene and unclean surfaces. The
mite that causes scabies can cause outbreaks in health care facilities. Others, such as malaria,
are spread via mosquitoes (vectors) and so can spread within health care facilities if patients
are not protected from mosquito and other insect bites. (WHO 2002)

Laboratory Methods of Identification

Several laboratory methods for identification of parasite infestation are available. They include
microscopy, serology-based assays, and molecular-based essays. Direct examination of stool
or urine for blood or ova from intracellular parasites is the primary method of diagnosis for
parasites in some laboratories. (APIC 2014b)

Microbial Pathogenesis (How Microbes Cause Disease)

Normal Flora/Commensal Microbiota

Normal flora/commensal microbiotan vary by body site. For example, coagulase-negative

staphylococci are common on the skin and E. coli in the gut. (APIC 2014b; WHO 2002)

Implications for health care: Commensal bacteria can cause opportunistic infections when the
immune system is compromised (e.g., in infants, the elderly, or those with acute or chronic
disease) or the other body defenses are interrupted (e.g., a surgical wound disrupting the
protective barrier of the skin, a medical device like an IV or urinary catheter entering the body,
or prolonged use of antimicrobial agents leading to an imbalance in the commensal gut
microbiota). Examples include coagulase-negative staphylococci from the skin, which can
cause an IV line infection, and E. coli from the gut, which can cause a urinary tract infection.
(WHO 2002)

Colonization

Examples of colonization include Neisseria meningitidis in the throat, Salmonella species in

the gut, methicillin-resistant S. aureus (MRSA) in the nose, or yeast in the genital tract.

32
Implications for Healthcare: Colonization may result in infection of the colonized person
when the immune or other body defenses are interrupted (e.g., a person colonized with MRSA
has surgery, which interrupts the natural barrier of the skin, and develops a MRSA surgical site
infection [SSI]). Transmission to others (e.g., a person with Salmonella colonization is
involved with food preparation at the health care facility and does not wash his/her hands and
transmits Salmonella to patients).

Organisms that are resistant to antibiotics often colonize hospitalized patients, which can then
lead to infections that are difficult to treat. Surveillance cultures (such as nose swabs for
MRSA and rectal swabs for vancomycin-resistant enterococci [VRE] or carbapenem-resistant
Enterobacteriaceae [CRE]) may be used in some settings to identify patients with colonization.
If colonization with MRSA, which can cause serious SSIs, is identified before surgery from
surveillance cultures of the nose (or other sites), medications to decolonize can be prescribed
to decrease the risk of an SSI from MRSA.

Infection

An infection usually causes clinically apparent symptoms or sometimes may cause no

symptoms and be subclinical. Symptoms vary according to the type of microorganism and the
location of the infection. Symptoms are a result of the actions of the microorganisms on the
body (e.g., diarrhea, necrotic tissue) and the immune response to them (e.g., fever, purulence).
The characteristics and location of the microorganism as well as the immune status of the
person determine if and how an infection progresses. (APIC 2014b)

Implications for Healthcare: People seeking care at health care facilities may be the more
vulnerable and prone to infections, particularly infants, pregnant women, the elderly, people
with acute or chronic diseases, and those with a condition that suppresses the immune system
and/or disrupts body defenses (wounds, invasive medical devices). It is important to protect
patients from exposure to pathogenic microorganisms in the facility and identify any patients
with infections that may spread to others.

33
Sources of Microorganisms

HAIs can be categorized according to the source of the microorganisms that cause them. Bacteria
can come from:

 The Patient (Endogenous): Organisms from the individual‘s own body (normal flora
or colonization) can cause infection when the immune system is compromised, other
body defenses are interrupted (via a wound or medical device), or antibiotic therapy
causes overgrowth of some microorganisms (such as yeast in the gastrointestinal and
reproductive tracts). (APIC 2014b; WHO 2002)

Implications for healthcare: IPC includes surgical asepsis, pre-operative skin

antisepsis, preventive care when inserting and maintaining invasive medical devices,
removal of invasive medical devices as soon as possible, decolonization of colonized
patients using an appropriate antimicrobial agent, patient education on hand hygiene
and cleanliness, and rational use of antibiotics.

 Another Person (Exogenous infection): Organisms that cause infection can come
from a source outside of the individual, such as:
o Other patients (direct contact with blood or other body fluids, respiratory
droplets, unwashed hands)
o Airborne (aerosols/air droplets carrying TB, varicella, or measles)
o Staff (contaminated or colonized hands, clothing, skin)
o Objects contaminated by an infected person (equipment, environmental
surfaces) or contaminated sources (water, fluids, food) (APIC 2014b; WHO
2002)
Implications for Health Care: IPC includes Standard Precautions, including hand
hygiene and use of personal protective equipment, and isolation using Transmission-
Based Precautions. Administrative and environmental controls should also be
considered.

34
  The health care environment: Organisms causing infection can come from the
hospital environment where they live permanently or transiently, including places such
as:
o Water, damp areas, fluids, and even disinfectants (e.g., Pseudomonas spp.,
Acinetobacter spp., Mycobacterium spp., Legionella spp.)
o Surfaces, equipment, supplies, and patient care items if re-used and/or not well-
cleaned.
o Food prepared or stored by the hospital or the patients‘ families.
o Dust/soil, such as during construction or renovation of the facility (e.g.,
Aspergillus spp.) (APIC 2014b; WHO 2002)

Implications for health care: IPC includes proper handling of fluids, correct handling
and dilution of disinfectants, elimination of damp areas when possible, use of the
cleanest water available, monitoring of the food service, regular and thorough
environmental cleaning, hand hygiene, proper cleaning of multi-use items, and
isolation/careful control in areas undergoing construction/renovation.

Background of Microorganisms of Interest for Infection Prevention and control

Characteristics of Organisms Commonly Associated with Health Care-Associated
Infections

Microorganisms have characteristics that enable them to survive and/or easily spread in health
care environments. These characteristics include:

 Are able to survive on the hands of HCWs, environmental surfaces, and medical
equipment when IPC practices such as hand hygiene, cleaning, disinfection, and
sterilization are suboptimal. Examples include influenza virus, RSV, and S. aureus,
which can live for hours or days on hands and surfaces if not cleaned.

 Can survive dryness, heat, and disinfectants and so can cause infections in patients
and HCWs in health care facilities despite IPC methods such as hand hygiene,
cleaning, disinfection, and sterilization. Examples include norovirus, C. difficile, some
molds that survive by forming spores, Pseudomonas spp., and microorganisms that
have been known to survive in disinfectants.

35
 Live in blood and body fluids even though they cannot survive for long in the health
care environment. These microorganisms can be passed from person to person via
items contaminated with blood or body fluids—even minute amounts. Examples
include hepatitis B virus, hepatitis C virus, and HIV on or in dialysis machines, multi-
dose vials, multi-use lancets, or insulin pens; and Ebola virus on hands, equipment, and
surfaces that are not adequately cleaned.

 Thrive in damp areas, and thus the drains, sinks, and equipment that use water (such
as humidifiers, patient warmers, and respiratory equipment) can harbor these
organisms. Fluids used in health care, such as IV fluids and disinfectants, can also
grow microorganisms. Examples include Mycobacterium spp. and gram-negative
bacteria such as Acinetobacter spp., Pseudomonas spp., Burkholderia spp., and
Enterobacteriaceae.

 Colonize patients and staff, allowing the microorganisms to survive in the health care
environment and pass from person to person, causing an infection if the immune
defenses become suboptimal, such as after surgery or when medical devices are in
place. Examples include S. aureus, Enterobacteriaceae, and Enterococcus spp.

 Are small in size and able to remain suspended in the air and be transmitted short
distances through the air in respiratory droplets, particularly when propelled by
coughing or sneezing, and therefore can cause transmission if personal protective
equipment to protect the nose, mouth, and eyes—as described for Standard and
Transmission-Based Precautions—is inadequate. Examples include influenza and N.
meningitidis.

 Are very small in size and so able to float long distances on air currents if the
ventilation of the facility is not protective of staff and patients. Examples include the
viruses causing varicella, measles, and SARS.

 Are resistant to antimicrobials; examples include MRSA, VRE, and CRE. Source:
CDC 2014.

36
These characteristics help determine which microorganisms commonly cause HAIs. The
causes of HAIs are generally similar, no matter the country or region (see Table 1-2-2).
Although, gram-negative organisms are more likely to be the most common cause of
bloodstream infection in middle- and low-resource settings than in high-income settings. A
knowledge of the specific microbes and the microbial patterns of infection in your facility
(from surveillance), country (from the health department or published articles), or region (from
combined data such as those in Table 1-2-2) can be helpful in guiding IPC efforts at your
facility. (Mahon et al. 2014; WHO 2011)
Figure 2.0-8: Microorganisms That Cause the Four HAIs of Global Public Health Interest

HAI Microorganisms That Cause the HAIs

Central line-associated Coagulase-negative staphylococci, S. aureus, Enterococcus spp.,
bloodstream infection Candida species, MRSA, Klebsiella pneumonia, Escherichia coli,
Pseudomonas aeruginosa
Surgical site infection S. aureus, coagulase-negative staphylococci, Enterococcus spp., E.
coli, P. aeruginosa, Enterobacter species, K. pneumoniae and
oxytoca, Candida spp., Acinetobacter Baumannii

Catheter-associated E. coli, Enterococcus spp., P. aeruginosa, Candida spp., K.

urinary tract infection pneumoniae, Enterobacter spp.

Pneumonia E. coli, Klebsiella spp., Proteus spp., S. pneumoniae, H. influenzae,

S. auerus, Acinetobacter spp., P. aeruginosa
Adapted from: American Thoracic Society and Infectious Diseases Society of America 2005; Carr 1998; CDC
2011; Hidron et al. 2008.

Gram-Negative Bacteria

Health care-associated infections caused by gram-negative bacteria include pneumonia,

bloodstream infections, wound or surgical site infections, and meningitis. Gram-negative
bacteria are often resistant to antibiotics. This group, which includes Klebsiella spp.,
Acinetobacter spp., Pseudomonas aeruginosa, and E. coli, among many others, is found in
damp areas and is transmitted via unwashed hands of HCWs, water sources, and inadequately
cleaned medical equipment. Careful attention to IPC practices such as Standard Precautions,
including hand hygiene and proper environmental cleaning, reduces the risk of patients
acquiring infections.

37
 Enterobacteriaceae are a group consisting of several families of gram-negative
bacteria, many of which are normally present in the gut, including E. coli, and species
of Proteus, Enterobacter, Klebsiella, Citrobacter, and Serratia. However, patients
whose care requires medical devices (endotracheal tubes, urinary catheters, or IV
catheters) and those who are on long courses of antibiotics are at risk of developing
localized or bloodstream infections with these organisms. Members of this group can
cause gastrointestinal illness (e.g., Shigella, Salmonella, and Yersinia).

Enterobacteriaceae in health care settings are of particular concern because they have
become resistant to most or all available antibiotics and pass this resistance along to
other bacteria. Similar to other gram-negative organisms, prevention includes cleaning,
preventing damp areas, and paying careful attention to IPC measures such as Standard
Precautions and hand hygiene. Rational use of antimicrobials is also a critical
component. Contact Precautions may be warranted for known cases of multidrug-
resistant colonization or infection. (CDC 2014; WHO 2002)

 Acinetobacter species are commonly found in water and soil but infections with this
organism rarely occur in the community. Outbreaks of pneumonia and blood and
wound infections in hospitals, including intensive care units, are usually caused by
Acinetobacter baumannii. Acinetobacter spp. can also colonize patients (such as those
on a ventilator, with wounds, or with a long hospital stay) and spread to other patients.
Prevention includes cleaning, preventing damp areas, and paying careful attention to
IPC practices such as Standard Precautions, including hand hygiene and environmental
cleaning. (CDC 2014; WHO 2002)

 Pseudomonas infection is caused by strains of bacteria found in the health care

environment, especially Pseudomonas aeruginosa. Although P. aeruginosa can cause
infections in the community (such as ear and eye infections), serious infections usually
occur in health care settings. Patients with weak immune systems, those with medical
devices (endotracheal tubes, urinary catheters, or IV catheters) and those with wounds
from surgery or from burns are at risk for life-threatening infections. Prevention
includes cleaning, preventing damp areas, and paying careful attention to IPC practices

38
 such as Standard Precautions, including hand hygiene and environmental cleaning.
(CDC 2014; WHO 2002)

Gram-Positive Bacteria

Gram-positive bacteria often cause infections in health care settings. These bacteria have
sturdy cell walls and are therefore capable of surviving for longer periods on surfaces in the
health care environment and on the skin. (WHO 2002)

 Staphylococcus aureus is found on the skin and in the nasal passages of about 30% of
people. It causes skin infections in the community; however, in health care settings S.
aureus can cause serious and life-threatening infections such as pneumonia, sepsis,
endocarditis, osteomyelitis, and SSI. Patients with weak immune systems, those with
medical devices (endotracheal tubes, urinary catheters, or IV catheters), and those with
chronic conditions such as diabetes or cancer are at risk. S. aureus can become resistant
to antibiotics, making the infections more difficult to treat (specifically the group of
beta-lactam antibiotics that include methicillin, oxacillin, penicillin, and amoxicillin).
These are known as methicillin-resistant Staphylococcus aureus (MRSA). Prevention
includes careful attention to IPC practices such as Standard Precautions, including
hand hygiene and environmental cleaning, and excellent asepsis of the skin before
procedures. Contact Precautions may be warranted for known cases of MRSA. (CDC
2014; WHO 2002)

Organisms Specific to Particular Body Systems

It can be helpful for the IPC team to be aware of the microorganisms that typically cause
infections to various body systems (see Table 2.0.3). Those infections occurring in the
community may be caused by different organisms than those acquired in the health care
facility. An occurrence of one of these infections should alert the IPC team to investigate a
possible HAI. In addition, infections with certain organisms warrant Transmission-Based
Precautions to prevent their spread within the facility.

39
 Table 2.0-2 Background of the Common Organisms That Cause Infection of Body Systems

Infection/Site Common Organisms

Bone and joint Osteomyelitis: S. aureus, Salmonella sp., Pseudomonas sp., Streptococcus
Infections agalactiae, Septic arthritis: S. aureus, Neisseria gonorrhoeae, S. pneumoniae,
S. pyogenes
Endocarditis/ St. viridans, S. aureus, Enterococcus spp., Haemophilus spp., S. epidermidis,
heart valve Candida spp.
Gastroenteritis/ Salmonella sp., Shigella spp., Campylobacter spp., E. coli O157:H7, viruses, G.
Intestines lamblia, Entamoeba histolytica, Yersinia spp., Vibrio spp., C. difficile

Meningitis/brain Neonates: Gram-negative bacilli, St. agalactiae (group B), Listeria

Membrane monocytogenes
Infants: St. agalactiae (group B), E. coli, H. influenzae, S. pneumoniae, N.
meningitides
Children: S. pneumoniae, N. meningitides
Older adults: S. pneumoniae, N. meningitides, L. monocytogenes, aerobic gram-
negative Bacilli
Others: C. neoformans, M. tuberculosis, viruses

Peritonitis/ Bacteroides spp., anaerobic cocci, Enterococcus spp., Enterobacteriaceae, S.

Abdomen aureus, Candida spp.

Respiratory tract Pharyngitis: S. pyogenes, respiratory viruses, C. albicans, N. gonorrhoeae,

infections, upper Corynebacterium Diphtheria
Sinusitis: S. pneumoniae, H. influenzae, S. pyogenes, S. aureus, gram-negative
bacilli
Respiratory tract Bronchitis: S. pneumoniae, H. influenzae, respiratory viruses, Bordetella
infections, lower pertussis, RSV
Pneumonia: S. pneumoniae, H. influenzae, Mycoplasma pneumoniae,
Chlamydophila pneumoniae, Mycobacterium tuberculosis, S. aureus, gram-
negative bacilli, anaerobes, Legionella pneumophila, Pneumocystis jiroveci
(carinii)
Empyema: S. aureus, Streptococcus spp., anaerobes, S. pyogenes, H. influenza
Sexually Chlamydia trachomatis, N. gonorrhoeae, Bacteroides spp., Enterobacteriaceae,
transmitted Gardnerella
diseases vaginalis, Mobiluncus sp., Trichomonas vaginalis, Treponema pallidum, HIV,
Skin infections cytomegalovirus, human papillomavirus, pubic lice, scabies
S. aureus, S. pyogenes, Candida spp., dermatophytes, gram-negative bacilli,
Clostridium
spp.
Burns: S. aureus, Candida spp., P. aeruginosa
Urinary tract E. coli and other Enterobacteriaceae, Enterococcus spp., Candida spp.,
Infections Klebsiella spp.,
Proteus spp., Pseudomonas spp., S. saprophyticus
Sources:APIC2014b;Brooks2012;Mahonetal.2014

40
Summary
Microorganisms that IPC staff may encounter in health care facilities include bacteria, fungi,
parasites, and viruses. Collaboration with the clinical laboratory can increase the IPC team‘s
capacity to identify, investigate, and contain infectious diseases.

Knowledge of the microorganisms that cause HAIs and the methods used to identify them are
important in the day-to-day work of an IPC team and will help improve patient safety at the facility.
The IPC team needs to aware of, and knowledgeable about, the basic characteristics of
microorganisms that cause HAIs and should be familiar with the characteristics of those organisms
that are significant in their setting and patient population.

41
CHAPTER 3: STANDARD AND TRANSMISSION-BASED PRECAUTIONS
Key Topics:

Key components of Standard Precautions

Key components of Transmission-based Precautions
Empiric /Syndromic use of transmission-Based Precautions
Recommended precautions for each route of infection transmission

Definition of Key Terms

Airborne transmission is the spread of an infectious agent carried through the air by particles
smaller than 5 µm in size.

Cohorting is the practice of placing patients with the same infectious disease (e.g., measles, influenza)
or colonization (e.g., multidrug-resistant organisms) but no other infection, in proximity (e.g., the
same room, the same ward, or the same area of a ward).

Colonization is the establishment of a site of pathogen reproduction in or on a host individual that

does not necessarily result in clinical symptoms or findings (e.g., cellular change or damage). A
colonized individual may transmit the colonizing pathogens to their immediate surroundings and other
individuals.

Contact transmission occurs when infectious agents/pathogens (e.g., bacteria, viruses, fungi,
parasites) are transmitted directly or indirectly from one infected or colonized individual to a
susceptible host. This can occur through physical contact (e.g., touching) with the infected individual
or with contaminated equipment/environmental surfaces. Infectious agents/pathogens can often
survive on physical surfaces from several hours up to several months.

Droplet nuclei are small particles involved in the airborne transmission of pathogen-containing
respiratory secretions expelled into the air by coughing. They are small, dry particles that can remain
airborne for long periods of time and distance.

Droplet transmission occurs when infectious droplets larger than 5 µm in size are spread and land
directly on or come in contact with a susceptible host‘s mucous membranes of the nose or mouth or
conjunctivae of the eye. Droplets can be produced by coughing, sneezing, talking, or during
procedures (e.g., bronchoscopy or suctioning). Due to their size, particles remain airborne briefly and

42
can travel about 1 meter (3 feet) or less. Droplet transmission requires close proximity or contact
between the source and the susceptible host. Droplets may also land on surfaces and then be
transferred by contact transmission.

Empiric in the context of health services refers to an action, intervention, or practice being
implemented on the basis of a clinical educated guess, based on experience and in the absence of
laboratory test results for specific diagnosis. The empiric action, intervention, or practice is continued
until the definitive diagnosis is made.

Engineering controls are methods that are built into the design of the environment, equipment, or a
process to minimize the hazards associated with use. An example is a medical device or piece of
equipment that limits exposure to bloodborne pathogens in the workplace, such as sharps disposal
containers, self-sheathing needles (a barrel or cover that automatically slides over the needle and locks
in place once the needle has been removed from the patient), sharps with injury protection, and
needleless systems.

Health care-associated infection (HAI) is an infection that occurs in a patient as a result of care at a
health care facility and was not present at the time of arrival at the facility. To be considered an HAI,
the infection must begin on or after the third day of admission to the health care facility (the day of
admission is Day 1) or on the day of or the day after discharge from the facility. The term ―health care-
associated infection‖ replaces the formerly used ―nosocomial‖ or ―hospital‖ infection because
evidence has shown that these infections can affect patients in any setting where they receive health
care.

Injection safety is a set of techniques used to perform injections in an optimally safe manner for
patients and health care workers (HCWs) during patient care.

Personal Protective Equipment (PPE) items are the protective barriers and respirators used alone or
in combination by an HCW to protect mucous membranes, airways, skin, and clothing from contact
with harmful or infectious agents. PPE may also be used on an infectious patient to prevent the spread
of infectious agents (e.g., surgical mask worn by a patient during transport to control the spread of
illness).

Respiratory hygiene/cough etiquette are measures taken to prevent transmission of respiratory

infections including influenza in health care facilities. They involve maintaining at least a 1-meter (3-
foot) distance from other individuals in common waiting areas, covering mouth/nose when

43
sneezing/coughing, performing hand hygiene after soiling hands with respiratory secretions, and
placing visual alerts to remind HCWs, patients, and visitors to practice respiratory hygiene and cough
etiquette.

Sharps safety and needle safety are procedures used to handle needles and other sharp devices in a
manner that will prevent injury and exposure from infectious agents during routine patient care.

Standard Precautions are a set of infection prevention and control practices (IPC) used for every
patient encounter to reduce the risk of transmission of blood borne and other pathogens from both
recognized and unrecognized sources. They are the basic level of IPC practices to be used, at a
minimum, in preventing the spread of infectious agents to all individuals in the health care facility.

Syndromic approach is an approach that bases preventive actions on a set of signs and symptoms that
are suggestive of a clinical condition rather than a specific diagnosis. The symptoms could be related
to multiple systems or organs.

BACKGROUND
The guideline issued by the CDC in 1996 involves two level approaches, namely standard precaution
and transmission precaution. Standard Precautions combine the major features of universal precaution
and body substance isolation. The basic concept in the implementation of Standard Precautions is the
maintenance of a physical, mechanical, or chemical barrier between microorganisms, the environment,
and an individual, thus breaking the disease transmission cycle. The rationale is that, for transmission
to occur within the health care setting, all elements in the disease transmission cycle must be present
(see chapter one disease transmission cycle). Whether it is a woman coming for antenatal care, a
hospitalized patient, or an HCW caring for patients, Standard Precautions help prevent the spread of
blood borne pathogens, respiratory viruses (e.g., hepatitis B, hepatitis C, HIV, and influenza), and
other infectious diseases in health care facilities

Standard Precautions

This are set of guidelines designed to create physical, chemical and mechanical protective barrier
between microorganism and person to prevent the spread of infection (the barrier serves to break the
diseases transmission cycle)

Example of barriers

 Physical Barrier – PPE

44
  Mechanical Barrier – HLD and Sterilization
 Chemical Barrier – Antiseptic and Disinfectant

Standard Precautions are first level precautions. The aim of standard precautions is to reduce the risk
of transmitting micro microorganism from known or unknown sources of infection (e.g. respiratory
droplet, contaminated object) within health care settings. Applying Standard Precautions while
providing patient care is based on the anticipated interaction HCW will have with blood, body fluid
or potential pathogen exposure from patients. They provide a rationale for appropriate utilization of
limited IPC resources.

Key principles of Standard Precautions

 Consider every client and patient as potentially infectious or susceptible to infection.

 Apply to all patients and clients attending health care facility
 Apply to all blood, body fluid, secretion, execration (except sweat), mucous membrane and
no intact skin.

Key Components of Standard Precautions

The components of Standard Precautions create protective barriers for preventing infections in
visitors, patients, and HCWs and are based upon the premise that every person (patient, visitor, or
HCW) is potentially infectious and susceptible to infection.

Key Components of standard precaution includes

 Hand Hygiene involves HCWs cleaning their hands before, after, and at specific moments
during patient care and when performing health care tasks. Hand hygiene is the single most
important intervention for preventing transmission of infections (e.g., person to person or
contaminated object to person). It must be performed consistently at the recommended
moment during patient care using soap and water or alcohol-based handrub (ABHR) and
with a technique that effectively removes microorganisms from hands (For detailed
information see Volume 1, Chapter 4: Hand Hygiene).

 Use of PPE relies on an HCW‘s assessment of the likely risk of contact with potentially
infectious materials during each task. The appropriate PPE should be chosen by the HCW
according to the assessed risk. The risk is not based on the appearance, characteristics, or
diagnosis of the patient, but rather the potential for the HCW coming into contact with

45
 blood, body fluids, non-intact skin, mucous membranes, or items that have been in contact
with these. The risk may be re-assessed during the task (e.g., if the patient starts vomiting)
and PPE added as needed. PPE may include the following depending on the assessed risk
(For detailed information see Volume 1, Chapter 5: Personal Protective Equipment).

 Safe Injection Practices are those that do not harm the patient, do not expose the HCW to
any risks, provided by skilled person, using appropriate injection equipment and do not
result in waste that is dangerous for the community (For detailed information see Volume 1,
Chapter 6: Sharps and Injection Safety).

 Environmental Cleaning of noncritical care equipment, instruments, devices, and

environmental surfaces. Clean patient care equipment between each use on patients to
prevent cross-contamination between patients (For detailed information see Volume 1,
Chapter 9: Environmental Cleaning).

 Instrument Processing -processing instruments and other items (before reuse) so as to

reduce the transmission of infection during clinical procedures and patient care by cleaning
and sterilization or HLD (For detailed information see Volume 1, Chapter 7:
Decontamination of Instruments and Medical Devices).

 Processing Textiles and Laundry in a manner that:

 Removes pathogens from the textiles and protects cleaned textiles from reintroduction of
pathogens.
 Reduces risk for transfer of pathogens to HCWs, other patients, and the environment.
(For detailed information, see Volume 1, Chapter 8: Processing Reusable Textiles and
Laundry Service).

 Healthcare Waste Management: Healthcare Waste (HCW) is a key issue to control and
reduce HAIs in Health-Care Facilities (HCF) and to ensure that the environment is well
protected. Healthcare Waste Management (HCWM) should be part of the overall
management system of a HCF and reflect the quality of the services provided by the
facilities.

46
Transmission-Based Precautions

Although the spread of infectious disease in hospitals has been recognized for many years,
understanding on how to prevent these infections and implementing the successful remedial policies
and practices have been not easy so far.

Isolation guidelines involve a two level approach: Standard Precautions, which apply to all clients and
patients attending healthcare facilities on the one hand, and Transmission-Based Precautions which
apply primarily to hospitalized patients on the other (Garner & HICPAC, 1996). Actually, either
approach is too interlinked to be used in separation. Thus, the relatively specific approach-
transmission-based precautions must be used in conjunction with the Standard Precautions.

Transmission-Based Precautions are for patients who are known or suspected to be infected or
colonized with infectious agents including epidemiologically important pathogens which require
additional control measures to effectively prevent transmission. Since the infective agent is not often
known at the time of admission to a healthcare facility, Transmission-Based Precautions are used
empirically according to the clinical syndrome and the likely etiologic agents at the time. Later,
the course of management should be modified as soon as the pathogen is identified or a
transmissible infectious etiology is ruled out.

There are three main types of Transmission-based Precautions namely:

 Airborne Precaution
 Droplet Precaution
 Contact Precaution

Note:
For some diseases that have multiple routes of transmission, more than
oneTransmission-Based Precautions category may be used (e.g., influenza, Middle East
Respiratory Syndrome-coronavirus [MERS-CoV], varicella)

When used either individually or in combination, each routes of transmission based precautions are
always used in addition to Standard Precautions. When Transmission-Based Precautions are
indicated, efforts must be made to counteract possible adverse effects on patients (i.e. anxiety,
depression and other mood disturbances, perceptions of stigma, reduced contact with clinical

47
staff, and increase in preventable adverse events in order to improve acceptance by the patients
and adherence by healthcare workers).

Airborne Precautions

Airborne Precautions prevent transmission of infectious agents that remain infectious over long
distances (particles which are 5μm or less in size and can remain in the air for several hours and be
widely dispersed). This transmission can occur either through airborne droplet nuclei or dust
particles containing the infectious microorganisms, which can be produced by coughing, sneezing,
talking, or by procedures (e.g., bronchoscopy or suctioning). Special air handling and ventilation
are needed to ensure prevention of airborne transmission of infectious agents. Airborne particles do
not land on and contaminate surfaces. These precautions are effective in preventing infections like
Mycobacterium tuberculosis, Chicken pox and measles. They are recommended for patients with
either known or suspected infections that could be transmitted by airborne route. The precautions
include:

Patient Placement

Patients should be placed in airborne infection isolation room (AIIR). An AIIR is a single-
patient room that is equipped with special air handling and ventilation capacity (i.e. a facility
which could create negative pressure relative to the surrounding area, 12 air exchanges per hour for
new construction and renovation and 6 air exchanges per hour for existing facilities, air exhausted
directly to the outside, etc.). In a setting where resources are limited, the air in the room should be
exhausted to the outside using a fan or other filtration system keeping the door closed all the time.

 If private room not available, place patients in a room with patient having active infection
with the same disease, but with no other infection (cohorting).
 The staff on duty should check all visitors for susceptibility before allowing them to visit.
 Limit movements in and out of the room to HCWs caring for the patient.

 In areas where TB is prevalent, it is important to devise a mechanism to quickly assess

patients with suspected TB and put them under airborne precautions including

 Respiratory hygiene and cough etiquette to prevent the spread of respiratory secretions via
droplets expelled from the respiratory tract onto the hands and surfaces. This includes:

48
 o Cover the mouth and nose when coughing and sneezing and dispose of used tissues
in the nearest waste container.
o Perform hand hygiene after contact with respiratory secretions and contaminated
objects.
 Maintain an appropriate distance from and between symptomatic patients, at least 1 meter (3
feet).
 Identify persons with symptoms suggestive of acute respiratory illness and teach them to use
a surgical mask and practice cough etiquette.

During seasons of high transmission of respiratory diseases, screen patients for symptoms of
respiratory infections and provide a separate space in the waiting area distant from other patients (at
least 1 meter/3 feet) Apply additional disease- or syndrome-specific Transmission-Based
Precautions as needed.

The transmission of SARS-CoV in emergency departments by patients and their family members
during the widespread SARS outbreaks in 2003 and later on Ebola highlighted the need for
vigilance and prompt implementation of infection control measures at the spot within a healthcare
setting (e.g. reception and triage areas in emergency departments, outpatient clinics and physician
offices).

The strategy targets patients, accompanying family members and friends with undiagnosed
transmissible respiratory infections, and applies the procedure to any person with signs of illness
like cough, congestion, rhinorrhea, or increased production of respiratory secretions on arrival at the
health facilities and afterwards. The term cough etiquette is derived from recommended
source control measures for M. tuberculosis.

The elements of Respiratory Hygiene/Cough Etiquette generally include

 Education of healthcare facility staff, patients, and visitors;

 Posted signs, in language(s) appropriate to the population served, with instructions to
patients and accompanying family members or friends. Post visual alerts at the entrance
to and inside the outpatient facilities (e.g. Emergency departments, physician offices,
outpatient clinics) with instructions to patients and persons accompanying them to practice
respiratory hygiene/cough etiquette and inform a staff member of their symptoms as soon as
possible. Generally, a person having a cough should be provided with a mask.

49
  Source control measures (e.g. covering the mouth/nose with a tissue when coughing and
prompt disposal of used tissues, using surgical masks on the coughing person when tolerated
and appropriate);
 Hygiene of the hand after contact with respiratory secretions; and
 Spatial separation, ideally>3 feet (one meter), of persons with respiratory infections in
common waiting areas when possible. When possible, encourage persons in common
waiting areas who are coughing to sit at least one m eter 3 feet (or a meter) away from
others.
 Covering sneezes and coughs and placing masks on coughing patients are proven
means of source containment that prevent infected persons from dispersing respiratory
secretions into the air.
 Restrict susceptible HCWs from entering the room of patients known or
suspected to have measles, chicken pox, disseminated zoster, or smallpox if
 Other, immune HCWs are available.

Use of PPE

 Wear a particulate respirator such as a fit-tested N95 and conduct a seal check before entering
the patient‘s room. (Or at least a surgical mask if respirator not available). A seal check
should be performed every time the N95 is used.
 In case of chickenpox or measles, no mask is needed for immune persons, but susceptible
persons should not be allowed to enter the room.
 Remove respirator or surgical mask after leaving the room and place in a plastic bag or
waste container with tight-fitting lid.
 Gown, gloves, and eye protection are not needed for many organisms transmitted exclusively
by the airborne route (such as M. Tuberculosis, Measles) but may be needed when an
infectious microorganism is transmitted by multiple routes (e.g., Varicella Virus).

Patient Transport

Limit transport of patient to essential reasons only, for example, diagnostic tests or therapeutic
procedures that cannot be performed in the room. If the patient needs to leave the room for a test or
procedure:

50
  Alert the department or facility where the patient is being transported so they can prepare to
receive a patient on Transmission-Based Precautions.

 Use PPE appropriately

 Ensure that patients on Droplet or Airborne Precautions wear a surgical mask while outside
of the patient room;

 Cover wounds with appropriate dressings

 Clean and disinfect the wheelchair or coach after transportation.

 Remove PPE and perform hand hygiene once the patient has been transported.

Droplet Precautions
These precautions reduce the risks of transmission of pathogens spread wholly or partly by
droplets larger than 5μm in size (e.g. Bordatella pertussis, H. influenza & N. Meningitides,
M. pneumonia, flu, mumps, and rubella viruses). Other conditions include Diphtheria, Pertussis,
Pneumonic Plague and S. pharyngitis.

These remain in the air briefly and can travel about 1 meter (3 feet) or less. Droplet transmission
requires close proximity or contact between the source and the susceptible host. Droplets may also
land on surfaces and then be transferred by contact transmission.

Patient Placement

 Private room, door may be left open. Patients should wear a surgical mask in waiting rooms
and when outside of the patient room.
 If private room is not available, place the patient in a room with patient having active
infection with the same disease, not with other infection.
 If neither option is available, maintain over 1 meter (3 feet) spatial separation between
patient beds and use of a physical barrier, such as a curtain or divider, are especially
important to prevent transmission by droplets.
 Limit transport of patient to essential purposes only and notify area receiving patients.

Use of PPE

 Wear eye protection and a face mask or face shield, which cover eyes, nose, and mouth
completely, before entry into the patient care area.

51
  Remove PPE after leaving the patient care area. If PPE is to be re-used, it must be cleaned
and disinfected before each reuse.
 Always perform hand hygiene before and immediately after patient care.

Cleaning

 Ensure that rooms of patients on Droplet Precautions are frequently cleaned and Disinfected (at
least daily and prior to use by another patient). Focus cleaning on surfaces, frequently touched
items, and equipment in the immediate patient area.
 Use gloves, gown and face/eye protection when cleaning patient care equipment and the
environment of a patient who has been on Contact Precautions.

Contact Precautions
Patients are placed on Contact Precautions when they have suspected or known infections that are
spread directly or indirectly from an infected or colonized individual by touch or contact with the
patient or the patient‘s environment (surfaces and equipment). Contact is a common way that germs
spread in health care facilities. Organisms that require Contact Precautions include Cholera, Varicella-
Zoster (shingles); neonatal or mucocutaneous Herpes simplex virus; Enterovirus meningitis; patients
infected or colonized with enteric pathogens, hemorrhagic fever viruses, multidrug-resistant organisms
such as and Carbapenem-Resistant Enterobacteriaceae (CRE); and C. Difficile. Chicken pox is spread
both by the airborne and contact routes at different stages of illness. Contact precautions should be
implemented for patient with wet or draining infection that may be contagious (e.g. draining abscesses,
herpes zoster, impetigo, conjunctivitis, scabies, lice and wound infection).

Patient Placement

Isolate patients who require Contact Precautions in a single room, if possible. The door may be left
open in this case. If private room is not available, place the patient in a room with patient having active
infection with the same microorganism, not with other infections (cohorting). In multi-patient rooms,
more than one meter (3 feet) spatial separation between patient beds is advised to reduce the
opportunities for inadvertent sharing of items between the infected/colonized patient and other patients.

Use of PPE

 Put on a clean, non-sterile gown and gloves upon entering the patient care area; remove and
properly discard before exiting the patient room.

52
  Perform hand hygiene immediately after removing PPE
 For semi-private or multi-patient rooms, do not use the same PPE between patients.
 Remove PPE, perform hand hygiene, and put on new PPE before coming in contact with
another patient or patient environment (e.g., bed, patient locker, over-bed table, IV stand etc.).

Hand Washing

 Involves HCWs cleaning their hands before, after, and at specific moments during patient care
and when performing health care tasks.
 Wash hands with antimicrobial agent or use alcohol hand rub before entering room and after
removing gloves (if patient has C. difficile diarrhea, need to wash hands with soap and water
after removing gloves).
 Do not touch potentially contaminated surfaces or items before leaving the room.

Patient Transport

 Limit transport of patients to essential purposes only.

 During transport, ensure precautions that are maintained to minimize risk of transmission of
organisms (i.e. cover patient with clean linen not what was used on patients‘ bed).

Patient Care Equipment

 Use disposable or dedicated patient care equipment (e.g., blood pressure cuffs) and clean and
disinfect equipment before reuse on other patients.

Cleaning

 Ensure that rooms of patients on Contact Precautions are frequently cleaned and disinfected (at
least daily and prior to use by another patient).
 Focus cleaning on toilets, frequently touched surfaces, and equipment in the immediate patient
area.
 Use gloves and gown when cleaning patient care equipment and the environment of a patient
who has been on Contact Precautions.
 Organisms that form spores (such as norovirus and C. difficile) require cleaning products, such
as bleach, that inactivate spores, which are more difficult to destroy than vegetative
microorganisms.

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Empiric / Syndromic Use of Transmission-Based Precautions

Every effort should be made to diagnose the microorganism responsible for infection; however,
laboratory diagnosis is not immediately available and not always available. In these circumstances,
precautions must be based on empiric/syndromic findings. If there is any question about whether a
patient without a known diagnosis has a specific infection, implement Transmission-Based
Precautions based on the patient‘s signs and symptoms until a definitive diagnosis (i.e., laboratory
test results) can be made.

A complete listing of clinical syndromes or conditions warranting the empirical use of

Transmission- based precautions is presented in table.
Table 3.0-1 Empiric use of Transmission –Based Precaution (based on sign and symptoms) for
isolation of patient in hospital

Contact Droplet Airborne

Acute diarrhea in an incontinent or Symptoms of upper respiratory Chronic cough/fever/weight
diapered patient infection; cough, runny nose, sore loss/night sweats and upper lobe
throat, congestion. chest findings
Diarrhea in an adult with a history of
recent antibiotic use or Severe during periods when Cough or fever and chest findings in
hospitalization (in settings with C. pertussis is present in the community a person who is infected with HIV or
difficile) at high risk for HIV
Suspected meningitis: fever,
Upper respiratory infections in vomiting, and stiff, persistent cough Rashes (vesicles or pustules)
infants and young children (wear neck suggestive varicella
mask as per Standard Precautions)
Hemorrhagic rash with fever Acute respiratory distress syndrome
History of infection/colonization when new respiratory organisms are
with multidrug-resistant organisms Generalized rash of unknown cause a risk in the community
(use Airborne Precautions for
tuberculosis [TB]) Vesicular rash (suspected varicella)
(wear gown, gloves and eye
Abscess or infected draining wound protection also)
that cannot be covered with
bandages

Skin or wound infection with

excessive drainage in a patient with
recent hospitalization (in settings
where multidrug-resistant
microorganisms are prevalent)

Adapted from: Siegel et al. 2017; WHO 2008.

In all situations, Transmission-Based Precautions must be used in conjunction with Standard

Precautions. (Siegel et al. 2017).

54
Summary

To protect HCWs, patients, and visitors from acquiring infections during health care facility visits,
ensure compliance with Standard Precautions for all patients at all times and apply Transmission-
Based Precautions to all patients with potential or confirmed infections that are transmitted via contact,
droplet, and airborne routes.

Standard Precautions, including hand hygiene, are the cornerstone of IPC. They provide the first line
of defense in the prevention of transmission of pathogens in health care facilities. Transmission-Based
Precautions, including their empiric use, are designed to provide additional protection and reduce the
risk of transmissions via airborne, droplet, and contact routes among hospitalized patients and HCWs.

These guidelines serve as the minimum requirements that should be enforced in all health care settings
to protect patients, visitors, and HCWs

55
CHAPTER 4: HAND HYGIENE
Key Topics
When to perform hand hygiene (World Health Organization‘s (WHO‘s) ―5 Moments for
Hand Hygiene‖)
Proper technique for washing hands with soap and water
Proper technique for use of alcohol-based hand rub
Issues and considerations related to hand hygiene
Monitoring hand hygiene
WHO‘s strategy for improving hand hygiene programs

Definition of Key Terms

Alcohol-Based Hand Rub (ABHR) is a fast-acting, antiseptic hand rub that does not require water to
reduce resident flora, kills transient flora on the hands, and has the potential to protect the skin
(depending on the ingredients).

Antiseptic agents or antimicrobial soap (terms used interchangeably) are chemicals applied to
the skin or other living tissue to inhibit or kill microorganisms (both transient and resident). These
agents, which include alcohol (ethyl or isopropyl), dilute iodine solutions, iodophors, chlorhexidine,
and triclosan, are used to reduce the total bacterial count.

Antiseptic hand washing is washing hands with soap and water or with products containing an
antiseptic agent.

Clean water is natural or chemically treated or filtered water that is safe to drink and use for other
purposes (e.g., hand washing and general medical use) because it meets national public health
standards and the WHO guidelines for drinking-water quality.

Emollient is an organic agent (e.g., glycerol, propylene glycol, or sorbitol) that is added to ABHR to
soften the skin and help prevent skin damage (e.g., cracking, drying, irritation, and dermatitis) that is
often caused by frequent hand hygiene.

Hand disinfection is a term that WHO does not recommend using because disinfection normally refers
to the decontamination of non-living surfaces and objects.

Hand hygiene is the process of removing soil, debris, and microbes by cleansing hands using soap and
water, ABHR, antiseptic agents, or antimicrobial soap.

56
Hand washing is the process of mechanically removing soil, debris, and transient flora from hands
using soap and clean water.

Healthcare Associated/Acquired infection (HAI) is an infection that occurs in a patient as a result

of care at a health care facility and was not present at the time of arrival at the facility. To be
considered an HAI, the infection must begin on or after the third day of admission to the health care
facility (the day of admission is Day 1) or on the day of or the day after discharge from the facility.
The term ―healthcare associated/acquired infection‖ replaces the formerly used ―nosocomial‖ or
―hospital‖ infection because evidence has shown that these infections can affect patients in any
setting where they receive health care.

Microorganisms are causative agents of infection, and include bacteria, viruses, fungi, and
parasites. Some bacteria can exist in a vegetative state (during which the organism is active and
infective) and as endospores (in which a tough, dormant, non-reproductive structure protects the
cell). Endospores are more difficult to kill due to their protective coating.

Persistent activity is prolonged or extended protective activity that prevents the growth or survival of
microorganisms after application of an antiseptic; it is also called ―residual‖ activity.

Point of care is the place where three elements come together: the patient, the Health-Care Worker
(HCW), and the care or treatment involving contact with the patient or the surrounding environment. For
this chapter, the concept embraces the need to perform hand hygiene at recommended moments exactly
where care delivery takes place. This requires that a hand hygiene product (e.g., ABHR) be easily
accessible and as close as possible—within arm‘s reach—to where patient care or treatment is provided.

Resident flora are microorganisms that live in the deeper layers of the skin and within hair follicles and
cannot be completely removed, even by vigorous washing and rinsing with plain soap and clean water.
In most cases, resident flora is not likely to be associated with infections; however, the hands or
fingernails of some HCWs can become colonized by microorganisms that do cause infection (e.g.,
Staphylococcus aureus, gram-negative bacilli, or yeast), which can be transmitted to patients.

Soap (term is used interchangeably with detergent) is a cleaning product (e.g., bar, liquid, leaflet, or
powder) that lowers surface tension of water, thereby helping to remove dirt and debris. Plain soaps do
not claim to be antimicrobial on their labels and require friction (i.e., scrubbing) to mechanically remove
microorganisms. Antiseptic (antimicrobial) soaps kill or inhibit growth of most microorganisms.

57
Standard Precautions are a set of infection control practices used for every patient encounter to
reduce the risk of transmission of bloodborne and other pathogens from both recognized and
unrecognized sources. They are the basic level of infection control practices to be used, at a
minimum, in preventing the spread of infectious agents to all individuals in the health care facility
(see Module 1, Chapter 2, Standard and Transmission-Based Precautions).

Surgical hand preparation refers to the protocol used preoperatively by surgical teams to eliminate
transient flora and reduce resident skin flora. The process involves an antiseptic hand wash or
antiseptic hand rub and rubbing/scrubbing for specific amounts of times using specific techniques
prior to donning gloves. Antiseptics used for surgical hand preparation often have persistent
antimicrobial activity (for details, see Module 7, Chapter 2, Use of Antiseptics in Health Care
Facilities):
Surgical hand rub refers to surgical hand preparation with a waterless ABHR.
Surgical hand scrub refers to surgical hand preparation with antimicrobial soap and water.

Transient flora is microorganisms acquired through contact with individuals or contaminated

surfaces during the course of normal, daily activities. They live in the upper layers of the skin and
are more amenable to removal by hand hygiene. They are the microorganisms most likely to cause
HAIs.

BACKGROUND
Hand hygiene is the single most important measure to prevent transmission of infection and is the
cornerstone of Infection Prevention and Control (IPC). The original study in this field was conducted
at a maternity hospital in Vienna, Austria, in 1847. This study demonstrated that the mortality rate
among mothers was significantly lower when the HCWs cleaned their hands with an antiseptic agent
(Semmelweiss 1861). Numerous other studies since then have demonstrated that HCWs‘ hands
become contaminated during routine care of patients and can transmit infectious diseases from patient
to patient (AORN Recommended Practices Committee 2004; Duckro et al. 2005; Ojajarvi 1980; Pittet
et al. 1999; Riggs et al. 2007; Sanderson and Weissler 1992). Proper hand hygiene can prevent
transmission of microorganisms and decrease the frequency of HAIs. Despite evidence that hand
hygiene prevents transmission of infections, compliance with hand hygiene recommendations during
patient care continues to present ongoing challenges in all settings. Methods used to improve
compliance with hand hygiene are addressed later in this chapter.

58
The goal of hand hygiene is to remove soil, dirt, and debris and reduce both transient and resident
flora. Hand hygiene can be performed using ABHR or by washing hands with water and plain or
antimicrobial soap (bar or liquid) that contains an antiseptic agent such as chlorhexidine, iodophors, or
triclosan. (WHO 2009a)

Traditionally, hand washing with soap and water has been the primary method of hand hygiene;
however, ABHR has been shown to be more effective for standard hand hygiene than plain or
antimicrobial soaps. (CDC 2002). However, ABHR effectiveness is best achieved when hands are not
visibly soiled.

Recommendations for when and how to perform hand hygiene are described in this chapter. For
information and instructions about surgical hand scrub and surgical hand rub, see Chapter 7, Surgical
Antisepsis and Antiseptics in Health Care Facilities.

―Failure to perform appropriate hand hygiene is considered to be the leading cause of

healthcare associated infections (HAIs) and the spread of multidrug resistant microorganisms,
and has been recognized as a significant contributor to outbreaks.”

Boyce et al. 2002

When to Perform Hand Hygiene (Hand Hygiene Opportunities)

The World Health Organization has five recommended points in time when hand hygiene should occur
in order to prevent transmission of HAIs. These recommendations are called the ―My 5 Moments for
Hand Hygiene‖ and focus on the following times:

 Before making contact with a patient

 Before performing a clean/aseptic task, including touching invasive devices
 After performing a task involving the risk of exposure to a body fluid, including touching
invasive devices
 After patient contact
 After touching equipment in the patient‘s surrounding areas (WHO 2006a)

The ―5 Moments‖ are numbered according to health care workflow in an attempt to ease recall for
HCWs (see Figure 4.0.1).-

59
 Table 4.0-1 WHO‟s Five Recommended Moments for Hand Hygiene

BEFORE PATIENT WHEN? Clean your hands before touching a patient when approaching him or her
1 CONTACT WHY? To protect the patient against harmful germs carried on your hands.
WHEN? Clean your hands before any aseptic task
BEFORE ASEPTIC
2 TASK
WHY? To protect the patient against harmful germs, including patients own germs,
entering his or her body.
WHEN? Clean your hands immediately after exposure risk to body fluids (and after
AFTER BODY glove removal)
3 FLUID
WHY? To protect yourself and healthcare environment form patient‘s harmful
EXPOSURE RISK
germs.
WHEN? Clean your hand after touching the patient and his or her immediate
AFTER PATIENT surrounding and leaving the room.
4 CONTACT WHY? To protect yourself and healthcare environment form patient‘s harmful
germs.
WHEN? Clean your hands after touching any object in the patients immediate
AFTER CONTACT
surroundings, when leaving. Even without touching the patient.
5 WITH PATIENT
WHY? To protect yourself and healthcare environment form patient‘s harmful
SURROUNDING
germs.
Reprinted from: The ―My 5 Moments for Hand Hygiene,‖ © World Health Organization (2009):
http://www.who.int/gpsc/5may/background/5moments/en/. Accessed June 28, 2016.

Other opportunities for hand hygiene

 Immediately on arrival and before departure from work (the health facility).
 Immediately after touching contaminated instruments or articles.

 Before putting on gloves and after removing them

 Whenever the hands become visibly soiled after nasal blowing or following a covered
sneeze
 Before touching the face (eyes, nose or mouth)
 Before and after cleaning the environment
 Before and after preparing food
 Before eating and drinking or serving food

 After visiting the toilet

Hand Hygiene for Patients and Patient Care-takers and Visitors

 Patients, their care-takers and visitors should also be instructed on proper hand hygiene with
alcohol rub or soap and water as indicated
 Opportunities for hand hygiene by patients, care-takers and visitors include:
 Before eating
60
  After using the toilet
 Before and after handling their babies
 Before and after helping to care for patients
 When hands are soiled

Hand Hygiene Methods

Hand washing with Soap and Water

The purpose of routine hand washing in health care is to remove dirt and organic material, as well
microbial contaminants, from the hands. Clean water must be used to prevent microorganisms in the
water from contaminating the hands. However, water alone is not effective at removing substances
containing fats and oils, which are often present on soiled hands. Proper hand washing also requires
soap, which is rubbed on all hand surfaces, followed by thorough rinsing and drying.

The cleansing activity of hand washing is achieved by both friction and the detergent properties of the
soap. Plain soap has minimal antimicrobial properties, but assists with the mechanical removal of
debris and loosely adherent microbes, while the mechanical action removes some bacteria from hands.
Time is also an important factor—hand washing for 30 seconds has been shown to remove 10 times
the amount of bacteria as hand washing for 15 seconds. The entire hand washing procedure, if
completed properly, as described step by step in Figure 4.0.1, should take 40–60 seconds. (CDC 2002;
WHO 2009a)

61
 Figure 4.0-1. The Steps for Routine Hand Washing (How to Properly Wash Your Hands)
Reprinted from: ―How to Handwash,‖ © World Health Organization (2009).
http://www.who.int/gpsc/5may/How_To_HandWash_Poster.pdf. Accessed May 6, 2016.

Hand washing with soap and water is recommended (rather than using ABHR) in the following
situations:

 If hands are visibly soiled or contaminated with blood or body fluids

 After using the toilet
 Before eating
 To remove the buildup of emollients (e.g., glycerol) on hands after repeated use of ABHR
 In outbreaks of C. difficile, but not in health care settings with only a few cases of C.
difficile. (Cohen et al. 2010; Siegel et al. 2007) C. difficile is a bacterial infection that causes
severe diarrhea and is common in some settings.

62
Avoiding contamination of hands during hand washing
Since microorganisms grow and multiply in moisture and in standing water, the following are
recommended to prevent contamination of hands during hand washing:

 Avoid bar soaps when possible because they can become contaminated, leading to
colonization of microorganisms on hands. There is some evidence, however, that the actual
hazard of transmitting microorganisms through hand washing with previously used bar soaps
is negligible. If bar soap is used, provide small bars and use soap racks that drain the water
after use. (WHO 2009a)
 Do not add liquid soap to a partially empty liquid soap dispenser. This is known as ―topping
off.‖ The practice of topping off dispensers may lead to bacterial contamination of the soap.
Using refill packets avoids this problem but if they are not available, dispensers should be
thoroughly cleaned and dried before refilling. (WHO 2009a)
 Filter and/or treat water if a health care facility‘s water is suspected of being contaminated;
this will make the water microbiologically safer. (WHO 2009a) (See Volume 1, Chapter 11:
Food and Water Safety, and Volume 1, Section 2, Chapter 5: Preventing Health Care-
Associated Infectious Diarrhea.)
 Use running water for hand hygiene. In settings where no running water is available, water
―flowing‖ from a pre-filled container with a tap is preferable to still-standing water in a
basin. Use a container with a tap that can be turned off preferably with the back of the elbow
(when hands are lathered) and turned on again with the back of the elbow for rinsing. As a
last resort, use a bucket with a lid or a pitcher and a mug to draw water from the bucket, with
the help of an assistant, if available. (WHO 2009a)
 Avoid dipping hands into basins of standing water. Even with the addition of an antiseptic
agent (e.g., Dettol or Savlon), microorganisms can survive and multiply in these solutions.
(Rutala 1996)
 If a drain is not available where hands are washed, collect water used from hand hygiene in a
bucket which is deep enough to prevent the dirty water from splashing out, and discard it in a
drain or in a latrine.
 Dry hands properly because wet hands can more readily acquire and spread microorganisms.
Dry hands thoroughly with a method that does not re-contaminate the hands. Paper towels or
single-use clean cloths/towels are an option. Make sure that towels are not used multiple
times or by multiple individuals because shared towels quickly become contaminated.
63
 (WHO 2009a). Air-dry hands if disposable or single use towels are not available. Do not dry
hands on personal clothing.

Alcohol-Based Hand Rub (ABHR)

The antimicrobial activity of alcohol results from its ability to denature proteins (i.e., the ability to
dissolve some microbe components) and kill microbes. Alcohol solutions containing 60–80% alcohol
are most effective, with higher concentrations being less effective. This paradox results from the fact
that proteins are not denatured easily in the absence of water; as a result, microorganisms are not killed
as easily with higher alcohol-based solutions (> 80% alcohol). (WHO 2009a)

The use of an ABHR is more effective in killing transient and resident flora than hand washing with
antimicrobial agents or plain soap and water. It also has persistent (long-lasting) activity. ABHR is
quick and convenient to use and can easily be made available at the point of care. ABHR usually
contains a small amount of an emollient (e.g. glycerol, propylene glycol, or sorbitol) that protects and
softens skin. ABHR should be used at any of the ―5 Moments‖ described earlier in this chapter, unless
hands are visibly soiled. (CDC 2002; Girou et al. 2002; WHO 2009a)

To be effective, approximately 3–5 mL(i.e., 1 teaspoon) of ABHR should be used. The ideal volume
of ABHR to apply to the hands varies according to different formulations of the product and hand size
(refer to manufacturer‘s instructions for use). ABHR should be used, following the steps shown in
Figure 1-3, for approximately 20–30 seconds or until the solution has fully dried. Since ABHR does
not remove soil or organic matter, if hands are visibly soiled or contaminated with blood or body
fluids, wash hands with soap and water. To reduce the buildup of emollients on hands after repeated
use of ABHR, washing hands with soap and water after every 5–10 applications of ABHR is
recommended.

In C. difficile outbreak settings, hand washing with soap and water is recommended over ABHR as it
is more effective than ABHR in removing endospores. If there are only a few cases of C. difficile,
normal use of ABHR is recommended (Cohen et al. 2010; Siegel et al. 2007; WHO 2009a). The need
for using soap and water over ABHR during outbreaks of norovirus is an unresolved issue. (Siegel et
al. 2007; WHO 2009a)

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 Figure 4.0-2 WHO Recommendation on How to Perform Hand Hygiene with ABHR

Reprinted from: ―How to hand rub,‖ © World Health Organization (2009).

http://www.who.int/gpsc/5may/How_To_HandRub_Poster.pdf. Accessed May 6, 2016.

Producing alcohol-based hand rub

An effective ABHR solution is inexpensive and simple to make, even in limited-resource settings.
WHO provides procedures for making ABHR in health care facility pharmacies (see Box 1-4-1).

Alcohol-Based Hand Rub Formulation

Formulation 1: To produce final concentrations of ethanol 80% v/v, glycerol 1.45% v/v, hydrogen
peroxide (H2O2) 0.125% v/v:
Pour into a 1,000-mL graduated flask:
1. Ethanol 96% v/v, 833.0 mL
2. H2O2 3%, 41.7 mL
3. Glycerol 98%, 14.5 mL

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Top up the flask to 1,000 mL with distilled water or water that has been boiled and cooled; shake the
flask gently to mix the contents.
Formulation 2: To produce final concentrations of isopropyl alcohol 75% v/v, glycerol 1.45 v/v,
hydrogen peroxide 0.125% v/v:
Pour into a 1,000-mL graduated flask:
1. Isopropyl alcohol (with a purity of 99.8%), 751.5 mL
2. H2O2 3%, 41.7 mL
3. Glycerol 98%, 14.5 mL
Top up the flask to 1,000 mL with distilled water or water that has been boiled and cooled; shake the
flask gently to mix the contents.
v/v=volume percent, meaning 80 parts absolute alcohol in volume and 20 parts water measured as
volume, not as weight

Adapted from: WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety
Challenge. Clean Care Is Safer Care, page 49. © World Health Organization (2009).

Do not add ABHR to a partially empty dispenser. This practice of ―topping off‖ dispensers may lead
to bacterial contamination. The use of refill packets avoids this problem but if they are not available,
the dispensers should first be thoroughly cleaned and dried before refilling. (WHO 2009a)

Antiseptic Soaps
Antiseptic soaps may be used in place of plain soap during the ―My 5 Moments for Hand Hygiene‖
described above but are not recommended for most settings. Hand washing with antiseptic soap is
more irritating to the skin and more expensive than using ABHR. Therefore, if available, ABHR
should be used under normal circumstances. (WHO 2009a)

Use of antiseptic soaps is recommended for surgical hand scrub and before entry into special areas of
health care facilities (e.g., neonatal intensive care units).

Surgical Hand Scrub

The purpose of the surgical hand scrub is to mechanically remove soil, dirt, debris, and transient flora
microorganisms and to reduce resident flora before and for the duration of the surgery. The goal is to
prevent wound contamination by microorganisms from the hands and arms of the surgical team
members.

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Issues and Considerations Related to Hand Hygiene

Glove Use

While the effectiveness of gloves in preventing contamination of HCWs‘ hands has been confirmed,
gloves do not provide complete protection against hand contamination. Contamination may occur as a
result of small, undetected holes in gloves, as well as during glove removal. Thus, wearing gloves does
not replace the need for proper hand hygiene. Hand hygiene should always be performed before
putting on and after removing gloves (see Module 3, Chapter 1, Personal Protective Equipment, for
details of correct glove use). (CDC 2002; WHO 2002)

Wearing the same pair of gloves and cleaning gloved hands between patients or between dirty and
clean body sites is not a safe hand hygiene practice (Siegel et al. 2007; WHO 2009a; WHO 2009c;
WHO 2009d). Not changing gloves between patients has been associated with transmission of
microorganisms such as methicillin-resistant S. aureus (MRSA) and gram-negative bacilli.
Reprocessing gloves is not recommended.

Every effort must be made to reinforce the message that gloves do not replace the use of hand hygiene
and that when gloves are required, they should be used in addition to hand hygiene (see Volume 1,
Chapter 5: Personal Protective Equipment, for more information on glove use).

Hand Lotions and Hand Creams

In an effort to minimize hand hygiene-related contact dermatitis (a skin rash caused by irritation from
a substance such as soap due to frequent hand hygiene), hand lotions, creams, barrier creams, and
moisturizing skin care products are recommended. Hand lotions and creams often contain humectants
(substances that help retain moisture) and various fats and oils. These humectants can increase
hydration and replace altered or depleted skin lipids that can serve as a barrier to microorganisms on
normal skin. Several studies have shown that regular use (i.e., at least twice per day) of such products
can help prevent and treat contact dermatitis. There is also biologic evidence that emollients (e.g.,
glycerol and sorbitol) contained in ABHR, with or without antiseptics, may decrease cross-
contamination because they reduce shedding of bacteria from skin for up to 4 hours. These products
are absorbed into the superficial layers of the epidermis and are designed to form a protective layer
that is not removed by standard hand washing. (Boyce et al. 2002; McCormick et al. 2000; WHO
2009a)

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Therefore, while use of hand lotions, creams, and moisturizers by HCWs should be encouraged there
are some considerations: First, to reduce the possibility of the products becoming contaminated,
provide small, individual-use containers or pump dispensers, which are completely emptied and
cleaned before being refilled. Refilling or topping off lotion containers may lead to contamination and
proliferation of bacteria within the lotion. Second, to avoid confusion, hand lotion dispensers should
not be located near dispensers of antiseptic solutions. Additionally, oil-based barrier products, such as
those containing petroleum jelly (e.g., Vaseline® or lanolin), should not be used because they damage
latex rubber gloves.

Resistance to Topical Antiseptic Agents

With the increasing use of topical antiseptics, particularly in home settings, concern has been raised
regarding the development of resistance to these antiseptics by microorganisms. Although low-level
bacterial tolerance to commonly used antiseptic agents has been observed, studies have shown no
clinical evidence to date that supports the development of resistant microorganisms following use of
any topical antiseptic agents (WHO 2009a).

Lesions and Skin Breaks

Cuticles, hands, and forearms should be free of lesions (e.g., ulcers, abscesses, and tumors), dermatitis,
eczema, and skin breaks (e.g., cuts, abrasions, and cracking). Broken skin should be covered with
waterproof dressings. If covering is not possible, HCWs with active lesions should not perform
clinical duties until the lesions are healed. In particular, surgical HCWs with skin lesions should not
operate until the lesions are healed.

Religious and Cultural Considerations

It is clear that cultural and religious factors strongly influence attitudes toward hand washing. During
efforts to enhance hand hygiene compliance, it is advisable to consider possible religious and cultural
factors which may act as barriers to practice and tailor promotional activities to address these issues.
WHO‘s Guidelines on Hand Hygiene in Health Care provide information outlining these
considerations (WHO 2009a).

Fingernails

Research has shown that the area beneath the fingernails harbors the highest concentrations of bacteria
on the hands. This area most frequently harbors coagulase-negative staphylococci (a bacterium

68
normally found on the skin), gram-negative rods (bacteria known to cause infection), Corynebacteria
(bacteria), and yeasts. Fingernails longer than 0.2 cm (0.08 inches) have been shown to increase
carriage rates of S. aureus. Moreover, long nails, either natural or artificial, tend to puncture gloves
more easily than short nails. Therefore, nails should be kept moderately short —not extend more than
0.5 cm (0.2 inches) beyond the fingertip. (CDC 2002; Fagernes and Lingaas 2011; McGinley et al.
1988; Olsen et al. 1993; WHO 2009a)

Artificial Nails

Individuals with artificial nails have been shown to harbor more pathogenic organisms (i.e., disease-
causing microorganisms), especially gram-negative bacilli and yeast, on the nails and in the area
beneath the fingernails. Studies have demonstrated that the longer the artificial nail is, the more likely
that a pathogen can be isolated. Thus, artificial nails (e.g., nail wraps, nail tips, acrylic lengtheners)
should not be worn in clinical areas because they constitute an infection risk in high-risk areas.
(Hedderwick et al. 2000; Jumma 2005; Siegel et al. 2007)

Nail polish

There is concern that individuals wearing nail polish may be hesitant to perform rigorous hand hygiene
in an effort to protect their nails, although no studies have demonstrated a relationship between freshly
applied nail polish and infection. But, compromises in hand hygiene technique may lead to
transmission of infection. Chipped nail polish supports the growth of larger numbers of organisms on
fingernails compared to freshly polished or natural nails. Also, dark-colored nail polish may prevent
dirt and debris under fingernails from being seen and removed (Baumgardner et al. 1993; CDC 2002;
Rothrock 2006). The recommendation is health workers better avoid using dark-colored nail polish
while providing patient care.

Jewelry
Current evidence demonstrates that wearing rings increases hand contamination. Research has also
shown that HCWs wearing wristwatches had a higher total bacterial count on their hands compared to
HCWs without wristwatches. Surgical team members should not wear rings because it may be more
difficult for them to put on surgical gloves without tearing them. (Fagernes and Lingaas 2011; Siegel
et al. 2007; Trick et al. 2003). Rings with ridges or stones should be avoided, because of the greater
difficulty in cleaning effectively, and increased likelihood of damage to gloves and injury to patients.

69
If plain wedding rings are worn they should be moved up and down during hand hygiene for more
effective cleaning.

In summary healthcare workers should adhere to the following to ensure effective hand hygiene
practices;

 Keep nails short, clean and without polish or artificial nail extensions
 Do not wear wrist watches and jewelry including wearing rings with ridges or stones
 Cover any cuts or abrasions with waterproof dressings
 Keep sleeves short or rolled up

Hand Care

Hand care is important to protect the skin from drying and cracking. Cracked skin may encourage
microbial colonization and broken areas can present a site of entry for pathogens. Hand creams can
be applied to care for the skin on hands.

Communal tubs of hand cream must be avoided as these may contain bacteria over time, and lead to
contamination of hands.

Note: the following recommendations for hand care to prevent irritation due to frequent hand
hygiene (based on WHO (2009) hand care recommendations);

 Develop a regular routine of using a protective hand cream or lotion, at least daily
 Do not routinely wash hands with soap and water immediately before or after using an
alcohol-based hand rub
 After hand rubbing or hand washing, let your hands dry completely before putting on gloves
 Use alcohol based hand rubs with emollients rather than detergent based soaps
 Select efficacious products with the least potential for irritation
 Avoid unnecessary prolonged glove use
 Dry hands completely after washing and prior to gloving
 Avoid rough paper towels; pat rather than rub dry
 Don‘t use soaps, detergents, or aqueous creams or lotions containing sodium lauryl sulfate
 When skin is damaged or frequent hand washing is required, a mild soap (without antiseptic
agent) should be used to remove soil and debris.

70
  In high-risk areas such as the operating room, neonatal ICU or transplant units, hand scrub
protocols that use soft brushes or sponges for a shorter time (at least two minutes) should
replace harsh scrubbing by hard brushes for 6 to10 minutes.

Monitoring Hand Hygiene

The WHO Guidelines on Hand Hygiene in Health Care encourage providers in all health care settings
to evaluate, improve, and monitor the reliability of hand hygiene practices with the aim of changing
the behavior of HCWs. Optimizing hand hygiene compliance at the 5 recommended moments for hand
hygiene increases patient safety. (WHO 2009a; WHO 2009e)

Hand hygiene compliance can be monitored both directly and indirectly (see Table 4.0.2) (WHO
2009a). Each method of monitoring hand hygiene has its own advantages and disadvantages (see
Table 1-4-3 for advantages and disadvantages of each of the monitoring techniques). The direct
observation of hand hygiene compliance by a validated observer, however, is considered the ―gold
standard‖ in hand hygiene monitoring. It is often valuable to utilize more than one method of
monitoring at the same time. (The Joint Commission 2009; WHO 2009a)

Validity and reliability are important aspects of direct hand hygiene monitoring. The validity of a new
observer should be confirmed by either joint observations with another confirmed observer or by being
tested through the WHO Training Film, which is available online. Results should be compared and any
discrepancies should be discussed. This process should be repeated until the HCW is fully competent.
(WHO 2009a)

Validity: doing a procedure technically correctly following the ―gold standard‖ for that procedure.
Reliability: completing a procedure technically correctly at all times following the ―gold standard‖ for
that procedure

Table 4.0-2 Hand Hygiene Observation Methods

Direct Methods of Hand Hygiene Observation Indirect Methods of Hand Hygiene Observation
Direct Observation Monitoring consumption of products (soap or ABHR)
Patient assessment Automated monitoring of use of sinks or ABHR
dispensers

In the implementation of a hand hygiene monitoring program, expectations for performing hand
hygiene should be clearly defined and made known within the health care facility. Policies detailing
these expectations should also be in place. Monitoring should occur on a regular, routine basis and a
set minimum number of observations should be collected in a given monitoring period.

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 Table 4.0-3 Advantages and Disadvantages of Various Hand Hygiene Monitoring Approaches

Monitoring Approach Advantages Disadvantages

Direct observations by expert Only way to reliably capture all Time-consuming

observers hand hygiene opportunities
Skilled and validated observers required
Details can be observed
Prone to observation, observer, and
Unforeseen qualitative issues can selection bias
be detected while observing hand
hygiene

Self-reports by HCWs Inexpensive Overestimate of true compliance

Not reliable

Direct observations by Inexpensive Potential negative impact on patient-

patients HCW relationship

Reliability and validity required and

remain to be demonstrated

Consumption of hygiene Inexpensive Does not reliably measure the need for
products (e.g., towels, soap, hand hygiene (denominator)
and ABHR) Reflects overall hand hygiene
activity (selection biased) No information about the appropriate
timing of hand hygiene actions
Validity may be improved by
using indirect denominators (e.g., Prolonged stocking of products at ward
patient-days or workload that is level complicates and might jeopardize
converted into total hand hygiene the validity
opportunities)
Validity threatened by increased patient
and visitor usage

Not able to discriminate between

individual or professional group usage

Reprinted from: WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge. Clean Care
Is Safer Care. Process and Outcome Measurement, page 162. © World Health Organization (2009).

Direct Monitoring

The goal of the direct hand hygiene observers is to observe HCWs during their usual patient care
activities. The observers should assess the HCWs‘ compliance with indications for hand hygiene and
with facility policies on hand hygiene practices. It is preferable that observers have training and
experience as patient care professionals but this is not necessary.

Hand hygiene observations should focus on the two essential parameters for determining hand hygiene
compliance:

1. The indication for hand hygiene

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 2. The observed hand hygiene action related to the indication

When the HCW is observed, the action is considered to have been either ―performed‖ or ―not
performed.‖ (WHO 2006b)

WHO recommends that the ―5 Moments‖ be utilized as a framework for observing opportunities for
hand hygiene. It is possible, however, to simplify which moments are observed, based on the
objectives of the period of observation and/or the resources available. Observation can be limited to
certain professional role categories or disciplines or certain indications within the ―5 Moments‖ (e.g.,
in some settings it may be appropriate to observe the action of hand hygiene only before and after
contact with the patient or the patient environment). (WHO 2006b; WHO 2009a)

Observations should be collected in a standard way, such as on a form (see Appendix 4A) with each
hand hygiene observation session on a separate form. A standard form should have three main
sections:

 A header containing information about the health care facility and the location within the
facility where the session was completed
 A second header containing information on the session observed
 Columns below the headers representing the sequence of actions for different HCWs observed
during the same session, with each column representing one HCW (See Appendix 4B for the
WHO Observation Form – Short Description of Items on the Form.) (WHO 2009a; WHO
2009e)

Content can be adapted to suit the needs of the facility.See Appendix 4C is a sample observation form
for hand hygiene data collection. This form reflects a modified approach that looks at hand hygiene
compliance at room entry and room exit only (useful for areas with single-patient rooms).

Hand hygiene compliance (%) is the simplest way to analyze the hand hygiene data collected. Hand
hygiene compliance is the ratio of the number of actions to the number of opportunities:

Compliance (%) = (# of Hand Hygiene Actions/Total # of Opportunities) x 100

Compliance data can be summarized based on total compliance by HCW, by role or discipline (e.g.,
doctors, nurses), or by location (e.g., ward A, ward B), depending on the objectives of the monitoring
program. It is important to provide feedback and disseminate compliance data to the HCWs and
73
leaders after the observation session/assessments are completed. Minimizing the delay between
observation and reporting of results may help increase the effects of the monitoring. (WHO 2009a)

There are some limitations with direct monitoring of hand hygiene. For example, HCWs may improve
or modify their behavior in response to being observed or studied, resulting in an overestimate of
compliance. Thus, it is important to be aware of this effect when evaluating compliance rates.

Indirect Monitoring

Indirect hand hygiene monitoring, such as monitoring the consumption of hand hygiene products (e.g.,
soap, ABHR, paper towels) to estimate the number of hand hygiene actions, is a less expensive
monitoring approach and can be useful in settings where resources for direct monitoring are limited.
However, this methodology requires validation to be most effective. One of the major limitations to
this type of indirect monitoring is that it is impossible to determine if the hand hygiene actions were
performed at the proper moment. (WHO 2009a)

Implementation of a Multimodal Hand Hygiene Improvement Strategy

The WHO Multimodal Hand Hygiene Improvement Strategy identifies key components to address
during the implementation of a hand hygiene improvement strategy. (WHO 2009a; WHO 2009e) (See
Appendix 4D.) The components are:-

 System change to ensure that infrastructure is in place, including availability of ABHR and
access to a safe and continuous supply of water, soap, and towels—to allow HCWs to
practice hand hygiene
 Training and education of HCWs
 Monitoring of hand hygiene practices and provision of feedback
 Reminders in the workplace
 Creation of a safety culture

In order to implement these components, the guidelines detail five sequential steps, listed below, with
each step building on the activities and actions in the previous steps (see Figure 4.0.3). Rather than a
linear process, the five steps should be considered a cyclical process, with each cycle being repeated,
refined, and enhanced at least every 5 years. It is imperative to evaluate success factors and areas of
weakness within the program in order to achieve long-term sustainability and process improvement.
(WHO 2009a)

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Figure 4.0-3. Five Steps of the Hand Hygiene Improvement Strategy
Adapted from: WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge: Clean Care
Is Safer Care. The WHO Multimodal Hand Hygiene Improvement Strategy, page 99. © World Health Organization
(2009).

Although complex, the hand hygiene improvement strategy lays the groundwork for the
implementation of a sustainable hand hygiene monitoring program. It is aimed at improving hand
hygiene compliance and increasing patient safety in the health care facility. The basic elements of each
step are listed below. (WHO 2009a; WHO 2009e)

Step 1: Facility Preparedness

Assess and ensure the preparedness of the health care facility. Consider the following:

 Identify a person or team to coordinate the program.

 Identify HCWs and facility leadership who will play a major role in program
implementation.
 Obtain raw materials to produce ABHR at the health care facility‘s pharmacy (if necessary).
 Train observers on how to monitor hand hygiene practices.
 Train identified persons on how to calculate hand hygiene compliance.

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Step 2: Baseline Evaluation

Include a baseline evaluation of hand hygiene practices, facility infrastructure, HCW knowledge, and
current beliefs about hand hygiene. Consider the following:

 Survey HCWs on their perceptions of hand hygiene (e.g., do they think hand hygiene is
important, and/or effective, and/or necessary?).
 Survey HCWs on their knowledge of hand hygiene (e.g., do they know how and when to
perform proper hand hygiene?).
 Look for details in the health care facility‘s structure that may help explain current hand
hygiene compliance (e.g., is there easy access to running water, sinks, and/or ABHR?).
 Monitor use of soap and ABHR, if applicable.
 Collect baseline data on hand hygiene compliance.
 Make sure that ABHR and dispensers are available in time for the start of Step 3.
 Compile data on hand hygiene practices.

Step 3: Implementation

Implement the planned program. Consider the following:

 Share baseline data with HCWs.

 Distribute educational materials, hand hygiene guidelines, and/or policies to HCWs.
 Distribute ABHR to HCWs.
 Measure how much ABHR is used each month.
 Hold education and training sessions.
 Survey HCWs on their opinion of the ABHR (e.g., do they find it acceptable?).
 Continue to monitor hand hygiene compliance observations, if possible.
 Meet monthly with key HCWs involved with the hand hygiene program.

Step 4: Follow-Up Evaluation

Evaluate the short-term impact of the implemented hand hygiene program. Considered the following:

 Survey HCWs and health care facility leadership on their perceptions of hand hygiene (e.g.
Do they think hand hygiene is important and/or effective and/or necessary?).

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  Survey HCWs on their knowledge of hand hygiene (e.g. Do they know how and when to
perform proper hand hygiene?).
 Inspect the health care facility structure to determine if there are still any barriers to hand
hygiene compliance related to structural issues.
 Collect data on soap and ABHR use.
 Collect data on hand hygiene compliance.
 Complete data entry.

Step 5: Development of an Ongoing Action Plan and Review Cycle

Develop an ongoing action plan and review cycle. Consider the following:

 Review collected data and results carefully.

 Prepare a report of the findings of the entire program.
 Share information about the findings of the program with leadership and HCWs.
 Create a 5-year plan of action to continue to improve and promote hand hygiene compliance.

Modifying a Hand Hygiene Program

In situations where the complete implementation of the WHO hand hygiene improvement strategy is
not possible, due to either limited resources or time, a hand hygiene improvement team should focus
on the minimum criteria listed below (see Table 4.0-1). These criteria ensure achievement of each
component of the multimodal strategy and include the most pertinent steps of the program. (WHO
2009a)

Table 4.0-4 Minimum Criteria for Implementation

Multimodal Component Minimum Criteria for Implementation
1a. System change: ABHR Bottles of ABHR are positioned at the point of care in each
ward or given to HCWs.
1b. System change: Access There is one sink for at least every 10 beds; soap; running
to safe, continuous water water; and clean, dry towels available at every sink.
supply and towels
2. Training and education A program to update training over the short, medium, and
long term is established.
3. Observation and Two periods of observational monitoring are undertaken, the

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feedback baseline evaluation and the follow-up evaluation.
4. Reminders in the ―How to‖ and ―5 Moments‖ posters are displayed in all wards
workplace (e.g., patient rooms, health facility staff areas, outpatient
areas, ambulatory departments).
5. Institutional safety The Chief Executive, Chief Medical Officer/Medical
climate Superintendent, and Chief Nurse all make a visible
commitment to support hand hygiene improvement during
program implementation (e.g. verbal announcements and/or
formal letters to health facility staff).
Reprinted from: Guide to Implementation: A Guide to the Implementation of the WHO Multimodal Hand Hygiene
Improvement Strategy, page 39. © World Health Organization (2009).

Key Message

―The hands of healthcare workers are a major source of transmission of nosocomial pathogens.‖

Summary
Hand hygiene is the single most important measure to prevent transmission of infection and is the
cornerstone of IPC. The goal of hand hygiene in health care is to prevent transmission of infections
through removing bacteria from hands at strategic ―moments‖ during the care of patients. Hand
hygiene can be performed using ABHR or by washing hands with water and soap. ABHR has been
shown to be more effective for standard hand hygiene than plain or antimicrobial soaps and more
easily available at the point of care. Despite evidence proving that hand hygiene prevents transmission
of infections, compliance with hand hygiene recommendations during patient care continues to be
challenging in all settings and requires constant and ongoing efforts from IPC staff. The WHO
Multimodal Hand Hygiene Improvement Strategy provides a guide for implementation of a sustainable
hand hygiene program at health care facilities.

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CHAPTER 5: PERSONAL PROTECTIVE EQUIPMENT (PPE)
Key Topics:

Types and uses of PPE

Instructions for putting on and removing PPE
Type of PPE to prevent transmission of infection during out break

Definition of key Terms

Droplet nuclei are small particles involved in airborne transmission of pathogen-containing

respiratory secretions expelled into the air by coughing. They are reduced by evaporation to small, dry
particles that can remain airborne for long periods of time and distance.
Droplet transmission occurs when infectious droplets larger than 5 µm in size are spread and land
directly on or come in contact with a susceptible host‘s mucous membranes of the nose or mouth or
conjunctivae of the eye. Droplets can be produced by coughing, sneezing, talking, or during
procedures (e.g., bronchoscopy or suctioning). Due to their size, particles remain airborne briefly and
travel approximately 1 meter (3 feet) or less. Droplet transmission requires close proximity or contact
between the source and the susceptible host. Droplets may also land on surfaces and then be
transferred by contact transmission.

Engineering controls are methods that are built into the design of the environment, equipment, or a
process to minimize the hazards associated with use. An example is a medical device or piece of
equipment that limits exposure to bloodborne pathogen hazards in the workplace, such as sharps
disposal containers, self-sheathing needles (a barrel or cover that automatically slides over the
Personal Protective Equipment

Personal protective equipment (PPE) items are the protective barriers and respirators used alone or
in combination by a health care worker (HCW) to protect mucous membranes, airways, skin, and
clothing from contact with harmful or infectious agents. PPE may also be used on an infectious patient
to prevent the spread of infectious agents (e.g., surgical mask worn by a patient to control the spread
of illness).

Respirator fit testing is a test protocol conducted to verify that a respirator is both comfortable and
correctly fits the user without leakage. Fit testing uses a test agent, either qualitatively detected by the
wearer‘s sense of taste, smell, or involuntary cough (irritant smoke) or quantitatively measured by an

79
instrument, to verify the respirator‘s fit. The benefits of this testing include better protection for the
HCW/user and verification that the user is wearing a correctly fitting model and size of respirator.

Seal check is a procedure conducted by the wearer of a particulate respirator to determine if the
respirator is properly sealed to the face. The user seal check can be either a positive pressure check
(i.e., breathing out to check for leak on exhalation), or negative pressure check (i.e., breathing in to
check for leak on inhalation), or both.

OVERIVEW

Healthcare workers are confronted each day with the difficult question of how to work safely within
the potentially hazardous environment of health care facilities. Today, the most common
occupational risk the healthcare personnel face is due to contact with blood and body fluids during
routine works like cleaning, instrument processing and patient care. This exposure to pathogens
increases risk of getting are Healthcare Associated Infections and possible death. Health workers in
some occupational settings such as surgery and delivery rooms, have a higher risk of exposure to
pathogens than those in all other departments combined (Gershon & Vlahov, 1992; Gershon &
Zirkin, 1995). However, there is no area of clinical care practice without risk of exposure to
infectious substances. Use of risk appropriate personal protective equipment (PPE) is one of the
components of Standard Precautions, which refers to wearing of protective barriers or clothing.

The use of PPE is ages old and has been reasonably helpful to protect patients or clients from
microorganisms which could be transmitted by medical staff and others working in the healthcare
setting. Lately, with the emergence of HIV/AIDS, HBV, HCV and resurgence of Tuberculosis in
many countries including Ethiopia, there is increased awareness on the importance of PPE for
protecting healthcare workers as well. Hospital administrators, supervisors and healthcare
workers need to be aware not only of the benefits and limitations of specific PPE, but also of the
actual role PPE play in preventing infection so that they can use them effectively and efficiently.

The basic principle behind wearing personal protective equipment is to get physical
barrier/protection from pathogenic microorganisms. PPE includes: gloves, masks/respirators,
eyewear (face shields, goggles or glasses), caps, gowns, aprons, boots and other items. The most
effective barriers are made of treated fabrics or synthetic materials that do not allow water or other
liquids (blood or body fluids) to penetrate them. These fluid-resistant materials are not, however,
are not widely available because they are expensive. Lightweight cotton clothes (with a thread

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 count of 140/inch2) are materials most commonly used for surgical clothing (masks, caps and
gowns) and drapes in many countries. Unfortunately, lightweight cotton does not provide an
effective barrier because moisture can pass through it easily, allowing contamination.

Denims, canvas and heavy twill, on the other hand, are too dense to allow steam penetration (i.e.
they cannot be sterilized); and hard to wash and take too long to dry as well. When fabric is used, it
should be white or light-colored showing dirt and contamination more easily. To be effective, PPE
must be selected, worn and removed correctly. The state of the PPE is also important for it to
effectively provide protection. For example, surgical gowns and drapes have proved to be preventive
for impending wound infection only when dry. When wet, however, clothes act as a wick or sponge
to draw bacteria from the skin or equipment up through the fabric that can then contaminate a
surgical wound

Types and Uses of PPE

As a rule, PPE selection should be based on risk assessment. If there is risk of exposure of patients or
health workers, then the PPE or combination of PPEs appropriate for the identified risk should be
used. Effectiveness in protection is also dependent on the practice of correct procedures and
adherence to rules for wearing (putting-on) and removing (putting-off) of PPE.

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.
Table 5.0-1 How Personal Protective Equipment Blocks the Spread of Microorganisms

where microorganisms How Barriers to stop the Must be used for Who the
are found microorganisms are spread of microorganisms (examples of barriers
(risk assessment) spread indications) protect

Healthcare Staff
Hair and scalp Shedding skin or hair Cap Invasive procedures where tissue Service Provider and
beneath the skin is exposed Patients
Situation where splashing or
Nose and mouth Coughing, talking Mask (water resistant), exposure of blood, body fluids,
secretions or excretions is likely

Face (eyes nose or Splashing Masks, face shields, goggles

mouth)

Body, Arm and skin Shedding skin or hair Scrub suit, cover gowns

Nose and mouth Coughing, talking Masks Situation which call for droplet
transmission

Special Masks (N95%) When airborne transmission is

anticipated.

Hands Touching Gloves with hand washing When there is a reasonable Patient
or alcohol hand rubbing chance of hand coming in
contact with blood and other
body fluids

Feet and lower legs Splashes, Spills and Closed boots or closed-toe Situation where splashing or Service provider
Sharp Material shoes (open sandals are not blood, body fluids, secretions or
acceptable) excretions is likely

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Patient
Mucous membrane Touching Gloves Situation where is direct contact Service provider and
and non-intact skin with mucous membrane and Patient
non- intact skin

Blood and body Splashing or spraying Gloves, eyewear, mask, Invasive procedures where tissue Service provider and
fluids drapes, and apron beneath the skin is exposed Patient

Touching (contact) Instrument processing Situation where splashing or

exposure of blood, body fluids,
Accidental exposure Protective footwear, secretions or excretions is likely
with contaminated decontamination and
needles disposal; use of a Safe or
and scalpel blades Neutral Zone during surgery

Contaminated Items or Infectious waste Utility gloves, plastic bags Collection, transportation and Staff
waste and proper disposal disposal of waste

Unprepared skin Touching Skin preparation, drapes, Invasive procedures where tissue Patient
gloves beneath the skin is exposed

Clinic or hospital Touching Gloves hand washing, Environmental cleaning and Staff and their
environment Appropriate dressing disinfection families

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 PPE should be;

 Made available close to the point of use for easy accessibility

 Stored neatly in a clean / dry area to prevent contamination until required for use
 Preferably single use if reusable there must be a clear policy and SOP for placement in bins
after use and removal for laundering and recycling
 Have an SOP for stock ordering and rotation to ensure there is always an adequate supply
based on usage and that older items are always used first. Do not wait for stocks to run out
before ordering more

Table 5.0-2 Types and Uses of PPE

Types of PPE Provides protection for:

Cap Hair and Scalp
Google Eyes
Face Masks Nose, Mouth and Lower Jaw
Face Shield Face
Gloves Hand
Gowns Upper body, skin and cloth
Apron Front of the body
Boots Lower legs and feet
Shoe cover Shoe

Caps

Head covers are most commonly used as part of surgical attire in surgical and procedure areas.
When used, head covers or caps should be large enough to cover the entire scalp and hair (see
Figure 5.0.1 A, B, and C). Facial hair is also required to be covered for surgical procedures in
sterile areas (e.g., in the operating theater) using a facial hair covering. They can be disposable or
made of reusable cloth that can be laundered. In the surgical and procedure areas, a new clean head
covering should be worn each day and changed sooner when soiled with blood or body fluids. The
same standard and regularity of cleaning expected for surgical scrubs should be applied when
cleaning head/facial coverings (e.g., laundered at the hospital and changed at least daily).

Caps are used to keep the hair and scalp covered so that flakes of the skin and hair are not shed up
on the wound during surgery. Caps meant to be reliably protective should be large enough to cover
all of the hair on the scalp

84
Head covers or caps are most often worn during surgery and in procedure areas where a sterile field
is required. They are not necessary for most other areas in the health care facility. Head covers are
not part of routine PPE for Contact, Droplet or Airborne Precautions but are used for during
outbreaks for VHF (See Volume 1, Chapter 5 Use of Personal Protective Equipment during
Outbreaks of Viral Hemorrhagic Fever, in this Chapter for use of head covers in during outbreaks
of VHF).

Figure 5.0-1 Surgical Head Coverings

Health care works wear caps

 To protect the patient form infection coming from hair and scalp and
 To protect the staff from splashes and exposure to blood.

Patients wear caps

 To keep the sterile field during invasive procedure

Protective Eye Wear

There are four different types of eye protection that are effective in preventing infection in health
care facilities (see Figure 5.0.2):
1. Goggles
2. Safety Glass
3. Masks attached shield
4. Face shield

Eye protection should be comfortable, allow for sufficient peripheral vision (i.e., the area that is
visible outside the central area of focus), and must be adjustable to ensure secure fit. Compared to
85
older styles of goggles, newer styles may provide better indirect airflow properties to reduce
fogging, provide better peripheral vision, and offer more size options for fitting goggles to different
HCWs.

Eye wear protects the staff during accidental splash of blood or other body fluid by covering the
eyes. Masks and eyewear should be worn when performing any task where an accidental splash
into the face could occur (e.g. performing cesarean section, vaginal delivery or cleaning instruments)
when giving care to patients with droplet precautions. If face shields are not available, goggles or
glasses and mask can be used together.

Eye and face protection must be worn when there is risk of splashing body fluids onto mucous
membranes e.g. eyes/nose. Eyes can be protected by wearing either goggles or a visor. If reusable
eye/face protection is used, it should be decontaminated in accordance with the manufacturer‘s
guidelines. Hands should always be decontaminated after removing the equipment.

Note: Personal eyeglasses and contact lenses are NOT considered adequate eye protection. (Siegel
et al., 2007)

Suitable protective eye/face equipment should:

 As part of Standard Precautions

 As part of Droplet Precautions to protect from respiratory secretions
 During procedures and surgery when splashing is likely to happen
 During specimen collection or aerosol-generating procedures on patients with specific
respiratory tract pathogens (e.g., TB or novel respiratory viruses) (WHO 2008 tract
pathogens (e.g., TB or novel respiratory viruses) (WHO 2008).
 Cover the entire face area (e.g. face shield) if protection of the mouth and nose area is also
required
 Be changed if visibly soiled
 Be removed using the ear-pieces / head-band to avoid touching potentially contaminated
surfaces
 Be disposed of after use if single-use or placed into a receptacle for reprocessing
 Fit over personal glasses and anti-fog properties should be considered

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 Figure 5.0-2. Different types of Eye Protection Equipment‟s

How to wear protective eyewear

Put on eye protection after putting on the isolation gown and mask (if used) but before putting on
gloves (see Figure 5.3).

Figure 5.0-3. Putting on Eye Protection

Source: Siegel et al. 2007.

Removal of face shield, goggles, and mask can be performed safely after gloves have been removed
(see Figure 5.0.4). The ties, ear pieces, and/or head band used to secure the equipment to the head
are considered ―clean‖ and safe to touch with bare hands. If the ties, ear pieces, and/or head band
are found to be contaminated, they should be removed using gloved hands and the skin/face should
be rinsed using ample running water and soap. The front of a mask, goggles, and face shield is
considered contaminated.

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 Figure 5.0-4. Taking off Eye Protection

Source: Siegel et al. 2007.

Masks

There are many different types of masks used to cover the mouth and nose. Masks made from
cotton or paper are comfortable but are not fluid-resistant (do not protect from splashes) and are not
an effective filter to prevent inhalation of microorganisms transmitted via droplet nuclei (≤ 5 µm).
Masks made from synthetic materials provide protection from large droplets (> 5 µm) spread by
coughs or sneezes. They may be more difficult to breathe through than cotton or paper masks. The
use of masks during patient care is part of Standard Precautions when there is a potential for
splashes or droplet transmission and is part of Droplet Precautions. (Siegel et al. 2007)

There are two types of masks:

 Surgical masks: Regulating bodies (such as The United States Food and Drug
Administration [FDA], the European Union, and WHO) require surgical masks to have fluid-
resistant properties.

 Procedure/isolation masks: These are not regulated, and they do not have any
specifications for their manufacture.

Surgical Masks

Masks should be large enough to cover the nose, the lower part of the face, the jaw and all of the
facial hair. They are worn in an attempt to retain/confine moist droplets expelled as health workers
or surgical staff speaks, cough or sneeze. Equally important, is its protective function against
accidental splashes of blood or other contaminated body fluids on the health workers‘ nose or
mouth. This preventive function, however, would not be effective unless the masks are made of
fluid-resistant materials.
When removing, one should handle the masks by the strings do it with great care as the center of
the mask is the most contaminated site of all other parts (Rothrock, McEwen & Smith, 2003).

88
Respirators
This are special types of masks called particulate respirators worn by healthcare personnel for
protection against inhalation exposure to airborne infectious agents that are < 5μm. These include
infectious droplet nuclei from patients with Micobacterium tuberculosis, Variola virus [smallpox],
SARS-CoV), and dust particles containing infectious particles such as spores of environmental
fungi (e.g. Aspergillus sp.). Respirators should be worn when filtering inhaled air is deemed
important. These articles contain multiple layers of filter material and fit into the face tightly
allowing no air leaks around the mask when breathing. The N95 disposable particulate and air
purifying respirator is the type used most commonly by healthcare personnel. Other respirators
used include N-99 and N-100 particulate respirators; powered air-purifying respirators with high
efficiency filters; and non-powered full-face piece electrometric negative pressure respirators
(Siegel JD. et al.; HICPAC, 2007).

Figure 5.0-5. Types of Masks

Gowns

Types of gowns and their purposes Gowns should fully cover the torso of the HCW, fit
comfortably over the body, and have long sleeves that fit snuggly at the wrists.
There are three types of protective gowns used in health care facilities:
1. Isolation gowns,
2. Surgical gowns, and

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 3. Coverall suits (see Volume 2, Section 5, Chapter 1: Use of Personal Protective Equipment
during Outbreaks of Viral Hemorrhagic Fever).
Isolation gowns should be long-sleeved, fluid-resistant, single- use, and preferably disposable.
Isolation gowns are designed to prevent contamination of HCWs‘ arms, exposed areas of the body,
and clothing from blood and body fluids and other potentially infectious material.

Note: Isolation gowns should be worn in combination with gloves and other PPE, as recommended

Surgical gowns are sterile and preferably fluid-resistant, with sleeves that either taper gently toward
the wrists or end with elastic or ties around the wrists. Large, droopy sleeves are not recommended
because they can cause accidental contamination. Surgical gowns are used during surgery or
procedures to protect patients and the sterile field from microorganisms from blood and other body
fluids (e.g., amniotic fluid) present on the HCW‘s clothing, the front of the HCW‘s body, and the
HCW‘s arms.

When the surgical gowns are put on, the cuffs of sterile surgical gloves should completely cover the
end of the sleeves of the gowns.

Lightweight cloth or paper gowns are not recommended because they offer little protection against
moisture, which can easily pass through, allowing the passage of microorganisms. If a cloth or paper
gown is used, always wear a plastic apron under/over it.

If a protective covering fails (e.g., during a large spill) and skin/clothing becomes contaminated with
blood or body fluids, clothing should be removed and laundered immediately. The HCW should
bathe as soon as possible after completing the operation or procedure.

Coveralls are full-body suits made from materials that are lightweight, breathable, and impermeable
to liquids (see Figure 5.0.6). These are to be worn by all HCWs who work in isolation areas for
treating highly infectious diseases (e.g., VHF). They are designed to go over a scrub suit and create
a barrier to eliminate or reduce contact exposure to blood, body fluids, and highly infectious
microorganisms (CDC 2015). Coveralls without attached hood and with thumbholes are
recommended.
Steps for putting on coverall suits
 Assess the garment for any visible tears or compromise to integrity
 Make sure that a trained observer is watching and monitoring the steps.
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  Perform hand hygiene.
 Put on the scrub suit, rubber boots or shoe covers, and a pair of sterile or non-sterile gloves.
 Unfold the coverall suit and unzip.
 Slide legs, one by one, into the suit.
 Slide arms, one by one, into the suit.
 Tuck the cuffs of the first pair of gloves under the sleeves of the coverall suit.
 Insert thumbs into thumb hole (if provided).
 Close the zip by pulling it up to the neck.
 Cover the zip with the additional flap if available

Steps for removing coverall suits

 Make sure that a trained observer is watching and monitoring the removal process and is
ready to assist, if needed.
 See the step-by-step PPE removal checklist in Appendix 2-B for essential steps leading up to
removal of the coverall.
 Disinfect inner gloves using alcohol-based hand-rub (ABHR) or 0.5% chlorine solution
covering all surfaces of the gloved hands.
 Lift the chin.
 Find the zip at the level of the belly and carefully trace fingers of one hand up to find the zip
tab.
 Hold the outside of the top of suit with the other hand (do not let it go).
 Unzip or unfasten the suit completely (still holding the top near the zip).
 Gently pull the side of the suit being held partially over the shoulder.
 Perform a rotating movement of the shoulder inside out (one by one) to remove the coverall
and carefully move the coverall down the body, turning inside out.
 Do a ―moon walk‖ to remove the legs of the suit over the boots.
 Carefully place it in the waste bag, touching only the inside.
 Avoid contact of the scrub suit with the outer surface of the gown.
 Disinfect gloved hands using ABHR or 0.5% chlorine solution, covering all surfaces of the
gloved hands.
 See the step-by-step PPE removal checklist for essential next steps in removal of PPE.

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 Figure 5.0-6. Coverall Suit

When to wear gowns

The type of gown to use is based on the type of patient interaction, including the anticipated degree
of contact with infectious material and the potential for blood and body fluid penetration of the
barrier and the type of task to be carried out by the HCW:
 During Standard Precautions, an isolation gown (with gloves) is worn if blood or body fluid
contact, spills, or splashes onto clothing is anticipated.
 During Contact and Droplet Precautions, an isolation gown (with gloves) is used to prevent
transmission of an infectious agent that cannot be prevented by Standard Precautions alone.
 During surgical procedures, deliveries, or other aseptic procedures, a sterile surgical gown is
worn to protect the sterile field and the clothes of the scrub team or those performing the
procedure.

How to wear and remove gowns

Full coverage of the arms and body front, from the neck to the mid-thigh or below, will ensure that
clothing and exposed areas of the upper body are protected. Isolation gowns are always worn in
combination with gloves and other PPE (e.g., masks, eye protection) according to the type of
transmission being prevented (contact, droplet etc.).
Isolation gowns are usually the first piece of PPE to be put on (see Figure 1-5-7 A). HCWs should
remove isolation gowns before leaving the patient care area to prevent possible contamination of the
environment outside of the patient care area (see Figure 1-5-7 B). (Siegel et al. 2007)

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 Figure 5.0-7. A and B. Putting on and Removing an Isolation Gown Respectively
Adapted from: Siegel et al. 2007.

Plastic Apron

It is used to protect clothing or surfaces from contamination. Reusable aprons which are made of
rubber or plastic provide ha waterproof barrier along the front of the personnel‘s body. Thus, it
should also be worn during cleaning and procedures with likelihood of splashes or spillage of blood,
body fluids, secretions or excretions (e.g. when conducting deliveries). Disposable water-proof
aprons are also available for clinical use.

93
Aprons keep contaminated fluids off the healthcare worker‘s clothing‘s and skin. For example,
during invasive procedures, wearing a water resistant apron (disposable of reusable) will not only
help to guard the healthcare providers against exposure to blood or body fluids (e.g. amniotic
fluid), but also prevents the healthcare workers‘ abdominal skin from being a source of
contamination to the patient.

Gloves

Healthcare Workers Wear Gloves for the Following Three Reasons:

1. To reduce the risk of acquiring infections to the staff from patients
2. To reduce the risk of transmitting microorganisms including skin flora from provider to
clients/patients
3. To reduce contamination of the hands of the staff by microorganisms which are
transmissible from one patient to another (cross-contamination).

Types of Gloves

Surgical Glove - should be used when performing invasive medical or surgical procedures.
Clean Examination Gloves - provide protection to healthcare workers when performing many
of their routine duties. These gloves can be used whenever contact with mucous membrane and
non-intact skin is anticipated (e.g. during medical examinations and procedures such as pelvic
examination).
Utility or Heavy-Duty Household Gloves - should be worn when processing instruments,
equipment and other items, for handling and disposing contaminated waste, and when cleaning
contaminated surfaces. Double gloving of either new examination gloves or reprocessed surgical
gloves provide some protection in case utility gloves are not available.

Note:
Clear understanding of the parameters to opt for sterile or high- level disinfected gloves is
important. Judicious use of these options can reduce costs and at times maintain safety both for the
patients and the staff.

The use of high-level disinfected surgical gloves when performing surgical or invasive procedures
is the only acceptable alternative on condition that sterile surgical gloves are not

94
The following table provides guidelines on uses of gloves in common medical and surgical
Procedures
Table 5.0-3Advantages and Disadvantages of Different Types of Non-Sterile Gloves

Material Advantage Disadvantage

Latex  Offer best fit, natural feel, and dexterity  Long contact with fatty substances
 Approved by regulatory authorities (e.g., fatty tissue and vegetable
 Provide protection against most chemicals, including oils) will disintegrate latex gloves
acids and bases, chlorine, iodine, and formaldehyde  Not recommended for HCWs with
 Offer better puncture resistance than other gloves (e.g., known allergies to latex
vinyl gloves)
Vinyl  First synthetic material gloves available on the market  Loose-fitting (i.e., baggy), have
 Least expensive of the three types and generally limited elasticity, and tear easily
available in low- and middle-income countries  Have higher failure rates than
 Recommended if they are the only type of non-sterile latex or nitrile gloves because they
glove available and the risk of exposure to blood and tear more easily and they are
body fluids is high loose-fitting around the wrist,
 Acceptable for short procedures/tasks (e.g., suctioning which can allow fluids to
endotracheal secretions, removing IV lines) that contaminate an HCW‘s hand
involve minimum risk of glove tears, have low risk of
exposure to contaminants, and involve minimal stress
on the gloves
Nitrile  Allergy-free  Not recommended for HCWs with
 Preferred choice for HCWs with latex allergies known allergies to nitrile
 Made from synthetic materials and are very elastic compounds
 Can be used with petroleum-based substances,
including hand moisturizers
 3–5 times more puncture-resistant than latex gloves
 Fit well on hands like latex gloves
 More elastic than vinyl gloves
 Available in various thicknesses and colors

The best surgical gloves are made of latex rubber because of the rubber‘s natural elasticity,
sensitivity, durability and a comfortable fit. An increasing problem of latex allergy now a days
created a demand for a search of another material causing little or no such problem.
Consequently, a new synthetic rubber-like material called ―Nitrile,‖ which has properties similar to
latex, has been developed to make better gloves. This new fabric of gloves is less likely to cause
allergic reactions in the user. In many countries, the only type of examination gloves usually
available is made up of vinyl, a synthetic material that is less expensive than latex rubber. Even
though Vinyl is cheaper, it is inelastic (does not stretch like latex) making these gloves loose-fitting
and easy to tear. To conclude, better quality examination gloves, so far, are made from latex or
Nitrile and they can be found in medical supply stores in most countries. Utility gloves which are
made of thick rubber are more intractable and deliberately meant for maximal protection during
heavy duty activities.

95
Making decision on which type of examination glove is best for a task (if a choice is available)
largely depends on the degree of risk from the exposure (low or high risk) to a potentially pathogen
laden blood or body fluids; the length of the procedure to be carried out; and the possibility of the
development of allergy to latex or, rarely, to Nitrile.

Vinyl examination gloves should only be used for short tasks involving minimal stress on the glove
and low risk of exposure. Nonetheless, if they are the only type of examination glove
available and the risk of exposure to blood and body fluids is high, frequent changing or double
gloving should be considered.

Natural rubber latex examination gloves provide the best protection. Hence, they are the most
appropriate for surgical procedures and tasks involving moderate to high risk such as exposure to
blood or body fluids. At this juncture, it should be well taken up that these gloves should avoided if
the staff have known or suspected allergy to latex or for prolonged contact (>1 hour) with high-
level disinfectants such as Glutaraldehyde (for it may cause loss of effectiveness due to breakdown
of latex).

Nitrile examination gloves are best for the staff with latex allergy and may be used for activities
involving moderate to high risk. Nitrile gloves have many of the characteristics of latex but a better
resistance to oil-based products. In this sense, the staff with known allergy to Nitrile or latex
compounds should not use these gloves.

Note: When using latex rubber gloves, avoid use of hand cream or lotions that contain mineral
oil, petroleum jelly (Vaseline) or lanolin to protect your hands, because they may cause the gloves
to break down within minutes.

WHEN TO WEAR GLOVES

Depending on the situation, surgical gloves, clean examination or utility gloves should be worn
by all staff where:
 There is a chance of hands coming in contact with blood or other body fluids, mucous
membranes or none intact skin;
 They perform invasive medical procedures (e.g. Inserting vascular devices such
asperipheral venous lines); or
 They handle contaminated waste items or touch contaminated surfaces.

96
The Glove Pyramid – to aid decision making on when to wear (and not wear) gloves

Gloves must be worn according to STANDARD and CONTACT PRECAUTIONS. The

pyramid details some clinical examples in which gloves are not indicated, and others in which
clean or sterile gloves are indicated. Hand hygiene should be performed when appropriate
regardless of indications for glove use.

Figure 5.0-8. The Glove Pyramid – to aid decision making on when to wear (and not wear)
gloves
Image from WHO (2009); Hand Hygiene Why, How and When & When

WHEN TO USE DOUBLE GLOVES

The transmission of HBV and HCV from surgeon to patient and vice versa is known to have
occurred even in the absence of incorrect application of the technique and apparent problems of
97
intactness of the gloves (Davis, 2001). Even the best quality, new latex rubber surgical gloves
may leak up to 4% of the time. Moreover, it was found that latex gloves gradually become weaker
and lose their intactness especially when exposed to fat on surfaces of wounds.

Although double gloving is of little benefit in preventing exposure to blood in case of needle sticks
or other similar injuries, it may decrease the risk of blood-hand contact. A recent study, for
instance, showed that surgeons wearing single gloves had a blood-hand contact rate of 14%
while those wearing double gloves had only a rate of 5% (Tokars et al., 1995; Tokars et al.,
1992). As recommended in this study, the following are reasonable guidelines for when to use
double gloves:

 The procedure involves coming in contact with large amounts of blood or other
body fluids (e.g. vaginal deliveries and cesarean sections).

 Orthopedic procedures in which sharp bone fragments, wire sutures and other
sharp-edged materials are likely to be encountered.

 Surgical procedures lasting more than 30 minutes. (Most surgeons, these days use
double glove routinely).

When double gloving, the first glove should be a half size larger than normally worn gloves. The
second pair, however, should be the correct size as this will help prevent the hand from
cramping. Whether or not the surgeon, assistant or nurse should double glove must be considered
carefully especially in setups where gloves are reused and t he risk of contracting blood borne
pathogens such as HIV, is high (>5% prevalence).

In general, for short time surgical procedures (30 minutes or less) and those involving minimal
exposure to blood or mucous secretions (e.g. laparoscopy or mini-laparotomy), double gloving is
probably not necessary.

When to Use Elbow Length Gloves

Elbow length gloves should be used during vaginal deliveries and cesarean sections where the
chance of coming in contact with blood is 25% and 35% respectively. Elbow length gloves are
also recommended to be used during performing procedures like manual removal of placenta and
any other procedure where cont act with a large volume of blood or body fluids is likely. This
kind of glove is generally meant to give protection to the hands including the forearms.

98
How to Use Gloves

Although the effectiveness of gloves in preventing contamination of the healthcare workers‘ hands
has been repeatedly confirmed (Tenorio et al., 2001), wearing gloves does not replace the need for
hand washing. The truth is that even the best quality latex surgical gloves may have small and
unnoticeable defects; they may be torn during use; and the hands can become contaminated during
removal (Bagg et al., 1990; Davis, 2001).

Note:
Practice of hand hygiene, coupled with the use of protective gloves, is a key
component in minimizing the spread of disease

The purpose of donning and removing sterile gloves as indicated in Figure 5.0.10 is to ensure
maximum asepsis for patients and protect the healthcare workers from the patient‘s body fluid.
In the correct usage of gloves-an instrument to achieve this double goal, the skin of the
46
healthcare worker remains exclusively in contact with the inner surface of the glove and has no
contact with the outer surface. Any error in the performance of this technique leads to a lack of
asepsis requiring a change of glove.

Procedure for wearing Sterile Gloves

1. Perform hand hygiene before an ―aseptic procedure‘‘ by surgical hand scrub.

2. Check the package for intactness. Open the first non-sterile packaging by peeling it
completely off the heat seal (cover) to expose the second sterile wrapper, but without
touching it.

3. Place the second sterile package on a clean and dry surface without touching the surface.
Open the package and fold it towards the bottom so as to unfold the paper and keep it
open.
4. Using the thumb and index finger of one hand, carefully grasp the folded cuff edge of the
glove.

5. Slip the other hand into the glove in a single movement, keeping the folded cuff at the
wrist level.
6-7. Pick up the second glove by sliding the fingers of the gloved hand underneath the cuff of
the glove.

99
 8-10. In a single movement, slip the second glove on to the ungloved hand while avoiding any
contact/resting of the gloved hand on surface other than the glove to be donned
(contact/resting constitutes a lack of asepsis and requires a change of glove).
11. If necessary, after donning both gloves, adjust the fingers and inter-digital spaces until the
gloves fit comfortably.
12-13. Unfold the cuff of the first gloved hand by gently slipping the fingers of the other hand
inside the fold, making sure that any contact with the outer surface of the glove is avoided
(lack of asepsis requiring a change of gloves).
14. The hands are gloved and must touch exclusively sterile devices or the previously-
disinfected patient‘s body area.
15-17. Remove the first glove by peeling it back with the fingers of the opposite hand.
Remove the glove by rolling it inside out to the second finger joint (do not remove
completely).
18. Remove the other glove by turning its outer edge on the fingers of the partially ungloved
hand.
19. Remove the glove by turning it inside out entirely (ball forming) to ensure that the skin of
the health-care worker is always and exclusively in contact with the inner surface of the
glove.
20. Discard gloves.
21. Perform hand hygiene after glove removal according to the recommended indication.

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 Figure 5.0-9. How to don and remove examination gloves

Donning surgical sterile gloves at the time of a surgical intervention follows the same sequences
except that:
 It is preceded by a surgical hand preparation.
 Donning of the gloves is performed after putting on the sterile surgical gown.
 The opening of the first packaging (non-sterile) is done by an assistant.
 The second packaging (sterile) is placed on a sterile surface and then used for the
intervention.
 Gloves should cover the wrists of the sterile gown.

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 Figure 5.0-10. How to wear (don) sterile gloves

Figure 5.0-11. How to remove (doff) sterile gloves

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Some Dos and Don‟ts about Gloves
 Do wear the correct size gloves, A poorly fitting glove can limit your ability to perform
the task and may get damaged easily
 Do change surgical gloves periodically (every 45 minutes) during long cases as the
protective effect of latex gloves decreases with time and in apparent tears may occur.
 Do keep fingernails trimmed moderately short (less than 3mm beyond the finger tip) to
reduce the risk of tears.
 Do pull gloves up over cuffs of gown (if worn) to protect the wrists.
 Do use water-soluble hand lotions and moisturizers often to prevent hands from drying,
and cracking due to frequent hand washing and gloving.
 Don‘t use oil-based hand lotions or creams, because they will damage latex surgical and
examination gloves.
 Don‘t use latex gloves if you or the patients have an allergy to latex.
 Don‘t store gloves in areas where there are extremes of temperature (e.g. direct sunlight,
near the heater, air conditioner, ultraviolet light, and X-ray machine). These conditions
may damage the gloves (cause breakdown of the material they are made of), thus
reducing their effectiveness as a barrier.
 Don‘t reprocess gloves that are cracked or have detectable holes/tears.
 Don‘t reprocess examination gloves for reuse.
 Re-process utility gloves by immersing them in a 0.5% Chlorine solution briefly,
remove gloves by inverting them and then soak them in the 0.5% Chlorine solution
for 10 minutes before washing and drying them for reuse.

Note: A separate pair of gloves must be used for each client to avoid cross-contamination
or when moving from one site to another site on the same patient (i.e. from
respiratory care to a dressing change). It is preferable to use new and single use
(disposable) gloves only.

How to make Elbow Length Gloves

When readymade elbow length gloves are not available, an effective alternative material (as
described below) can easily be made from previously used surgical latex gloves that have been

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 re-processed (decontaminated, cleaned and dried, through the two methods of either sterilization
or high-level disinfection).

The acceptable ―leak rate for new surgical and examination gloves designated by regulatory
agencies is up to 4% (Davis 2001)1. Cut one or more fingers depending on the size of your
hands completely off. Do the same for the other pair of the glove shown just below to allow all of
the fingers slip into the gloves (see Figure 5.0.12)

1. Cut the one finger (one or more fingers depending on the size of your hands)
completely off each glove just below where all the fingers join the gloves.
2. Sterilize or HLD 2–3 pairs of cut-off (fingerless) gloves according to the
recommended process for each method and store the gloves after final processing in a
sterile or high-level disinfected container until needed.
How to Use

 Perform surgical hand scrub.

 Put on the intact sterile or HLD surgical gloves to completely cover up the distal end of the
fingerless gloves. (See Figure 4.4).
 Put the fingerless sterile or HLD gloves and pull them up to the forearms.

Figure 5.0-12. Cutting the Four Fingers off a Glove

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 Allergic reactions to gloves

Allergic reactions to latex rubber gloves are being increasingly reported among healthcare workers
of all types including housekeepers, laboratory workers and dentists. If possible, non-latex
(Nitrile) or low-allergen latex gloves should be used if allergy is suspected (Allergic reactions to
Nitrile also occur, less frequently though). Furthermore, wearing powder-free gloves is
recommended (Powdered gloves may result in more reactions because the powder from the gloves
carries the latex particles in the air). If at all this is not possible, wearing clothes or vinyl gloves
beneath latex gloves may help to prevent skin sensitization. It will not, however, prevent possible
sensitivity of the mucous membranes of the eyes and nose if these gloves are powdered (Garner &
HICPAC, 1996).

People with sensitivity do have symptoms like skin rashes, runny nose and itchy eyes that may
persist or get progressively worse (i.e., cause breathing problems such as asthma). An allergic
reaction following the use of latex can develop within a month. Reactions generally take long
time (3 to 5 years) to develop even in susceptible people and may not develop for as long as 15
years (Baumann, 1992). No matter what, there still exists no therapy or desensitization for latex
allergy. Therefore, the only option is to avoid contact with it.

Footwear

It‘s worn to protect the feet from injury by sharp or heavy items or fluids that may accidentally
spill over, drip, or even pour out upon them. All footwear should have closed toes, low heels, and
nonskid soles. Clean, sturdy shoes are recommended for all clinical areas. Rubber boots or leather
shoes provide the best protection. They must be kept clean. For this reason, sandals and other
open-toe shoes or shoes made of soft materials are not acceptable. Rubber boots or leather shoes
are acceptable, but they must be kept clean and free of contamination from blood or other body
fluid spills. Shoe covers are unnecessary if clean and sturdy shoes are available for dedicated use
only in the surgical area. However, Shoe covers may be needed to minimize contamination from
and of shoes. Shoe covers are not meant to prevent transmission of bacteria from the floor but
rather prevent contamination of shoes with blood and body fluids. (AORN 2015; Bearman et al.
2014)

Wash hands before and after donning and removing PPE

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 Instructions for Putting On and Removing Personal Protective Equipment
Putting on and removing PPE in the proper order and manner is just as important as wearing PPE.
Failure to properly put on or remove PPE could lead to exposure to or lack of protection against
infectious agents. The order of putting on PPE and removing PPE depends upon the purpose for
which the PPE is being used. PPE is used for Standard Precautions, operating theaters, isolation
rooms during Transmission-Based Precautions, and during disease outbreaks (e.g., novel
respiratory disease, VHF). (See Volume 2, Section 4, Chapter 2: Use of Personal Protective
Equipment during Outbreaks of Viral Hemorrhagic Fever,)

Choosing PPE for Standard and Transmission-based Precautions

For the purpose of Standard Precautions, PPE are chosen based on the risk of exposure to blood or
body fluids during patient care. The choice could be simply a pair of non-sterile gloves if touching
contaminated surfaces or gown, gloves, mask and eye protection if extensive splashing is
expected. For the purpose of transmission-based precautions septic items of PPE are designated for
each type (e.g. only an N95 respirator if providing care to a suspected case of TB, as Airborne
Precautions do not require use of gown or gloves). (For more information, see chapter 3 for
standard and Transmission-Based Precautions and chapter 5 for appropriate PPE for each
precaution) In case you need to wear multiple PPE, the sequence described below should be
followed for safely putting on and removing PPE. For details about putting on or removing PPE,
see the sections earlier in this chapter about each specific item of PPE.

Sequence for Putting on PPE for Standard and Transmission-based Precautions

1. Put on protective boots or shoe covers (if needed).

2. Perform hand hygiene.
3. Put on a gown.
4. Put on a procedure mask/N95 respirator.
5. Put on goggles or a face shield.
6. Lastly, put on gloves.
Source: CDC 2004.

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Sequence for Removing PPE

PPE should be removed at the doorway before leaving the patient room or in the outer room:

1. Remove gloves.
2. Remove goggles/ face shield by the ―clean‖ head band or ear pieces.
3. Remove the gown.
4. Remove the mask or respirator.
5. Dispose of single-use and reusable PPE in designated containers.
6. Remove shoe covers or boots (if used) before leaving the area.
7. Perform hand hygiene.

Sequence for Putting on PPE for Sterile Surgical Procedures in the Operating Theater

1. Change from street clothes to a clean scrub suit (one that has been processed in the health
care facility laundry). Remove all jewelry.
2. Put on non-skid, low-heel shoes with closed toes and back, rubber boots, or shoe covers
when there is a risk of gross contamination with blood or body fluids.
3. Perform hand hygiene.
4. Put on a plastic apron if the sterile surgical gown is not fluid-resistant.
5. Put on a surgical head cover (and facial hair cover, if needed) to ensure that hair on the
head (and beard) are fully covered.
6. Put on a surgical mask, one that fits well and fully covers the mouth and the nose.
7. Put on appropriately sized, well-fitting goggles or a chin-length face shield.
8. Perform a surgical hand scrub using soap and water and ABHR (see Volume 1, Chapter 4:
Hand Hygiene).
9. Put on a sterile surgical gown without contamination (see Figure 5.0.7 A).
10. Lastly, put on sterile surgical gloves without contamination (see Figure 5.0.7 B).

Note: There may be instances where PPE to protect the HCW from infectious disease may be
required in addition to surgical attire, such as a respirator for surgery on a patient with known or
suspected TB or additional skin coverage for surgery on a patient with known or suspected viral
hemorrhagic fever.

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Sequence for Removing PPE following Sterile Surgical Procedures in the Operating
Theater

1. Remove the gloves following the recommended steps and dispose of in a waste container;
do not reprocess or reuse the gloves.
2. Remove the gown, avoid touching the outer side of the gown, and dispose of in a waste
container (if a single-use gown) or place the used gown in a container for processing later.
3. Remove the plastic apron, if one was used, and dispose of in a waste container (if a single-
use apron) or place the used apron in a container for processing later.
4. Remove eye protection.
5. Remove the surgical mask.
6. Perform hand hygiene.
7. These steps will be performed at the end of day unless any item becomes soiled.
8. Remove the head cover (and facial cover).
9. Remove shoe covers (if worn).
10. Remove shoes.
11. Remove scrub suit.
12. Lastly, perform hand hygiene.
Adapted from: AORN 2015.

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109
110
Types of Personal Protective Equipment to Prevent Transmission During Disease
Outbreaks

List of Personal Protective Equipment

PPE recommended by the World Health Organization (WHO) for HCWs who provide care and
treatment to VHF patients includes:
 Fluid-resistant coverall or gown:
 Without an attached hood
 With thumb holes or loops
 Waterproof apron
 Waterproof boots
 Fluid-resistant isolation mask with a design that does not collapse against the mouth
 Face shield
 Respirator—required when performing aerosol-generating procedures is anticipated
 Head cover that covers head and neck (separate from the gown or coverall)
 Double gloves with cuffs to mid-forearm (nitrile preferred over latex)
(Ruparelia et al. 2015)

Summary
The use of PPE is recommended to protect HCWs from hazards encountered during their regular,
daily duties. An adequate supply of PPE should be available for use at the point of care. In addition,
management staff should be aware when and how to replenish PPE supplies. In situations with
limited resources, PPE should be prioritized to provide, at a minimum, implementation of Standard
Precautions. Staff should be educated and trained on the indications for PPE, the benefits and
limitations of specific PPE, and the correct procedure for putting on, wearing, and removing PPE so
that PPE can be used effectively and efficiently. Health care facility support and feedback from
supervisors is also necessary to create sustained compliance with PPE guidance.

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CHAPTER 6: SHARPS AND INJECTION SAFETY
Key Topics:

Magnitude of unsafe injection

The risks and impacts associated with unsafe injection practices
Common reason for prescribing and providing unnecessary and unsafe injection
Unsafe injection practice: Transmission pathways
The best practices in injection safety
Role of prescriber in injection safety
Principles in safe injection practice
Injection devices and their safety features
Safe handling of medications containing vials (single and multiple dose vials)
Sharp safety

Dentition of Key Terms

Blood borne pathogens: are infectious microorganisms (bacteria, viruses, and other
microorganisms) contained in blood and other potentially infectious body fluids (including urine,
respiratory secretions, cerebrospinal, peritoneal, pleural, pericardial, and synovial amniotic fluids,
semen, vaginal secretions, breast milk, and saliva). The pathogens of primary concern are hepatitis
B virus (HBV), hepatitis C virus (HCV), and HIV.

Health care worker (HCW), in this manual, is someone who works in a health care facility and
provides health care and services to people, either directly or indirectly as a clinician, nurse,
midwife, aide, helper, laboratory or x-ray technician, cleaner, or waste handler.

Multi-dose vial is a vial of liquid medication intended for parenteral administration (injection or
infusion) that the manufacturer has prepared to contain more than one dose of a medication. Multi-
dose vials are labeled as such by the manufacturer and typically contain an antimicrobial
preservative to help prevent the growth of bacteria. The preservative has no effect on viruses and
does not protect against contamination when HCWs fail to follow safe injection practices.

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Post-Exposure Prophylaxis (PEP) is a preventive medical treatment for which a person may
qualify following potential exposure to a disease-causing pathogen, such as a HIV or HBV, to
prevent becoming infected.

Safe injection is one that does not harm the recipient, does not expose the HCW to any avoidable
risks, provided by skilled person, using appropriate injection equipment and does not result in
waste that is dangerous for the community.

Sharps are instruments, needles, and any other objects that can easily penetrate through the skin.

Sharps injuries are injuries from a ―sharp‖ penetrating the skin. ―Sharps‖ include syringe needles,
scalpels, broken glass, and other objects that may be contaminated with blood or body fluids. These
injuries potentially expose HCWs to infections from blood borne pathogens.

Sharps injury prevention strategies are measures taken to prevent injuries while handling sharps.
These measures include elimination of hazards and the use of engineering controls, administrative
controls, work space practices, and personal protective equipment.

Single-use or single-dose vial is a vial of liquid medication intended for parenteral administration
(injection or infusion) that is meant for use in a single patient for a single case/procedure/injection.
Single-use or single-dose vials are labeled as such by the manufacturer and do not contain
antimicrobial preservative.

Standard Precautions are a set of infection control practices used for every patient encounter to
reduce the risk of transmission of blood borne and other pathogens from both recognized and
unrecognized sources. They are the basic level of infection control practices to be used, at a
minimum, in preventing the spread of infectious agents to all individuals in the health care facility.

Administrative controls, also known as ―work practice controls,‖ are changes in work procedures
such as written policies, rules, protocols, supervision, schedules, and training, with the goal of
reducing the duration, frequency, and severity of exposure to hazardous situations and substances
(e.g., blood, body fluids, and chemicals).

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BACKGROUND

WHO estimates that in developing and transitional member States, 16 billion healthcare injections
are administered each year i.e. an average of 3.4 injections per person yearly. Concurrently, it is
also estimated that at least 50 % of all injections are unsafe.

Injection safety baseline studies conducted by MOH and MMIS in 2004 and 2005 showed about
74% of injections were unsafe, about 72% of health facilities practiced unsafe disposal and the
prevalence rate of needle stick injury was 30 to 35%. It is also reported that almost half (45%) of
the community members have a tendency of preferring injections to other preparations.

Improper use of syringes, needles, and medication vials during routine healthcare procedures such
as administering injections have resulted in more than 40 outbreaks in both hospital and non-
hospital settings with transmission of blood borne viruses, including Hepatitis C virus. A
mathematical model developed by WHO suggests that in the year 2000, reuse of injection devices
in developing and transitional member states, is estimated to have caused 22 million new infections
with Hepatitis B virus (one-third of all such infections); two million new infections with hepatitis C
virus (40% of all such infections); and 260,000 new HIV infections (5% of all such infections). The
infections acquired in the year 2000 alone, are known to have caused an estimated nine million
years of life lost (adjusted for disability) between year 2000 and 2030.

A safe injection, as has already been briefly defined, does not harm the recipient, expose the
provider to any avoidable risk and result in any waste that is dangerous to the community. Unsafe
injection practice, on the contrary, is the one that could harm the recipient, and/or the provider
and/or may result in waste that is dangerous to the community.

Magnitude of Unsafe Injection

Each year, 16 billion injections are given in developing and transitional countries.

Most of the injections are therapeutic (90 to 95%); while few (5 to 10%) are given for
immunization.

The great majority (70%) of these injections are unnecessary given when oral medications
could have been prescribed.

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 A study of 40 health facilities using a combined survey/observation method found that about 74%
of the injections were unsafe. The fact that Ethiopian patients generally prefer injections to other
forms of medications further increases the risk of disease transmission;

Injection providers (about 47%) are known to believe that oral medications are less effective than
injections for the treatment of fever caused by minor illness

Risk and Impacts of Unsafe Injection

Table 6.0-1Conditions Causing Risks to Community, Patients/Clients and Providers

Community Patient/Client Providers

 Unsafe waste  Use of injections when there are other suitable alternatives  Shortage or absence of
disposal system of  Applying pressure to bleeding sites with dirty material or appropriate injection
health facilities finger and safety devices
 Receiving  Drug administered at incorrect anatomical site. For  Carrying used needles
injections from example, before disposal
inform injectors 1. Infants vaccinated at the buttocks rather than anterior-  Placing needle on a
 Leaving sharps in lateral thigh surface prior to disposal
accessible place to 2. Giving large boluses of intramuscular injections  Recapping needles
the public, 3. Injecting a nerve (either one or two hand)
especially children  Use of unsterile syringes and needles (or use of ―new‖ but  Manually detaching
 Sharing needles damaged compromised package) needles from syringes
and syringe  Re-use of syringe and needles  Manipulating used
 Reusing needles  Use of opened multi-use vials stored beyond sharps (cleaning,
and syringes recommended time (contaminated drug use) bending, breaking or
 Using wrong diluents or wrong amount cutting hypodermic
 Use of expired drugs needle)
 Syringes are loaded with different medications  Passing on sharps from
 Loading syringe with multiple doses one health worker to
 Drugs and vaccines are stored in the same refrigerator another
 Accidental switching of drugs  Sharps are found in
 Health workers not following aseptic techniques unexpected places like
 Patient/client moves during administration of injection linen
 Sharps are found in unexpected places like linen  Overfilling of sharps‘
 Self-medication containers
 Using a syringe on an
agitated patient without
assistant or
patient/client moves
during administration of
injection

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Risk to Patients

Unsafe injections can result in transmission of a wide variety of pathogens, including viruses,
bacteria, fungi, and parasites. The World Health Organization (WHO) estimates that in low- and
middle-income countries, 16 billion health care injections are administered each year, translating to
approximately three injections per person per year, many of which are unnecessary. Reuse of
syringes or needles, which is common in many settings, exposes patients to pathogens either
directly (via contaminated equipment) or indirectly (via contaminated medication vials). The risks
of unsafe injection practices have been well-documented for the three primary blood borne
pathogens: HIV, HBV, and HCV. Worldwide, each year, the overuse of injections and unsafe
injection practices combine to cause an estimated:

 8–16 million HBV infections

 2.3–4.7 million HCV infections
 80,000–160,000 HIV infections
(Hutin et al. 2003; Wilburn and Eijkemans 2007; WHO 2015)

Adverse effects are often caused by an unsafe injection. This is an incidence which harms a person
receiving healthcare caused by poor injection practices rather than the underlying disease
which caused the patient to seek treatment. Adverse events caused by an unsafe injection include:

 Transmission of blood born infections - occurs due to inoculation of infectious agents

into the patient‘s body. There are about 40 blood borne pathogens that could be
transmitted via injection. Among these, HBV, HCV, HIV/AIDS are the commonest and
with grave implications.
 Injection abscesses - these are inflammatory conditions ranges from the initial signs of
inflammation to big swellings occurring from suppurative processes.
 Paralysis following the damage of a nerve as a result of injection of a drug into a nerve and
trauma.
 Drug/allergic reactions shock - a life threatening condition characterized by sudden
collapse of the circulatory system due to immunological response to the injected drug, or
other local or systemic allergic reactions.

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Risk to Health Care Workers

Globally, in the course of their duties, HCWs are at an increased risk from blood borne pathogens
because they handle sharps, including needles and syringes. It is estimated that 39% of HCV, 37%
of HBV, and 4.4% of HIV infection among HCWs worldwide are attributable to occupational
exposure to sharps injuries. (Prüss-Üstün et al., 2005). Both patients and HCWs are at risk of blood
borne disease from unsafe injection practices. Eliminating unnecessary injections and using safe
injection practices are the best ways to protect patients and staff from the risks.

Impacts of Unsafe Injection

 Health Impacts unsafe injections have always been known to negatively affect people‘s
health not only patients but also on care providers The health problems could range from
simple to deadly ones.(refer Table 6.0.2)

Table 6.0-2 Proportion of Infections and Total Burden of Disease Caused by Unsafe Injection

Infections Estimated Burden of Infections Due Estimated Proportion of Infections

to Unsafe Injection Practices Due to Unsafe Injection Practices
Hepatitis B 22 million new cases 32%
Hepatitis C 2 million new cases 40%
HIV/AIDS 260,000 new cases 5%
Deaths in 2000 due to unsafe injection practices in the past, 501,000 deaths
Source: WHO. “Safety of Injections. Global Facts and Figures,” PP 1-2.

 Socio-Economic each year, the annual global burden of indirect medical costs due to
hepatitis B, hepatitis C and HIV/AIDS is estimated to be US$ 535 million.
 Psycho-Social impact includes: Stigma, discrimination and social isolation following
infections like HIV, Stress associated with HIV, burden on family & the community
(unproductive, children will be orphans, etc), risk of transmitting infections to family and
the community. The Psycho-Social impacts can be seen at an individual, family,
community and country level.

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 Common Reasons for Prescribing and Providing Unnecessary and/or Unsafe
Injections

1. Inadequate dissemination/promotion and use of standard treatment guidelines.

2. Prescriber‘s predilections to injections. Lack of knowledge on the dangers of injections,

wrong perception that injections are more effective than oral medications, give more
rapid relief, are more potent are some factors influencing for an over use of injections.
Other known factors are: financial incentive for prescribing injections and the fear that
patients will go elsewhere if therapy is given otherwise or Perceived belief that patients
prefer injections.

3. Informal providers giving injections.

Unsafe Injection Practices: Transmission Pathways

Double dipping is the reuse of a syringe that has been used to inject medication into a patient to
withdraw medication from a multi-dose vial using a new needle and injecting another patient with
the medication. This results in contamination of the medication in the vial and the syringe.

Even if a new needle is attached, when this syringe is used on subsequent patients, patients can
become infected with blood borne pathogens from contamination within the syringe. Even if a new
needle and new syringe are used for subsequent patients, they can become infected with blood
borne pathogens from the contaminated liquid in the vial. Figure 6.0.1 shows the pathway of
transmission of blood borne pathogens, in this case HCV, via unsafe injection practices.

Figure 6.0-1.Unsafe Injection Practices and Disease Transmission Source: CDC 2008.

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 Best Practices in Injection Safety

1. Elimination of Unnecessary Injection: The results of a survey conducted through

interview of patients showed that 76.2% of the prescriptions had at least one injection.
The study was conducted in four regions of Ethiopia. The most commonly prescribed
medications include antibiotics, analgesics, antispasmodics and vitamins. All of these
medications were just as effective if they were given by mouth. Many injectable
medications have an oral equivalent that are equally strong, effective and much safer.
Therefore, unnecessary injections should be reduced through:

A. Promoting Rational Prescribing:- injections should only be used during life

threatening conditions, mal-absorption syndromes or inability to swallow.
B. Educating the Patients:- encourage patients to accept oral medications; and
explain the risks associated with injections when possible to limit the use only
when necessary.

2. Administer Injections Safely

Make sure that the „right‟ things/ways are fulfilled when administering injections
(Refer Table 6.0.3)

Standards for Administering Injections (Refer Table 6.0.3)

 Prepare a well-laid up tray including emergency drugs for management or possible

drug reaction.
 Wash hands with soap and water. Alcohol could be used as a secondary step after
soap and water except for EPI injection.
 Dry up hands. You can use small paper towels or any single use towels.
 Check for the integrity of the vial/ampoule for the following expiry date, breach,
leaks, particles or any contamination.
 Make sure that the right dose, formulation and route are used for the right
patient or client.

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  For medications that need to be reconstituted, (powder forms) it should be done
according to the manufacturer‘s instruction and use the correct diluents.
 Draw the right dose as prescribed, including expelling the air using right
injection equipment.
 Ensure aseptic technique while giving the injection.
 Administer the drug at the correct site.
 Dispose the used syringes and needles immediately into the sharp‘s container.
(Never give used syringes and needles to patients or clients to carry home even if they
came with the equipment).
 A patient should be kept in the room for at least 5 minutes after the injection has
been given and be observed for any possible adverse effect or events.
 Thank the patient or the client.
 Record the date and time of injection administered.

The Role of Prescribers and Providers in Injection Safety

Avoid unnecessary injections. Therefore, injections should only be used in:

 Life threatening conditions

 Mal-absorption syndromes or
 Inability to swallow

Prescribers and Service providers should also:

 Encourage patients to accept oral medications when possible.

 Injections should be given only when necessary.
 Explain the risks associated with injections
 Explain to patients the need to take oral drugs as prescribed and review these instruction
with them.
 Inform patients the potential side effects of medications that is being prescribed
 Explore why patients prefer injections

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Figure 6.0-2: Right Ways to Give Safe Injection

Rights Standards Always check and verify all Method of Verification

„rights‟

1. Right Patient What is the name on the prescription? Ask patient/guardian, etc. to repeat
name
Is this the right patient?

2. Right Drug Is the name of the drug on the Verify name of drug on
prescription the same as the prescription with injection to be
injection you are about to administered
administer?
If you are unsure verify with
physician or pharmacist

3. Right Formulation Could the medication be given orally Discuss with patient available
instead of as an injection? choices

4. Right Injection Use only sterile, non-reusable Check to ensure that syringe/needle
Equipment package is unbroken
syringes, dental cartridge, etc.

5. Right Dosage Check dosage against patient‘s age, Read the pharmaceutical
recommendations of the drug If
weight and the pharmacokinetics of the
unsure, verify with the
drug
physician/prescriber

6. Right Time Follow the specific dose interval Be mindful of the action of the
drug and why the time interval
should be followed.

Explain the importance of this to

the patient

7. Right Route Be sure to use the correct route of Observe the direction of the prescriber
administration (intra-muscular, intravenous,
Check prescription or other
intra-dermal or subcutaneous)
related records

8. Right Storage Right temperature, Vaccine Vial Monitor Check cold chain issues including
(VVM) shake test Vaccine Vial Monitor

9. Right Method of Do not recap needle. Check the safety box for correct
Disposal
Dispose of used syringe and needle method of disposal
immediately after use in appropriate
safety box

Or

Use the needle cutter and safety box

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Principles of Safe Injection

Practices

Evidence-based safety practice can be divided into four major areas of Intervention: (refer to Box
1-6-1)

1. Use Sterile Injection Equipment

Single use syringe and needle for each injection is recommended and Auto-disable syringes are
mandatory for all immunization injections).

For curative and other purpose injections, syringes with reuse prevention devices and safety
features are recommended. Where these ones are not available, standard disposable syringes can
be used. Studies showed that unsafe injection practices such as using the same needle, syringe or
both for more than one injection or improperly processed syringes and needles are responsible for
the transmission of HIV, HBV and HIV (Drucker et al., 2001; Simonsen et al., 1999).
Therefore, after each use, the assembled needle and syringes should be placed in containers for
disposal of sharps.

2. Prevent Contamination of Injection Equipment and Medication

 Prepare each injection in a clean designated area where blood or body fluid
contamination is unlikely.
 Use single dose vials rather than multi-dose vials.
 If multi-dose vials must be used, always pierce the septum with a sterile needle and
avoid leaving the needle in place in the stopper of the vial.
 Select pop-open ampoules rather than ampoules that require use of a metal file to open.
 If you are using an ampoule that requires a metal file to open, protect fingers with a
clean barrier (e.g. small gauze pad) when opening the ampoule.
 Inspect medicaments and discard those with visible contamination or breaches of
integrity (e.g. cracks, leaks).
 Follow product-specific recommendation for use, storage and handling.

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  Swabbing of a new vial tops or ampoules with an antiseptic or disinfect is unnecessary.
If swabbing with an antiseptic is selected for use, use a clean, single use swab and
maintain product specific recommendation contact time. Do not use cotton balls stored
wet in a multi-use container.
 Swabbing of clean skin before giving an injection is unnecessary. Wash skin visibly
soiled or dirty with soap and water. If swabbing with an antiseptic is selected for use,
use a clean, single use swab and maintain product specific recommendation contact
time. Do not use cotton balls stored wet in a multi-use container.
 Discard a needle that has touched any non-sterile surface.

3. Prevent Injuries to the Provider

Hypodermic needles (hollow bore needles) cause most of the injuries to healthcare workers at all
levels. Injuries may occur during procedures, (clinicians), cleaning and washing (house-keepers)
and handling waste materials

Precautions to take before an Injection, precautions are taken depending on the types of
procedure being carried out.

 Anticipate and take measures to prevent sudden patient movement during and after
injection.
 Do not recap, bend or break needles prior to disposal of single use needles and syringes
after giving injections. However, if there is a need to recap a needle due to various
reasons, needles must be recapped using the ―one-handed‖ recap method as follows:
 First, place the needle cap on a firm and flat surface, and then remove the hand.
 Next, with one hand holding the syringe, use the needle to ―scoop‖ up the cap
 (Figure 6.0.2).
 With the cap now covering the needle tip, turn the syringe upright (vertical) so the
needle and syringe are pointing toward the ceiling.
 Finally, using the forefinger and thumb of your other hand, grasp the cap just above
its open end (Figure 6.0.2) and push the cap firmly down onto the hub (the place
where the needle joins the syringe under the cap).

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 1. Place the cap on a flat surface, and then remove your hand
from the cap. With one hand, hold the syringe and use the
needle to scoop up the cap.
2. When the cap covers the needle completely, use your other
hand to secure the cap on the needle hub. Handle the cap at
the bottom, near the hub.
Figure 6.0-3. One Handed Recap Method

 Do not decontaminate the needle and syringes prior to disposal.

 Do not disassemble the needle and syringe after use.
 All used syringes and needles or any other sharps should be discarded at the point of
use in an enclosed sharp container which is puncture and leak proof and sealed
before being completely full.
 During injection, disposable gloves are indicated only if excessive bleeding anticipated.

4. Prevent Access to Used Needles and Syringes

 Seal sharp containers for transport to a secure area in preparation for disposal. After
closing and sealing sharps containers, never open, empty or reuse them.
 Manage/dispose sharps waste in an efficient, safe and environment-friendly way to
protect people from voluntary or accidental exposure to used injection equipment.
 Disposal of used syringes, needles and sharp containers.
 The following guiding principles should be used for disposal of syringes, needles, and
sharps containers.
 Dispose all sharps in a safety box immediately after injection.
 If the syringe is a retractable one, make sure to engage the retraction feature before
disposing of the syringe.
 Collect used syringes and needles at the point of use in an enclosed sharps container (safety
box) that is puncture and leak-proof.
 Do not use boxes that are open, overflowing or punctured. Get a new one instead Dispose
safety boxes when 2/3 full.
 Dispose of the sharps and sharp containers by burning, burying or encapsulation.
 Always put on a heavy duty gloves when handling sharps containers.

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Best Practices for Administering Injection

Select safe medicines

 Proper handling of medicines including keeping it in a clean environment.

 Label them clearly
 Observe proper storage conditions, including temperature and humidity (as
recommended by manufacturer)
 Check expiry dates

Use of sterile equipment

 Use needle and syringe from sealed package

 Use syringes with re-use prevention features

Avoid contamination (Adhere to principles of Aseptic Technique)

 Wash hands
 Prepare on clean surface
 Do not touch part of needle that will come in contact with patient‘s tissue and avoid
recapping. If recap is necessary, apply one hand technique.
 Do not leave the needle in the rubber cap of the vial

Re-constitute drugs or vaccines safely

 Use new sterile syringe and needle for each reconstitution

 Use the correct diluents/water for injection
 Reconstitute according to the manufacturers‘ specifications

Disposal of injection wastes and sharps properly

 Immediate disposal of needle and syringe in puncture- and leak-proof container

Disseminate public health education and information.

Injection Devices and Their Safety Features

Syringes and needles are the major devices needed to provide injection and the following are
used as standard types of syringes in healthcare facilities (refer table 1-6-4):

1. Auto disable syringe.

2. Manually retractable.
3. Automatically retractable.
4. Standard Disposable.
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Both private and public health facilities should use the above listed syringe and needles
to provide any type of injections. After injections syringe and needles should be disposed in
to safety boxes.

Special Note:

All patients undergoing an injection should be counseled before injection is given e.g. on the
type of drug, side effects, possible adverse effects/events following the administration of the
injection and total number of doses to be given by injection.

Self-injecting patients such as diabetic patients should be properly informed about their
medications and how to ensure safety or injection. In case a patient needs to take the injection
equipment home, he/she should be counseled on the storage, disposal and sterility of their drugs
and equipment.

Table 6.0-3Types of Injection Devices: Advantages and Disadvantages

Type of Device Advantag Disadvantages

Auto-disable  Cannot be reused es  More expensive than standard
syringes  They save time for healthcare workers disposable (but are still
from the burden of sterilization affordable)
 Eliminate the patient-to-patient disease  Have no safety features
transmission caused by the use of  Need collection and disposal
contaminated syringes and needles system
Manually  Cannot be reused  Not automatic; relies on good will
retractable  Safety feature: needle retracts inside barrel of healthcare worker
 They save time for healthcare workers  More costly
from the burden of sterilization
 Eliminate the patient-to-patient disease
transmission caused by the use of
contaminated syringes and needles
Automatically  Cannot be reused. Automatic  Most costly
retractable  Safety feature: needle retracts inside barrel
 It saves time for healthcare workers from
the burden of sterilization
 Eliminate the patient-to-patient disease
transmission caused by the use of
contaminated syringes and needles

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 Standard disposable  Cheap  Can be reused without
 Ava ilable on local market. Sterilization
 They save time for healthcare workers  Have no safety features
from the burden of sterilization  Need sharps container or needle
 Eliminate the patient-to-patient disease remover
transmission caused by the use of  Carry a high risk of infections
contaminated syringes and needles

Safe Handling of Vials Containing Medication (Single-Use and Multi-Dose Vials)

Practical guidance on use of safe injection devices

When using a sterile, single-use device (i.e., a syringe and hypodermic needle that are not separated
or manipulated unless necessary):
 Use a new device for every patient, including for withdrawing medication. This practice is
considered a very basic IPC precaution and is promoted by WHO (Safe Injection Global
Network [SIGN]) and the US Centers for Disease Control and Prevention (CDC), among
others. Figure 6.0.3 shows the ―ONE and ONLY Campaign,‖ which advocates for one
needle, one syringe, and only one use.
 Inspect the packaging of the device to ensure that the protective barrier has not been
breached.
 Discard the device if the package has been punctured, torn, or damaged by exposure to
moisture, or if the expiry date has passed.
 (WHO 2010)

Figure 6.0-4. ONE and ONLY Campaign

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Practical guidance on handling parenteral medication

 When giving medication:

 ALWAYS follow the one needle, one syringe, one injection rule.
 DO NOT use a single-loaded syringe to administer medication to several patients even
if you change the needle every time between patients. See Figure 6-1. Unsafe Injection
Practices and Disease Transmission in this chapter. (Always follow the one needle, one
syringe, one injection rule.)
 DO NOT use the same mixing syringe and needle to reconstitute several vials. See
Figure 1-1, Unsafe Injection Practices and Disease Transmission, in this chapter.
 DO NOT combine leftover medications for later use.
 DO NOT use single-use vials for multiple patients, if at all possible.

 When using single-use vials:

 Vials labeled by the manufacturer as ―single-dose,‖ ―single-use,‖ or ―preservative-free‖

should be used only for a single patient.
 There may be circumstances when the contents of single-use vials must be used for
multiple patients. In this situation, contents from an unopened single-use vial can be
repackaged one time into multiple single-use syringes for multiple patients. However,
this should be performed only by a trained HCW in an area away from patient care and
in accordance with strict IPC standards. Label as described below. Store for only 24
hours.
 Check that you have the right medication vial for the patient‘s prescription.
 Double-check the expiration date and if the vial has previously been opened, the current
date is within 24 hours of opening (unless a shorter or longer time frame is otherwise
specified by the manufacturer).
 Follow the principle of one syringe, one needle, one time.
 Discard the single-use vial after use.
 Discard a single-use vial:
 If sterility or content is compromised

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  If the expiry date or time has passed
 If found to be undated, improperly stored, inadvertently contaminated, perceived to be
contaminated, or already punctured, regardless of expiration date

When using multi-dose vials:

 If a multi-dose vial is assigned to a single patient (e.g., insulin pen), check that you have
the right vial for the patient.
 Double-check the expiration date and if previously opened, check that the vial is labeled
by the manufacturer as a multi-dose vial and the current date is within 28 days of
opening, unless a shorter or longer time frame is otherwise specified by the
manufacturer.
 Follow the principle of one syringe, one needle, one time.
 Remove the needle cap and insert the needle tip until it touches the bottom of the bottle.
 When withdrawing medication from a multi-dose vial, avoid double dipping, this may
contaminate the contents of the vial and transmit infection to subsequent patients. See
the Needles and Syringes section in this chapter.
 If newly opened, label the multi-dose vial. See the Labeling section in this chapter.
 DO NOT store multi-dose vials in patient care areas, where they could be inadvertently
contaminated.

 Discard a multi-dose vial:

 If sterility or content is compromised

 If the expiry date or time has passed (even if the vial contains antimicrobial
preservatives)
 If it is not properly stored after opening, or within 28 days of opening, unless a shorter
or longer time frame is otherwise specified by the manufacturer, or follow the
manufacturer‘s instructions for the time the vial can be used once opened
 If found to be undated, improperly stored, inadvertently contaminated, perceived to be
contaminated, or has a visible hole in the rubber septum, regardless of expiration date, if
thought to be a single-use rather than multi-dose vial.

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Safe Preparation of Parenteral Medication

Injections should be prepared in a designated clean area, away from patient care, where
contamination by blood and body fluids is unlikely.

Practical guidance on setting up for preparing injections

Three steps must be followed when preparing injections

1. Keep the injection preparation area free of clutter so all surfaces can be easily cleaned.
2. Before starting the injection session, and whenever there is contamination with blood or
body fluids, clean the preparation surfaces with a surface antiseptic such as 0.5% sodium
hypochlorite solution, 70% alcohol (isopropyl alcohol or ethanol), or other suitable surface
disinfectant and allow the preparation to dry.
3. Perform hand hygiene and assemble all equipment needed for the injection: sterile, single-
use needles and syringes; reconstitution solution, such as sterile water or a specific diluent;
alcohol swab or cotton wool; and a sharps container.
(WHO 2010)

Procedure for vials with a rubber septum

Many vials have a rubber septum (stopper).

 Wipe the access rubber septum with 70% alcohol (isopropyl alcohol or ethanol) with a swab
or cotton-wool ball and allow it to dry before piercing the vial or inserting a device into the
bottle.
 Use a new, single-use, disposable, sterile syringe and needle for each insertion into a vial.
 Never leave a needle in a multi-dose vial. This practice provides a direct route for
microorganisms including HIV to enter the bottle and contaminate the fluid between each
use.
 Once the loaded syringe and needle have been withdrawn from a multi-dose vial, administer
the injection as soon as possible.

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 Reconstitution
 Always use a sterile syringe and a sterile needle to withdraw the reconstitution solution
from an ampoule or a vial, insert the needle into the rubber septum in the single- or multi-
dose vial, and inject the necessary amount of reconstitution fluid.
 Remove the needle and syringe and discard them immediately as a single unit into a sharps
container.
 Mix the contents of the vial thoroughly until all visible particles have dissolved.

Delay in administration

 If a dose has been withdrawn into a syringe and cannot be administered immediately for any
reason, cover the needle with the cap using a one-handed scoop technique. Do not keep the
medication longer than 24 hours unless a shorter or longer time frame is otherwise specified
by the manufacturer. Inject the medication as soon as possible after withdrawing from the
vial. See the section on labeling in this chapter. (WHO 2010).

Labeling

After reconstitution of a vaccine or medication in a multi-dose vial (e.g., BCG vaccine), label the
vial and the final medication container with:

 Date and time of preparation

 Type and volume of diluent (if applicable)
 Final concentration
 Expiry date and time after reconstitution
 Name and signature of the person reconstituting the drug

For multi-dose medications that DO NOT require reconstitution (e.g., lignocaine), label the
container with:

 Date and time of first piercing of the vial

 Expiry date and time after reconstitution
 Name and signature of the person first piercing the vial

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Procedure for Pop-Open Ampoules

 Whenever possible, use vials with a rubber septum. If not available, use pop-open ampoules
rather than ampoules that require use of a metal file to open. When opening glass ampoules,
always protect fingers with a clean barrier, such as a small gauze pad (see Figure 1-6-4).
 Pop-open vials cannot be stored for later use.
(Hutin et al. 2003)

Figure 6.0-5. Breaking Open an Ampoule

Source: Doyle and McCutcheon 2015.

Safe Administration of Injections

Aseptic techniques should be followed for all injections.

Practical guidance on administering injections

General

 When administering an injection:

 Ensure that the patient is adequately prepared for and informed about the procedure.
 Check the drug chart or prescription for the medication and the five ―rights‖: right patient, right
drug, right dose, right route, right time.
 Perform hand hygiene.
 Wipe the top of the vial with 70% alcohol (isopropyl alcohol or ethanol) using a swab or
cotton-wool ball. Allow it to dry.
 Open the package in front of the patient to reassure the person that the syringe and needle have
not been used previously.
 Use a sterile syringe and needle to withdraw the medication from the ampoule or vial.

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Important points

 DO NOT allow the needle to touch any contaminated surface.

 DO NOT reuse a syringe, even if the needle has been changed.
 DO NOT touch the rubber septum after disinfection with the 70% alcohol (isopropyl alcohol or
ethanol).
 DO NOT re-enter a multi-dose vial with the same needle used for mixing or reconstituting
medications.
 DO NOT re-enter a vial with a needle or syringe used on a patient if that vial will be used to
withdraw medication again (whether it is for the same patient or for another patient).
 DO NOT use bags or bottles of intravenous solution as a common source of supply for
injections (e.g., normal saline flushes) for multiple patients. These are not manufactured as
multi-dose and do not have any preservative (see Box 1-6-1).
Practical guidance on prevention of sharps injuries

 Do not bend, break, manipulate, or manually remove needles before disposal.

 Avoid recapping needles, but if a needle must be recapped, use a single-handed scoop technique
(see Figure 6.0.2).
How to withdraw medication using an auto disable syringe?

WHO recommended several years ago that all immunizations be given using auto disable syringes
to improve injection safety Since then, auto-disposable syringes have been widely used in both
campaign and routine immunization settings. Although there are many types of auto-disable
syringes, they are all similar in that they only permit the syringe to be filled and be emptied at once.
Auto-disposable syringes are a single-use, disposable syringe with a metal clip that locks the
plunger after a single use (i.e. it cannot be pulled back a second time). To use auto-syringes, end-
users need to familiar with or to have a basic orientation.

 Open the sterile pack containing the needle and syringe and attach the needle firmly.
 Remove the needle cap and insert the needle tip until it touches the bottom of the bottle
as shown in Figure 6.0.4 (to avoid drawing air into the syringe, the needle tip should
stay below the fluid level in the bottle).

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  While holding the bottle with one hand, slowly pull back on the plunger of the syringe
and draw up fluid to just above the fill line make (Figure 6.0.5). For the solo shot FX
syringes used with DMPA, the ―fill line‖ mark is at 1ml.

Figure 6.0-6. Withdrawing Medication Using an Auto-Disable Syringe

Withdraw the needle and syringe from the bottle and hold the syringe upright (needle pointing to
the ceiling) to see if any air is in the syringe. If there are air bubbles, slowly push the plunger in,
but only until the ―fill line‖ mark is reached.

Check that the fluid level in the syringe is at or slightly above the ―fill line‖ mark. If it is below the
fill line mark, there may not be enough medication to be effective and the injection should not
be administered. In this situation, either inject the medication back into the single dose bottle and
draw up the medication again using a new auto-disable syringe and needle, or discard the partially
filled syringe and use a new bottle and auto-disable syringe and needle.

Sharps Safety

Safety or Sharps Boxes

Safety or sharps box is a puncture and leak-resistant container for disposal of sharps including
hypodermic needles, needles from IV bags, lancets, scalpels and suture needles. May be made of
thick cards or disposable plastic bottles with narrow necks.

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 Categories of Sharps:

 Operating room- specific sharps requiring similar disposal include: surgical drain
trocars, needle point cautery tips, wire sutures, orthopedic drill bits and a range of
hollow injection.
 Special needles used by radiologists and anesthesiologists for various medical invasive
procedures as well.
 Routine use needles and other sharps e.g. blades, pins.
Proper Management of Safety Box:

 Can be free-standing or fixed.

 Should be easily accessible to health worker for easy disposal of needles
 Should not be easily accessible for public
 Dispose when 3/4 full\
 Use 1 per defined area of need.

Figure 6.0-7. Standard Safety Box

Sharps containers-dos and don‟ts:

 Do put sharps containers as close to the point of use as possible, ideally within arm‘s
reach.
 Do attach containers to walls or other surfaces if at all possible.

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  Do mark them clearly so that people will not unknowingly use them as for discarding
other items.
 Do place them at a convenient height so staff can use and replace them easily.
 Do mark the fill line at the three quarters full level.
 Don‘t shake a container to settle its contents and make room for more sharps.
 Don‘t place containers in high traffic areas where people could bump into them or be
stuck by someone carrying sharps to be disposed of.
 Don‘t place containers on the floor or anywhere they could be knocked over or easily
reached by a child.
 Don‘t place containers near light switches, overhead fans or thermostat controls where
people might accidentally put their hand into them.
 Do not put the following items on the sharp box: latex gloves, IV bags or extension tubes,
dressing materials (like adhesive tape and gauze), compresses, cotton pads, empty vials and
ampoule broken thermometers

Safe Disposal of Used Needles and Syringes

 Use of best practices can help to prevent sharps injuries to HCWs.

Other Sharps Safety Dos and Don‟ts

o Do wear gloves when using needles

o Do discard needles with syringes and other sharps immediately after use
o Do discard needles and other sharps in sharps container
o Do not walk around with needles and other sharps
o Do use receivers to pass sharps to others and alert them before passing the sharps
o Do not remove bend, break
o Do not recap needles after use
o Do not leave sharps lying around the facility
o Do not point needles and other sharps at yourself or others

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Summary

Injection safety is;

 An integral component of infection prevention and control,

 An element of Standard Precautions,
 Key element of patient and healthcare workers safety,
 Supported by infection prevention and control policies and procedures such as
hygiene of the hand, housekeeping, and waste management.

Injections present risks to patients, HCWs, and the community and should be limited where
alternative administration routes are available. Safe injection practices are one of the components of
Standard Precautions. A safe injection is one that does not harm the recipient, does not expose the
HCW to any avoidable risks, and does not result in waste that is dangerous for the community
(Rapiti et al. 2005). Safe injection practices include the proper use of single-use and multi-dose
vials. It is the responsibility of each HCW to ensure safe injection practices for every patient.

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CHAPTER 7: DECONTAMINATION AND REPROCESSING OF MEDICAL
DEVICES (INSTRUMENT PROCESSING)
Key Topics
Level of Disinfection or Sterilization Required
Guideline for Processing Instruments
Commonly Used Disinfectants
Cleaning
High level disinfection
Chemical disinfectants
Preparation and packaging for reprocessing
Processing of endoscopes
Sterilization
Safe transport and Sterile storage

Definition of Key Terms

Bio-burden: is the population of viable microorganisms on devices, instruments, equipment, or

products. When measured, bio-burden is expressed as the total count of bacterial and fungal
colony-forming units per single item.

Cleaning: The first step required to physically remove contamination by foreign material. It will
also remove organic matter, such a blood and microorganisms, to prepare a surgical instrument or
equipment for disinfection or sterilization.

Decontamination: Removes soil and pathogenic microorganisms from objects so they are safe to
handle, subject to further processing, use or discard. (Centers for Disease Control and Prevention
[CDC] .Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008).

High-level disinfection (HLD): is a process that kills all microorganisms but not necessarily high
numbers of bacterial spores. HLD is achieved by soaking items in liquid chemicals classified as
high-level disinfectants or by boiling or steaming for the appropriate time (20 minutes).

138
Instrument processing areas: are places anywhere in the health care facility where soiled
instruments, equipment, and other items are cleaned and processed by means of either high-level
disinfection or sterilization.

Intermediate-level disinfection: is a process that destroys all vegetative bacteria, including

tuberculosis bacilli, all fungi, and most viruses (except some non-lipid viruses) but not bacterial
spores. Intermediate-level disinfection is carried out using chemicals that have been approved as
intermediate-level disinfectants or those that are approved as ―tuberculocidal‖ in the national
infection prevention and control guidelines.

Log10 reduction and kill rate: is a quantitative (calculable) measurement describing the
percentage of contaminants killed during instrument processing procedures. 1 log10 reduction
means a 90% reduction in microbes on a given surface. For example, if there are 1 million
microbes on a surface, 1 log10 reduction or kill rate will remove 90% of 1 million microbes, 2
log10 kill rate will remove 99% of microbes, and 5 log10 reduction or kill rate will remove
99.999%. Therefore, a 6 log10 reduction or kill rate will remove 99.9999% of microbes, which
means that only 1 microbe will survive at the end of the procedure that has a kill rate of 6 log10
reductions.

Low-level disinfection: is a process that destroy all vegetative bacteria (except tuberculosis
bacilli), lipid viruses, some non-lipid viruses, and some fungi, but not bacterial spores. Low-level
disinfection is carried out using chemicals that have been approved to achieve low-level
disinfection.

Pasteurization: is a disinfection process that uses hot water at temperatures of 65–77°C (149–
170.6°F) for a contact time of at least 30 minutes to kill or markedly reduce the number of
microorganisms other than bacterial spores.

Point of use: refers to a place and time where equipment, instruments, and supplies are used on
patients (e.g., the patients‘ bedsides, procedure rooms, delivery rooms, operating theaters).

Sterilization: A process that eliminates all microorganisms (bacteria, viruses, fungi and
parasites) including bacterial endospores from inanimate objects by high-pressure steam
(autoclave), dry heat (oven), chemical sterilization or radiation

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BACKGROUND

As the prime concern of safety procedures is to protect both patients and the staff from infection,
the transmission of infection from medical devices and equipment contaminated with patient‘s
body fluid is the focal area of intervention in health facilities. Instruments which are reused
without being properly processed and made safe are one of the causes of infections in developing
countries. Healthcare workers are increasingly at risk of becoming infected with serious blood
borne viruses such as HBV, HCV and HIV. Some research findings showed that there are 8 to 16
million new infections of Hepatitis B annually due to unsterile injections in developing countries.
On the other hand, it was found that HIV survives in needles and syringes for more than 4 weeks
at room temperature (Abdala et al., 1999; Rich et al., 1998). Thus, the greatest risk results from
the staff‘s in direct contact with these life threatening infections while they perform or assist
with surgical procedures (physicians, nurses and midwives); process surgical instruments and
equipment (staff); perform housekeeping and waste management tasks; including disposal of
infectious waste items.

The basic infection prevention processes recommended to reduce disease transmission from
soiled instruments; surgical gloves and other reusable items are by way of decontamination,
cleaning and either sterilization or High-Level Disinfection (HLD). Regardless of the type of the
operative procedures, the steps in processing surgical instruments and other items are the same.
(Illustrated in Figure7.0.1)

In the effort put to create an infection-free environment, it is important that the rationale for each
of the recommended infection prevention processes, and their limitations, be clearly understood
by clinic staff at all levels from healthcare providers to cleaning and maintenance personnel.
Infection prevention principles require that all reused medical equipment should be properly
processed before reusing them to avert infections related to medical equipment. Processing these
reusable instruments is not knowledge and technology intensive. Rather, they need only simple
and basic trainings on how to process them after procedures.

After completing an operation or invasive medical procedure or while still wearing gloves, the
physician or assistant should dispose of contaminated objects (gauze or cotton and other waste
items) in a plastic bag or leak proof covered container. Disposable sharps (e.g. scalpel

140
blades and suture needles) should be placed in a sharps container. Afterwards all reusable items
should be cleaned at the point of use (soaked in a solution of warm water and detergent to
prevent blood from drying on the surface of the items).

Following pre-cleaning at the point of use, the instruments and reusable items are transported
to instrument processing area, preferably centrally, where they should be thoroughly cleaned
with soap and water and be completely rinsed and dried.

Level of Disinfection or Sterilization Required

A rational approach for processing medical devices and surgical instruments for patient care was
first described by Earle H. Spaulding more than 45 years ago (Spaulding 1968) and it is still
relevant in making decisions about the final approach to instrument processing. Spaulding
classified instruments and patient care devices into three categories, based upon how the device
is used. Items are classified as:
 Non-critical—come in contact with intact skin but not mucous membranes
 Semi-critical—come in contact with mucous membranes or non-intact skin
 Critical—come in contact with sterile areas of the body including the vascular system

Table 7.0-1 Spaulding‟s Risk Classification and Level of Processing

Risk Level of Examples

category disinfection/sterilization

Critical Sterilization Reusable surgical instruments

Semi- High-level disinfection Respiratory instruments, specula used for

critical vaginal examination, endoscopes

Non-critical Cleaning Blood pressure cuffs, stethoscopes

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Guidelines for Processing Items

In all steps, special attention should be given to proper handling of the instruments and other
items to minimize the risk of accidental injury or exposure to blood and other body fluids of the
sterile processing staff and to attain high quality end result.

POINT-OF-USE
CLEANING
(Occurs immediately after use)

CLEANING
Thoroughly wash, rinse, and dry

STERILIZATION HIGH-LEVEL DISINFECTION

Chemical Autoclave Dry Heat Pasteurization Steaming Chemical
(Steam / Boiling
Soak time sterilization) Temperature Lid on 20 Soak time
depends on Time, temperature, depends on Lid on 20 minutes depends on
manufacturers‘ and pressure depend manufacturers‘ minutes manufacturers
instructions on manufacturers‘ instructions ‘ instructions
instructions

COOL Store
appropriately or
use immediately

Figure 7.0-1. Work flow for instrument processing and other medical devices

Each item, be it soiled metal instruments, requires special handling and processing in order to:

 Minimize the risk of accidental injury or exposure to blood or body fluid to the cleaning
and housekeeping staff; and

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  Provide a high-quality end product (i.e. sterile, if not available high-level
disinfected instruments and other items). Specific guidelines for processing instruments,
equipment and other items used to provide healthcare services are summarized in
Illustrated in Figure7.0.1.

In this table, the first column lists the items to be processed. The next two columns describe how
to clean each item. In the last two columns, the conditions for high-level disinfection or
sterilization are presented. If correctly performed, these processes provide excellent barriers
preventing the spread of infection from surgical instruments, surgical gloves and other items to
keep patients and healthcare personnel safe.

Commonly Used Chemical Disinfectants

Disinfectants are chemicals that destroy or inactivate microorganisms.

Properties of an Ideal Disinfectant

 Wide antimicrobial spectrum

 Rapidly kills microorganisms
 Active in the presence of organic matter and compatible with soaps, detergents, and other
chemicals encountered in use
 Non-toxic
 Does not cause the deterioration of cloth, rubber, plastics, and other materials
 Leaves an antimicrobial film on the treated surface
 Easy to use with clear label instructions
 Pleasant odor or no odor to facilitate its routine use
 Not prohibitively high in cost
 Soluble in water
 Stable in concentrate and at use-dilution
 Good cleaning properties
 Environmentally friendly on disposal

The most commonly used chemical disinfectants in healthcare settings are:

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  Alcohols
 Chlorine and chlorine releasing compounds
 Sodium hypochlorite (Chlorine bleach)
 Calcium hypochlorite or chlorinated lime
 Sodium dichloroisocyanurate
 Glutaraldehyde
 Iodine and Iodophor solutions
 Hydrogen Peroxide

Alcohols

Ethyl and isopropyl (2-propyl) alcohol (60 to 90%) are disinfectants which are relatively cheaper
and commonly available. Their rapid action and absence of chemical residue make them ideal for
disinfection of many medical items. The activity of both alcohols, however, drops sharply when
diluted below 50%. To attain better results, therefore, the optimal concentration of the solution
should be kept between 60 to 90% with water (volume/volume).

Advantages

 Rapidly kill all fungi and bacteria including Mycobacteria; Isopropyl alcohol kills most
viruses including HBV and HIV while Ethyl alcohol kills all viruses; both are also
tuberculocidal (Rutala, 1996).
 Rapid killing action
 Not corrosive to metal.
 Less costly in comparison with other disinfectants.
 Useful for soaking rubber or latex items occasionally.
 Leave no chemical residue and therefore do not require rinsing.

Limitation

 Evaporate rapidly making extended contact time difficult unless the items are immersed.
 Do not penetrate organic material and are easily inactivated.
 Are flammable

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  May swell or harden rubber and plastic materials if used repeatedly or for prolonged
periods of time.
 Damage shellac mounting of lenses in endoscopes.

Considerations for Use

 They are primarily used as antiseptic and as a low or intermediate-level disinfectant

(wiping oral and rectal thermometers and disinfecting external surfaces of equipment-
stethoscopes, cryoprobe tips, ultrasound probes, Ambu bags or anatomic models).
 Should be stored in a cool and well-ventilated place for they are flammable.

Chlorine and Chlorine Releasing Compounds

Chlorine solutions - are fast acting, very effective against HBV, HCV and HIV/AIDS,
relatively cheaper and readily available intermediate level disinfectants (CDC, 1987; WHO,
1989). A major disadvantage is that concentrated Chlorine solutions (>0.5%) can corrode
metals;

NOTE: CHLORINE SOLUTIONS SHOULD NOT BE USED AS for HLD

Hypochlorites are the most widely used chemicals among Chlorine disinfectants and are
available in liquid (sodium hypochlorite) and solid (Calcium hypochlorite and Sodium
dichloroisocyanurate) forms. Chlorine-releasing compounds available in powder (Calcium
hypochlorite or Chlorinated lime) or tablet form (Sodium dichloroisocyanurate). (Rutala et al.,
1998).

Soaking of instruments in disinfectant prior to cleaning

According to the WHO and PHAO, soaking of instruments in 0.5% chlorine solution or any other
disinfectant prior to cleaning is not recommended for the following reasons:

 It may damage/corrode the instruments

 The disinfectant may be inactivated by blood and body fluids, which could become a source of
microbial contamination and formation of biofilm

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 Transportation of contaminated items soaked in chemical disinfectant to the decontamination
area may pose a risk to health care workers and result in inappropriate handling and accidental
damage May contribute to the development of antimicrobial resistance to disinfectants.

Formaldehyde

Formaldehyde in both liquid and gaseous forms can be used for a chemical sterilization, as well
as a high-level disinfectant (Taylor, Barbeito & Gremillion 1969; Tulis, 1973). A commercially
available solution of Formaldehyde (Formalin) which contains 35 to 40% formaldehyde by
weight should be diluted with boiled water (1:5) to a final solution containing about 8%
Formaldehyde. Despite its limitation, formaldehyde continues to be used in many countries
because both liquid and solid forms (Para formaldehyde) are very cheap and readily available.
Thus, its use in hospitals and clinics persisted for many years. Switching over to a less toxic
compounds such as Glutaraldehydes or other newer high-level disinfectants, is strongly
recommended but difficult to implement because of the high cost of these alternatives.

Note:
Formaldehyde is being used as a high- level disinfectant as well as a sterilant in Ethiopia,
but globally it‘s slowly being phased out because of its toxicity.

Advantages

 Not readily inactivated by organic materials.

 Can be used for up to 14 days.
 Can safely be used on surgical endoscopes (laparoscopes) because 8% formaldehyde
will not corrode metal or damage instruments lenses, plastics or rubber.
Limitation
 Causes skin irritation.
 Is a Potential carcinogen.
 Irritates the skin, eyes and respiratory tract, even at low concentrations.
 For sterilization, 24 hours soaking in 8% formaldehyde solution kill all microorganisms,
including bacterial endospores.

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This compound produces a dangerous gas (bis-chloroethyl-ether) when mixed with
chlorine.

Glutaraldehyde

Glutaraldehyde‘s are widely used for chemical sterilization and HLD of medical instruments.
Aqueous solutions are acidic (pH < 7) and are activated only when made alkaline. There are
many types of Glutaraldehyde‘s available worldwide. The most commonly used antiseptic is an
alkaline-stabilized 2% Glutaraldehyde available commercially as Cidex® or Cidex 7®. These
chemicals which are derivatives of Formaldehyde are also irritating and their fumes are very
unpleasant. Therefore, they should be used only in well-ventilated rooms. Due to the fact that the
stability and activity of Glutaraldehyde‘s vary considerably depending on how they are prepared
and stored, the manufacturers‘ directions must be followed carefully.

Do not dilute this chemical unless specified in the manufacturer‟s instructions

Advantages

 Not readily inactivated by organic materials.

 Can generally be used for up to 14 to 28 days.
 Can safely be used on surgical endoscopes (laparoscopes) for they will not corrode metal
or damage lenses instruments (endoscopes), plastics or rubber.

Limitation
 Can cause skin irritation or dermatitis with chronic exposure.
 Vapors are irritating to mucous membranes (eye, nose and mouth) and respiratory tract.
 Works best at room temperature (20 to 250C or 68 to 770F).
 Is costly

Orthophthalaldehyde (OPA)

Orthophthalaldehyde (OPA) has a number of features that make it a good choice for high-level
disinfecting instruments and medical devices. It is relatively fast-acting, it is non-irritating to
eyes and nasal mucosa, and it does not require activation. It kills all vegetative bacteria, fungi,
and non-enveloped and enveloped viruses (high-level disinfectant). It does not kill all bacterial

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spores; therefore, it cannot be used to achieve sterilization. It is compatible with most metals and
plastics and can be used to process most endoscopes. However, there are reports of serious
anaphylactic reaction in bladder cancer patients; therefore, OPA should not be used to process
scopes for use in patients with bladder cancer.

Once OPA solution is poured into the disinfection container, it can be used for 14 days as long as
the solution concentration meets the minimum effective concentration. The concentration must
be tested using the approved test strips provided by the manufacturer before the first use and then
regularly to assure that the minimum concentration is met. The manufacturer recommends testing
the solution prior to each use, and it should be done at a minimum daily. A log should be kept to
document the quality control results. OPA must be used within 24 months of the date of
manufacture. Unopened bottles should be stored in a cool, dry place. Once the bottle of OPA is
opened, it must be discarded within 75 days or by the bottle expiration date, whichever date
comes first. HCWs handling OPA must wear personal protective equipment (PPE), including
gloves and face and eye protection. OPA stains unprotected skin gray.

Items should be thoroughly cleaned and dried prior to OPA disinfection. The contact time for
HLD using OPA is 12 minutes at 20°C (68°F). Ensure that all surfaces and lumens contact the
disinfectant for the entire soaking time. This means lumens must be filled with disinfectant and
free of air bubbles.

After disinfection time, items are removed from the disinfection solution and rinsed. OPA
requires three complete rinses in water for 1 minute each. Items that may come in contact with
non-intact skin and mucous membranes may be rinsed with clean, potable water. If the water
quality is not reliable, a final rinse with 70% isopropyl alcohol will help eliminate any microbes
and speed the drying process. When used for HLD of endoscopes, all lumens and channels
should be rinsed with 70% alcohol after the third water rinse to help dry the channels. If items are
not rinsed properly, the residual OPA can causes staining of patients‘ and HCWs‘ skin.

OPA can be safely disposed of in a sewerage system. No deactivation is required prior to

disposal down the drain, though it should be accompanied with large amounts of water.

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OPA is not approved for sterilization. If sterilization methods are not available and OPA is used
to high-level disinfect items that will be used on sterile tissue, the three rinses should be done
with sterile water.

Iodine and Iodophor Solutions

Iodine solutions (1 to 3% aqueous or tincture) and Iodophor (Iodine complexes with an organic
material) have been used primarily as antiseptics.

Note:

For many years, Iodophor s manufactured for use as antiseptics proved to be ineffective for
disinfecting inorganic objects and surfaces. Usually, antiseptics have significantly less Iodine
(Rutala, 1996). Whatever the case may be, it is good to make sure that labels are checked.

Iodophors are not high-level disinfectants because conclusive evidence is lacking on their
effectiveness against bacterial endospores and some fungi. For an instance, Pseudomonas
species, a group of gram-negative bacteria, have been known to multiply in Iodophors (Favero,

1985; Rutala, 1993). These solutions are generally nontoxic and nonirritating to skin and mucous
membranes. Iodophors must be properly diluted to be effective. Interestingly enough, correctly
diluted Iodophors have more active killing power than the full strength Iodophors due to the
decreased availability of ―free‖ Iodine in the latter.

Advantages

 They do not cause deterioration or softening of plastic items if they are kept dry
between soakings.
 Diluted solutions of Iodine and Iodophors are nontoxic and nonirritating (unless there
is known allergy to it).
 Can be used for disinfection of blood culture bottles and medical equipment such
as thermometers.

Limitations

 It is an oxidizing agent (causes rust) and should be used only for high-quality stainless-
steel equipment or plastic materials.

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  Like Alcohol and Chlorine, Iodine and Iodophors are inactivated by organic materials;
therefore, only previously cleaned instruments should be placed in Iodine or Iodophor
solutions.
Note:
To effectively avoid inactivation, medical articles/equipment should first be thoroughly rinsed
with sterile water or boiled and filtered (if necessary) water at least three times after soaking.

Allergic reactions can also occur to the staff handling Iodine solutions and Iodophors. Therefore,
they are:
 Primarily used as antiseptic for skin and mucous membranes (aqueous preparations only).
 Used for decontamination when the commercial preparation with aqueous solutions is
available but must be made fresh on daily basis.

Hydrogen Peroxide

Hydrogen Peroxide - (H2O2) is often available locally and is relatively cheaper than any other
chemical disinfectants and can be used to achieve HLD and sterilization. It has activity against a
wide range of microorganisms including vegetative bacteria, fungi, and viruses. Hydrogen
peroxide (3% solution) works effectively at lower pH and is stable at room temperature.
Hydrogen peroxide does not damage glass and plastic articles and is safe on ventilators. It does
have compatibility concerns with selected metals so approval from the device manufacturer
should be obtained prior to use of this method on items where corrosion would be a concern. It
has low toxicity and irritancy rating. No activation is required.

A 3% solution can achieve HLD using a contact time of 30 minutes at 20°C (68°F). To achieve
sterilization, a higher concentration (7.5% solution) and a longer contact time are required (6
hours at 20°C [68°F]).

Follow manufacturer‘s instructions for product-specific contact time. After the first use,
hydrogen peroxide can be used for a maximum of 21 days. The concentration of hydrogen
peroxide must be monitored regularly by testing the minimum effective concentration. Items
processed using hydrogen peroxide should be thoroughly rinsed with plenty of water. Chemical
irritation has been identified in an endoscopy unit where endoscopes were disinfected with
hydrogen peroxide.

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The major limitation of this compound is that it is highly corrosive and should not be used to
disinfect copper, aluminum, zinc or brass. It loses its potency rapidly when exposed to heat and
light, it should be stored in a cool and dark place. WHO does not recommend using H2O2 in hot
(tropical) climates because of its instability in the presence of heat and light (WHO, 1989).

Other Chemical Sterilants

Paracetic acid (Peroxyacetic acid) - the acid is rapidly acting and effective against all
microorganisms. Unlike other similar compounds, its activity will not be impeded by organic
matters on items to be sterilized and it decomposes into safe products. When diluted, it is very
unstable and must be used with a specially designed automatic sterilizer (APIC, 2002). It is
usually used for sterilizing different types of endoscopes and other heat-sensitive instruments.
Para formaldehyde - this solid polymer of formaldehyde may be vaporized by dry heat in an
enclosed area to sterilize objects (Taylor et al., 1969). This technique, called ―self- sterilization‖
(Tulis, 1973), may be suitable for sterilizing endoscopes and other heat- sensitive instruments.

Gas plasma sterilization (hydrogen peroxide based) - this method can sterilize items in less than
an hour and has no harmful by products. It does not penetrate well, however, and cannot be used
on paper or linen. A specialized sterilizer is required for performing gas plasma sterilization
(Taurasi, 1997).

Disposal of Used Chemical Containers

 Glass containers - may be washed with soap, rinsed, dried and reused.
Alternatively, thoroughly rinse them (at least two times) with water and dispose of by
burying.5

 Plastic containers - used for toxic substances such as Glutaraldehydes or

Formaldehyde should be rinsed (at least three times) with water and disposed of by
burning.

Disposal of Used Chemicals

Wastes should carefully be poured down into a utility sink drain or a flushable toilet and then
rinsed or flushed with water. Liquid wastes can also be poured into a latrine. The activity, however,

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should be done without losing sight of precaution to avoid splashing. Rinse the toilet or sink
carefully and thoroughly with water to remove residual wastes.

Products not to be used as Disinfectants

Many antiseptic solutions are incorrectly used as disinfectants. Although antiseptics (sometimes
called ―skin disinfectants‘‘) are adequate for cleansing skin before surgical procedures, they are
not appropriate for disinfecting surgical instruments and gloves. These antiseptics do not reliably
destroy bacteria, virus or endospores. For example, Savlon (Chlorhexidine gluconate with or
without Cetrimide), which is readily available worldwide, is often mistakenly used as a
disinfectant.

Antiseptics that should not be used as Disinfectants are:

 Acridine derivatives (e.g. gentian or crystal violet)
 Cetrimide (e.g. Cetavlon®)
 Chlorhexidine gluconate and cetrimide in various concentrations (e.g. Savlon)
 Chlorhexidine gluconate (e.g. Hibiscrub®, Hibitane®)
 Chlorinated lime and Boric acid (e.g. Eusol®)
 Chloroxylenol in alcohol (e.g. Dettol®)
 Hexachlorophene (e.g. PhisoHex®)
 Mercury compounds

Mercury Solutions - (such as mercury laurel) can cause birth defects and are too toxic to use as
either disinfectants or antiseptics although it is known to possess functions of low-level
disinfectants (Block, 1991). Other products frequently used to disinfect equipment are 1 to 2%
Phenol (e.g. Phenol®), 5% Carbolic acid (Lysol®) and Benzalkonium chloride, and Quaternary
ammonium compound (Zephiran®). These are low-level disinfectants and should only be used to
decontaminate environmental surfaces (e.g. floors or walls).

Storage of Disinfectants

 Chemical disinfectants should be stored in a cool and dark area.

 Never store chemicals in direct sunlight or in excessive heat (e.g. upper shelves in a tin-
roofed building).

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Cleaning

Cleaning is a critical step in instrument processing because:

 It makes instruments safer for additional processing, which reduces the risk of
infection for the HCWs who handle the instruments.
 It reduces damage to instruments. At the end of a clinical or surgical procedure,
surgical instrument and equipment are contaminated with tissue particles, body fluids,
and blood. Long contact with blood is corrosive and can damage surgical instruments.
 It makes instruments easier to process. Once blood dries on an instrument, it is
difficult to clean, especially if the blood has entered the hinges and sockets.
 Bioburden and residual cleaning agents remaining on an item can inactivate chemical
disinfectants or sterilants and protect microorganisms from destruction, which can
result in disinfection and sterilization failures (Zuhlsdorf et al. 2004). And also
instruments and materials used during an operation will be covered with blood and tissue
remains. They may have been in touch also with chemicals and fluids, dirt and dust.
Hinged instruments may have remnants of blood and tissue from the operation. The
tubing of hollow instruments may be also full of these soiled materials.

Therefore, it is important to follow all the necessary steps to properly clean instruments prior
to high-level disinfection or sterilization. Before transport to the instrument processing area,
HCWs should perform point-of-use cleaning— wiping instruments to remove tissue and
blood immediately at the conclusion of the procedure.

Once instruments are in the instrument processing area, cleaning involves thorough cleaning
of them with water and a detergent and/or an enzymatic cleaner followed by thorough
rinsing, and then drying before further processing.

Cleaning is a process of physically removing infectious agents and other organic matters on
which they live and thrive but does not necessarily destroy infectious agents. It is an essential
pre-requisite to ensure effective disinfection or sterilization by reducing the number of
microorganisms, especially endospores causing tetanus usually found on soiled instruments and
equipment. Neither sterilization nor high level disinfection could be effective without prior
cleaning (Porter, 1987).
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Cleaning using hand soap (bar) or powdered laundry detergent is not advisable because the fatty
acids in them react with the minerals in hard water leaving a residue or scum (insoluble calcium
salt) which is difficult to remove. Using liquid soap, however, is better in that it mixes easily
with water than bar or powdered soaps. It can also break fats and grease very easily making the
cleaning process easier and more effective. The water we use for cleaning purpose should be a
tap water which is not contaminated. If this is not possible, one may optionally use water boiled
for 10 minutes and filtered to remove particulate matter (if necessary), or chlorinated water-water
treated with a dilute bleach solution (sodium hypochlorite) to make the final concentration
0.001%.

It is not advisable to use abrasive cleaners (e.g. Vim® or Comet®) or steel wool because these
products can scratch or pit metal or stainless steel. These scratches then become a good hiding
place for microorganisms and make cleaning more difficult hence increasing the chance of
rusting.
Note

Many cleaning products contain ammonia which can interact with bleach and
cause the formation of toxic fumes. Check the label of any cleaning product to see
if it contains ammonia. (Sometimes you can be alerted about it if you come
across to pungent smell of ammonia when opening the container).

 Cleaning is the first step in reprocessing a device after use

 Failure to properly clean an instrument may allow foreign material (e.g. soil and organic
materials, including microorganisms) located outside and inside of the device to hinder
disinfection and/or sterilization.
 Cleaning is accomplished by using a manual process with cleaning chemicals (detergent)
and water, brushing or flushing, or by using ultrasonic and or washer disinfectors to
remove foreign material. Not every facility has a high level of resources, but medical
devices must be thoroughly cleaned prior to disinfection or sterilization, irrespective of
available resources.

One can clean without sterilizing, but one cannot sterilize without cleaning!

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 Table 7.0-2 Effectiveness of Methods of Processing Instruments

METHOD EFFECTIVENESS END POINT

(kill or remove microorganisms)
Cleaning (soap and
Up to 80% Until visibly clean
rinsing with water)

High-Level 95% (does not inactivate Boiling or chemical for

Disinfection endospores) 20 minutes
High-pressure steam, dry
Sterilization 100% heat or chemical for the
recommended time

As shown in Table 7.0.2, most microorganisms (up to 80%) in blood and other organic material
are removed during the cleaning process. Moreover, a study showed that following the standard
cleaning, most non lumen surgical instruments are found to contain less than 100 colony-forming
units (CFU) consisting of relatively non-pathogenic microorganisms (Rutala et al., 1998). This
study confirmed that thorough cleaning is more effective than was previously assumed and
documented the importance of cleaning in producing the desired safe outcome of surgery.
Once an item is washed, it needs also to be rinsed and dried. Thorough rinsing with clean water
removes any soap residue that can interfere with sterilization or HLD. After rinsing, items should
be dried especially if they will be sterilized or high-level disinfected using chemical disinfectants
It should be noted that water possibly remaining on the surgical articles/equipment (e.g. surgical
instruments), if not dried well, dilutes the solution and may hamper the process.
Note: Soaking of instruments in 0.5 chlorine solution or any other disinfectant before
cleaning is not recommended for the following reasons:
 It may damage/corrode instruments
 The disinfectant may be inactivated by blood and body fluids, which could become a
source of microbial contamination and formation of biofilm
 Transportation of contaminated items soaked in chemical disinfectants to the
decontamination area may pose a risk to healthcare workers and may result in appropriate
handling and accidental damage.
 May contribute to the development of antimicrobial Resistance to disinfectants

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Steps of manual cleaning:
Facilities with minimal resources can adequately clean and prepare devices for sterilization with
an effective manual cleaning process. However, it is vital that all devices be disassembled so that
all surfaces may be cleaned and disinfected, irrespective of the cleaning method chose.

 Ensure that the device to be cleaned is compatible with the chemical solution used in the
facility
 Completely submerge immersible items during the cleaning process to minimize
aerosolization and to assist in cleaning
 Remove gross soil using tools, such as brushes and cloths
 Clean devices that have lumens with an appropriate brush, then manually or mechanically
flush with a detergent solution and rinse with potable water

 Check devices with lumens for obstructions and leakage

1. Put on Personal Protective Equipment (PPE) including a water-resistant gown, gloves, face
mask and head cover. If gloves are torn or damaged, they should be discarded; otherwise,
they should be cleaned and left to dry for re-use in the following day. Even when wearing
heavy-duty utility gloves, care should be taken to prevent needle sticks or cuts when washing
sharps.
2. Fill sink or appropriate basin with sufficient warm water for complete immersion of the
devices being cleaned
3. Add the appropriate quantity of detergent following the manufacturer‘s instructions for
dosage

4. Clean the device under the surface of the water so that aerosols are not produced

5. Use appropriate brushes to properly clean box locks, lumens and other hard-to-clean areas

A. Use soft (nylon) bristle brushes so that the surface of the instrument is not
damaged
B. Brushes used to clean lumens must be the same diameter as the instrument to
ensure that all internal surfaces can be reached
C. Brushes must also be long enough to exit the distal end of the instrument

156
 NOTE: Brushes should be thermally or chemically disinfected at the end of the
day. If this is not possible, they should be cleaned and left to dry. Brushes should
be replaced when damaged.

6. In another sink or basin, completely immerse the device in clean purified water and rinse the
device thoroughly
7. Air-dry or hand-dry using a disposable clean, non-linting cloth
Note:

Instruments that will further be processed with chemical solutions must dry
completely to avoid diluting the chemicals; however, items to be treated with high
level disinfection by boiling or steaming do not need to be dried first.
Items that cannot be cleaned thoroughly should not be reused but be
discarded after use.

Summary of Cleaning:

 Surgical instruments should be disassembled to allow effective cleaning

 Physical cleaning reduces the bioburden or the microbial load sufficiently to allow the
process of sterilization or high-level disinfection to be effective
 Dirt protects microorganisms from contact with the disinfectants, steam and other
chemicals, thereby rendering the process ineffective
 Some chemicals used for reprocessing devices are inactivated in the presence of organic
matter
 Some chemicals used for reprocessing are inactivated when mixed with other chemicals
(incompatible)
 The life of the instruments is prolonged if soil and debris are removed regularly

Cleaning Products:

There is no single cleaning agent that removes all types of bioburden. Bioburden is made up of a
variety of matter, which may be soluble or insoluble in water and can be organic or inorganic.

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Properties Associated with Ideal Cleaning Agents:

 Emulsification
 Surfactation
 Dispersion and suspension
 Water softening
 Free rinsing
 Non-toxic
 Have a neutral PH
 Have a long life
 Be cost effective

Selection of Cleaning Agents

Deposits of dust, soil and microbial residue on equipment can contribute to healthcare-associated
infections. Cleaning agents remove organic, inorganic and microbial contaminants. No single
compound has all the properties that are required to remove all soil deposits. The first step in
cleaning is the use of surfactants or surface-active agents to reduce tension, which assists in soil
being held in the cleaning solution.

Enzymatic (proteolytic) cleaners

Gross soil should first be removed by rinsing with detergent and water. If blood has dried or
hardened, soaking in a warm solution of an enzymatic cleaner is required. Cleaning agents
containing enzymes to break down proteinaceous matter may be used for sensitive equipment if
the equipment manufacturer approves their use.

Remember

Enzymatic cleaners are not disinfectants; they only remove protein from surfaces.
Rubber or nitrile globes are recommended when handling enzymatic solutions –
enzymatic cleaners will degrade latex gloves.

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Summary of Recommendations

 `Disposable sharps shall be disposed of in an appropriate, puncture-resistant, sharps

container at the point of use prior to transportation
 Soiled medical devices shall be handled in a manner that reduces the risk of exposure
and/or injury to staff/visitors/patients/residents or contamination of environmental
surfaces
 Contaminated devices shall not be transported through areas designated for the storage of
clean or sterile supplies, visit/patient/resident care areas of high-traffic areas
 Sterile and soiled devices should not be transported together
 Reusable medical devices must be thoroughly cleaned before disinfection or sterilization
 If cleaning cannot be done immediately, the medical device should be pre-treated to
prevent organic matter from drying on it.
 The process for cleaning (decontamination) should include written protocols for
disassembly, sorting, pre-treatment, physical removal of organic material, rinsing and
drying
 It is strongly recommended that catheters, tubing, and other medical devices with small
lumens that are very difficult to clean be designated as single-use material and not be
reprocessed and reused.

Preparation and Packaging for Reprocessing

The inspection, assembly and packaging of reusable surgical instruments and medical devices is
a crucial part of the reprocessing cycle.

All instruments and other items should be thoroughly cleaned and dried before being disinfected
or prepared for sterilization. In some cases, it is not necessary to completely dry the items
(needles or the like which have small openings) being sterilized for the small amount of
water left inside these openings help in the steam sterilization process. For such items, flushing
them with distilled or boiled water just prior to packaging for steam sterilization should be
done after cleaning. Finally, all jointed instruments should be open (or be unlocked) and
disassembled. Reusable cloth items should be laundered and dried after use or prior to
sterilization in order to:

159
  Remove organic matter, and
 Prolong the life of the cloth by restoring the fabric‘s normal moisture (water) content.

Inspection and Function Testing (Post-Cleaning)

 Each set should be inspected separately

 Box joints, serrations and crevices should be critically inspected for cleanliness
 Hinges on devices, such as artery forceps and clamps, should be checked for ease of
movement
 Jaws and teeth should be checked for alignment
 Ratchets should be checked for security
 Multi-part instruments should be assembled to ensure that all parts are complete and
working
 Multi-part instruments should be assembled or disassembled for sterilization per
manufacturers‘ instructions
 Any damaged, incomplete or malfunctioning devices should be reported immediately to
the supervisor
 Cutting edges on devices, such as scissors, rongeurs, chisels and curettes, should be
checked for sharpness
 Hinges on devices, such as artery forceps and clamps, should be checked for ease of
movement
 Each device should be checked after each cleaning cycle to ensure that all screws on
jointed devices are tight and have not become loose during the cleaning process

Placing Items in Surgical Trays or Sets

Devices should be prepared for sterilization in the following way‖

 Clean and dry

 Jointed instruments in the open or unlocked position
 Multi-part or sliding pieces disassembled, unless otherwise indicated by the device
manufacturer

160
  Devices with concave surfaces that will retain water must be placed in such a manner that
condensate does not collect
 Heavy items arranged so as to not damage lighter more delicate items
 Sharp instruments with tips protected without being too tight

Assembly

The purpose of assembly and checking is to ensure that:

 All devices are present in accordance with the surgical tray list
 All devices are assembled correctly in accordance with the manufacturers‘ instructions
 All devices are placed in the correct tray in a manner that ensures ease of use by the user

The area where assembly and checking takes place should be a designated and controlled area to
optimize the effect of the sterilization process and minimize contamination of the sets.

Packing and Wrapping for Steam Sterilization

Wrapping items to be sterilized permit sterile items to be handled and stored without being
contaminated (See Figure 7.0.2 for typical wrapping techniques). Materials used for wrappers
should:
 Allow air removal and steam penetration
 Act as a barrier to microorganisms and fluids
 Capable of withstanding high temperatures
 Resist tears and punctures and be free of holes
 Be nontoxic and low-lint
 Not be costly

Types of materials that can be used as wrappers include:

 Muslin cloth (140 thread count) - use two double thicknesses wraps (four layers in all)
as this is the least effective of all materials used for wrapping. Use for both steam and dry
heat sterilization.
 Paper - double wrapping (two layers) is recommended. Use it for steam sterilization only
and avoid reuse.

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Tips for wrapping

 At least two layers of wrapping should always be used to reduce the possibility of
contaminating the contents during unwrapping.
 Do not wrap packages too tightly. If they are wrapped too tightly, air can become trapped
at the center of the packages preventing the temperature from getting high enough to kill
all the microorganisms. Also, wrapping with strings or rubber bands or tying linen too
tightly can prevent steam from reaching all surfaces.
 The outer wrapper of the pack can be loosely secured using linen ties. Packs can be
secured with linen ties made from the same cloth. Hemmed strips of about ½ inch wide
and of varied lengths. One or two of such strips can be used for each package. Because
they can fit to almost any size of package, they eliminate the need for an expensive and
hard-to-remove indicator tape.
 Do not wrap items in any waterproof material such as plastic or canvas for steam
sterilization as the steam cannot penetrate the material and leave the item unsterilized.
 Wrappers should not be reused if they are torn, stained with oils or have hard or gummy
deposits.

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Figure 7.0-2. Typical Wrapping Techniques

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Packing and Wrapping for Dry Heat Sterilization

Packaging materials for dry-heat sterilization should allow easy heat penetration, provide an
adequate barrier to microorganisms after sterilization, resist tearing or puncturing before and
after sterilization, have proven seal integrity, allow for ease of aseptic presentation, be free of
toxic ingredients, be low-linting or lint-free, and be cost-effective and readily available. The
material should have been approved for use with dry-heat sterilization.

Packaging Materials for Dry-Heat Sterilizer

 Medical-grade paper, bleached crepe paper, cellulose, and synthetic fibers

 Aluminum foil (thicker than domestic use foil)
 Glass bottles, vials, and ampoules for liquids
 Non-perforated glass or metal containers
 Transparent peel pouches approved by the manufacturer for use in dry-heat sterilizers

High-Level Disinfection

Sterilization is the safest and most effective method for the reprocessing of surgical instruments
because it kills all vegetative microorganisms and microbial spores. However, sterilization is not
always suitable because some materials cannot withstand the high temperatures used during the
sterilization process and sterilization may not be consistently available in some low-resource
settings.
There are three levels of disinfection: low-level, intermediate-level, and high-level. The level of
disinfection needed is based on how the item will be used. Per the Spaulding classification, devices
that come in contact with intact skin are classified as non-critical items and should be processed by
intermediate- or low-level disinfection. Surgical instruments and medical devices that come in
contact with non-intact skin or mucous membranes (classified as semi-critical devices) must, at a
minimum, be high level disinfected, though sterilization is always preferable when possible.
High-level disinfection can be achieved by:
 Pasteurization/ Boiling in water,
 Steaming
 Soaking instruments in chemical disinfectants (chemical disinfection).

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To be effective, all steps in performing each method must be monitored carefully. Essentially all
vegetative forms of bacteria are killed by moist heat at temperatures of 60 to750C within 10
minutes (Salle, 1973). Hepatitis B virus, which is one of the most difficult viruses to kill, is
inactivated in 10 minutes when heated to 800C (Kobayashi et al., 1984; Russell et al., 1982).
Even though many types of spores can be k i l l e d when boiled at 99.50C for 15 to 20 minutes
(Williams & Zimmerman, 1951), Clostridium tetani spores are quite heat-resistant and can
survive even boiling for up to 90 minutes (Spaulding, 1939).

The highest temperature that boiling water or low-pressure steam will reach is 1000C (2120F) at sea
level. Because the boiling point of water is 1.10C lower for each 1,000 feet in altitude, it is best to
boil or steam items to be high-level disinfected for a minimum of 20 minutes. This provides a
margin of safety for variations in altitudes up to 5,500 meters (18,000 ft) and at the same time
eliminates the risk of infection from some, but not all endospores.

Boiling Versus Steaming

In both boiling and steaming, moist heat is used to kill microorganisms. Steaming has several
distinct advantages over boiling for the final processing of surgical gloves and other items such
as plastic cannula and syringes. It is less destructive but more cost-effective for it uses much less
fuel than boiling. For example, only about a liter of water is needed to steam gloves or instruments,
whereas 4 to 5 liters are required for boiling. Besides, it is free from discoloration of instruments
resulting from calcium or other heavy metals contained in some tap water for the steam contains
only pure water molecules. Finally, although boiling and steaming gloves are equally easy to do,
drying boiled gloves is not practical because it is difficult to prevent contamination while they are
being dried in the open air. If steaming is instead opted to, they remain in the closed steamer pan
which results in little or no contamination of gloves.

The major limitation of steaming is that if the steamers available locally are small, they can
practically be used only for a small number of items (e.g. one set of instruments or 15 to 20 pairs of
surgical gloves) per tray or pan. For steaming to be effective, the bottom pan must contain enough
water to continue boiling throughout the steaming process. By contrast, large boiling pots are
easier to use for metal instruments and do not need to be monitored the entire time to be sure that
the process is being done correctly.

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Both boiling and steaming share some advantages and limitations over chemical high-level
disinfection which is the only other method of HLD.

Advantages

 Inexpensive procedures.

 Easily taught to healthcare workers.

 Require no special chemicals or dilutions and leave no chemical residue.
 Heat sources (boilers or rice cookers) are commonly available.

Limitation

 Length of processing time must be carefully measured (i.e. start timing only after the
steam begins to escape or water has reached a rolling boil). Once timing starts, no
additional items or water can be added.
 Objects cannot be packaged prior to HLD; therefore, there is a greater chance of
contamination if items are to be stored.
 Requires a fuel source that may be unreliable.

High-Level Disinfection by Boiling

Pasteurization can be used to achieve HLD of instruments and medical devices. It is carried out
by heating at 77°C (170.6°F) for 30 minutes or boiling at 100oC (212°F) for 20 minutes.

Boiling has been a common practice for HLD of instruments and equipment used for semi-
critical and sometimes critical procedures as it was the only available option in some low-income
countries.

Pasteurization/ Boiling in water is an effective and practical way to high-level disinfect

instruments and other items. Although boiling instruments in water for 20 minutes will kill all
vegetative forms of bacteria, viruses (including HBV, HCV and HIV), yeasts and fungi; it will
not kill all endospores reliably.

Instructions for HLD by Boiling

STEP 1 clean all instruments along with other items to be high level disinfected.

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STEP 2 If possible, completely immerse items in the water. Adjust the water level so that there
is at least 2.5cm (1 inch) of water above the instruments. Further, make sure that all
bowls and containers to be boiled are full of water. For example, one needs to empty
bowls that turned bottom side up and float on the surface containing air pockets.

Note:

A study documented that the interior temperature of a plastic cannula floating

on the surface of boiling water reaches a temperature of 96 to 980c in less than
a minute. Therefore, for items that float (e.g. syringes, plastic MVA cannula or
rubber items), it is not necessary that they be fully covered by the water to
achieve HLD if the pot is covered with a lid (IPAS, 1993).

STEP 3 Close-lid over pan and bring water to a gentle rolling boil. Boiling too vigorously
wastes fuel, rapidly evaporates the water and may damage delicate [or sharp]
instruments or other items. Hence, a gentle rolling boil is sufficient and will prevent
instruments or other items from being bounced around and possibly damaged by
striking other instruments or the side walls of the boiling pot.

STEP 4 Start timer. In the HLD log, note time on the clock and record the time when rolling
boil begins.

STEP 5 Boil all items for the required time: 30 minute at 77°C (170.6°F) or 20 minutes at
100°C (212°F).

Tips on Boiling
 Always boil for the required time period in a container with a lid.
 Start timing when the water begins to boil.
 Metal instruments should be completely covered with water during boiling.
 Do not add anything to the pot after timing begins.

STEP 6 Remove all items after the recommended time with a high-level disinfected forceps.
Never leave boiled instruments in the water that has stopped boiling. Because, as the

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 water cools and the steam condense, air and dust particles are drawn down into the
container and may contaminate those instruments (Perkins, 1983).

STEP 7 Use instruments and other items immediately or else, pick them up with high-level
disinfected forceps or gloves and place objects in a high-level disinfected
container with a tight-fitting cover. If any pooled water remains in the bottom of the
container, remove the already dried items and place them in another high-level
disinfected container that is dry and can be tightly covered.

Protecting the Life of Instruments that are frequently Boiled

Lime deposits may form on metal instruments that are frequently boiled. This scale formation
caused by lime salts in the water, is difficult to avoid. Following the steps below, however, can
minimize the problem of lime deposits. These steps are:

STEP 1 Boil the water for 10 minutes at the beginning of each day before use (This precipitates
much of the lime salt in the water on to the walls of the boiling pot before objects are
added).

STEP 2 Use the same water throughout the day adding enough water only to keep the surface at
least an inch above the instruments to be high-level disinfected (Frequent draining and
replacing the water; and boiling too vigorously, increase the risk of lime deposits on
instruments).

STEP 3 Drain and clean the boiler or pot at the end of each day to remove lime deposits.

High-Level Disinfection by Steaming

Steaming surgical gloves has been used as the final step in processing gloves for many years in
Indonesia and other parts of Southeast Asia. A study conducted on the practice later, confirmed the
effectiveness of this process of making gloves ready for re-use (Macintosh et al., 1994).

The steamer used in the study (Figure 7.0.3) consists of:

 A bottom pan (approximately 31cm in diameter) for boiling water;

 One, two or three circular pans with multiple 0.5cm (diameter) holes in their bottoms to
permit the passage of steam through them and water back down to the bottom pan; and

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  A lid that fits on the top pan.

High-level disinfection by steaming is an option for plastic items used for

patient care.

Figure 7.0-3. Steamer Used for HLD

Two types of tests were conducted to determine whether surgical gloves and other items could be
high-level disinfected using this process. In the first set of experiments, a thermocouple was
placed inside a glove in each of the three pans and the rate and extent of the temperature change
was recorded. As shown in Figure 10.5, when 5 to 15 pairs of surgical gloves were placed in
each of the three pans, the temperature reached 96 to 980C in less than 4 minutes in the bottom
and middle pans and within 6 minutes in the upper pan. Thereafter, the temperature remained
constant throughout the remaining 20 minutes. In the second set of experiments, batches of new
surgical gloves were contaminated with Staphylococcus epidermidis, Staphylococcus aureus,
Pseudomonas aeruginosa and Candida albicans as well as Bacillus subtilis (heat-sensitive) and
Bacillus stearothermophilus (heat-resistant) endospores. Next, the gloves were placed in each of
the three pans and steamed for 20 minutes. After this, the gloves were removed from the pans
and incubated for 24 hours in sterile media and then were placed on blood agar. In all cases (6,
15 and 30 gloves per pan), there was no growth of any microorganisms or B. subtilis endospores
within 24 hours. As was expected, only a reduction in the number of B. stearothermophilus
(heat-resistant) endospores occurred, nothing more than that.

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Materials needed for high-level disinfection by steaming include:

 Steamer pan without holes to hold water (such as momo steamer)

 Two to three additional pans with holes to allow steam to move to upper pan. The pans
should be deep enough to fit the largest item being steamed
 A tight-fitting lid to cover the upper pan
 An additional bottom pan for drying the processed items
Instructions for HLD by Steaming

After instruments and other items have been thoroughly cleaned, they are ready for HLD by
steaming.

STEP 1 Perform hand hygiene and

STEP 2 Fill the bottom pan of the steamer with approximately 1 liter of clean water – about half
the volume of the pan

STEP 3 Place instruments, plastic MVA cannula and other items in one of the steamer pans with
holes in its bottom (Figure 7.0.3). To make removal from the pan easier, do not overfill
the pan.
Repeat this process up until three steamer pans have been filled. Stack the filled
steamer pans on top of a bottom pan containing water for boiling. A second empty pan
without holes should be placed on the counter next to the heat source (see Step 7)

STEP 4 Place a lid on the top pan and bring the water to a full rolling boil.
It should be noted that when water only simmers, very little steam is formed and the
temperature may not get high enough to kill microorganisms.

STEP 5 When steam begins to come out between the pans and the lid, start the timer or note the
time on a clock and record the time in the HLD log.

STEP 6 Steam items for 20 minutes.

STEP 7 Remove the top steamer pan and put the lid on the pan that was below it (the pan now
on top). Gently shake excess water from the pan just removed.

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STEP 8 Put the pan just removed onto the empty pan (see Step 3). Repeat until all pans are
restacked on this empty pan and cover the top pan with the lid. This step allows the items
to cool and dry without becoming contaminated.

STEP 9 Allow items to dry in the air while in the steamer pans (1 to 2 hours) before using.

STEP 10 Using high-level disinfected forceps; transfer the dry items to a dry, high-level
disinfected container3 with a tight-fitting cover. Instruments and other items can also be
stored in the stacked and covered steamer pans as long as a bottom pan (with no
holes) is used.

High-Level Disinfection using Chemicals

Although a number of disinfectants are commercially available in most countries, four

disinfectants- OPA, Glutaraldehydes, Formaldehyde and Peroxide-are routinely used as high-
level disinfectants. (Table 7.0.4) provides guidelines for preparing and using these disinfectants).
These chemicals can achieve high-level disinfection if the items being disinfected are thoroughly
cleaned before immersion. A high-level disinfectant should be selected for use based on the
characteristics of the items to be disinfected, the physical area (i.e. whether it is well ventilated)
and the skills of personnel available to do the procedure.

Key Steps in Chemical High-Level Disinfection

 Thoroughly clean instruments and other items that may have been contaminated with
blood and body fluids and thoroughly clean and dry them before placing them in the
disinfectant solution.

 Completely immerse all items in the high-level disinfectant.

 Soak them for 20 minutes.

 Remove items using high-level disinfected or sterile forceps or gloves.

 Rinse well with boiled and filtered (if necessary) water three times and air dry.

 Use promptly or store in a dry, high-level disinfected and covered container.

Adapted from: Tietjen and McIntosh 1989.

How to Prepare an HLD Container

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  For small containers, boil water in the covered container for 20 minutes; then pour out the
water which can be used for other purposes; replace the cover; and allow the container to
dry.
 For large containers, fill a plastic container with 0.5% chlorine solution and immerse the
cover in chlorine solution as well. Then soak them for 20 minutes. Thereafter, rinse the
cover and the inside of the container three times with boiled water and allow them to dry
in the air. Note that large metal containers cannot be HLD using chemicals.

Factors That Affect Disinfection Process

 Quantity and location of the microorganisms: As the quantity of microorganisms

increases, longer exposure times as well as higher concentrations of chemical
disinfectants are needed to effectively disinfect instruments and devices. Therefore, it is
essential that health care workers (HCWs) thoroughly clean items prior to disinfection.
 Quantity and location of organic matter: The presence of organic matter such as tissue
particles, blood, and other body fluids can inactivate some disinfectants and compromise
their effectiveness. Also, biofilm formation makes it more difficult to adequately clean
items. Thorough cleaning of instruments and devices is essential to reduce organic
materials and biofilms prior to the disinfection process (Acosta-Gnass and Stempliuk
2009).
 Concentration of the disinfectant: The concentration of the disinfectant should be such
that it effectively kills microorganisms and at the same time does not harm the
instruments and devices being disinfected.
 Physical and chemical factors: Some disinfectants require a specific temperature or pH
level to be effective. Always follow the manufacturer‘s instructions for use.
 Duration of exposure: Each disinfection method and disinfectant is associated with a
specific amount of time that is necessary for achieving the desired results.
 Resistance of microorganism to the chemical agent: Resistance of microorganisms to
various disinfectants can occur therefore, it is important to periodically review for
documented or potential resistance of microorganisms to the disinfectant being used.

Sterilization

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Sterilization is a process in which the destruction of all micro-organisms including bacterial
endospores takes place. This can be achieved by either physical or chemical methods and is
necessary especially for medical devices penetrating sterile body sites or having direct contact
with the blood (Spaulding, 1939).

The proper sterilization of medical devices, surgical instruments, supplies and equipment utilized
in direct patient care and/or surgery is very critical in the modern healthcare delivery system and
of great impact on patients‘ safety. Sterilization in health facilities can be achieved by high
pressure steam (autoclaves), dry heat (oven), chemical sterilants (Glutaraldehyde or
formaldehyde solutions) or physical agents (radiation).

Note:

Rinsing an item with Alcohol and then igniting it with a match (flaming) is not an
effective method of disinfection or sterilization.

Essentials of Sterilization Process:

1. The sterilants and sterilizing equipment must be validated and appropriate in design and
operation to correctly integrate key yardsticks like: time, temperature, contact, pressure
(for steam sterilization) and right sterilants (for chemical sterilization) to be as effective
as they should be.
2. Instruments must be thoroughly cleaned to reduce dirt in order to guarantee effectiveness
of the sterilization process. The higher the dirt the greater the challenge to the
sterilization process. Therefore, it could be said that the effective sterilization is entwined
with an effective removal of the dirt before making it ready for sterilization.
3. There must be close and adequate contact between the chemical sterilant and all surfaces
and crevices of the device to be sterilized.

The Effectiveness of any Sterilization Method is also dependent Upon Four Other Factors:

1. The type of micro-organism present.

2. The number of micro-organisms present.

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 3. The amount and type of organic material that protects the micro-organisms. Blood or
tissue remaining on poorly cleaned instruments acts as a shield to microorganisms during
the sterilization process.
4. The number of cracks and scratches on an instrument that might harbor micro-organisms.

Important Reminder:

Sterilization is a process, not a single event; therefore, all phases and

steps in the process must be carried out correctly.

Method of Sterilization
I. High Pressure Steam Sterilization (Autoclaves)
II. II. Dry-heat sterilization (oven)
III. Chemical Sterilization

Standard Conditions for Steam Sterilization

Steam sterilization (Gravity): In the usual practice, the temperature in steaming process should
be 1210C (2500F) and its pressure,106 kPa (15 lbs/in2) the time being 20 minutes for unwrapped
items; and 30 minutes for wrapped items. As an alternative, it could be set at a higher
temperature of 1320C (2700F) with the pressure of 30lbs/in2; and the duration being 15 minutes
for wrapped items. Whatever the case may be, one should allow all items to dry before removing
them from the sterilizer.

Note: Pressure settings (kPa or lbs/in2) may vary slightly depending on the sterilizer used.
When possible, follow manufacturers‘ recommendations.

Remember:

 Exposure time begins only after the sterilizer has reached the target
temperature.
 Do not overload the sterilizer (Leave at least 7.5 cm [3 inches] between the
items and walls of sterilizer). Overloading alters heat convection and increases the
time required to sterilize.
Source: Perkins 1983

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I. High Pressure Steam Sterilization (Autoclaves)

Steam Sterilization is generally considered the method of choice for sterilizing instruments and
other items used in healthcare facilities. In settings where electricity is a problem, instruments
can be sterilized in a non-electric steam sterilizer using kerosene or other fuel as a heat source.

Rationale of Steam Sterilization:

 Saturated steam is an extremely effective carrier of thermal energy that makes it many
times more effective in conveying the necessary energy to the items to be sterilized than
dry air.
 Steam is an effective sterilant in that it can soften any resistant and protective outer
layer of the micro-organisms allowing coagulation of the inner sensitive portion of the
micro-organisms.
Advantages

 Most commonly used effective method of sterilization.

 Sterilization cycle time is shorter in steam sterilization than in any other type of
sterilization.

Limitations

 Requires a continuous source of heat (wood fuel, kerosene or electricity).

 Requires a trained biomedical technician to perform preventative maintenance.
 Requires strict adherence to time, temperature and pressure settings.
 Difficult to produce dry packs because breaks in procedure are common (e.g. not
allowing items to dry before removing, especially in hot, humid climates).
 Repeated sterilization cycles can cause pitting and dulling of cutting edges of instruments
i.e. scissors).
 Plastic items cannot withstand high temperatures.

There are three types of high-pressure steam sterilizers:

 Gravity displacement
 Prevacuum
 Flash or Immediate use sterilizers (IUS)

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Gravity Displacement Sterilizers:

Table-top models are relatively simple to operate and these are essentially horizontal pressure
cookers. A pool of water in the bottom of the sterilizer is heated until it turns into steam using a
power source of electricity or kerosene. The steam then rises to the top of the chamber because it
is lighter than the cool air in the chamber. As more and more steam is produced, the cool air is
forced out of the chamber through the drain near the bottom of the chamber. When the steam
pushes all the cool air out, steam enters the drain, triggering thermally (heat) regulated valve to
close. Once the valve is closed, the steam continues to build up pressure until the operating
temperature (normally 1210C/2500F) is reached. The timer can now be activated and be counted
down. At the end of the cycle (normally 20 minutes for unwrapped items and 30 minutes for
wrapped items), the relief valve opens to allow the steam to escape. Usually the steam passes
through the water reservoir where it condenses back to water and thus does not enter the room.
After the pressure on the gauge reads zero, the door can be opened 12 to 14cm (5 to 6 inches).
Items inside it should be left to cool for 30 minutes. If steam is still present (and the chamber is
quite warm), condensation of the moist air may cause wetness of the items or packs if they are
placed on a cool or cold surface.

Figure 7.0-4. Simplified Diagram of a Gravity Displacement Steam Sterilizer

Prevacuum Sterilizers

These sterilizers are similar to the gravity displacement sterilizers except that they have a
vacuum pump system to remove the air in the chamber before the steam is let in. This step
reduces the total cycle time. Most prevacuum sterilizers are operated at the same temperature

176
(1210C/2500F) as gravity displacement sterilizers. A special type of vacuum sterilizer called a
high-speed vacuum sterilizer, however, is operated at a higher temperature (1340C/2750F). The
vacuum system not only shortens the cycle time, but also reduces the chance of creation of air
pockets. Because a prevacuum sterilizer is more complex to operate, it is necessary to monitor its
functioning closely and maintain it on regular basis

Flash Sterilizers

These are small table-top prevacuum sterilizers usually located in operating rooms or adjacent to
them. They operate at a higher temperature (1340C/2750F) and thus have a shorter cycle time.
Due to their small size, their use is normally limited to sterilization of unwrapped surgical
instruments for emergency purposes (e.g. dropped instruments, etc).

Most healthcare facilities often use gravity displacement sterilizers. In most countries, high-
speed vacuum and flash sterilizers are usually found only in large referral hospitals (Webb,
1986).

Operation

Instructions for operating on the steam sterilizers (autoclaves) and its routine maintenance should
be included in the basic training of healthcare staff. A steam sterilizer will reliably sterilize items
only when kept in good working condition and operated correctly. Sterilization by steam requires
four conditions: adequate contact, sufficient temperature, proper time and sufficient moisture.
Even if these conditions are all necessary for sterilization to take place, sterilization failures in
clinics and hospitals are most often caused by lack of steam contact or failure to attain adequate
temperature (Webb, 1986).

Contact

The most frequent reason for sterilization failure is the lack of contact between the steam and the
microorganisms. This failure may be related to human error or mechanical malfunction. Frequent
causes of steam contact failure include the following:

 Failure to clean the object being sterilized adequately.

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  Instruments which are closed locked or stacked.
 Packages wrapped too tightly.
 Packs which are over staffed.
 Wrong position of container.
 Clogged strainer.
 Other mechanical problems

Temperature

The next most important factor in steam sterilization is temperature. The most commonly used
temperature for steam sterilization is 1210C (2500F). When an object at room temperature is
placed in a sterilizer, the steam transmits thermal energy to the object until the object reaches the
same temperature as the steam. Under normal circumstances, this equilibrium occurs within a
few minutes. If the steam is unsaturated (too dry) or if the steam is prevented from reaching all
parts of the object, the temperature may never reach the level required for sterilization. The only
way to be certain that the sterilizer is working correctly is, to make sure that the temperature at
all points inside the load has reached the full operating temperature of 1210C (2500F).

Timing

Just as it takes a certain amount of time to cook food, sterilization/killing micro-organisms/does

need time to do the work. In both cases, the hotter the temperature, the less time is required.
Sterilization time is measured in D-values. A D-value is the amount of time required to kill 90%
of the microorganisms present. Different microorganisms are killed in different scales/measures
of time. In other words, each kind of microorganism has a different set of D-values
corresponding with certain measure/level of temperature.

Moisture

Last, but surely not least, is the moisture requirement. Adequate moisture content of the sterilizer
atmosphere is mandatory for effective sterilization by steam.

Adequate moisture content implies that the steam must be ―saturated‖ having a relative humidity
of 100%. When any cool object is placed in the sterilizer, the steam at the surface of the object

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cools and becomes supersaturated. Water begins to condense on the surface of the object. This
condensation produces two immediate effects:

 The volume of gas in the sterilizer chamber decreases as the steam (water vapor) changes to
liquid state and more steam is drawn into the chamber and hence comes in to an increased
contact with the articles being sterilized.
 Very large amount of thermal energy is transferred to the object raising the temperature of
the article significantly. The amount of heat released is best explained by comparing the
calories required to change the temperature of steam against the calories absorbed when
water is converted to water vapor (steam).

If the steam is not saturated (less than 100% relative humidity), two problems will soon develop
which individually or together interfere with the adequacy of the sterilization process:

 Articles in the sterilizer will remain dry and the microorganisms present cannot be killed as
readily as under wet conditions (Water vapor softens the capsules of microorganisms making
them more vulnerable to destruction by heat).
 Articles in the sterilizer will remain ―cool‖ much longer especially if they are wrapped. Again
using the home kitchen as an example, if a kettle of beans is placed in an oven (dry heat), it
may take hours for them to be cooked. On the other hand, if they are placed in a pressure
cooker (saturated steam) they will cook them much more quickly. Saturated steam is a much
better ―carrier‖ of thermal energy than dry air.
In summary, saturation of the steam is vital to sterilizer operation because water vapor is the best
carrier of thermal energy which at times make the microorganisms more vulnerable to
destruction by heat (Webb, 1986).

Effective Sterilization Depends on Correctly Following Procedures of the Process

These include:

 Routine maintenance,
 Preparing items to be sterilized,
 Packaging and wrapping,
 Loading,

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  Operating, and
 Unloading the sterilizer.

It is only when all these procedures are strictly undertaken that items
would certainly be sterilized.

Routine Maintenance

Although there are many brands of steam sterilizers, routine maintenance practices are generally
the same regardless of the make or type. For routine maintenance:

 The outlet screen (or pin-trap) should be removed daily and cleaned using a mild soap
and brush under running water.
 The chamber should be cleaned daily using a soft cloth, or for large sterilizers, a long-
handled mop which is used only for this purpose. Do not use abrasives or steel wool
because they may scratch the stainless steel surface and increase the occurrence of
corrosion.
 All door gaskets should be cleaned daily with a lint-free cloth and checked for defects.
Defective rubber gaskets should be replaced.
 The carriage (loading cart used to hold the packs placed in a sterilizer) should be cleaned
daily using a mild soap and lint-free cloth. (The wheels of the loading cart also should be
cleaned at this time, removing any string or other debris).
 The exhaust line (or chamber drain) should be flushed weekly. This will keep the drain
free of substances that might hinder air or steam removal from the chamber. Before
flushing the exhaust line, check the maintenance instructions because Trisodium
phosphate solution (a special type of soap) is often recommended (DHEW, 1975; Webb
1986).
This can be prepared by adding one ounce of Trisodium phosphate to one liter (one quart)
hot water. If this chemical is not available, the exhaust line can be flushed with hot water
containing a mild soap solution. To do this, one should first remove the screen. Then pour one
liter (one quart) of the solution down the drain using a funnel. Complete the process by pouring a
liter of hot water to rinse out the soap and replace the screen. Usually, high-pressure steam
sterilizers (autoclaves) also contain specific instructions on the operations and the routine

180
maintenance. Managers should make copies of these instructions to avail it for the service of the
staff. If replacement copies are needed, they can be obtained by writing to the individual
manufacturer (normally the address can be found on the autoclave) or the donor agency
providing with the equipment.

Note:

To aid the prevention of dulling of the sharp points and cutting edges, wrap the
sharp edges and needle points in gauze before sterilizing. Repair (sharpen) or
replace instruments as needed.

Loading and Unloading

Objectives

 To load items into the autoclave in such a way that it allows passage of the most steam
through the load.
 To unload the steam autoclave so as to maintain the sterility of the items processed
through a sterilizing cycle.

General Principles

 The total weight of an individual pack should not exceed 11 kg (24 pounds).
 When loading, leave sufficient space for steam to circulate freely and avoid overloading.
Always leave 3 inches between the top-most pack and the top of the chamber. Items
should not touch the chamber wall. Never overload the sterilization chamber.
 Do not place packages on the floor of the chamber.
 Place all packs (linen, gloves, etc) on edge and place canisters, utensils and treatment
trays on their sides.
 Place instrument sets in trays having mesh or perforated bottoms flat on the shelves.
 In combination loads of cloth (or paper) packs and instruments trays, place linens on top
shelves and trays on lower shelves. This prevents any condensation (moisture) which
forms on cool metal when steam initially contacts with the item from dripping onto linen
packs (DHEW, 1975).

181
  Load packages containing similar types of item in one load, when possible. For example,
all textile packs should be sterilized in one cycle
 Surgical gloves should be sterilized by themselves or placed on the top shelves.
 Nested packs should be positioned in the same direction to help prevent air pockets so
that the condensation can drain and the steam can circulate freely. Shelves (metal wire) or
a loading cart must be used to ensure proper loading. It is preferable to use the cart that
comes with the sterilizer. See Figure7.0.5.
Note:

If an item goes in wet, it will come out wet. All items (instruments, basins and
glassware) must be dry before being loaded into the sterilizer. This helps prevent
―wet packs‖. The sterilizer is capable of drying items that have become moist
during a properly loaded and operated sterilization process, but it still cannot
remove excess moisture.

Metals and Glassware

 Instrument sets should not exceed 8kg (18lbs). Basin sets should not exceed 3kg (7lbs).
 This is done for reasons of limiting the amount of condensation which forms when steam
contacts cool metal. Using these limits ensures that the items will dry during the
sterilization cycle.
 Solid containers should be placed on their sides to allow airflow out of them. If air is
trapped in a solid container, it will prevent the steam from contacting the inner surface
and prevent sterilization.
Linens

 Linen packs should not be too large and heavy (not more that 5kg or 12 pounds) to secure
better steam penetration of the pack in 30 minutes (the time allowed for sterilizing
wrapped items).
 Packs containing sheets, table covers and towels are most impenetrable and difficult to
reach each fiber for the steam. Such packs must be placed on the edge of the shelf to
insure better steam penetration.

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 Figure 7.0-5. Loading Steam Sterilizer

Liquids

 Sterilize liquid and solution bottles separately from all other items.
 Liquids must be sterilized by themselves. The amount of liquid in the bottle, not the
size of the container, determines the time required for sterilization.
 Use only Borosilicate heat-resistant glass (Pyrex®).
 Use only automatic self-sealing caps for closure.

Combination Loads

 In loads which combine linens (fabrics) and metal items, place linens on top shelves and
metal items below. This prevents condensation from dripping onto the linen packs,
causing them to absorb the excess moisture.
 When a load is made up of wrapped and unwrapped items requiring different times to
ensure sterilization, the longest required time (i.e. 30 minutes) must be used

183
  The fundamental rule in loading the sterilizer is to prepare all items and arrange the load
in such a manner as to encounter the least possible resistance to the passage of steam
through the load (i.e. from the top of the chamber toward the bottom).

Unloading Tips

 Open the sterilizer door slightly 12-14 cm (5-6 inches) at the end of the cycle (when the
chamber gauge reaches ―0‖) and allow items to remain inside to reduce the potential for
condensation (formation of water drops on the packages).
 Allow instrument packs to dry completely before removal (usually takes 30 minutes).
Cooling time could be as long as 2 hours, based on room temperature and humidity.
 Do not handle the packs during the cooling time
 Place sterile trays and packs on surfaces padded with paper or fabric (avoid placing warm
packs on cold metal surfaces so as to prevent condensation).
 Store when packs reach room temperature (usually takes about an hour).
 Sterilized packs and articles should be handled gently and used as reasonably as possible.
 Return any pack that drops on the floor for reprocessing (remove items from the package
and repackage before reprocessing).
(Acosta-Gnass and Stempliuk 2009; Tietjen et al. 2003)

If a pack is dropped, turns to be moist or comes into contact with moisture,

it must be considered contaminated.

Steam Sterilizing Liquids

Sterile water can be prepared only by steam sterilization.

Instructions

 All liquids should be in heat-resistant glass (Pyrex) closed with automatic self-sealing
caps.
 Load steam sterilizer with liquids only.
 Wait until thermometer indicator shows 1210C (2500F) and 106 kPa (15lbs/in2).
 Time the sterilization using a clock. The amount (volume) of solution in the bottle
determines the sterilization time, not the size of the bottle:

184
 75 to 200ml 20 minutes
200 to 500ml 25 minutes
500 to 1000ml 30 minutes
1000 to 1500ml 35 minutes
1500 to 2000ml 40 minutes

Note:

If bottles of solutions with different volumes are sterilized in the same load,
use the sterilization time recommended for the bottle containing the largest
volume of liquid.

 When the sterilization cycle has ended, release the pressure slowly, taking not less than
15 minutes, until the chamber pressure is at ―0.‖ Turn operating valve off and open the door
only 1cm (½ inch). (Suddenly opening the door all the way after a sterilization cycle could
cause liquids to boil over or bottles to burst). Wait an additional 30 minutes for the chamber
to cool before removing the load.

Instructions of Operating a Steam Sterilizer

STEP 1 Thoroughly clean and dry all instruments and other items to be sterilized.

STEP 2 All jointed instruments should be in an open or unlock position, while instruments
composed of more than one part or sliding parts should be disassembled.

STEP 3 Instruments should not be held tightly together by rubber bands or any other means that
will prevent steam contact with all surfaces.

STEP 4 Arrange packs in the chamber to allow free circulation and penetration of steam to all
surfaces.

STEP 5 When using a steam sterilizer, it is best to wrap clean instruments or other clean items in
a double thickness of muslin or newsprint. (Unwrapped instruments must be used
immediately after removal from the sterilizer, unless they are kept in a covered, sterile
container.)

STEP 6 Sterilize at 1210C (2500F) for 30 minutes for wrapped items and 20 minutes for
unwrapped items; set time of the clock.

185
STEP 7 Wait 20 to 30 minutes (or until the pressure gauge reads zero) to permit the sterilizer to
cool sufficiently. Then open the lid or door to allow steam to escape. Allow instrument
packs to dry completely before removal which may take up to 30 minutes (Wet packs
act like a wick drawing in bacteria, viruses and fungi from the environment). Wrapped
instrument packs are considered unacceptable if there are water droplets or visible
moisture on the package exterior when they are removed from the steam sterilizer
chamber. If using rigid containers (e.g. drums), close the gaskets.

STEP 8 To prevent condensation when removing the packs from the chamber, place sterile trays
and packs on a surface padded with paper or fabric.

STEP 9 After sterilizing, items wrapped in cloth or papers are considered sterile as long as the
pack remains clean, dry (including no water stains) and intact. Unwrapped items must
be used immediately or stored in covered sterile containers.

 Maintain a steam sterilizer log including heat begun, correct temperature and pressure
achieved, heat turned down, and heat turned off.
 Each l o a d should be monitored with mechanical (time, temperature and pressure) and
chemical (internal and external chemical test strips) indicators.
 Autoclave should be tested daily with an air-removal test to ensure proper removal
of air.
 If steam escapes from the safety valve or under the lid, the autoclave is not working
correctly. Rather, it is merely steaming items at low-pressure (which may be equivalent to
HLD, not sterilization). Then, what is to be done?
 If steam escapes from the safety valve instead of the pressure valve, the pressure valve
must be cleaned and inspected.

 If steam escapes from under the lid, the gasket (rubber ring) must be cleaned and dried or
replaced.

Non-Electric Gravity Displacement Steam Sterilizer

To operate a non-electric gravity displacement steam sterilizer:

186
Figure 7.0-6. Non-Electric Gravity Displacement Steam Sterilizer

 Clean and dry all instruments to be sterilized.

 Put all jointed instruments in the opened or unlocked position. Disassemble instruments
composed of more than one part or sliding parts.
 Wrap clean instruments or other objects as described earlier in this chapter. Instruments
should not be held tightly together by rubber bands or any other means that will prevent
steam contact with all surfaces. (See the Packaging Medical Devices and Surgical
Instruments for Steam Sterilization section in this chapter.)
 Arrange packs loosely in the chamber to allow free circulation and penetration of steam
to all surfaces. Follow the manufacturer‘s instructions for load size.
 Bring water to boil until steam escapes from the pressure valve; turn down the heat but
keep steam coming out of the pressure valve. Do not allow the sterilizer to boil dry.
Steam should always be escaping from the pressure valve.
 Sterilize for 30 minutes for wrapped objects, 20 minutes for unwrapped objects. Time
with a clock. Start timing only after the temperature and pressure have reached the
required parameters.

187
  After the appropriate time, turn off the heat and wait about 30 minutes (or until the
pressure gauge reads zero) to permit the sterilizer to cool sufficiently before opening the
lid to allow steam to escape.
 Allow instrument packs to dry completely before removal; this may take an additional 30
minutes.
 (Damp packs act like a wick, drawing in microorganisms from the environment.)
Wrapped instrument packs are considered unacceptable if there are water droplets or
visible moisture on the outside of the package when removed from the sterilizer chamber.
 To prevent contamination by condensation, place sterile trays and packs on a surface
padded with paper or fabric after removing them from the chamber. (Do not store trays or
packs in a plastic dust cover until they reach room temperature; this usually takes about 1
hour.)

II. Dry Heat Sterilization Method

Dry heat sterilization is caused by hot air that destroys micro-organisms through oxidation that

causes slow destruction of the micro-organisms protein. Dry heat sterilization methods have limited

value because it is difficult to maintain the same temperature throughout the process. Moreover, dry

heat sterilization takes longer than steam sterilization, because the moisture in the steam sterilization

process significantly speeds up the penetration of heat and shortens the time needed to kill

microorganism. When available, dry heat is a practical means by which needles and other sharp

instruments are sterilized. Dry-heat sterilization can be achieved with a simple oven as long as a

thermometer is used to verify the temperature inside the oven. Dry heat sterilization is accomplished

by thermal (heat) conduction. Initially, heat is absorbed by the exterior surface of an item and then

passed to the next layer. Eventually, the entire object reaches the temperature needed for

sterilization.

188
 Note:
Just as with steam sterilization, thorough cleaning of the object prior to
dry heat sterilization is critical. If an instrument is not properly cleaned,
effective sterilization cannot be ensured regardless of how long the instrument is
heated.

Advantages

 An effective method as dry heat reaches all surfaces of instruments by conduction, even
for instruments that cannot be disassembled.
 Protective of sharps or instruments with a cutting edge (fewer problems with dulling of
cutting edges).
 Leaves no chemical residue.
 Eliminates ―wet pack‖ problems in humid climates.
Limitations

 Plastic and rubber items cannot be dry-heat sterilized because temperatures used (160 to
1700C) are too high for these materials.
 Dry heat penetrates materials slowly and unevenly.
 Requires oven and continuous source of electricity

Conditions for Effective use of Dry-Heat Sterilizers

 Adherence to specific instructions: Instructions about the load, volume, and thermal
resistance of the material must be considered at all times.
 Airflow rate and distribution: Irrespective of how airflow and air distribution are
managed, they affect heat energy transfer efficiency. The heated air must be distributed
uniformly within the load. Optimum air speed reduces microbial resistance by
dehydrating cells and thus reduces sterilization time.
 Load configuration and distribution: The size and density of the load as well as the
number and shape of the instruments affect airflow and air distribution.
 Temperature: The higher the temperature, the shorter the exposure time. The range is
from 121–180°C (250–356°F), but 160–170°C (320–338°F) is the optimum.
 Time: The time depends upon the temperature chosen.

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Instructions for Operating on Dry Heat Oven

To ensure correct operation, consult specific operating instructions supplied by the oven‘s
manufacturer.

STEP 1 Decontaminate, clean and dry all instruments and other items to be sterilized.

STEP 2 If desired, wrap instruments in aluminum foil or place in a metal container with a tight-
fitting closed lid. Wrapping helps prevent recontamination prior to use. Hypodermic or
suture needles should be placed in glass tubes with cotton stoppers.
STEP 3 Place loose (unwrapped) instruments in metal containers or on trays in the oven and heat
them to the desired temperature.
STEP 4 After the desired temperature is reached, begin timing. The following temperature/time
ratios are recommended (APIC 2002):

1700C (3400F) 60 minutes

1600C (3200F) 120 minutes
1500C (3000F) 150 minutes
1400C (2850F) 180 minutes
1210C (2500F) overnight
Note:

Use dry heat only for items that can withstand a temperature of 1700C (3400F)
(Perkins, 1983). Needles and other instruments with cutting edges should be
sterilized at lower temperatures (1600C [3200F]) because higher temperatures can
destroy the sharpness of cutting edges (Ibid).

Depending on the temperature selected, the total cycle time (preheating, sterilization
time and cool down) will range from about 2.5 hours at 1700C to more than 8 hours at
1210C.

STEP 5 After cooling, remove packs and/or metal containers and store.

Loose items should be removed with sterile forceps/pickups and used immediately or
placed in a sterile container with a tight-fitting lid until the time of use.

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Dry heat:

 Heat treatment in 1700C (3400F) for an hour (total cycle time-placing instruments in
the oven for an hour, and then cooling for 2 to 2.5 hours), or
 Heat treatment in 1600C (3200F) for 2 hours (total cycle time is from 3 to 3.5 hours).

Preventing Errors

 Sterilization equipment should be calibrated and processes should be validated.

 The coldest point should have a minimum temperature of 170°C (338°F) for sterilization
to be effective.
 Instruments should be wrapped in materials that can withstand high temperatures
(aluminum foils, stainless steel containers, peel pouches).
 Do not stack the packages tightly; leave enough room between surfaces.
 Carry out chemical and biological controls on a regular basis as per the manufacturer‘s
instructions.

III. Chemical Sterilization

Chemical sterilization is an alternative to high-pressure steam or dry-heat sterilization and often

called ―cold sterilization‖. If objects need to be sterilized and when the availing methods like
high-pressure steam or dry-heat sterilization would damage them or equipment are not available
(or operational), they can be chemically sterilized.

Many chemicals, both in liquid and gas form, are available for processing instruments. Chemicals
that are approved as sterilants can also be used as high-level disinfectants but those approved only
for HLD cannot be used as sterilants. Formaldehyde is no longer included as a sterilant or a high-
level disinfectant due to its toxicity.

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 Table 7.0-3 Liquid Chemicals Used for Sterilization

Chemical Sterilant Soak Time High-Level Soak Effecti

for Disinfectant Time for ve Life
Sterilization HLD
Glutaraldehyde 2– Yes 10 hrs at 20– Yes 20–90 min 14 days
4% 25°C (68–77°F) at 20–25°C
or (68–77°F)
7 hrs, 40 min at
35°C (95°F)
Glutaraldehyde Yes 8 hrs at 20°C Yes 10 min at 14 days
3.4% and (68°F) 20°C
isopropanol 20.1% (68°F)

Hydrogen peroxide Yes 6 hrs at 20°C Yes 30 min at 21 days

7.5% (68°F) 20°C
(68°F)
Peracetic acid 0.31– Yes 2 hrs at 20°C Yes 5 min at 5 days
0.38% (68°F) 25oC (77°F)

Hydrogen peroxide Yes 5 hrs at 25°C Yes 5 min at 5 days

8.3% and paracetic (77°F) 25°C
acid 7% (77°F)

Hydrogen peroxide Yes 8 hrs at 20°C Yes 25 min at 14 days

1.0% and paracetic (68°F) 20°C
acid 0.08% (68°F)

Adapted from: FDA 2015; Rutala et al. 2008.

Instructions on the use of Chemical Sterilization

STEP 1 Thoroughly clean and dry all instruments and other items to be sterilized.

STEP 2 Check the expiry date on the container and prepare the chemical sterilant solution
following manufactures instruction.
STEP 3 Completely submerge items in a clean container filled with the chemical solution and
place the lid on the container for the recommended period of time..
STEP 4 Remove objects from the solution with sterile forceps; rinse all surfaces three times in
sterile water; and air dry them. Ideally, three separate (sequential) rinse containers
should be used.

STEP 5 Store objects in a sterile container with a tight-fitting lid if they will not be used
immediately.

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Monitoring Sterilization Procedures

Sterilization procedures can be monitored routinely using a combination of biological, chemical and
mechanical indicators as parameters. Different sterilization processes have different monitoring
requirement.

Biological Indicators

Monitoring the sterilization process with reliable biological indicators at regular intervals is
strongly recommended. Measurements should be performed with a biological indicator that
employs spores of established resistance in a known population. The biological indicator types
and minimum recommended intervals should be:

 Steam Sterilizers - a highly resistant but relatively harmless (nonpathogenic)

microorganism called Geobacillus stearothermophilus is used to test steam sterilizers. As
used in hospitals and clinics to test sterilizers, this microorganism has a D-value of about
2 minutes at 1210C (2500F). In other words, it would take 2 minutes at 1210C (2500F) to
kill 90% of the test microorganisms present. Through research, mathematical calculation
and intelligent ―guesses‖, authorities have generally agreed that for normal hospital
sterilization, about six Geobacillus stearothermophilus D-values (or about 12 minutes)
should be sufficient to kill essentially all pathogenic microorganisms and give a large
margin of safety. For reasons of the absence of internal temperature sensing devices such
as temperature-specific chemical indicators in many countries, extra time is
recommended as an added safety margin. Thus, twenty minutes for unwrapped and 30
minutes for wrapped packs are considered sufficient to kill most microorganisms. This
biological indicator should be done weekly and as deemed necessary.
 Dry-Heat Sterilizers - Bacillus subtilis, is used as an indicator on weekly basis and as
deemed necessary. Similar to Geobacillus stearothermophilus, the recommended time and
temperature is found to be effective in the sterilization of the instruments.

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Chemical Indicators

Chemical indicators include indicator tape or labels which monitor time, temperature and
pressure for steam sterilization and for dry-heat sterilization. These indicators should be used on
the inside and outside of each package or container.

 External Indicators - are used to verify whether the items have been exposed to the
correct conditions of the sterilization process and the specific pack has been sterilized.
 Internal Indicators - are placed inside a pack or container in the area most difficult for
the sterilization agent to reach (i.e. the middle of a linen pack). This is the indicator that
tells if the item has been sterilized.

Chemical indicators like heat sensitive tape or glass vials containing pellets that melt at
certain temperatures and duration do not imply achieved/successful sterilization. They do,
however, indicate whether mechanical or procedural problems have occurred in the sterilization
process.

Mechanical Indicators

Mechanical indicators for sterilizers provide a visible record of the time, temperature and
pressure for the sterilization cycle. This is usually a printout or graph from the sterilizer or it can
be a log of time, temperature and pressure kept by the person responsible for the sterilization
process that day.

Storage

All sterile items should be stored appropriately to protect them from dust, dirt, moisture, animals
and insects. The storage area should be located next to the place of sterilization or connected to it
in a separately enclosed area with limited access that is used just to store sterile and clean patient
care supplies. In smaller clinics, this area may be just a room close to the Central Supplies
Department or in the Operating Room.

194
Instructions for Storing Sterile Items

1. Keep the storage area clean, dry, dust-free and lint-free.

2. Control temperature and humidity (approximate temperature 24oC and relative humidity
<70%) when possible.
3. Packs and containers with sterile (or high-level disinfected) items should be stored 20 to
25cm off the floor, 45 to 50cm from the ceiling and 15 to 20cm from an outside wall.

4. Do not use cardboard boxes for storage because cardboard boxes shed dust and debris
and may harbor insects.

5. Date and rotate the supplies (first in/first out). This process serves as a reminder, but does
not guarantee sterility of the packs.

6. Distribute sterile and high-level disinfected items from this area.

Shelf Life

 The shelf life of an item (how long items can be considered sterile) after sterilization is
event-related. An item remains sterile until something causes the package or container to
become contaminated as time goes on since sterilization is not the determining factor.
 To make sure items remain sterile until you need them, prevent events that can
contaminate sterile packs and protect them by placing them in plastic covers (thick
polyethylene bags). An event can be a tear or worn-out area in the wrapping, the package
becoming wet or anything else that will enable microorganism to enter the package
becoming wet or anything else that will enable microorganism to enter the package or
container.
 Before using any sterile item, look at the package to make sure that the wrapping is intact
and the seal is unbroken, clean and dry (as well as having not water stains).

 If the quality of wrapping clothes is poor and plastic bags are not available, limiting the
shelf life is a reasonable option to resort to and secure the sterility of the instruments.

195
The Shelf Life of Sterilization Depends on the Following Factors:

 Quality of the wrapper or container.

 Number of times a package is handled before use.
 Number of people who have handled the package.
 Whether the package is stored on open or closed shelves.
 Condition of storage area (e.g. humidity and cleanliness).
 Frequent or improper handling or storage.
 Use of plastic dust cover and method of sealing (AORN, 1992).

Note:

 To make sure items remain sterile until you need them;

 Prevent events that can contaminate sterile packs, and
 Protect them by placing in plastic cover (bags).

In some healthcare facilities, where replacement of supplies is limited and the cloth used for
wrapping is of poor quality, time as a limiting factor also serves as safety margin. If plastic
covers (bags) are unavailable for the sterilized items, limiting the shelf life to a specific length of
time (e.g. one month) may be reasonable decisions as long as the pack remains dry and intact.

Other Sterilization Methods

Gas Sterilization - one of the first uses of Formaldehyde gas was to fumigate rooms a practice
which has long been proven to be ineffective and unnecessary (Schmidt, 1899). Due to the
irritating nature of its vapor to the skin, eyes, respiratory tract and its carcinogenic effects, the
use of formaldehyde in this form should be limited.

Ethylene Oxide (ETO) - is the other gas which is most frequently used in the United States and
several other countries for sterilization of heat and moisture sensitive surgical instruments such
as plastic devices and delicate instruments. Sterilization using ETO, however, is a more
complicated (requires a 2-hour exposure time and a long aeration period) and costly process than
either steam or dry-heat sterilization because items that are sterilized by ETO needed to be

196
aerated (exposed to the outside), so that the residual ETO gas can diffuse out of the packages and
items. This can take longer leading to complete cycle times of 24 hours or more (Steel man,
1992). Moreover, it requires sophisticated equipment and skilled staff specially trained for its
safe use-making it impractical for use in many countries (Gruendemann & Mangum, 2001). ETO
is also hazardous to healthcare workers, patients and the environment.

Because ETO is moderately toxic when inhaled, regular exposure to low levels (greater than one
part per million) may produce harmful effects in humans. Moreover, the gas is irritating to the
eyes and mucous membranes. Likewise, the residual ETO on instruments can cause skin injuries
and inflammatory reactions in patients. Above all, because of the toxicity of this gas and
category as a potential carcinogen as well as mutagen, the disposal of it is difficult (Ibid.).

Ultraviolet Light Sterilization

Ultraviolet (UV) light has been used to help disinfect the air for more than 50 years (Morris,
1972). However, UV irradiation has very limited energy; UV light does not penetrate dust,
mucous or water. Therefore, despite the manufacturers‘ claims, it cannot be used to sterilize
water. Theoretically, an intense UV light can be both bactericidal and veridical; practically,
however, it was found out that only limited disinfection of instruments could be achieved. For
surfaces that cannot be reached by the UV rays (e.g. inside the barrel of a needle or laparoscope),
any microorganisms present will not be killed (Ibid). For these and other issues, UV radiation is
neither practical nor effective method in most situations (Riley & Nardell, 1989).

Sterilization for Prion Disease

Prion diseases, such as Creutzfeldt-Jakob disease (CJD), are a group of degenerative brain
diseases that have received much attention during the past few years. They occur in animals
(dogs, cows and primates) as well as humans and are rapidly fatal once symptoms develop. In
humans, CJD remains rare with an incidence of less than one per million in the general
population (Holman et al., 1996). Creutzfeldt-Jakob disease (CJD) poses a unique infection
prevention problem because prions which are protein-containing infectious agents can survive
recommended heat or high-pressure steam sterilization processes. In addition to that, chemical
disinfectants including sterilants like Gluteraldehyde and Formaldehyde are not strong enough to
eliminate the infectivity of Prions on contaminated instruments and other items. Therefore,

197
surgical instruments and other critical devices contaminated with high-risk tissue (i.e. brain,
spinal cord and eye tissue) from patients with known or suspected CJD require special treatment
(Rutala & Weber, 2001).

For handling and processing of prion contaminated instruments please refer to Jhpiego‘s
Infection Prevention Manual, 2018 or WHO‘s Decontamination and Reprocessing of Medical
Devices for Heath Care Facilities, 2016.

Summary

Applying Spaulding‘s classification of non-critical, semi-critical, or critical items determines the

method that should be used to process instruments. Cleaning is the most important step in
instrument processing because it makes instruments safer for additional processing prevents
bioburden from drying on instruments and ensures that there are no residual bioburden or cleaning
chemicals on the instruments that may interfere with the subsequent high-level disinfection or
sterilization process. Policies should be in place and all HCWs who perform instrument cleaning
throughout the facility should be trained and competent in the appropriate way to clean surgical
instruments and other equipment. All semi-critical instruments and devices that come in contact
with mucous membranes and non-intact skin should be, at a minimum, high-level disinfected. HLD
can be carried out by soaking in a high-level disinfectant, steaming or by boiling. Sterilization of
medical devices and surgical instruments plays a vital role in reducing surgical site infections and
infection as a result of other invasive procedures. Monitoring the quality of the sterilization process
as well as appropriately following recommendations will assist health care facilities in optimizing
the safety of sterile medical devices and surgical instruments used for patient care.

198
 Table 7.0-4 Preparing and Using Chemical Disinfectants

Disinfectant
Time
(common Effective How to Skin Eye Respiratory Leaves Time Needed Activated Shelf Life a
Corrosive Needed for
solution or Concentration Dilute Irritant Irritant Irritant Residue Sterilization
HLD
brand)

CHEMICALS FOR STERILIZATION OR HIGH-LEVEL DISINFECTION

0.1% Dilution Yes (with Yes Yes Yesc Yes 20 minutes Do not use Change every 14
days, procedures prolonged sooner if cloudy.
varyb contact)
Formaldehyde 8% 1 part Yes Yes Yes No Yes 20 minutes 24 hours Change every 14
days, (35B40%) 35B40% sooner if cloudy.
solution to 4 parts boiled water
Glutaraldehyde Varies (2–4%) Add activator Yes Yes Yes No Yes 20 minutes 10 hours for Change every 14–28
(Cidex7) ( vapors) at 25ΕCd Cidex7 days; sooner if cloudy.
Hydrogen 6% 1 part 30% Yes Yes No Yes No 20 minutes Do not use Change daily; sooner
Peroxide solution to 4 if cloudy. (30%)
parts boiled
Water

CHEMICALS FOR DISINFECTION (alcohols and Iodophors are not high-level disinfectants)
Alcohol (ethyl 60B90% Use full Yes (can Yes No No No Do not use Do not use If container (bottle)
or isopropyl) strength dry skin) kept closed, use until
empty.
Iodophors (10% Approximately 1 part 10% No Yes No Yes Yes Do not use Do not use If container (bottle)
povidone- 2.5% PVI to 3 parts kept closed, use until
iodine) (PVI) water empty.
a
All chemical disinfectants are heat and light sensitive and should be stored away from direct sunlight and in a cool place (<40ΕC).
b
See Tables 10.1 and 10.2 for instructions on preparing chlorine solutions.
c
Only corrosive with prolonged (>20 minutes) contact at concentrations >0.5% if not rinsed immediately with boiled water.
d
Different commercial preparations of Cidex and other glutaraldehydes are effective at lower temperatures (20°C) and for longer activated shelf life. Always check manufacturers‘
instructions.
Adapted from: Rutala 1996.

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 Table 7.0-5 Guidelines for Processing Instruments, Surgical Gloves and Other Items

DECONTAMINATION CLEANING STERILIZATIONa HIGH-LEVEL DISINFECTION

b
INSTRUMENTS OR OTHER Destroys all microorganisms, including
Removes all visible blood, body fluids Destroys all viruses, bacteria, parasites, fungi
ITEMS and dirt. endospores. and some endospores.

Airways (plastic) Point of use cleaning to prevent Wash with soap and water. Not necessary Not necessary
blood and fluids from drying on Rinse with clean water, air or
it. Wiping with damp cloth or towel dry.
soak in water and wipe.
Ambu bags and CPR face masks Point of use cleaning to prevent Wash with soap and water. Not necessary Not necessary
blood and fluids from drying on Rinse with clean water, air or
it. Wiping with damp cloth or towel dry.
soak in water and wipe.
Aprons (heavy plastic or rubber) Wipe with 0.5% chlorine Wash with liquid soap and Not necessary Not necessary
solution. Rinse with clean water. water. Rinse with clean water,
Between each procedure or each air or towel dry at the end of the
time they are taken off. day or when visibly soiled.

Bed pans, urinals or Not necessary. Using a brush, wash Not necessary Not necessary
emesis basins with disinfectant solution
(soap and
0.5% chlorine). Rinse with
clean water.
Blood pressure cuff If contaminated with blood or If soiled, wash with soap and Not necessary Not necessary
body fluids, wipe with gauze water. Rinse with clean water,
pad or cloth soaked with 0.5% air or towel dry.
chlorine solution.

Diaphragms or fitting rings Point of use cleaning to prevent Wash with soap and water. Not necessary but can be Steam or boil for 20 minutes.
(used for sizing with clients) blood and fluids from drying on Rinse with clean water. Air or autoclaved at 121°C (250°F) Chemically high-level disinfect
it. Wiping with damp cloth or towel dry. 106 kPa (15lbs/in2) for 20 by soaking in 8%
soak in water and wipe. minutes (unwrapped). formaldehyde, or a 2 to 4%
Glutaraldehyde for
20 minutes. Rinse well in
water that has been boiled.
Exam or operating room tables Wipe off with 0.5% Wash with soap and water if Not necessary Not necessary
or other large surface areas chlorine solution. organic material remains after
(carts and stretchers) decontamination.
 Table 7.0-6 Guidelines for Processing Instruments, Surgical Gloves and Other Items (Continued…)

b
INSTRUMENTS OR OTHER DECONTAMINATION CLEANING STERILIZATION HIGH-LEVEL DISINFECTION
Removes all visible blood, body fluids Destroys all microorganisms, including Destroys all viruses, bacteria, parasites, fungi
ITEMS and dirt. endospores. and some endospores.

Footwear (rubber shoes or Wipe with 0.5% chlorine Wash with liquid soap and Not necessary Not necessary
boots) solution. Rinse with clean water. water. Rinse with clean water,
At the end of the day or when air or towel dry at the end of the
visibly soiled. day or when visibly soiled.
Hypodermic needles and Unnecessary Disassemble, and then wash Preferable (glass only): Acceptable (glass or plastic):
syringes with soap and water. Rinse with Dry heat for 2 hours after Steam or boil for 20 minutes.
(glass or plastic) clean water, air or towel dry reaching 160°C (320°F) (glass
syringes (only air dry needles). syringes only), or (Chemical HLD is not
Autoclave at 121°C (250°F) and recommended because chemical
106 kPa (15lbs/in2) for 20 residue may remain even after
minutes (30 minutes if repeated rinsing with boiled
wrapped). water. These residues may
interfere with the action of drugs
being injected.)
IUDs and inserters Not appropriate Not appropriate Not recommended. Most IUDs Not recommended
(never reuse) and inserters come in sterile
packages. Discard if package
seal is broken.
Laparoscopes Wipe exposed surfaces with Disassemble, then using a brush Sterilize daily using Between cases, soak for 20
gauze pad soaked in 60-90% wash with soap and water. Rinse chemical sterilization. Soak in: minutes in:
alcohol; rinse immediately. with clean water, towel dry. a Glutaraldehyde (usually a Glutaraldehyde
2%) (usually
for 10 hours, or 2 to 4%), or
8% formaldehyde for 24 hours. 8% formaldehyde, or
Rinse with sterile water or Rinse three times with water that
water which has been boiled has been boiled for 20 minutes.
for 20 minutes three times.

PPE (caps, masks, cover Not necessary. (Laundry staff Wash with soap and hot water. Not necessary Not necessary
gowns)d should wear plastic aprons, Rinse with clean water, air or
gloves and protective foot and machine dry. Wrap for reuse.
eyewear when handling soiled
linen.)

17
 Table 7.0-7 Guidelines for Processing Instruments, Surgical Gloves and Other Items (Continued…)

PRE CLEANING CLEANING STERILIZATIONa HIGH-LEVEL DISINFECTION

b
INSTRUMENTS OR OTHER Destroys all microorganisms, including
. First step in instrument and other item Removes all visible blood, body fluids Destroys all viruses, bacteria, parasites, fungi
ITEMS processing and dirt. endospores. and some endospores.

Stethoscopes Wipe with gauze pad soaked If soiled, wash with soap and Not necessary Not necessary
in water. Rinse with clean water,
60–90% alcohol. air or towel dry.
Storage containers Point of use cleaning to prevent Wash with soap and water. Dry heat for 1 hour after Boil container and lid for 20
for instruments (metal or plastic) blood and fluids from drying on Rinse with clean water, air or reaching minutes. If container is too
it. Wiping with damp cloth or towel dry. 170°C (340°F), or large: Fill container with 0.5%
soak in water and wipe. Autoclave at 121°C (250°F) chlorine solution and soak for 20
and minutes. Rinse with water that
106 kPa (15 lbs/in2) for has been boiled for 20 minutes
20 minutes (30 minutes if and air dry before use.
wrapped).
Suction bulbs (rubber) Wipe with 0.5% chlorine Wash with soap and water. Not necessary Not necessary
solution. If contaminated with Rinse with clean water, air or
blood and body fluid. towel dry.

Suction cannula (plastic) for Point of use cleaning to prevent Pass soapy water through Not recommended. (Heat from Steam or boil for 20 minutes.
manual vacuum aspiration blood and fluids from drying on cannula three times, removing autoclaving or dry-heat
(MVA) it. Wiping with damp cloth or all particles. ovens will damage cannula.)
soak in water and wipe.
Suction catheters Point of use cleaning to prevent Pass soapy water through Not recommended. (Heat from Steam or boil for 20 minutes.
(rubber or plastic) blood and fluids from drying on catheter three times. Rinse three autoclaving or dry-heat (Chemical HLD is
it. Wiping with damp cloth or times with clean water (inside ovens will damage plastic not recommended because
soak in water and wipe.. and outside). catheters; rubber catheters can chemical residue may remain
be autoclaved.) even after repeated rinsing
with boiled water.)
Surgical gloves Re use Not Recommended Re use Not Recommended Re use Not Recommended Re use Not Recommended
 Table 7.0-8 Guidelines for Processing Instruments, Surgical Gloves and Other Items (Continued…)

PRE CLEANING CLEANING STERILIZATIONa HIGH-LEVEL DISINFECTION

b
INSTRUMENTS OR OTHER Destroys all microorganisms, including
First step in handling used items; s. Removes all visible blood, body fluids Destroys all viruses, bacteria, parasites,
ITEMS and dirt. endospores. fungi and some endospores.

Surgical gowns, linen drapes Not necessary. (Laundry staff Wash with soap and hot water. Autoclave at 120°C/250°F Not practical
and wrappersd should wear plastic aprons, Rinse with clean water, air or and
gloves and protective foot and machine dry. 106 kPa (15 lbs/in2) for
eyewear, when handling soiled 30 minutes.
linen.)
Surgical instruments (metal) Point of use cleaning to prevent Using a brush, wash with Preferable: Acceptable:
blood and fluids from drying on soap and water. Rinse with Dry heat for 1 hour after Steam or boil for 20 minutes.
it. Wiping with damp cloth or clean water. If to be sterilized, reaching Chemically high-level
soak in water and wipe. air or towel dry and wrap in 170°C (340°F)e, or disinfect by soaking for 20
packs or individually. Autoclave at 121°C (250°F) minutes. Rinse
and well with boiled water and
106 kPa (15 lbs/in2) for 20 air
minutes dry before use or storage.
(30 minutes if wrapped).
For sharp instruments: Dry heat
Thermometers (glass) Not necessary Wipe with disinfectant solution Not
for 2necessary
hours after reaching 160°C Not necessary
(soap and 0.5% chlorine). Rinse (320°F).e
with clean water, air or towel
dry.
Transfer forceps (chittle) Point of use cleaning to prevent Using a brush, wash with Preferable: Acceptable:
and container (metal) blood and fluids from drying on soap and water. Rinse with Dry heat for 1 hour after Steam or boil for 20 minutes.
it. Wiping with damp cloth or clean water. If to be sterilized, reaching Chemically high-level
soak in water and wipe. air or towel dry. 170°C (340°F)e, or disinfect by soaking for 20
Autoclave at 121°C (250°F) minutes. Rinse well with
and boiled water and air dry
106 kPa (15 lbs/in2) for before use.
Urinary catheters (rubber Point of use cleaning to prevent Using a brush, wash with Preferable
20 minutes (metal
(30only):
minutes if Acceptable (rubber or metal):
and straight metal) blood and fluids from drying on soap and water. Rinse three Dry heat for 2 hours after
wrapped). Steam or boil for 20 minutes.
it. Wiping with damp cloth or times with clean water (inside reaching
soak in water and wipe. and outside). 160°C (320°F), or
Autoclave at 121°C (250°F)
and
106 kPa (15 lbs/in2) for 20
minutes
(30 minutes if wrapped).

176
 Table 7.0-9 Guidelines for Processing Instruments, Surgical Gloves and Other Items (Continued…)

DECONTAMINATION CLEANING STERILIZATIONa HIGH-LEVEL DISINFECTION

b
INSTRUMENTS OR OTHER Destroys all microorganisms, including
First step in handling used items; it reduces Removes all visible blood, body fluids Destroys all viruses, bacteria, parasites, fungi
ITEMS risk of HBV, HCV and HIV viruses. and dirt. endospores. and some endospores.

Ventilator tubing or circuits Not necessary Using a brush, wash with Not possible using an
soap and water. Rinse with autoclave or dry heat oven. Acceptable
clean water and air dry. Steam or boil for 20 minutes.
Air dry before use.
a
If unwrapped, use immediately; if wrapped, reprocess if package becomes damaged or contaminated.
b
If sterilization (dry-heat or autoclave) is not available, these items can be high-level disinfected either by boiling, steaming or soaking in a chemical disinfectant.
c
Avoid prolonged exposure (> 20 minutes) to chlorine solution (> 0.5%) to minimize corrosion (rusting) of instruments and deterioration of rubber or cloth products.
d
Paper or plastic gowns, caps or masks. Place in a plastic bag or leak proof, covered waste container for disposal.
e
Instruments with cutting edges or needles should not be sterilized at temperatures above 1600C to avoid dulling.

177
CHAPTER 8: PROCESSING REUSABLE TEXTILES AND LAUNDRY
SERVICES
Key Topics
Minimum requirements for standard laundry

Periodic Monitoring and routine maintenance issues

Key steps in processing textile

The use of Personal Protective Equipment

Collecting, transporting and sorting used textile

Washing, and drying (Laundering) used textile

Storing, Transporting, and Distributing Hygienically Clean Textiles

Definition of Key Terms

Detergent is a cleaning agent that makes no antimicrobial claims on the label. Detergents (liquid
or powder) are composed of a hydrophilic (water-seeking) component and a lipophilic (fat-
seeking) component. These detergents can be divided into four types: anionic, cationic,
amphoteric, and nonionic detergents.

Textiles cloth items used in healthcare facilities by housekeeping staff (bedding and towels),
cleaning staff (cleaning cloths, gowns and caps), and surgical personnel (caps, masks, scrub
suits, surgical gowns, drapes and wrappers) as well as the staff of specialty units such as ICUs
and other units performing invasive medical procedures (e.g. anesthesiology, radiology or
cardiology).

Occupational Injury or Infection is an injury or infection acquired by the healthcare staff while
performing their normal duties.

Soaps and Detergents (Terms used Interchangeably) cleaning products (bar, liquid, leaflet or
powder) that lower surface tension thereby helping remove dirt, debris and transient
microorganisms on the hands. Plain soaps require friction (scrubbing) to mechanically remove
microorganisms while antiseptic (antimicrobial) soaps kill or inhibit growth of most
microorganisms.

205
Health care textiles are made from woven textile materials, either natural or synthetic fibers or a
mix of fibers, and material prepared from non-woven fibers. These textiles can be either single-use
or reusable items and used to make uniforms, PPE, surgical drapes, bed sheets, and other items.
They are generally referred to as textiles in health care facilities.

Soiled or Contaminated Textile is a cloth item coming from multiple sources within the hospital
or clinic that has been collected and brought to the laundry for processing.

Sorting is a process of inspecting and removing foreign and in some cases dangerous objects
(e.g. sharps or broken glass) from soiled textile before washing. This step is extremely important
because soiled textile from the operating room or clinic has occasionally been found containing
sharps (e.g. scalpels, sharp-tipped scissors, hypodermic and suture needles and towel clips)

BACKGROUND
Although soiled textile may contain large numbers of microorganisms, there is little risk to health
workers during textile processing. If work related infection occurs, it so happens often due to
healthcare workers‘ not using gloves or other personal protective equipment or washing their hands
during or after collecting, transporting and sorting soiled items. At this junction, therefore, no
special precautions would be necessary regardless of the patient‘s diagnosis if the standard
precautions are taken in all situations

Minimum Requirements for Standard Laundry

 Maintain the receiving area for contaminated textiles at negative pressure compared with
the clean areas of the laundry in accordance with FMOH-Infra-structure Directorate
construction standards for healthcare facilities in effect during the time of facility
construction.

 Ensure that laundry areas have hand washing facilities and products and appropriate PPE
available for workers.

 Use and maintain laundry equipment according to manufacturers' instructions.

 Do not leave damp textiles or fabrics in machines overnight.

206
  Disinfection of washing and drying machines in residential care is not needed as long as
gross soil is removed from items before washing. So, proper washing and drying procedures
are sufficient.

Periodic Monitoring

 Monitoring/inspection of the laundry unit on weekly basis (cleanness, functionality,

availability of all necessary detergent, PPE, water and all activities including collection,
storage, and recording/information (to assess work efficiency) of the unit). Facility should
develop monitoring check-list that includes the above requirement.
 Include the laundry activity in weekly, monthly, quarterly and yearly plan and report
accordingly.

 Use microbiologic sampling during outbreak investigations if epidemiologic evidence

indicates a role for health-care textiles and clothing in disease transmission.

Maintenance Issue of Laundry

 Use and maintain laundry equipment according to manufacturers' instruction.

 Make sure that spare parts are available for parts which can easily be damaged and
needing replacements on regular basis.
 Train the laundry staffs on users‘ maintenance and assign focal person for managing the
machine and reporting.

Types of Personal Protective Equipment to use in Laundry

Utility gloves, plastic or rubber apron, protective eyewear and closed shoes that protect feet from
dropped items and spilled blood and body fluids should always be used when collecting and
handling, transporting, sorting, hand washing soiled textile or loading it in automatic washers.
Note:
If utility gloves are not available, putting on two pairs of examination or
reprocessed surgical gloves (double gloving) provide some protection for the staff
responsible for collecting, transporting and sorting soiled textile and other items.

207
Processing Textile
Processing textile consists of all the steps required to collect, transport and sort soiled textile
as well as to launder (wash, dry and fold or pack), store and distribute it. Safely processing textile
from multiple sources is a complex process. To reduce the risk of contamination, procedures
should be in place to safely handle, process, and store textiles.

Staff handling the textiles should be properly trained on the processing procedures and should
protect themselves by applying Standard Precautions while collecting, transporting and sorting
soiled textile. They should wear thick utility or heavy-duty household gloves to minimize the risk
of accidental injury from a needle stick or other sharp object including broken glass. Staff
responsible for washing soiled items should wear utility gloves, protective eyewear and plastic or
rubber aprons and Rubber boots.

Table 8.0-1 Recommended PPE for Processing Textiles

Activity Type of PPE

Collecting soiled textiles Thick utility or heavy-duty household gloves

Transporting soiled textiles Closed-toe shoes to minimize the risk of accidental injury
from sharp objects or contact with blood or body fluids

Sorting soiled textiles Thick utility or heavy-duty household gloves

Hand washing soiled textiles Protective eyewear and mask or face shield

Loading washers Fluid-resistant gowns or plastic or rubber aprons

Handling disinfectant cleaning solutions Closed-toe shoes

Source: OSHA; Sehulster et al. 2015.

Principles and Key Steps In Processing Textile:

 Wear heavy-duty utility gloves and other PPE when collecting, handling, transporting,
sorting, and washing soiled textiles (see the section on PPE).
 Use PPE for Standard Precautions, carefully scrape off solid body fluids (e.g., stool or
vomit) using a firm, flat object and dispose in toilet or sluice before item is placed in
collection container.
 Use leak-proof containers for all textiles or at least those grossly contaminated with blood
or body fluids to protect staff from exposure to blood and body fluids.

208
  Do not sort textiles in patient care areas.
 Confine the soiled textiles to designated areas until transported to the laundry. Using the
principles of Standard Precautions, handle all discarded textiles as soiled, including items
on which there is no visible contamination.
 Launder all textiles present during procedures, regardless of whether or not they are visibly
dirty or were used in the procedure, such as sterile towel drapes contained in an opened
surgical pack that were not used during the procedure must be laundered before they can be
sterilized and reused.
 Transport textiles in covered containers or closed bags.
 Handle soiled textiles with minimum agitation to avoid contamination of air, surfaces, and
individuals.
 Handle soiled textiles as little as possible and with minimum contact to avoid accidents,
injuries, and the spread of microorganisms.
 Sort textiles in the laundry area carefully before washing.
 Follow special guidelines for textiles used in isolation areas for patients with highly
infectious diseases (e.g., viral hemorrhagic fever). Consult the ministry of health or World
Health Organization (WHO) guidelines.

Collecting, Transporting and Sorting used Textile

Design, Ventilation, and Space Requirements for Processing Textiles

 Processing areas for textiles should be physically separated from the patient care and food
preparation areas.
 Laundry areas should have hand hygiene facilities.
 Processing areas for soiled textiles must be physically separated (e.g., divided by walls)
from areas used for folding and storing clean textiles. If separate rooms are not possible, a
physical barrier between the clean and soiled textile areas should be constructed.
 Processing areas area considered ―soiled areas‖ and should be adequately ventilated.
 For facilities with natural ventilation, airflow should be away from other areas and air
should be exhausted out of the building.

209
Collecting, Handling and Transporting used Textiles

After invasive medical or surgical procedures or when changing textiles in patient rooms, the
following precautions and procedures should be applied in each situation (CDC 2011; Sehulster
et al. 2015). There are special guidelines for textiles used in isolation areas for patients with
highly infectious diseases (e.g., viral hemorrhagic fever), refer ministry of health or WHO
guidelines.

Collecting

 Collect and remove soiled textiles from patient rooms after each procedure daily, or as
needed.
 Use Standard Precautions, including PPE (see above), when collecting used textiles.
 Do not sort textiles in patient care areas.
 Collect used textiles at the point of use. Use leak-proof containers for all textiles; cloth bags
are adequate for patient care textiles not soaked with blood or body fluids.
 Roll items that are heavily contaminated with blood or body fluids carefully into the center
of the item and place in a leak-proof bag or a container with a lid if leak-proof bags are not
available.
 Do not sort or rinse textiles heavily contaminated with blood and body fluids in patient care
areas.
 Label clearly or use color coded containers for collecting and transporting used textiles.
 Wash and dry containers routinely before subsequent use. (See the Environmental Cleaning
chapter in this module for guidance on disinfectants.)

Note:
If utility gloves are not available, put on two pairs of non-sterile gloves (double gloving). This
provides some protection for HCWs responsible for collecting, transporting, and sorting soiled
textiles and other items.

Handling

 Handle soiled textiles as little as possible. To avoid the spread of microorganisms in the
environment and among HCWs and patients, do not shake soiled textiles.

210
  It is not necessary to routinely double bag or use additional precautions for textiles used by
patients in isolation. Two bags may be indicated if the textile cannot be placed in the bag
without contaminating the outside of the bag.

Transporting

 Transport collected soiled textiles to the processing area in closed bags, containers with lids,
or covered carts.
 Transport soiled textiles and clean textiles separately. If there are separate carts, trolleys, or
containers available for soiled and clean textiles, they should be labeled accordingly. If
soiled and clean textiles are transported in the same cart or container:
 Clean the containers and trolleys or carts thoroughly after transporting soiled textiles using
disinfectant cleaning solution (for detailed information see Volume 1, Chapter 9:
Environmental Cleaning).
 Keep soiled textiles in separate areas of the same cart where clean textiles are located and
cover both.

Sorting Soiled Textile

Careful sorting of textiles is extremely important for the safety of HCWs. Sorting must be carefully
performed because soiled textiles (e.g., large drapes and towel drapes) from the operating theater
(OT) and other procedure areas may contain sharps (e.g., scalpels, sharp-tipped scissors,
hypodermic and suture needles, and sharp-tipped towel clips). In addition, bedding from patients‘
rooms may contain soiled dressings (e.g., blood-stained or wet with other body fluids).

Sorting textiles also allows for customization of washing processes for various categories of textiles
or soil level. It also increases efficiency during inspection, folding, ironing, etc. Soiled textiles may
also contain non-infectious items (e.g., coins and keys). These items pose no risk and should be
returned directly to the patient. Please note that:

 The processing area for soiled textile must be separate from other areas used for folding and
storing clean textile, patient care and food preparation.
 Maintain adequate ventilation and physical barriers between the clean and soiled textile
areas.

211
  Do not sort or pre-rinse soiled textiles in patient care areas; they should be sorted in the
laundry area.
 Sort soiled textiles into appropriate wash loads by classification such as color, type of
fabric, soil type or soil load, and/or type of item (e.g., whites‘ items, cloth nappies/diapers,
cotton/wool items, mop heads, surgical drapes, etc.).
 Always wear protective eyewear, utility gloves, appropriate footwear and plastic or rubber
apron while handling soiled textile.
 Wash hands after removing the gloves. Although infrequent infection is related to sorting,
they have been attributed to failure of hand washing and proper use of PPE (McDonald,
2002).

Washing (Laundering) and Drying Textile

All textiles (e.g., bed sheets, surgical drapes, and gowns) used in the direct care of a patient must be
thoroughly washed and dried before reuse. Laundering removes pathogens from textiles, making
them hygienically clean1 and ready for use. Laundered textiles are not sterile and are not required to
be, including for neonatal intensive care units. (Sehulster et al. 2015)

Laundering standards in hospitals should address key, specific standards, for example, water
quality and temperature, amount of agitation needed, and chemical properties needed to properly
clean surgical attire. Effective laundering is dependent on the following factors, which, when used
together, have a greater effect than when used separately:

 Duration of cleaning
 Mechanical action (i.e., agitation)
 Chemicals used in the process
 Temperature of water and air in the machine dryer

If one of these factors is decreased (e.g., temperature), then other factors (e.g., chemicals,
mechanical action, or time) must be increased to result in the same level of cleanliness.

212
Laundering cycles consist of flush, main wash, disinfecting (bleaching), rinsing, and souring
(addition of a mild acid agent).
Decontamination of textiles by presoaking with soap, water, and chlorine solution prior to washing
is not necessary unless the item is heavily soiled or will be hand washed. Repeated soaking of
textiles in chlorine solution, even dilute solution, can cause fabric to deteriorate more quickly.
Note:
The storage time for soiled textiles before washing is a practical issue related to
available storage space and aesthetics, not an infection prevention concern.

Hand Washing Textile

Using Cold Water

Using cold water saves energy. Cool water cycles rely heavily on the action of bleach to kill
microbes. Temperatures of 22–25oC (71–77oF) for washing textiles is satisfactory for removing
microbes if the water cycle, type of soap or detergent, strength of chlorine solution, and other
additives are used in proper concentrations. WHO recommends soaking textiles in 0.05%–0.5%
chlorine solution for 15–30 minutes and then washing with soap and water to remove the bleach.
(AORN 2013; Fijan and Turk 2012; Sehulster et al. 2015; SEARO/WHO 2004)

Washing textiles by hand

The steps to properly hand wash textiles are:

STEP 1 Wear PPE while washing textiles by hand.

STEP 2 Separate heavily soiled textiles from non-soiled textiles and wash separately.

STEP 3 Wash the entire item in water with soap to remove all dirt and debris, even if not visible.

STEP 4 Soak in clean water with chlorine solution (0.005–0.015% or 50–150 parts per million

(ppm) for 30 minutes. Add sour (a mild acid agent) to prevent yellowing of the textile.

STEP 5 Wash again with soap and water to remove bleach.

STEP 6 Check the item for cleanliness. Rewash if it is still dirty or stained.
STEP 7 Rinse the item with clean water.
(Sehulster et al. 2015; SEARO/WHO 2004)

213
Machine Washing Textile
Heavy-duty washers or dryers are recommended for larger health care facilities (e.g., hospitals). To
properly machine wash textiles:

STEP 1 Wear PPE while handling and loading machines.

STEP 2 Separate heavily soiled textiles from non-soiled textiles and wash separately.

STEP 3 Follow manufacturers‘ instructions to adjust temperature settings, cycle time, type of soap,
and other washing agents to be added.

STEP 4 For hot-water washing at 70–80oC (158–176oF), use soap for ≥ 25 minutes to aid in
loosening soil. Add bleach and sour if stain removal is required. If not using hot water,
soaking textiles in 0.05%–0.5% chlorine solution for 15–30 minutes and then wash with
soap and water to remove the bleach.

STEP 5 When the wash cycle is complete, check the item for cleanliness. Rewash if it is dirty or
stained. (Heavily soiled textiles may require two wash cycles.)
(CDC 2011; SEARO/WHO 2004)

While using machine for washing textile:

 Do not overload the machine.

 A pre-wash rinse cycle of 15 minutes will remove remaining gross spillage.
 In cold water washes, chemicals such as bleach must be added (2ml of household
bleach for every liter of water) with detergent to facilitate disinfection.
 During the rinse cycle, souring agent should be added to the rinse cycle to
reduce alkalinity and prevent yellowing. This decreases the likelihood of skin
irritation and further reduces the number of bacteria present.
 Air dry or machine dry before further processing. Textile should be dried as
soon as possible after washing to prevent the re-growth of any bacteria not killed by
the washing procedure.

Please Note That: Lower temperature or cold water washing are satisfactory if the
cleaning products (type of soap or detergent, amount of bleach and other additive)
are appropriate and used in proper concentration. Using cold water also saves
energy.

214
Drying, Inspecting, and Folding Textiles

Steps to dry, inspect, and fold hand- and machine-washed textiles:

STEP 1 Completely air or machine-dry cleaned textile before further processing. A cycle in the
dryer has been associated with elimination of pathogenic bacteria. For air-drying, direct
sunlight is preferred. Keep the fabric off the ground, away from dust and moisture.

STEP 2 After textiles are totally dry, check for holes and threadbare (worn) areas. If these are
present, the item must be discarded or repaired before reuse or storage:

For holes, punctures, or tears or large areas to be repaired, the item should be patched with
the same quality material by stitching or heat sealing; otherwise, the item should not be
used for direct patient care or surgical procedures. Worn textiles can be cut into pieces
and used as cleaning cloths.

For surgical drapes, the percentage of exposed surface allowed to be patched depends on
the sterilization method used to process the item and the number of layers of fabric from
which the drape is made. For example, a drape should have no more than five patches per
area 30 centimeters (12 inches) square, or no more than 20% of the drape covered with
patches. Patches should be avoided, if possible, because they increase the thickness of the
item and decrease steam penetrability when sterilization is required.

STEP 3 Air-dried textiles should be ironed. Ironing has been associated with the elimination of
pathogenic bacteria and is essential to prevent parasites in some regions.

STEP 4 Clean, dry textiles should be folded. If sterile textiles are required (e.g., in the OT), prepare
and sterilize wrapped packs as discussed in Module 6, Chapter 4, Sterilization of
Reusable Surgical Instruments and Medical Devices. In neonatal intensive care units,
hygienically laundered textiles can safely be used; it is not necessary to use sterilized
textiles. (AORN 2013; Bearman et al. 2014; Sehulster et al. 2015; SEARO/WHO 2004;
Tietjen et al. 2003)

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Storing, Transporting, and Distributing Hygienically Clean Textiles

Storing Hygienically Clean Textiles

Procedures for proper storing of hygienically clean textiles:

 Store clean textiles in clean, closed storage areas.

 Store clean textiles in an area free of pests, dust, and lint and at room temperatures of 20–
25.6°C (68–78°F).
 Use physical barriers to separate folding and storage rooms from soiled areas.
 Ensure that storage shelves are: 2.5 to 5 cm (1 to 2 inches) from the wall
 Bottom shelf: 15 to 20 cm (6 to 8 inches) from the floor
 Top shelf: 30 to 45 cm (12 to 18 inches) below the ceiling
 Keep shelves clean and textiles covered, which can be achieved by: covering clean textiles
on a clean cart
 Wrapping bundles of clean textiles in plastic or other suitable material and closing securely
 Restrict access to the laundry storage room to authorized staff.
 Store hygienically clean surgical attire as close to the point of use as possible to avoid any
microbial contamination.
 Handle stored textiles as little as possible.
(APIC 2014; Sehulster et al. 2015)

Transporting Clean Textiles

Procedures for proper transporting of clean textiles:
 Hygienically clean and soiled textiles should be transported separately. If separate trolleys
or containers are used for clean and soiled textiles, they should be labeled accordingly.
 If clean and soiled textiles must be transported in the same cart, the following are options in
order of preference:
 Thoroughly clean the containers and trolley with disinfectant cleaning solution (e.g. 0.5%
hypochlorite solution) before transporting hygienically clean textiles; or
 Keep hygienically clean textiles in separate areas of the same trolley where soiled textiles
are located and cover both.
 Wrap or cover hygienically clean textiles during transport to avoid contamination.

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Distributing Hygienically Clean Textiles

It is important to protect hygienically clean textiles from environmental contaminants (e.g., dust and
dirt) until they are distributed for use. Outbreaks associated with textiles have resulted from
contamination of clean textiles; several outbreaks of Bacillus cereus in hospital settings were linked
to contaminated textiles. (Balm et al. 2012; Duffy et al. 2014; Hosein et al. 2013; Sasahara et al.
2011)

To avoid contamination of textiles in health care facilities:

 Do not leave extra textiles in patients‘ rooms.

 Handle clean textiles as little as possible.
 Avoid shaking clean textiles where dust and lint can be released into the room.
 Do not conduct routine microbiologic sampling of clean textiles.
 Clean soiled mattresses and pillows using the following guidelines before putting clean
textiles on them:
 Clean plastic-covered mattresses and pillows by wiping down with detergent.
Mattresses without plastic covers that have any blood or body fluids should have the
stains removed by either steam cleaning or manual washing. HCWs should wear PPE
during this cleaning process.(Sehulster et al. 2015; SEARO/WHO 2004)

Key Notes:
 Do not presorts or wash textile at the point of use
 The workers should not carry wet and soiled textile close to their body even though they
are wearing a plastic or rubber apron.
 Presoaking in soap, water and bleach is necessary only for heavily soiled textile
 Ironing especially using a steam iron will destroy pathogens
 Handle stored textile as little as possible
 Sterilization is the preferred end process for surgical gowns, textile drapes and
wrappers

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Summary

Facility staffs are often responsible for handling and processing reusable textiles at the facility.
Although soiled textiles may contain large numbers of microorganisms, the overall risk of disease
transmission is low if textiles are handled, transported, and laundered in a manner that avoids transfer
of microorganisms to patients, HCWs, and the environment. Health care outbreaks can occur because
of contaminated textiles and HCWs can experience injuries and exposures if these recommendations
are not followed.
Table 8.0-2vGuidelines for Processing Textile and Personal Protective Equipment (PPE)

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CHAPTER 9: ENVIRONMENTAL CLEANING IN HEALTH CARE
SETTING
Key Topics

Definition of Key Terms.

General principles of cleaning.
Ways of preparing disinfectant cleaning solutions.
When and how to clean low and high risk areas.
Cleaning spills of blood or other body fluids.
Cleaning the housekeeping equipment.
Definitions of Key Terms

Biofilm is an accumulated, thin layer of bacteria and extracellular material that tightly adheres to
surfaces (e.g., skin drains, urinary catheters) and cannot be easily removed. The presence of biofilm
can increase the resistance of the bacteria to antimicrobial drugs and reduce the effectiveness of
disinfectants and sterilization because products cannot penetrate the surface.

Cleaning is the removal of visible dirt (e.g., organic and inorganic material) from objects and
surfaces, normally accomplished manually or mechanically, using water with detergents or
enzymatic cleaners. Cleaning is required before high-level disinfection or sterilization because
tissue, blood, body fluids, dirt, and debris reduce the effectiveness of these processes.

Cleaning Solution is any combination of soap (or detergent) and water, with or without a
chemical disinfectant used to wash or wipe down surfaces such as floors, chairs, bench tops, walls
and ceilings (environmental surfaces).

Contact time is the length of time a cleaning product must remain wet on the surface being cleaned
for the disinfectant to kill the targeted microorganisms. Time of contact varies depending on the
type of cleaning product and the targeted microorganism (e.g., bacteria, viruses, mycobacteria,
spores). For use in health care facilities, the contact time for the organism that is most difficult to
kill is routinely adopted.

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Detergent (term is used interchangeably with soap) is a cleaning product (e.g., bar, liquid, leaflet,
or powder) that lowers surface tension of water, thereby helping to remove dirt and debris. Plain
soaps do not claim to be antimicrobial on their label and require friction (i.e., scrubbing) to
mechanically remove microorganisms. Antiseptic (antimicrobial) soaps do kill or inhibit growth of
some microorganisms, but not all. Commercial cleaning products (liquid or powder) that are
composed of two components-hydrophilic (water-seeking) and lipophilic (fat-seeking) components
and it can generally be divided into four types: anionic, cationic, amphoteric and nonionic
detergents.

Disinfectant Cleaning Solution - is a product that is a combination of detergent (soap) and a

chemical disinfectant. It is true, that not all detergents and disinfectants are compatible. But,
there still are range of several combinations such as alkaline detergents with chlorine
compounds, alkaline detergents with quaternary ammonium compounds (QUATs) or other
nonionic surfactants, and acid detergents with Iodophors which are available commercially or
can be prepared.

Disinfectants – are chemicals that destroy or inactivate microorganisms. Disinfectants are

classified as low, intermediate or high-level depending on their ability to kill or immobilize some
(low or intermediate-level) or all (high-level) microorganisms. While disinfectants may kill all
microorganisms, they do not kill all spores. Commonly used disinfectants for low-, intermediate-
level cleaning include phenols, chlorine or chlorine-containing compounds, and quaternary
ammonium compounds (QUAT) and hydrogen peroxides (H2O2). These classes of disinfectants
are often used to clean frequently touched surfaces in health care facilities.

Encapsulation- is filling a container with cement or clay, which, after hardening, can be
disposed of safely in a landfill.

Environmental cleaning - in health care facilities, refers to the general cleaning of surfaces and
equipment to reduce the number of microorganisms present and providing a clean and pleasant
atmosphere.

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Environmental Controls - activities of keeping standards specifying procedures to be followed
for the routine care, cleaning and disinfection of surfaces, beds, bedrails, bedside equipment and
other frequently touched surfaces .

Frequently touched surfaces - are surfaces in patient care areas in the health care facility with
frequent hand contact. These surfaces include door handles, light switches, countertops, bedrails
and ends of beds, patient charts, tap handles, hand rails, toilet flushes, rounding and medical
trolleys/carts, buttons on monitors, telephones, and call bells.( See figure 9.0.1)

Non-critical items - for the purposes of cleaning and disinfection, are items that come into contact
with intact skin but not mucous membranes (e.g., blood pressure cuffs, stethoscopes, and crutches).
Most can be cleaned and disinfected at the point of use using a low-level disinfectant.

Sanitizer - a chemical that reduces the number of bacterial contaminants on inanimate objects to
safe levels based on public health requirements (i.e. a chemical that kills 99.999% of the specific
test bacteria in 30 seconds under the conditions of the test). They are used in food service but not
for cleaning surfaces in health care facilities.

Scrubbing (frictional cleaning) - is the vigorous rubbing of a surface with a brush or other tool.
This is the best way to physically remove dirt, debris, and microorganisms.

Soap - is a term used interchangeably with detergent; see the definition of detergent.

Soaps and Detergents (terms used interchangeably) - are cleaning products (bar, liquid, leaflet
or powder) that lower surface tension thereby helping remove dirt, debris and transient
microorganisms from hands, utensils, equipment, etc. Plain soaps require friction (scrubbing) to
mechanically remove microorganisms; while antiseptic (antimicrobial) soaps kill or inhibit the
growth of most microorganisms

Sterilants - these are Chemicals used to destroy all forms of microorganisms including
endospores. Most sterilants are also high-level disinfectants when used for a shorter period of time.
These chemicals are to be applied only on inanimate objects (e.g. surgical instruments) that are
used in semi-critical and critical areas (e.g. surgery). It should be noted that they are not
meant to be used for cleaning environmental surfaces.

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Surfactant - an agent that reduces the surface tension of water or the tension at the interface
between water and another liquid; and a wetting agent found in many sterilants and disinfectants.

Terminal or discharge cleaning - is the process used to clean a patient‘s room after the patient has
been discharged or transferred or to clean patient treatment areas including operating theaters (OTs)
at the end of the day.

Figure 9.0-1 Frequently Touched Surfaces in an Examination Room Source: Jhpiego.

BACKGROUND
Accumulation of dust, soil and microbial contaminants on environmental surfaces is both unsightly
and potential source of HAIs. Effective and efficient cleaning methods and schedules are,
therefore, necessary to maintain a clean and healthy environment in healthcare settings (Chou,
2002).
Housekeeping practices in the healthcare facilities address the general cleaning of health facilities
including: the compound, the floors, walls, various type of equipment, tables and other surfaces.
Housekeeping activities are not expensive and technology intensive in most cases. The purpose of
general housekeeping is to:

 Reduce the number of microorganisms that may come in contact with patients, visitors,
staff and the community; and
 Provide a clean and pleasant atmosphere for patients and staff.

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Most of the areas in health facilities like waiting rooms and administrative offices are normally of
low-risk for they can be cleaned using only soap and water. In high-risk areas where heavy
contamination is expected, sources of contaminations such as toilets and latrines; and blood or
body fluid spills can be handled by disinfectants like 0.5% Chlorine or 1% Phenol which should be
added to the cleaning solution (SEARO, 1988). Using a disinfectant in addition to soap and water
is also recommended in other high-risk areas such as operating rooms, pre- and postoperative
recovery areas, dressing areas and intensive care units (ICUs).

In connection with this, patient rooms especially those items that might be touched bare handedly
by patients and the staff should be cleaned using a disinfectant solution to minimize the risk of
infection. For instance, a study in the area (McFarland et al., 1989) found that when patients who
did not have Clostridium difficile were admitted to a room previously occupied by a patient with
these bacteria, the risk of infection from the bacteria for these new patients is known to increase in
many folds-even in the context of correct use of precautions to prevent cross contamination.

If the purpose of housekeeping as stated above is to be achieved, it is important that housekeeping

staff be trained to perform their assigned tasks and are supervised on a regular basis. As part of
their training, it is important that the housekeeping staff:

 Understand the risk of exposure to contaminated items and surfaces when performing
environmental cleaning procedures; and
 Follow recommended policies and guidelines including the use of appropriate personal
protective equipment (PPE).

General Principles for Cleaning

 Scrubbing (frictional cleaning) is the best way to physically remove dirt, debris and
microorganisms.
 Cleaning is required prior to any disinfection process because dirt, debris and other
materials can decrease the effectiveness of many chemical disinfectants.
 Cleaning products should be selected on the basis of their use, efficacy, safety and cost.

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  Cleaning should always progress from the least soiled areas to the most soiled areas and
from high to low areas so that the dirtiest areas and debris falling on the floor will be
cleaned up last.
 Dry sweeping, mopping and dusting should be avoided to prevent dust, debris and
microorganisms from getting into the air and landing on clean surfaces. Airborne fungal
spores are especially important as they can cause fatal infections in immune-suppressed
patients (AORN et al., 1991).
 Instructions for mixing (dilution) should strictly be followed when using disinfectants.
(Too much or too little water may reduce the effectiveness of disinfectants).
 Cleaning methods and written cleaning schedules should be based on the type of the
surface, the amount and the extent of the soil present and the purpose of the area.
 Routine cleaning is necessary to maintain the standard of cleanliness. Also, schedules and
procedures should be consistent and posted.

How to Select Cleaning Products

There are different types of cleaning products which are used for different purposes. The
housekeeping staff in particular and health facility staff in general, have to get a clear idea on
how to select a cleaning product and for what purpose. There are some basic facts which should
be remembered before making selections of the products. An ideal cleaning product should
accomplish the following:

 Suspending fats in water (suspended fat in water).

 Saponification of fat (make fats water-soluble)
 Surfaction (decreasing surface tension of water and allowing greater penetration of the
agent into the dirt or soil).
 Dispersion (break up of soil into small particles).
 Protein destruction (break up proteins).
 Softening the water by removing calcium and magnesium from it.

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 The Main Guiding Principles for Resource Limited Areas are:

 Unnecessarily expensive products should not be selected.

 What is selected and bought should be based on evidence (not to be left to chance).
 The right product should be for the right purpose.

In conclusion, it is believed that the selection of disinfectants and other cleaning products should
be based on the following factors:

 Intended use of the product/s.

 Efficacy of the product/s.
 Acceptability of the product/s.
 Environment friendly.
 Safety of the product/s.
 Cost-effectiveness of the product/s.

Personal Protective Equipment for Housekeeping

The housekeeping staff in health facilities deals with dirt, soils and other materials that expose
them to risks of infections and other health hazards. To avoid this hazardous exposure, they have
to be equipped with the relevant personal protective equipment.

Some of personal protective equipment for housekeeping purposes is:

 Gloves preferably the utility or Heavy duty gloves

 Protective shoes
 Plastic or rubber apron
 Masks
 Protective eye wears
 The housekeeping staffs should use the above mentioned PPEs for:-

 Handling disinfectant cleaning solutions

 Cleaning patient care areas
 Cleaning heavily contaminated areas

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  Handling soiled linens
 Handling soiled items and instruments
 Handling or disposing of wastes
 When spills or splashes are expected

How to Prepare a Disinfectant Cleaning Solution

The disinfectant cleaning solutions contain both disinfectants for decontamination and detergents
(soap) for cleaning. When we use Chlorine solution, we should be very cautious. Although
chlorine-containing solutions (sodium hypochlorite) are excellent and inexpensive disinfectants,
they should not be mixed with cleaning solutions containing an acid (e.g. phosphoric acid) like
Ammonia or Ammonium chloride (NH4Cl).So doing will release chlorine gas and other by-
products that can result in temporary illness (nausea, tearing, headache or shortness of breath) of
the staff inhaling fumes in a poorly ventilated area (CDC, 1991). To find out if a cleaning
solution contains ammonia, first check the label. If it is not mentioned among the ingredients,
you may still be able to detect ammonia when opening the product by its pungent and burning
smell. If one is exposed to Chlorine gas or Ammonium chloride or other unpleasant (noxious)
gases with strong odors, the subject should immediately leave the room or the area until it
becomes completely ventilated.

STEP 1 Prepare a 0.5% Chlorine solution from liquid concentrates (See Equation 1-9-1) for
directions) or from Chlorine powder compounds (See Equation 1-9-2). Alternative
disinfectants that can be used include 1 to 2% Phenols or 5% Carbolic acid.

STEP 2 Add enough detergent to the 0.5% Chlorine solution or another disinfectant to make a
mild and soapy cleaning solution.

How to Prepare Chlorine Solution

 Formula for making a dilute solution from a concentrated solution

 Check concentration (% concentrate) of the chlorine solution.

 Determine total parts of water using the formula below
 Mix 1 part concentrated bleach with the total parts water required

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 Equation 1-9-1: Formula for making a dilute solution from a concentrated solution

Example: Make a dilute solution (0.5%) from 5% concentrated solution

STEP 1: Calculate TP water

STEP 2: Take 1-part concentrated solution and add to 9 parts of water.

 Formula for making a dilute solution from a dry powder

 Check concentration (% concentrate) of the powder you are using.

 Determine amount of chlorine (gm.) to be add in a liter of water using the formula
below.
 Mix the calculated amount of dry powdered with one liter of water.

Equation 1-9-2: Formula for making a dilute solution from a dry powder

Example: Make a dilute chlorine solution (0.5%) from a concentrated powder (35%)

STEP 1: Calculate grams/liter:

STEP 2: Add 14.2 grams to 1 liter of water

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Cleaning Methods

Cleaning should start with the least soiled area and extend to the most soiled area and from high
to low surfaces. Common methods of cleaning are briefly described below:

Wet Mopping Method (Preferable for Floor Cleaning)

Single-Bucket (Basin) Technique - one bucket of cleaning solution is used here. The solution,
however, needs to be changed when dirty. (The killing power of the cleaning product decreases
with the increased load of soil and organic material present).

Double-Bucket Technique - two different buckets are used here-one containing a cleaning
solution and the other containing water for rinsing. The mop is always rinsed and wrung out before
it is dipped into the cleaning solution. The double-bucket technique extends the life of the cleaning
solution (fewer changes are required) saving both labor and material costs.

Triple-Bucket Technique - the third bucket is used for wringing out the mop before rinsing which
extends the life of the rinse water.

Flooding Followed by Wet Vacuuming Method

 It is preferable for surgical suits.

 It eliminates mopping and minimizes the spread of micro-organisms.
 It increases the contact time of the disinfectant and the area to be cleaned.
 Preferably, it should be done at night when the traffic flow of the facility is low.

Dusting

 Should b e used for cleaning walls, ceilings, doors, windows, furniture and other
environmental surfaces.
 Clean clothes or mops are made wet with cleaning solution contained in a basin or
bucket. The double-bucket system minimizes the contamination of the cleaning solution.
 Dry dusting should be avoided, and dust cloths should not be shaken either for fear of
spreading of micro-organisms.

228
  Should be performed in a systematic way using a starting point as a reference to endure
that all surfaces have been reached.
 Check for a stain that may indicate possible leaks when doing high dusting, (ceiling tiles
and walls). Leaking holes or cracks should be repaired as soon as possible because moist
structure provides a reservoir for fungal growth.

Dry Vacuuming

 This is recommended only for cleaning carpets.

Schedules and Procedures for Specific Areas

In health facilities, housekeeping activities should be scheduled. Housekeeping schedule should be

planned, written and closely followed. Cleaning schedules should be developed according to the
need of each area.

Walls, Windows, Ceilings and Doors, including Door Handles - these should be cleaned at the
spot when visibly dirty with a damp cloth, detergent and water. In general, routine damp dusting
is adequate for these areas (disinfection is unnecessary). These surfaces are seldom heavily
contaminated with microorganisms as long as the surfaces remain dry and intact (Russellet et al.,
1982).

Chairs, Lamps, Tables, Tabletops, Beds, Handrails, Grab Bars, Lights, Tops of Doors and
Counters - these items should be wiped daily and whenever visibly soiled with a damp cloth
containing disinfectant cleaning solution. A disinfectant should be used when contaminations from
blood or other body fluid spills are present.

Non-Critical Equipment - (e.g. stethoscopes and blood pressure cuffs) these ones can just be
wiped daily and whenever visibly soiled with a damp cloth with detergent and water. If the
equipment is visibly soiled with blood or other body fluids or when the patient is under contact
precautions, however, it should be cleaned and disinfected before it is reused.

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Floors - floors usually cleaned (daily and as needed) with a wet mop, detergent and water. A
disinfectant should be used during an actual or potential contamination from sources like blood
or other body fluid spills as described below.

Sinks - scrub frequently (daily or more often as needed) with a separate mop, cloth or brush is
using a disinfectant cleaning solution. Following this, it needs to be rinsed with water.

Toilets and Latrines - scrub them frequently (daily and more often as needed) with a separate
mop, cloth or brush and a disinfectant cleaning solution.

Patient Rooms - they should be cleaned daily and right after patient is discharged using the
processes described above. The same cleaning process applies to rooms of patients who are
under isolation precautions. Any cleaning equipment used in the rooms of patients under isolation
precautions should be cleaned and disinfected before being used in another room.

Procedure Rooms - wipe horizontal surfaces, equipment and furniture used for the procedures,
with a disinfectant cleaning solution after each procedure and whenever visibly soiled. Clean
blood or other body fluid spills as described below.

Examination Rooms - wipe horizontal surfaces with a disinfectant cleaning solution whenever
visibly soiled. Linen or paper on the examination table should be changed and laid out for each
patient. Clean blood or other body fluid spills as described below.

Laboratory - wipe countertops with a disinfectant cleaning solution after each shift and
whenever visibly soiled. Clean blood or other body fluid spills as described below.

Curtains - change and clean curtains according to the routine schedule and when visibly soiled.

Carpets - vacuuming daily carpets in patient rooms or weekly in offices or conference rooms.

Soiled Linen - collect soiled linen daily (or more often as needed) put them in closed and leak
proof containers.

Waste - collect waste from all areas at least daily (or more frequently as needed) and avoid
overflowing.

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Waste Containers - clean contaminated waste containers each time following emptying. Clean
no contaminated waste containers when visibly soiled and at least once a week. Use a disinfectant
cleaning solution and scrub to remove soil and organic material.

Schedule and Procedures for the Operating Room

 At the beginning of each day, all flat (horizontal) surfaces (table, chairs, etc.) should be
wiped with a clean, lint-free and moist cloth to remove dust and lint that may have
collected overnight.
 Total cleaning is not necessary between each case for surgical procedures.
 Total cleaning or terminal cleaning (mopping floors and scrubbing all surfaces from top
to bottom) of the operating room should be done at the end of each day.

Note:

Do not dry mop or sweep the operating room. (This causes dust, debris
and microorganisms to become airborne and contaminate clean surfaces).

Total Cleaning

STEP 1 Move covered decontamination buckets to the central supply or processing room. A
clean bucket containing a fresh 0.5% chlorine solution or other locally available and
approved disinfectants should be provided at the beginning of each day and after each
case.

STEP 2 Remove covered contaminated waste container and replace it with a clean container.
Arrange for burning (incineration) or burial as soon as possible.

STEP 3 Close and remove sharps containers when three quarters full.

STEP 4 Remove soiled linen in closed leak proof containers.

STEP 5 Soak a cloth in disinfectant cleaning solution and wipe down all surfaces, including
counters, tabletops, sinks, lights, etc. Wash from top to bottom so that any debris that
falls on the floor will be cleaned up last.

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 Note:

All areas of the surgical suite, scrub sinks, scrub or utility areas, hallways
and equipment should be totally cleaned regardless of their being used during
the 24- hour surgery period.

Walls and Ceilings - wipe them with a damp cloth with detergent and water as needed for visible
soil.

Note:

If walls and ceilings are deteriorating or damp, cover them up with clean
plastic sheets during procedures.

Chairs, Lamps, Sink Tabletops and Counters - wipe them with a damp cloth with
disinfectant cleaning solution.

Operating Room Lamp - wipe them with a damp cloth with disinfectant cleaning
solution.

Note:

The double or triple bucket method is recommended for the cleaning of the
operating room and other areas of the surgical suite.

Operating Room Table - wipe it with a 0.5% Chlorine solution (or other approved
disinfectant) to decontaminate. Then clean top, sides, base, legs and any accessories (e.g. leg
stirrups) with a damp cloth and disinfectant cleaning solution.

Floors - clean with a wet mop using a disinfectant cleaning solution.

Vents (heating or air conditioning) - wipe them with a damp cloth with soap and water. When
carrying out, the following is advised:

Spills - clean spills with a 0.5% chlorine solution or other locally available and approved
disinfectants (see below).

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Operating Room Bed - wipe all surfaces and mattress pads with a disinfectant cleaning solution.

Instrument Tables (Trolley and Mayo stand) and other Flat Surfaces - wipe all flat surfaces
that have come in to an immediate contact with a patient or body fluids with a disinfectant
cleaning solution.

Center of Operating Room Surrounding the Operating Room Bed - mop it with a disinfectant
cleaning solution (if visibly soiled).

Waste - collect and remove all waste from the operating room in closed leak proof
containers.

Sharps Containers - close and remove containers from the operating room when they are three
quarters full.

Containers with a 0.5% Chlorine Solution for Decontamination - remove covered containers
with instruments from the operating room and replace them with clean containers with a fresh
0.5% chlorine solution.

Soiled linen - remove soiled linen in leak proof, covered waste containers.

Note:

 Cleaning the filters in air conditioners regularly will help them run more
efficiently and decrease the growth of molds.
 Because all patients are considered potentially susceptible and at times infectious,
standard precautions are to be used and no additional measures are necessary
even if a client is known to have an infection.

How to Clean Spills of Blood and Other Body Fluids

Clean spills of blood, body fluids and other potentially infectious fluids immediately:

 For small spills, remove visible material using a cloth soaked in a 0.5%
Chlorine solution, then wipe clean with a disinfectant cleaning solution while wearing
utility or examination gloves.

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  For large spills, flood the area with a 0.5% Chlorine solution and mop up the solution
and then clean as usual with detergent and water while wearing gloves.

How to Manage Spills of Mercury from Broken Thermometer and Blood Pressure
Equipment:

• Put examination gloves on both hands,

• Collect all droplets of mercury with a spoon.
• Place in a small, closed container for disposal (possibly encapsulation and burial of the
waste away from water resource area) or reuse,
• Wash or clean the area with a chlorine solution,
• Remove used gloves carefully and wash hands properly.

How to Clean Soiled and Contaminated Cleaning Equipment

STEP 1 Decontaminate cleaning equipment that has been contaminated with blood or body
fluids by soaking it for 10 minutes in a 0.5% Chlorine solution or other locally
approved and available disinfectants.

STEP 2 Wash cleaning buckets, cloths, brushes, mops and the like with detergent and water daily
or right away if visibly dirty.

STEP 3 Rinse them in clean water.

STEP 4 Dry them completely before reuse. (Wet clothes and mop heads are heavily contaminated
with microorganisms).

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Summary

• Housekeeping practices in the healthcare facilities including: the compound, the floors,
walls, various type of equipment, tables and other surfaces
• Dust, soil and microbial contaminants on environmental surfaces are potential source of
HAIs.
• Effective and efficient cleaning methods and schedules are necessary to maintain a clean
and healthy environment in healthcare settings
• Cleaning should start with the least soiled area and extend to the most soiled area and from
high to low surfaces.
• It is important that housekeeping staff be trained to perform their assigned tasks and are
supervised on a regular basis.
• Total cleaning or terminal cleaning (mopping floors and scrubbing all surfaces from top to
bottom) of the operating room should be done at the end of each day.
• Do not dry mop or sweep the operating room.

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CHAPTER 10: HEALTHCARE WASTE MANAGEMENT
Key Topics

Categories of health care waste

Reduction of health care waste
Segregation of waste at point of generation
Management of the health care waste process
Waste treatment and disposal methods
Definition of Key Terms

Combustible wastes are those that can be burned or will easily catch on fire, and include paper,
cardboard, and used dressings and gauze as well as some liquids and gases.

Cytotoxic waste contains by-products of drugs that kill dividing cells, used for treatment of
certain cancers. It also includes waste materials that can damage human genes (e.g., DNA) and
may cause cancers or congenital deformities in babies. This waste can include any items
exposed to these drugs including sharps, personal protective equipment (PPE), and body fluids.

Disposal is the final step in health care waste management and entails intentional treatment of
waste to render it harmless followed-by burial, deposit, discharge, dumping, placement, or
release of waste material into the air or water or onto/into land. It is undertaken without the
intention of retrieval/reuse.

Encapsulation is a process used when other options for safe disposal are not available. It
involves surrounding hazardous waste with an immobilizing agent within sealed, solid waste
containers to reduce the likelihood of future environmental, scavenger, or human contact with
waste.

General waste does not pose any particular biological, chemical, radioactive, or physical
hazard (e.g., paper boxes, newspapers and magazines, polyethylene bottles, polyester bags,
wood, other papers, metals [e.g., aluminum cans and containers], high-density polyethylene
[e.g., milk containers, saline bottles], glass, and construction/demolition materials).

Hazardous waste is waste that can pose a health risk to health care workers (HCWs), patients,
and other people who are exposed to it. It includes both chemical/radioactive and infectious

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health care waste, for example, sharps, pathological waste, pharmaceutical waste, and cytotoxic,
chemical, and radioactive waste.

Health care wastewater is any water that has been adversely affected in quality during the
provision of health care services. It is mainly liquid waste containing some solids produced by
staff and patients (i.e., human excrement) or during health care-related processes, or cooking,
cleaning, and laundering at the health care facility. This type of wastewater poses risks similar
to those of domestic wastewater, which is considered infectious. However, health care facilities
(depending on the services offered) also generate wastewater that poses a higher risk,
containing chemicals, pharmaceuticals, contagious microorganisms, and radioactive substances.

Incineration is one method of waste disposal and involves controlled burning of solid, liquid,
or gaseous combustible wastes that result in inorganic, non-combustible residue.

Infectious waste is waste that is potentially contaminated with blood, body fluids, or
pathogenic organisms, including, but not limited to, laboratory cultures, microbiological stocks,
excreta, and items soiled with blood or body fluids.

Municipal waste is general waste that is generated mainly by households, commercial

activities, and street-sweeping. Ideally, it is collected by municipalities (e.g., local villages or
cities) but in some locations this service is not available.

Residence time is the time that it takes between the entry of a waste substance into a furnace or
incinerator and the exit of exhaust gases or burn-out residue from the furnace or incinerator.

Sanitary landfill is an engineering method used for disposing of solid waste on land in a
manner that protects the environment (e.g., by spreading the waste in thin layers, compacting it
to the smallest practical volume, and then covering it with soil at the end of each working day).

Sewerage is the system for the collection and transport of human excrement and accompanying
water used in toilet systems (sewage). The system includes conduits (channels) and pipes
(sewers), and pumping stations.

Sharps waste includes used or unused sharps (e.g., hypodermic, intravenous, or other needles,
auto-disable syringes, syringes with attached needles, infusion sets, scalpels, pipettes, knives,
blades, and broken glass).

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Standard Precautions are a set of infection control practices used for every patient encounter
to reduce the risk of transmission of blood-borne and other pathogens from both recognized and
unrecognized sources. They are the basic level of infection control practices to be used, at a
minimum, in preventing the spread of infectious agents to all individuals in the health care
facility.

Waste management includes all activities, administrative and operational (including

transportation activities), involved in the handling of waste: generation, collection, transport,
storage, and disposal of waste.

Waste segregation is the systematic separation of health care waste into designated categories
according to the type of composition and hazards, to enhance the safety and efficiency of waste
handling and disposal.

BACKGROUND
Health care waste, produced in the course of delivering health care, is potentially hazardous, and
effective management is critical to infection prevention and control in health care. A health care
facility is responsible for managing public health and protecting the environment with regard to
the waste produced. However, the waste management process (generation, collection, transport,
storage, and disposal) entails considerable complexity, involving clinical and non-clinical staff
across a facility, and often depends on outside agencies.

Managing waste remains particularly challenging for facilities in limited-resource settings. Lack
of organization, financial resources, training, segregation, equipment, locations for storage, access
to PPE, municipal support, and safe disposal locations have been identified as among the
challenges (Awodele et al. 2016; Caniato et al. 2016). In 2002, the World Health Organization
(WHO) completed an assessment of biomedical waste disposal in 22 low-and middle-income
countries and found that up to 64% of these countries‘ health care facilities did not use
recommended waste disposal methods (WHO 1999). Public interest in waste management
practices of health care facilities and the impact on climate and the environment continues to
grow. Knowledge of the potential for harm from health care waste continues to be relevant to
governments and communities. (WHO 2014).

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Risks from health care waste include exposure to pathogenic organisms, harmful chemicals,
toxins, or radioactive substances, and injury from sharp items. Anyone who comes into contact
with waste, both in the community and within the facility (HCWs, patients, visitors, laundry
workers, cleaners, porters, etc.) may be at risk. Exposure to toxic agents contained in health care
waste can cause skin, respiratory tract, and neurological conditions. Recommendations for
reducing the risk from injury and infection are described in this chapter.

Infectious health care waste includes waste that has the potential for causing infection. HCWs can
be infected when they are exposed to waste through a skin puncture, broken skin, splashes into the
mouth or eyes, inhalation, or ingestion. Infectious conditions potentially transmitted from health
care waste include gastrointestinal conditions (i.e., diarrhea and vomiting), respiratory conditions,
skin and eye infections, meningitis, blood borne virus infections (e.g., HIV, hepatitis B and C),
and hemorrhagic fever—including Ebola Virus Disease.

Standard Precautions protect HCWs from the risks of handling infectious waste at each point
throughout the waste management process. All waste should be handled using Standard
Precautions (see Volume 1, Chapter 3, Standard and Transmission-Based Precautions) and waste
that includes any items potentially contaminated with blood and body fluids should be managed as
infectious waste.

Applying infection prevention and control recommendations to all aspects of waste handling
(generation, collection, transport, storage, and disposal) minimizes the risks to human health and
the environment.

Categories of Health Care Wastes

Categorizing the waste produced in health care facilities is a useful method of understand the
handling and disposal requirements for each type of waste.

Approximately 75–90% of the general waste produced by health care facilities is non-
contaminated and poses no risk of infection for those who handle it. Similar in nature to municipal
waste, all or most general waste can be discarded in dumps or landfills or burned in incinerators.
(WHO 2014)

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Infectious waste from health care facilities must be handled and disposed of properly because they
may carry microorganisms that have the potential to infect individuals who come in contact with
them.

There are other types of waste generated in health care facilities that do not contain infectious
agents but are considered hazardous because of the potential harm they can cause to the
environment. See Table 10.0.1 for details of various categories of waste generated by health care
facilities, as defined by WHO.

Table 10.0-1 Categories of Waste Generated by Health Care Facilities

Waste Category Descriptions and Examples

Non-Hazardous Health Care Waste
General waste Waste that does not pose any particular biological, chemical, radioactive, or physical hazard
(e.g., paper boxes, newspapers and magazines, polyethylene bottles, polyester bags, wood,
other papers, metals [e.g., aluminum cans and containers], high-density polyethylene [e.g.,
milk containers, saline bottles], glass, and construction/demolition materials).
Hazardous Health Care Waste
Sharps waste Used or unused sharps (e.g., hypodermic, intravenous, or other needles, auto-disable
syringes, syringes with attached needles, infusion sets, scalpels, pipettes, knives, blades, and
broken glass).
Infectious waste Infectious waste is waste that is potentially contaminated with blood, body fluids, or
pathogenic organisms, including, but not limited to, laboratory cultures, microbiological
stocks, excreta, and items soiled with blood or body fluids.
Pathological waste Waste that contains human tissues or fluids, organs, body parts, fetuses, and unused blood
products.
Pharmaceutical Pharmaceuticals that are expired or no longer needed and items contaminated by or
waste containing pharmaceuticals.

Cytotoxic waste Cytotoxic waste contains by-products of drugs that kill dividing cells, which are used for
treatment of certain cancers. It also includes waste materials that can damage human genes
(e.g., DNA) and may cause cancers or congenital deformities among babies. This waste can
include sharps, PPE, and body fluid exposed to the drugs.
Chemical waste Waste containing chemical substances (e.g., laboratory reagents, film developer);
disinfectants that are expired or no longer needed; solvents; and waste with a high content
of heavy metals (e.g., batteries, broken thermometers, and blood pressure gauges).
Radioactive waste Waste containing radioactive substances (e.g., unused liquids from radiotherapy or
laboratory research; contaminated glassware, packages, or absorbent paper; urine and
excreta from patients treated or tested with unsealed radionuclides; and sealed sources—
containers in which radioactive substances are stored and sealed).
Adapted from: World Health Organization (WHO). 2013. Safe Management of Wastes from Health-Care Activities,
2nd ed. page 4. WHO: Geneva, Switzerland.
http://apps.who.int/iris/bitstream/10665/85349/1/9789241548564_eng.pdf?ua=1.

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Sources of Health Care Wastes
The types and amount of health care waste generated in a health care facility depend upon the size
of the facility as well as the range of services provided. The larger the facility (e.g., university
hospital, regional hospital) and the more services provided (e.g., tertiary health care facility with a
trauma center, cancer treatment department), the more waste is produced and the greater variety of
waste generated. Table10.0.2 provides examples of health care waste from different sources in
health care facilities.

Table 10.0-2 Health Care Wastes from Different Sources in a Health Care Facility

Location Sharps Infectious and Chemical, Non-Hazardous or

Pathological Waste Pharmaceutical, General Waste
and Cytotoxic
Waste
Major Sources
Medical ward Hypodermic needles, Dressings, bandages, Broken Packaging, food
IV set needles, gauze and cotton thermometers, blood scraps, paper,
broken vials, and contaminated with pressure gauges, flowers, empty saline
ampoules blood or body fluids; spilled drugs, and bottles, non-bloody
gloves and masks spent disinfectants diapers, non-bloody
contaminated with intravenous tubing
blood or body fluids and bags
Operating theater Needles, intravenous Blood and other Used disinfectants Packaging,
sets, scalpels, blades, body fluids, suction and waste anesthetic uncontaminated
and saws canisters, gowns, gases gowns, gloves,
gloves, masks, gauze masks, hats, and
and other waste shoe covers
contaminated with
blood and body
fluids, tissues,
organs, fetuses, body
parts
Laboratory Needles, broken Blood and body Fixatives, formalin, Packaging, paper,
glass, petri dishes, fluids, xylene, toluene, and plastic
slides and cover microbiological methanol, methylene containers
slips, and broken cultures and stocks, chloride and other
pipettes tissue, infected solvents, and broken
animal carcasses, lab thermometers
tubes and containers
contaminated with
blood or body fluids
Pharmacy store Expired drugs, Packaging materials
spilled drugs and empty containers

Radiology Silver, fixing and Packaging materials

developing solutions,

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 acetic acid, and
glutaraldehyde
Chemotherapy Needles and syringes Bulk Packaging materials
chemotherapeutic
waste, vials, gloves
and other material
contaminated with
cytotoxic agents, and
contaminated excreta
and urine
Vaccination Needles and syringes Bulk vaccine waste, Packaging materials
campaigns vials, and gloves
Environmental Broken glass Disinfectants, Packaging, flowers,
services cleaners, spilled newspapers,
mercury, and magazines,
pesticides cardboard, plastic,
glass containers,
yard and plant waste
Engineering Cleaning solvents, Packaging,
oils, lubricants, construction or
thinners, asbestos, demolition waste,
broken mercury wood, and metal
devices, and batteries
Food services Leftovers, food
scraps, plastic and
paper packaging, and
containers
Minor Sources
Physician office Needles and Cotton, gauze, Broken Packaging, papers,
(Outpatient syringes, broken dressings, gloves, thermometers and newspapers,
department) ampoules, and vials masks, and other blood pressure magazines,
materials gauges, expired uncontaminated
contaminated with drugs, and used gloves, and masks
blood and other body disinfectants
fluids
Source: World Health Organization (WHO). 2014. Safe Management of Wastes from Health-Care Activities, 2nd
ed., page 12. WHO: Geneva, Switzerland.

http://apps.who.int/iris/bitstream/10665/85349/1/9789241548564_eng.pdf?ua=1.

Management of Health Care Waste

Reduction of Health Care Waste

The preferred strategies for reducing health care waste are to minimize waste generation by
preventing waste production, reducing waste production, reusing and recycling waste, and

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recovering useful substances from waste. The least preferable strategy is treating and disposing of
health care waste.

Health care facilities can take several steps to minimize waste, including monitoring the
consumption of hazardous substances and chemicals. Purchasing supplies with minimal packaging
and using reusable medical devices, where feasible, are other ways to minimize health care waste.
In addition, recycling waste when technologies are available will help minimize waste.

Chemical waste minimization options include:

 Using less toxic, environmentally friendly chemicals

 Using minimum concentrations when possible
 Ensuring good inventory control
 Designing proper storage areas
 Developing spill prevention and clean-up procedures
(WHO 2014)

Segregation of Waste at Point of Generation

While general waste is the least expensive and easiest to dispose of, infectious and hazardous
waste, which makes up 15% of waste, is more expensive and risky to handle. When general waste
is mixed with infectious or hazardous waste, the cross‐contamination is introduced and all the
resulting waste must be treated as infectious and hazardous.

Mixed waste occurs when wastes are not properly separated at the point of generation or are
mixed during any part of the waste management process. Segregation at the point of waste
generation will reduce the amount of waste that the facility must treat as infectious or hazardous
and is a key strategy for improving waste management at health care facilities.

Note:

Training HCWs and having conveniently placed sharps containers close to where
sharps are used will help eliminate problems with improper disposal.

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Use the following guidelines when disposing of infectious and general waste at the point of
generation in all types of health care facilities:

 The HCW who generates the waste should segregate it where it is generated (e.g., before
leaving a patient‘s room, examination room, operating theater, or laboratory).
 The waste should be separated into the local or WHO categories (based on its potential
hazard and final disposal method).
 Separating wastes by hand after generation puts HCWs at risk and should not be
allowed.
 Deposit infectious waste in a labeled or color-coded, leak-proof, puncture-resistant
container.
 Use leak-proof (plastic or galvanized metal) containers with tight-fitting covers for
contaminated and hazardous wastes to protect patients and HCWs.
 Where available and feasible, use sturdy plastic bags/bin liners inside of the waste
collection containers to assist with waste collection and transport. Do not re-use plastic
bags or bin liners.
 Use puncture-resistant sharps containers for all disposable sharps (e.g., sharps that will
not be reused).
Methods to encourage waste segregation include:
 Employ a ―Three-Bin System‖ to segregate waste into separate bins for general, non-
hazardous wastes, infectious waste, and sharps
 Use standardized, colored plastic bags (if available) or colored waste containers or
standardized, clearly labeled containers to alert HCWs to the contents of the containers.
 Place waste containers and sharps containers at or close to the point of waste generation
so waste and sharps can be placed directly into the container.

Note: The sharps container should be placed at the point of use so that HCWs do
not have to carry sharp items.

 Utilize tools such as a kidney dish or bowl to separate waste and transport it safely from
the point of waste generation to waste containers when waste containers and sharps

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 containers cannot be placed close to the point of waste generation (see Volume 1,
Chapter 13, Sharps Injuries and Management of Exposure to Blood-borne Pathogens).

 Train HCWs on the importance, categories, and methods of waste segregation.

Note: it is important to train all HCWs, including clinicians and cleaning staff,
and patients to keep infectious and non-infectious waste separate.

 Use workplace reminders (posters, signs) to remind staff how to segregate waste.
 Talk with HCWs, in each area of the facility, about the barriers to segregation in their
departments since these will vary widely according to the types of tasks performed and
the workflow.
(WHO 2014)

Table 10.0-3 WHO‟s Recommendation for Waste Segregation

Type of Waste Color of Container and Markings Type of Container
Highly infectious waste Yellow, marked ―highly infectious‖ Strong, leak-proof plastic bag or
with biohazard symbol container capable of being
autoclaved

Other infectious waste, (includes Yellow with biohazard symbol Leak-proof plastic bag or container
all pathological waste)

Sharps Yellow, marked ―SHARPS‖ with Puncture-proof container

biohazard symbol

Chemical and pharmaceutical Brown, labeled with appropriate Plastic bag or rigid container
waste hazard symbol

Radioactive waste Labeled with radiation symbol Lead box

General health care waste Black Plastic bag or container

Source: World Health Organization (WHO). 2014. Safe Management of Wastes from Health-Care Activities, 2nd ed.,
page 79. WHO: Geneva, Switzerland.

http://apps.who.int/iris/bitstream/10665/85349/1/9789241548564_eng.pdf?ua=1.

After segregation in patient care areas, separation during collection, transport, and storage of
waste must be maintained to obtain any benefit. All HCWs, including cleaners, porters, and those
collecting, transporting, storing, and disposing of the waste, must be educated about the
importance of segregation.

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In addition, use symbols to indicate the different categories of infectious and hazardous waste (see
Figure 10.0.4).

Biohazard Radiation Chemical Corrosive

Highly Flammable Chemical Toxic Chemical Explosive Chemical

Figure 10.0-1 Hazardous Waste Symbols for Health Care Facilities

Collection and Transportation of Waste in Health Care Facilities

To manage waste in health care facilities and ensure timely and safe disposal, waste collection and
transportation systems should be developed using the following criteria:

 Waste collection routes should be carefully planned and drawn out, taking into
consideration the principle of collecting from least to most infectious waste (e.g., the
laboratory would be last on a collection route).

Note: Waste bags and sharps containers should NOT be filled more than three-
quarters full.

 Waste collection timetables for each route should be carefully planned according to the
waste generation patterns of the various departments. For example, operating theaters,

246
 labor and delivery areas, laboratories, and outpatient clinics may generate more waste at
different times than other areas and require more frequent collection schedules.

Note:

 Never use hands to compress waste into containers.

 Hold plastic bags at the top.
 Keep bags from touching or brushing against the body while lifting or during
transport.

 Collect waste on a regular basis such as daily or sooner if needed according to the rate it is
generated and the size of the waste containers. Waste bags and sharps containers should
NOT be filled more than three-quarters full.
 Staff should be trained to understand risks and safety procedures for handling waste:
o Do not mix infectious/hazardous and general waste during collection or transport.
o Collect and transport infectious waste to disposal sites in leak-proof, covered,
contaminated-waste containers.
o Do not use equipment (e.g., wheelbarrow, trolley/cart) that is used to hold and
transport wastes for any other purpose in the health care facility.
o Use PPE when handling wastes.

Steps for collection and transport of solid infectious wastes:

STEP 1 Wear heavy-duty or utility gloves and closed-toe shoes when handling and transporting
all waste.

STEP 2 Collect waste containers and transport to the storage area or treatment area for final
disposal.

STEP 3 Clean infectious-waste containers each time they are emptied using soap/detergent and
water, disinfect with a low- to intermediate-level disinfectant, and allow to dry before
reuse. Clean non-contaminated-waste containers at least once a week or when visibly
soiled.

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STEP 4 Remove utility gloves and perform hand hygiene after handling wastes.

STEP 5 Wash and dry gloves (see Volume 1, Chapter 9: Environmental Cleaning).

When using plastic bags/bin liners:

 Tie bags securely to provide a barrier between the waste and the HCW.
 Label bags with the date and type of waste in them.
 Do not shake or squeeze bags in an attempt to reduce volume when sealing them.
 Carry sealed bags at the top (i.e. by their necks) to the transportation trolley/cart/bin.
 Do not lift or hold bags by the bottoms or sides.
 Carry bags away from the body.
 Ensure that bags are not broken, opened, or dropped.
 Do not throw bags.
When bags/bin liners are not available:

 Use waste containers with lids.

 Clearly identify the containers by appropriate color/labeling, for example, ―pathological
waste,‖ ―infectious waste,‖ and ―general municipal waste.‖
(WHO 2014)

Steps for collection and transport of sharps containers:

STEP 1 Wear heavy-duty utility gloves closed-toe shoes.

STEP 2 Pick up the sharps container from the clinical area—ensure that the container is closed
tightly so no sharps are spilled during transport.

STEP 3 Place the container in the designated part of the storage area when it is ready for
disposal.

STEP 4 Remove utility gloves and perform hand hygiene after handling waste.

STEP 5 Wash and dry gloves (see Volume 1, Chapter 9: Environmental Cleaning).

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Storage of Waste in Health Care Facilities

Waste storage areas in the health care facility should be kept clean, organized, protected from
pests and the public (children or scavengers), and well-shaded to reduce heat buildup).
Recommendations for waste storage areas include:

 An easy-to-clean, hard floor with good drainage

 Separate areas for infectious and general waste
 Separate cabinets to store pharmaceutical and other toxic wastes
 A good water supply with a sink for hand hygiene
 Regular cleaning
 Identification (signs) as a ―waste storage area‖
 Lockable door/gate.

Disposal of Health Care Waste

Recommended Waste Disposal Methods

Countries committed to minimizing the level of dangerous, cancer-causing chemicals (e.g., dioxin
and furans) in groundwater can adopt recommended approaches for waste treatment/dips.
However, meeting current guidelines may be challenging for facility in resource-limited settings.
Waste minimization to limit the volume of hazardous waste produced and waste segregation to
minimize the proportion of the total waste that is infectious/hazardous are key waste management
measures in all settings. Choosing the best currently available waste disposal method and working
towards safer waste disposal to protect the community and the environment is essential. Table
10.0.5 summarizes options for waste treatment that health care facilities can choose based on
available resources and the volume and types of waste generated. (WHO 2014)

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 Table 10.0-4 Methods for Treating Health Care Waste

Method Brief Description

Non-Burn Methods

Non-Infectious Waste

Thermal processes Use of heat to destroy microorganism in the waste

Chemical processes Disinfectants (e.g., chlorine dioxide, sodium hypochlorite, peracetic

acid, lime solution, ozone gas, dry inorganic compounds) used to treat
waste

Irradiation technologies Irradiation from electron beams, cobalt-60, or ultraviolet sources to

destroy microorganisms

Biological processes Use of natural living organisms to degrade organic matter (e.g.,
composting of kitchen wastes)

Mechanical processes Grinding, mixing, and compacting to reduce waste volume and to
supplement other health care waste processes (e.g., after waste
disinfection)

Infectious Waste

Autoclaving Use of high-pressure steam to kill microorganisms in infectious waste

and sterilize medical instruments

Integrated, steam-based treatment A continuous flow system that uses mechanical processes before,
during, and/or after steam-based processes (similar to autoclaving)
that transfers heat to the waste, making the waste unrecognizable

Microwave technologies Steam-based system that uses moist heat and steam generated by
microwave energy

Dry-heat treatment Dry-heat system that heats waste by conduction, natural or forced
convection, or thermal radiation

Chemical treatment Chemical disinfection for treating liquid waste (e.g., blood and body
fluids); solid waste should be shredded or mixed before it is
chemically disinfected

Burn Technologies

Incineration High-temperature, dry oxidation (1,200°C [2,192°F) process that

reduces organic and combustible waste to inorganic and incombustible
material using combustion, pyrolysis, or gasification

Other Methods

Encapsulation Filling containers (e.g., high-density polyethylene or metallic drums)

with three-quarters waste and then one-quarter medium substance
(e.g., plastic foam, bituminous sand, cement mortar, or clay material)
and sealing container to be disposed of in landfill site

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Inertization Mixing of waste (e.g., pharmaceutical and high-metal content ashes)
with cement and other substances before disposal to reduce the risk of
toxic substances leaching into surface and groundwater

Land disposal Removal of health care waste materials after minimization or

treatment to land sites (e.g., controlled landfills) for final disposal

Municipal and other external disposal sites Landfill or waste site operated in a controlled manner for municipal
waste, whether treated or untreated waste, based on municipal
guidelines

Adapted from: WHO 2014.

The following waste treatment methods are not recommended and should be avoided:

 Open piles of waste, because they:

o Are a risk to those who scavenge and unknowingly reuse contaminated items
o Allow persons to accidentally step on sharp items and injure themselves
o Produce foul odors
o Attract insects and animals
o Can scatter in the wind and rain

 Open burning, because:

o It is dangerous.
o Temperatures reached are not adequate to treat health care waste.
o It is unsightly.
o The smoke is a pollutant.
o The wind can scatter the waste.

Specific steps are required for disposing of different categories of waste. Infectious and hazardous
waste should be treated prior to final disposal. Figure 10.0.1 shows the acceptable methods of
waste disposal. See Appendix 1-10-1 Methods of Waste Disposal for Low-Resource Settings for
details.

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Figure 10.0-2:Practical Classification of Hospital Wastes and Methods of Disposal
Source: WHO. Practical Guidelines for Infection Control for Health Care Facilities, page 25. URL:
http://www.wpro.who.int/publications/docs/practical_guidelines_infection_control.pdf. WHO/South East Asia
Regional Office 2004. All rights reserved.

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Disposal of Solid Infectious Waste

Solid infectious waste consists of those items defined in national guidelines. Items such as
surgical specimens and those soaked with blood or body fluids are included. The method of
disposal for these items depends upon the type of material from which they are constructed. See
the sections on incineration, autoclaving, or burying in Appendix 1-10-1, Methods of Waste
Disposal for Low-Resource Settings.

Disposable Sharps

Sharps (e.g., hypodermic needles, suture needles, razors, and scalpel blades—see national
guidelines for specific items) require special handling because they are the items most likely to
injure the HCWs who use them as well as people in the community if these items go to the
municipal landfill without proper treatment methods.

Treatment and disposal methods for sharps include:

 By autoclave, followed by shredding (mechanical), and then disposal in a landfill or sharps

pit
 By incineration (sharp objects may not be completely destroyed by incineration, but it does
make them less likely to be reused or repurposed and less risky to handle) and disposal in an
ash pit
 By shredding (mechanical) and disposal in a sharps pit (there is a risk of exposure to staff
handling non-decontaminated sharps)
 If other treatment options are not available, small quantities of sharps waste can be
encapsulated and disposed of in a landfill.

Disposal of liquid infectious waste

Liquid infectious waste includes liquid culture media, blood, body fluids, and human excreta.
Products that can be added to liquid waste to solidify it for safer handling may be available.

Steps for proper handling of liquid infectious waste in volumes greater than 20 mL:

253
STEP 1 Put on PPE (utility gloves, face protection, long-sleeved, fluid-resistant gown, and
plastic apron, protective shoes) (see Chapter 5, Personal Protective Equipment) when
handling liquid wastes.

STEP 2 Determine if wastes require pre-treatment before disposal. Blood and other infectious
agents from laboratory work should be sterilized by steam sterilization at the earliest
stage (i.e., inside the health care facility) prior to disposal, if possible (see the
Recommended Waste Treatment Methods section in this chapter).

STEP 3 Carefully pour liquid wastes down a utility sink drain or into a flushable toilet and
thoroughly rinse with water to remove residual wastes. Clean and disinfect the
surfaces (e.g., toilet or sink) to remove residual wastes using 1.0% chlorine solution
and avoid splashing the chlorine solution. If a sewerage system does not exist,
dispose of liquids using incineration or burial and not into open drains.

STEP 4 Wash the container that held the waste with detergent and water, disinfect using
intermediate- or low-level disinfectant, and dry completely before storing and using.
(See Volume 1, Chapter 9 Environmental Cleaning, Volume 2, Section 3, Chapter 3:
Clinical Laboratory Biosafety.)

STEP 5 Remove PPE.

STEP 6 Perform hand hygiene.

(WHO 2014)

Disposal of Liquid Waste from Highly Infectious Diseases

During outbreaks of cholera and viral hemorrhagic fever such as Ebola Virus Disease, health care
facility sewage must be treated and disinfected. Vibrio cholerae, the causative agent of cholera,
and Ebola virus are easily killed and do not require use of strong disinfectants. Chlorine solutions
are not effective in disinfecting liquids with high organic content, such as blood and stool.
Therefore, in situations such as a cholera and outbreaks of viral hemorrhagic fever, feces and
vomit should be mixed with lime milk (calcium oxide) dry powder in a ratio of 1:2 for a minimum
of 6 hours of contact before disposing. Urine can be mixed with a 1:1 ratio with 2 hours of
minimum contact before disposing. (WHO 2014)

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Disposal of Pathological Waste

Pathological waste consists of tissues, organs, body parts, placentas, blood, body fluids, and other
waste from surgery and autopsy. It also includes human fetuses. It is sometimes referred to as
anatomical waste. Containers with pathological waste should be appropriately labeled using
recommended labeling for infectious waste.

Traditional options for disposal of pathological wastes:

 Burying in cemeteries or special burial sites

 Burning in crematoria or specially designed incinerators
 Placenta pit

Steps for using a Placenta Pit

Construct a placenta pit and dispose of placentas in the pit (see Figure 10-10 in Appendix 1-10-1
Methods of Waste Disposal for Low-Resource Settings for details.)

 Open the cover of the pit and dispose of placentas and other organic waste into the pit as
soon as possible without adding any disinfection to allow appropriate biodegradation to
kill microorganisms and other cells.
 Keep the opening of the pit covered with a heavy lid or a concrete slab.
 Close the pit once it is filled up to 0.5 meter below the underneath slab. Keep it closed for
2 years.

The contents of the pit can be safely removed and disposed of in a sanitary landfill and the pit can
be used again.

If a placenta pit is not available, for example, in areas with high water table, the option is to
incinerate or bury the pathological waste in a burial pit. Never leave pathological waste out in the
open.

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Other Hazardous Wastes

Chemical waste

Chemical waste includes residues of chemicals in their packaging, outdated or decomposed

chemicals, or chemicals that are no longer required. Small quantities of chemical waste are
generally collected in containers with infectious waste and can be incinerated, encapsulated, or
buried. Large quantities of chemical waste should not be collected with infectious waste. Since
there is no safe and inexpensive method for the disposal of chemical waste, the following options
are recommended:

 Return the chemical waste to the original supplier. This is the best option for the
disposal of specific chemical waste.

 Incinerate at a high temperature.

Because these chemical waste disposal methods can be expensive and may be impractical, it is
important to keep chemical waste to a minimum. (See the Reduction of Health Care Waste section
in this chapter.)

Note: Different types of chemical waste should never be mixed. Chemical waste
should not be disposed of in a sewer system.

Chemical containers
For plastic containers that held toxic substances such as glutaraldehyde (e.g., Cidex) or
formaldehyde, rinse three times (dispose of rinse water as chemical waste) with water and dispose
of by burning, encapsulating, or burying. Do not reuse these containers for other purposes.

Wear proper PPE to protect eyes and skin from splashes and rinse glass containers thoroughly
with water. Glass containers may be washed with soap, rinsed, and reused.

Pharmaceutical waste

Small quantities of non-hazardous pharmaceutical (drugs or medicines) waste are usually

incinerated, encapsulated, or safely buried. Examples of non-hazardous pharmaceutical waste
include vitamins, salts and amino acids (ampoules and fluids), solid or semi-solid tablets,
granules, powders, creams, gels, lotions and suppositories, and aerosols (e.g., sprays and inhalers).

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All controlled substances, cytotoxic/genotoxic drugs, anti-infective/antibiotic drugs, and
disinfectants and antiseptics are considered hazardous waste (WHO 2014). It should be noted that
temperatures reached in a single-chamber drum or brick incinerator may be insufficient to totally
destroy pharmaceuticals and therefore they can remain hazardous.

Options for disposal of small quantities of pharmaceutical waste, such as outdated drugs (except
cytotoxic drugs and antibiotics), include the following:

 Return of expired pharmaceuticals to the donor or manufacturer

 Encapsulation and burial in a sanitary landfill
 Chemical decomposition as per manufacturers‘ recommendations

For moderate quantities of relatively mild liquid (e.g., vitamin solutions, cough syrups,
intravenous solutions, eye drops)—dilute in large amounts of water and discharge into a sewer.
Antibiotics or cytotoxic drugs should not be discharged into municipal sewers or watercourses.

Large quantities of pharmaceutical waste may be disposed of by the following methods:

 Water-soluble, relatively mild pharmaceutical mixtures (e.g., vitamin solutions, cough

syrups, intravenous solutions, eye drops) may be diluted in large amounts of water and
then discharged into sanitation systems.
 Pharmaceutical waste can be returned to the original supplier if possible.
 Cytotoxic drugs and antibiotics may be incinerated; the residues (i.e., what is left over
after the wastes have been incinerated) can go into a landfill. An incinerator that is
capable of reaching a combustion temperature of at least 1,200°C (2,192°F) should be
used. Temperatures below 1,200°C may release cytotoxic vapors.
 Residues from cytotoxic drugs or other cytotoxic waste should never be mixed with
other pharmaceutical waste.
 Cytotoxic waste should never be discharged into natural water sources (rivers, lakes,
etc.) or landfills.
 If the above options are not available, cytotoxic substances may be encapsulated.

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Waste with a High content of Heavy Metals

Examples of wastes with heavy metal content include batteries that contain cadmium,
thermometers, and blood pressure machines containing mercury. Mercury is a potent neurotoxin,
especially during fetal and infant development. When released into water or air, mercury will
enter the environment and contaminate lakes, rivers, and streams. To minimize the risk of mercury
pollution, mercury-containing products (e.g., thermometers and blood pressure equipment) should
be replaced with those that do not contain mercury.

Waste with high content of heavy metals should not be incinerated because of the toxic metallic
vapors released in the air nor should it be buried without encapsulation (i.e., placed in a closed,
tight container) because it may pollute groundwater. Usually, health care facilities have small
amounts of this type of waste. Disposal options include:

 Recycling—the best disposal solution, if available.

 Encapsulation, if recycling is not feasible—encapsulated waste may be disposed of in a
landfill.

Note: Do not touch mercury droplets with your hands unless wearing non-sterile
or utility gloves.

Steps for disposal of mercury:

STEP 1 Put non-sterile gloves on both hands.

STEP 2 Collect all droplets of mercury with a spoon.

STEP 3 Place mercury in a small, plastic container with a tight-fitting lid and send it to the
manufacturer. If this is not possible, encapsulate mercury before final disposal in a
landfill.

The procedure for final disposal of mercury is very complex and requires expertise. Stabilization
of mercury into an insoluble substance and use of an encapsulation approach are currently being
recommended for disposal of mercury.

See Appendix 1-10-1, Methods of Waste Disposal for Low-Resource Settings for details.

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Non-Recyclable Aerosol Containers

Pressurized containers should never be burned or incinerated because of the risk of explosion.
Before aerosol containers are buried, any residual pressure should be released.

In summary, avoid buying or using chemical products that create difficult or expensive disposal
challenges, whenever possible. The ability of the health care facility to safely dispose of the
product after it is finished should be one of the considerations during product selection.

Summary
Health care waste is potentially hazardous. Health care facilities are responsible for
managing the waste they produce and appropriate management requires collective efforts of
various HCWs. However, waste management is complex and managing waste is challenging for
facilities in limited-resource settings. Guidelines for disposal of waste from health care facilities
set out by WHO in 2014 may not be immediately attainable by many facilities. Waste
minimization to limit the volume of hazardous waste produced and waste segregation to minimize
the proportion of the total waste that is infectious or hazardous are key waste management
measures in all settings. Choosing the best available waste disposal method and working towards
safer waste disposal to protect the community and the environment is essential. Effective waste
management will save resources, reduce costs, and prevent injuries and exposure to infectious
disease.

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Methods of Waste Disposal for Low-Resource Settings
Autoclaves

Autoclaves use low-heat, high-pressure steam to treat infectious wastes. They can treat a wide
range of health care wastes and consist of a metal vessel designed to withstand high pressures,
with a sealed door and pipes and valves through which steam is brought in and removed (Figure
1-10-7). Removal of air from the vessel is essential to ensure penetration of steam into the waste.
Since they must withstand repeated buildup and release of steam pressures, their construction
materials, engineering design, fabrication, accuracy of pressure and temperature sensors, and
testing must meet requirements to operate safely.

Autoclaves generate significantly fewer air pollutants than incinerators and other high-heat
thermal processes. However, waste must be properly segregated to prevent hazardous chemicals
from being autoclaved. Poorly segregated waste may emit low levels of alcohols, phenols,
formaldehyde, and other organic compounds in the air and pose health risks to the autoclave
operators and waste workers. Volatile and semi-volatile organic compounds, cytotoxic waste,
mercury, other hazardous chemical waste, and radioactive waste should not be treated in an
autoclave. Odors can also be a problem if ventilation is insufficient. The air that is removed must
be treated to prevent the release of pathogenic aerosols; this is usually done with a high-efficiency
particulate air (HEPA) filter or steam.

Treated waste from an autoclave will retain its physical appearance; shredders (though prone to
breakdowns) may reduce the volume 60–80%. Glass, plastic, and metal waste can be recycled
after it is sterilized.

The three common types of autoclaves are:

 Gravity-displacement autoclaves
 Pre-vacuum or high-vacuum autoclaves
 Pressure pulse autoclaves

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 Pressure Gauge Air Vacuum

Release Saf ety Filter

Valve Valve

Jacket

Auto clave Chamber

Charging
Door

Thermo couple
Steam Steam
Steam
Tr ap
Tr ap

Drain

Figure 10.0-3. Diagram of an Autoclave

Source: United Nations Development Programme (UNDP) Global Environment Facility (GEF) Training: Module
15 Non-Incineration Treatment and Disposal. http://www.gefmedwaste.org/trainings-overview.

Incineration of Waste

Incinerators can range from extremely sophisticated, high-temperature models to very basic units
that operate at much lower temperatures. Properly maintained and operated incinerators eliminate
microorganisms from waste and reduce the waste completely to ashes. When selecting an
incinerator, first analyze the needs of the health care facility and municipal or regional disposal
requirements. Factors to consider include infrastructure of the area, local resources to support
construction and operation, cost estimates, and environmental policies. (PATH 2010)

This section focuses on the selection, operation, and management of small-scale incinerators.

Design and types of incinerators

When performed properly, incineration is efficient and affordable. Important factors in an

incinerator design with regard to oxygen supplies are:

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 Air inlets must be the right size and in the correct location to allow for a good mixture of air
(oxygen) with the waste gases.
 The chimney diameter and length (minimum of 4 meters [13.1 feet]) must be carefully
designed (not too short and not too long) to control the air draft.
 The incinerator should be located away from objects such as buildings and trees.
 Ashes and other residues that build up and block the free passage of air (oxygen) must be
removed routinely. (PATH 2010)

There are four basic types of incinerators that are commonly used for treating waste:

 Double-chamber, high-temperature incinerators designed to burn infectious waste

 Single-chamber, high-temperature incinerators that are less expensive and are used when
double-chamber incinerators are not affordable
 Rotary kilns that operate at high temperatures and are used for destroying toxic, organic
constituents of hazardous waste and heat-resistant chemicals
 Drum or brick (clay) incinerators that operate at lower temperatures and are less effective
but can be made locally out of readily available materials

Note: Incinerators that meet specifications and are properly maintained and
operated eliminate microorganisms from waste and reduce the waste to ash.

Precautions

If resources are limited, the following precautions should be taken when considering incineration:

 Provide an effective system for waste reduction and segregation (separate by type of
waste).
 Use an engineer-designed incinerator with sufficient residence time and temperatures to
minimize incomplete combustion of products and premature failures.
 Place incinerators away from health care buildings, residential areas, or where food is
grown.
 Describe methods of operation clearly to achieve the desired combustion conditions and
emissions.
 Plan periodic maintenance to replace or repair defective components.

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Certain chemicals and waste products are highly combustible and should not be incinerated (see
Box 1-10-1).

Types of Wastes That Should Not Be Incinerated

 Plastics at low temperatures

 Large amounts of reactive chemical waste
 Pressurized gas containers (e.g., aerosol cans)
 Silver salts and photographic or radiographic wastes
 Plastics containing polyvinyl chloride (e.g., blood bags, IV tubing, or disposable
syringes)
 Waste with high mercury or cadmium content (e.g., broken thermometers, used
batteries, and lead-lined wooden panels)
 Radioactive materials
 Pharmaceuticals thermally stable in conditions below 1,200°C (2,192°F) (e.g., 5
fluorouracil) Source: WHO 2014

Small-scale incinerator for waste disposals

Ideally, a small-scale incinerator (see Figure10.0.8) should have the following characteristics:

 Has a minimum of two chambers

 Operates within a temperature range of 650–1,000°C (1,202–1,832°F)
 Has a minimum of 1-second smoke-residence time (i.e., amount of time that the gases
take to travel through the incinerator)
 Is corrosion-resistant

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 Figure 10.0-4. Standard Components of a Small-Scale Incinerator
Source: PATH 2010.

Encapsulation of Waste

Encapsulation is the process of mixing waste with cement or other substances before disposal.
This process is used to reduce the risk of injury to people, reduce access to scavengers, and
minimize the risk of toxic waste migrating into surface water or groundwater. Encapsulation is
primarily designed for safe disposal of sharps but can also be used for disposal of solid residues
from wastewater treatment, incinerator ash, or small quantities of heavy metals (e.g., mercury),
chemicals, and cytotoxic pharmaceuticals when they cannot be returned to the manufacturer. Hard
plastic boxes or metallic drums can be filled to three-quarters full and then topped with wet
cement or clay. After hardening, the containers can be sealed and disposed of safely in a landfill.
For waste containing small quantities of heavy metal, create a mixture of 65% waste material,
15% lime, 15% cement, and 5% water. This mixture is then poured into a container (e.g., plastic
or metal) and allowed to settle. Once it has completely dried, the container can be disposed of in a
landfill. (WHO 2014)

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Burying of Waste in Sanitary Landfills

In health care facilities with limited resources, short-term safe burial of wastes on or near the
facility may be the only option available for waste disposal. Safe onsite burial is practical for only
limited periods of time (1–2 years) and for relatively small quantities of waste. Burial can be used
as a method of waste disposal only where the water table is more than 4 meters (13.1 feet) below
the surface. During this interval, the health care facility should continue to look for better,
permanent methods for waste disposal.

Note: Large quantities (over 1 kg [2.2 pounds]) of chemical (liquid) wastes

should not be buried at the same time and burning of chemical waste should be
spread over several days.

Limit health risks and environmental pollution from burying health care wastes by:
 Restricting access to the disposal site—build a fence around the site to keep animals and
children away
 Lining the burial site with a material of low permeability (e.g., clay), if available
 Selecting a site at least 50 meters (164 feet) away from any water source to prevent
contamination of the water table

The site should:

 Have proper drainage

 Be located downhill from any wells
 Be free of standing water
 Not be in an area prone to flooding

How to Make and Use a Small Burial Site for Waste Disposal

STEP 1 Find an appropriate location.

STEP 2 Dig a pit 1 meter (3.2 feet) square and 2 meters (6.5 feet) deep. The bottom of the pit
should be 2 meters (6.5 feet) above the water table. Line the pit with clay or other low-
permeable material.

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STEP 3 Dispose of the infectious waste in the pit and cover the waste with 10–15 cm (4–6
inches) of dirt each day. The final layer of dirt should be 50–60 cm (20–24 inches) and
compacted to prevent odors and attraction of insects, and to keep animals from digging
up the buried waste. Depending on the volume of waste, this pit should last 30 to 60
days (see Figure 10.0.9). (WHO 2014)

Figure0-5. Plan for a Small Burial Pit

Source: WHO. 2014. Safe Management of Wastes from Health-Care Activities, 2nd ed. P 230. Geneva,
Switzerland: WHO. http://apps.who.int/iris/bitstream/10665/85349/1/9789241548564_eng.pdf?ua=1. All rights
reserved.

Placenta Pit
In many cultures, burying placentas is an important custom. In low-resource settings, a placenta
pit is an effective option for safe disposal. The site for a placenta pit should minimize public
accessibility and the size will depend upon the number of daily childbirths in a facility. On
average, one placenta and associated fluids require 5 liters (1.5 gallons) of pit capacity. Natural
degradation and draining of liquid into the subsoil greatly reduce the volume of waste in the pit
and facilitate the inactivation of pathogens. Small quantities of anatomical waste (e.g., body parts)
may also be disposed of in placenta pits, if other treatment options are not available or if
sociocultural or religious norms prohibit other forms of treatment.

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The pit should be designed to prevent contents from contaminating the groundwater (see Figure 1-
10-9). The bottom of the pit should be at least 1.5 meters (5 feet) above the level of the
groundwater. Placenta pits are not recommended in sites where the water table is near the surface
or in flood-prone areas. (WHO 2014)

Figure 10.0-6. Placenta Pit Plan

Source: WHO. Health Care Waste Management. Technology: Burial pit for organic waste. https://www.healthcare-
waste.org/resources/technologies/

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CHAPTER 11: FOOD AND WATER SAFETY
Key Topics:

Managing Water and Food Services

Water safety
Water Quality Monitoring and Surveillance
Prevention of Food and Water-Borne Diseases Occurrence Among patients hospitalized
in healthcare settings.

Definition of Key Terms

Clean water is natural or chemically treated and filtered water that is safe to drink and use for
other purposes (e.g., hand washing and general medical use) because it meets national public
health standards and/or the World Health Organization (WHO) guidelines for drinking-water
quality.

Contact time is the length of time a cleaning product must remain wet on the surface being
cleaned for the disinfectant to kill the targeted microorganisms. Time of contact varies depending
on the type of cleaning product and the targeted microorganism (e.g., bacteria, viruses,
mycobacteria, spores). For use in health care facilities, the contact time for the organism that is
most difficult to kill is routinely adopted.

Detergent (term is used interchangeably with soap) is a cleaning product (e.g., bar, liquid, leaflet,
or powder) that lowers surface tension of water, thereby helping to remove dirt and debris. Plain
soaps do not claim to be antimicrobial on their label and require friction (i.e., scrubbing) to
mechanically remove microorganisms. Antiseptic (antimicrobial) soaps do kill or inhibit growth
of some microorganisms but not all.

Disinfectant is a chemical that destroys or inactivates microorganisms on inanimate (non-living)

objects. Disinfectants are classified as low-, intermediate-, or high-level depending on their
ability to kill or inactivate some (low- or intermediate-level) or all (high-level) microorganisms.
While disinfectants may kill all microorganisms, they do not kill all spores. Commonly used
disinfectants for low-, intermediate-level cleaning include phenols, chlorine or chlorine-

268
containing compounds, and quaternary ammonium compounds (QUAT) and hydrogen peroxides
(H2O2). These classes of disinfectants are often used to clean frequently touched surfaces in
health care facilities.

Environmental cleaning, in health care facilities, refers to the general cleaning of surfaces and
equipment to reduce the number of microorganisms present and providing a clean and pleasant
atmosphere.

Foodborne or waterborne illness is any disease of an infectious or toxic nature caused by

ingestion of food or water.

Health care-associated diarrhea is diarrhea that begins on or after the third calendar day of
hospitalization (the day of hospital admission is Day 1).

Sanitizer is a chemical that reduces the number of bacterial contaminants on inanimate objects to
safe levels, based on public health requirements (e.g., a chemical that kills 99.999% of the
specific bacteria in 30 seconds under test conditions). They are used in food service but not for
cleaning surfaces in health care facilities.

Water based diseases: those transmitted through aquatic vectors (such as schistosomiasis)

Water borne diseases: those transmit through drinking water contamination (such as typhoid,
cholera, gastro-enteritis etc.)

Water related diseases: those spread by insects that depend on water (malaria and yellow fever)

Water washed disease: those diseases caused by the shortage of adequate water for personal
hygiene

BACKGROUND
Healthcare associated diarrhea is a common problem in hospitals, children‘s care facilities and
nursing homes (Lynch et al., 1997). Outbreaks in healthcare facilities among patient hospitalized
have mostly been associated with unsafe food and water. Variety of organisms including
Salmonella, Shigella, C.difficile, V. Cholera, C.albicans,Staph.aureus, cryptosporidium,
rotavirus and other enteroviruses are responsible for contamination of food and water. Factors

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that increase risk of water and food borne diseases in healthcare facilities include the fact that
they serve food for more hours, serve food for ill and immune-compromised patients, transporting
and distributing food at a greater distance and prepare nasogastric feeding and special diets. In
general, the staff are often transient, poorly trained in food handling and engage in unsafe
practices involving the storage, preparation and handling of raw meat, chicken, fish and fresh
eggs as well as some vegetables. Further, the quality of drinking water in countries with
limited resources is often poor and unsafe again contributing to poor quality food services hygiene
(scabies, and trachoma).

Managing Food and Water Services

Planning, implementing and monitoring food and water service in healthcare facilities are of
great value in preventing food and water contamination which at times leads to infection or
outbreaks among the hospitalized patients from such causes.

Principle of Food Safety

All activities in the food service department should be monitored regularly to be

sure that safety standards are being followed. These include:

 Temperature should be kept above 60oC/140oF or below 7oC/45oF. The temperature

pertinent for the right storage of food should be maintained and checked periodically. Warm
and perishable foods should be cooled while stored.

 Cooking should be complete and standardized. Besides, frozen food items should be
thawed before cooking to avoid the presence of cold spots in the interior.

 Personal Health and Hygiene of Food Service Staff this is of great importance and the
staff engaging in food service should be supervised by a knowledgeable person. Hand
hygiene plays crucial role in preventing healthcare associated diarrhea and other related
health problems. The staff should report any gastrointestinal problems or skin lesions
especially on hands. They need to know how to inspect properly; prepare and store the foods

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 they handle; how to clean and operate equipment they use such as slices; and blenders and
dishwashers if they are available and also management of wastes.

Food utensils should be washed with three compartment washing system.

These are washing, cleansing and sanitizing compartments.

Food Contamination

Food can be contaminated by the following three main hazard types:

• Physical hazards (foreign objects) – metal, wood, glass, plastic, etc.

• Chemical hazards – bleach, caustic soda, detergents, pesticides, etc.
• Microbiological – bacteria, viruses, moulds and parasites.

Food that is contaminated with any of these hazards is unsafe and unsuitable to eat.

Bacterial food poisoning

Bacteria are single-celled living micro-organisms. The most common form of food poisoning is
bacterial food poisoning. To survive and multiply, bacteria need; water, food, correct
temperatures, time, most but not all, need oxygen. Under these conditions, bacteria will multiply
by dividing in two every 10-20 minutes. After 6 hours, 1 bacterium can multiply into 262,144
bacteria, more than enough to cause food poisoning.

How do bacteria enter a food premises?

 Food handlers (especially their hands).

 Raw foods, such as meat, poultry, shellfish and vegetables.
 Pests and animals.
 Air and dust.
 Dirt and food waste.

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Potentially hazardous foods:

 Potentially hazardous foods support the growth of bacteria. They need to be kept at
temperatures either below 5°C or above 60°C to prevent the growth of any food
poisoning bacteria that may be present in the food.
 Examples of potentially hazardous foods include meat, poultry, seafood, eggs, dairy
foods, gravies and cooked rice.

Causes of food poisoning:-

1. Food at incorrect temperatures

Under ideal conditions, bacteria multiply rapidly between 5°C and 60°C (the danger zone for
food). Below 5°C, bacteria multiply slower. At freezing temperatures, bacteria stop
multiplying and become dormant. Freezing does not kill bacteria; most bacteria are killed at
temperatures above 60°C.

2. Cross-contamination

Cross-contamination occurs when food becomes contaminated with bacteria from another
source. Bacteria can be transported by hands, utensils, surfaces, equipment, tea towels, raw
food and pests. Common examples of cross contamination include unclean hands; dirty
knives; utensils; equipment and food contact surfaces (e.g chopping boards); blood dripping
from raw foods; storing raw food with cooked foods; storing food uncovered; and using dirty
cleaning cloths and tea towels.

3. Poor personal hygiene

Examples of poor personal hygiene include; Dirty hands and clothing, uncovered cuts and
wounds, long dirty fingernails, Excess jewellery on hands and wrists, Coughing and sneezing
over food, Handling food while ill, not washing hands after going to the toilet.

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4. Unclean food premises

Dirty kitchens increase the risk of cross-contamination from pests and particles of food, grease
and dirt.

5. Poor pest control - Common pests found in food premises includes:

Flies, Cockroaches, Rats and mice. These pests can carry food poisoning bacteria and may
also cause physical contamination of food with their droppings, eggs, fur and dead bodies.

Actions for Prevention of Food Poisoning

1. Temperature control

Minimise the time that potentially hazardous foods spend in the danger zone; always
remember to keep cold food cold at 5°C or colder and hot food hot at 60°C or hotter.

All food Health facilities are required to obtain and use a probe thermometer, accurate to +/-
1°C to monitor the temperature of potentially hazardous foods.

2. Avoid cross-contamination:– To avoid cross-contamination follow the following

Keep food covered until use, Practise correct personal hygiene, Separate raw and cooked, and
old and new food at all times, use separate equipment and utensils when preparing raw meats,
poultry and seafood, Clean and sanitise all equipment, utensils and food contact surfaces and
Store chemicals separate to food.

3. Personal hygiene – the following should be considered

Clean hands and clothing, minimise jewellery on hands and wrists, tie-back or cover hair,
Clean and short fingernails, avoid unnecessary contact with food, cover all cuts and sores with
a brightly coloured waterproof dressing, do not eat over food or food surfaces, do not prepare
food when you are ill, avoid touching your face and hair, do not cough or sneeze over food, do
not taste food with your fingers or ―double dip‖ with a spoon and if wearing gloves, change
frequently.

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 Proper Hand Washing

When should you wash your hands?

Before commencing or resuming work, after using the toilet, after smoking, after handling
rubbish, after using a handkerchief or tissue, after touching your hair or face, before and after
handling raw food, before handling cooked food and after any cleaning task.

Hand washing facilities - Must be accessible to all food handlers, to be used only for the
washing of hands, provide soap and warm portable water. Provide disposable towels for
drying hands. Provide a bin for the disposable towels.

4. Cleaning

Must be continuous and ongoing; thoroughly clean and sanitise all food surfaces, equipment
and utensils with hot water and detergent and chemicals (sanitisers). Remember that most
detergents do not kill bacteria, but hot water and sanitisers do! Implement a cleaning schedule
to ensure that cleaning is conducted on a regular basis (including hard reaching places).

Cleaning and sanitising with/without a dishwasher

 Wear rubber gloves to protect your hands from the hot water and chemicals.
 Remove food particles by scraping or soaking.
 Wash using hot water and detergent – change the water if it becomes cool or greasy.
 Rinse in hot water with chemical sanitiser or in very hot water (above 80°C - only if
sink has heating element and rinsing baskets) and leave to soak for 30 seconds.
 Either drip-dry or use a clean tea towel to reduce the risk of cross-contamination.

5. Pest Control

 Keep them out – seal the food premises.

 Starve them out – keep food premises clean.
 Throw them out – conduct regular pest inspections or services.
 Don‘t give them a home - remove all unnecessary equipment and items.
 Report all pest sightings or evidence of pest activity to your supervisor.

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6. Waste Management

 Place waste in plastic lined bins.

 Remove all waste from the premises as required.
 Empty and clean waste bins regularly.
 Ensure all external bins are covered.
 Protect external waste bin area from pests and birds.

Water Safety

The quality and quantity of drinking-water is a major determinant of health. The most
predominant waterborne disease, diarrhea, kills around 525 000 children under five each year.
Significant proportion of diarrheal disease can be prevented through safe drinking-water and
adequate sanitation and hygiene. Diarrhea is a leading cause of malnutrition in children under five
years old (WHO, 2017).

There are several variants of the feco-oral pathway of waterborne disease transmission. Infectious
diseases transmissions pathways through water supply are categorized into four:-

 Water borne diseases

 Water washed diseases
 Water based diseases
 Water related diseases

Drinking water quality and safety

Drinking-water should be suitable for human consumption and for all usual domestic purposes.
Drinking water contamination and chemical introduction can occur across the water supply chain.
These include contamination at the catchment areas and water sources (by human and animal
feces). Transmission can also result from contamination in the distribution system (through
―leaking‖ pipes, obsolete infrastructure, and inadequate treatment and storage) and unhygienic
handling of stored household water. Climate change can also affected the quality of drinking
water.

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Water Quality Parameters

Three categories of parameters for drinking DW: physical, chemical and bacteriological. A
national standard for drinking water quality was adapted from WHO recommendation.

Table 11.0-1 National standard for drinking water

Source: Compulsory Ethiopia drinking water Standard, 2013

Water Quality Monitoring and Surveillance

Drinking-water supply surveillance refers to ―continuous and vigilant public health assessment
and review of the safety and acceptability of drinking-water supplies‖ (WHO, 2011). It is a careful
watching and protecting of DW from possible contamination risks.

Four components of DWQS

 Sanitary inspection / survey – identify hazards

 Water quality monitoring/testing
 Data analysis, interpretation and reporting
 Remedial action

It includes institutional inspection, sanitary survey, continuous monitoring of physico-chemical

and microbiological parameters (laboratory or spot testing of water samples collected at different
locations, i.e. at source, pipe line, reservoirs and delivery points) and time, data processing,
evaluation followed by remedial action and preventive measures.

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Water Quality Monitoring

Improving and monitoring Water quality require strong and consistent monitoring mechanisms to
measure.

Progress and direct efforts where needs are greatest. Monitoring water quality at the facility level
is very important to early detect contaminants. Water containers and tankers should be cleaned
and disinfected regularly, and the water should be tested regularly.

Water Sampling Methods

Basically, there are two types of sampling methods:

 Probability and
 Non-probability

1. Probability Sampling methods:

Every unit of the population has an equal chance (probability) of being selected in the sample.
Methods includes

 Simple Random Sampling: A subset of a statistical population in which each member of

the subset has an equal probability of being chosen.
 Systematic Random Sampling: Systematic sampling is a statistical method involving the
selection of elements from an ordered sampling frame.
 Cluster Sampling: is a sampling technique used when "natural" but relatively
homogeneous groupings are evident in a statistical population.
 Stratified Random Sampling: is the process of dividing members of the population into
homogeneous subgroups before sampling.

2. Non-probability sampling: does not use random selection. Generalization of the findings is
not possible because the sample is not representative of population.

 Convenience Sampling: a sample population selected because it is readily available and

convenient.

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  Quota Sampling: population is first segmented into mutually exclusive sub-groups.
 Snowball Sampling: The first respondent refers a friend. The friend also refers a friend,
and so on.

Table 11.0-2 Sample Volume and Transportation Condition

Transport and
Sample type Amount required Stability
Storage

Chlorinated water 100 ml Water should be

sample collected to sterile
container with lid and
transported in an
insulated cold box as
soon as possible to
6 hrs
laboratory

Un chlorinated water 105 ml Water should be placed

sample in an insulated cold box
for transport to a water
testing

Sample De-chlorination

 When samples of chlorinated effluents are to be collected and tested, the sample
must be dechlorinated.
 Chlorine remaining in the sample can further disinfect the sample during any
holding time after sample collection.
 Since sterile sampling procedures must be followed for a valid bacteriological test,
the dechlorination steps cannot be performed after the sample is collected.
 Procedure for dechlorination
 Dechlorination of bacteriological samples is as follows:
 When the water to be examined is likely to contain chlorine or chloramines,
sufficient sodiumthiosulphate (Na2s2o3.5 H20) to neutralize this substance must be
added to each bottle as follows.
 Add 2-3 drops of sodiumthiosulphate to sample collection bottle
 Grams of Chemicals Required to Neutralize Residual Chlorine Concentrations
in 378,500 L of water.

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 Table 11.0-3 Sample De-chlorination

Sodium Thiosulfate Pentahydrate

Residual Chlorine Conc. (mg/L)
(Na2S2O3.5H2O)
0.3 181.44g

0.6 317.51g

0.9 498.95g

1 544.31g

1.3 725.75g

How to Collect Water Samples

 Samples should be collected in a non-reactive borosilicate glass plastic bottle or plastic

bag that has been cleaned, rinsed and sterilized
 105 ml for un-chlorinated and 100 ml for chlorinated water sample is the minimum
volume that should be taken as a sample to obtain reliable results, especially for
microbiological testing. More water should be collected than needed (i.e. 200 – 1000 ml)
in case if multiple tests are required.

Labeling of Water Sampling

Every sample container should have a label. The sample label has information about:

 Sample location,
 Sample description (e.g. inlet water, storage bucket water),
 ID number,
 Date and time,
 Name of the person collecting the sample,
 Test to be performed (optional)

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Sampling Tap water

 Remove any external fitting from the tap carefully clean and disinfect the inside and
outside of the tap.
 Clean carefully the outside nozzle of the tap ensures that any deposits in the pipes are
washed out.
 Turn the tap on full for one minute
 Sterilize the tap using the flame of blow lamp or gas of cotton wool soaked in alcohol
 Allow the tap to cool by running the water to waste for few seconds
 Fill the sample bottle from the gentile flow of water, and replace the cap of bottle
 Using water proof marker number the bottle with sample code

How to Transport Water Samples

 Bacteria do not generally survive well in water due to a variety of factors. It is well,
known that the numbers of bacteria within a water sample rapidly decline 24 hours after it
has been collected. Temperature can also affect die off within the water sample, with
higher temperatures leading to greater die offs.
 Samples should be collected and placed on ice in an insulated container if they cannot be
tested immediately; preferably held at <10 °C during transit. Samples should be tested the
same day and refrigerated overnight if necessary.
 If the time between collection and test exceeds 6 hours, the final report should include
information on the conditions and duration of sample transport. Samples exceeding 30
hours holding time (from collection to testing) should not be tested. Minimum sampling
frequency for drinking water in distribution system.

Table 11.0-4 Minimum sampling frequency for drinking water in distribution system.

Population served Sample to be taken monthly

Less than 5,000 1 sample

5,000-100,000 1 sample per 5,000 population

More than 100,000 1 sample per 10,000 population plus 10

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 more samples

Prevention of Food and Water-Borne Diseases Occurrence Among patients

hospitalized in healthcare settings

Educate or Assist the hospitalized patients and care takers should be trained and assisted on hand
washing during critical times (before preparing food, before eating, after toilet).

Medical Checkup of food handlers should be done quarterly. The check up for diseases
transmitted through contaminated food, water or air should be carried out on regular basis.
Cleanliness of the kitchen has to be done on daily basis monitored and verified in order to avoid
contamination of food during cooking.

Transportation and Storage of Row and Cooked Food purchased row food has to be
transported to the healthcare facilities with transportation free from biological and chemical
contaminants. Storage of row and cooked food should be separate and done in line with the
recommended temperature for each type of food to be stored (for example easily perishable and
cereals). In brief, the whole process including food handling has to be monitored daily. Food
items should not be shelved with other toxic materials like detergents, disinfectants, fuel, etc. If
there is no option rather than to shelf together, shelf food items at the top and other materials at
the bottom.

Water Safety Principle Identify the quality of water source used by the healthcare facility:
biological quality of the source (Total Coliform and E. coli count based on WHO guideline value
or country water quality standard if available). If it is feasible, examine the chemical quality as
well. Infected patients should be restricted from using communal baths

o Collection, Transportation, Storage and Handling of Water healthcare facilities has to

collect, transport, store and handle water with precaution to avoid risk of contamination
(i.e. use properly washed/sanitized container to collect and store water, separate container
for drinking and other purpose by clearly writing on the container which is for which.

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 o Making Water Collected from Unsafe Source Safe for hospitalized patients, water
boiled for 1 to 5 minutes is considered safe to drink while water boiled for 20 minutes is
labeled as high-level disinfected and hence even safer. Alternatively, water can be
disinfected and made safe for drinking by adding 3-5PPM based on the water quality and
the residual Cl2 should be 0.2-0.5 PPM. The formula for preparing 0.001% of Chlorine
solution is given in these guidelines.
o Monitoring/Inspection: the quality of water used by healthcare facilities including the
sources, collection, and storage should be inspected regularly. The microbial water quality
of the source should also be monitored quarterly.
o There are two types of sampling methods: probability and non-probability. When the
water to be examined is likely to contain chlorine or chloramines, sufficient sodium
thiosulphate (Na2S2O3.5H2O) to neutralize this substance must be added.

Summary

Factors that increase risk of water and food borne diseases in healthcare facilities include the fact
that they serve food for more hours, serve food for ill and immune-compromised patients,
transporting and distributing food at a greater distance and prepare nasogastric feeding and
special diets. In general, the staff are often transient, poorly trained in food handling and engage
in unsafe practices involving the storage, preparation and handling of raw meat, chicken, fish and
fresh eggs as well as some vegetables. Further, the quality of drinking water in countries with
limited resources is often poor and unsafe again contributing to poor quality food services.

Healthcare associated diarrhea is a common problem in hospitals, children‘s care facilities and
nursing homes. Outbreaks in healthcare facilities among patient hospitalized have mostly been
associated with unsafe food and water.

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CHAPTER 12: FACILITY DESIGN AND PATIENT FLOW
Key Topics

The significance of regulating traffic flow and defining activity patterns in health
facilities

Designing traffic flow and activity patterns in procedure rooms, instrument

processing and surgical areas.

The traffic flow requirements for different areas.

Definition of Key Terms

At point of use - equipment, instruments and supply items are at the place where needed (e.g.
sharps containers are placed within an arm‘s reach of where injections are being given).

Environmental Controls - standards specifying procedures to be followed on: the routine care,
cleaning and disinfection of environmental surfaces, beds, bedrails, bedside equipment and other
frequently touched surfaces.

Operating Room - is an area or space where surgical procedures are performed.

Surgical Unit - is a whole surgical area including: lockers and dressing rooms; preoperative and
recovery rooms; peripheral support areas including storage space for sterile and high-level
disinfected items; other consumable supplies and corridors leading to restricted areas; the
operating room(s), scrub sink areas and the nursing station.

Procedure areas - are areas where patients are examined and patient care procedures (e.g., pelvic
examinations, wound care management, blood drawing, immunizations, IUD insertions and
removals, and normal childbirth) are performed.

BACKGROUND
Regulating the flow of visitors, patients and the staff plays a central role in preventing disease
transmission in healthcare facilities. This is so for the number of microorganisms in a designated
area tends to be related to that of the number of people present and their activity. Microbial
contamination is found to be high in areas such as waiting rooms and places where soiled

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surgical instruments and other equipment are initially processed. Microbial contamination is
minimized by reducing the number of people coming to the area and defining the activities
taking place at each place.

An important objective of infection prevention and control is to minimize the level of microbial
contamination in areas where patient care and instrument processing take place. Such areas for
instrument processing include: procedure areas, surgical units, and work areas (where instruments
are processed).

These include dirty and clean areas where soiled instruments, equipment‘s and other items
are first cleaned and then processed and stored. It is important to direct activity patterns and
traffic flow in the above-mentioned areas to keep contaminated areas separate from areas where
procedures take place. The major areas are:

 Procedure areas - are settings where patients are examined and procedures (e.g. pelvic
examinations, wound care management, blood drawing, immunizations, IUD insertions
and removals, and normal childbirth) are carried out.

 Surgical units - are settings where major and minor operations are performed. The
surgical unit also includes preoperative and recovery rooms as well as several other areas.

 Work areas - are settings where instruments are being processed. These include dirty
and clean areas where soiled instruments, equipment and other items are first cleaned and
either high-level disinfected or sterilized and then stored.

It is important to direct activity patterns and traffic flow in these areas to keep contaminated
areas separate from areas where procedures take place. Activities such as waste disposal,
instrument processing and cleaning procedure areas should be carefully planned and organized to
minimize the risk of infection to patients and healthcare workers. Equally important, is designing
and implementing traffic flow patterns that prevent soiled instruments and other items from
coming across to the cleaned, high-level-disinfected or sterilized items. Traffic flow is also
related with separating people who have or are likely to have communicable diseases from those
who are at risk (susceptible). These people pose a great risk to susceptible patients and healthcare
workers simply by availing themselves in the same room; therefore, it is necessary to identify and
remove them quickly

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Facility Design, Space and Equipment Requirements

Healthcare facilities vary in the types of services they provide. For example, a rural clinic may
offer only a few procedures (e.g. IUD insertion and removal, immunizations, antenatal care and
minor surgery for suturing wounds). Larger facilities (including district and referral hospitals)
provide major and minor general surgical procedures, child delivery services in addition to
ambulatory procedures. Regardless of the size of the facility, the specific space and equipment
requirements to perform a particular procedure do not generally vary.

Microbial contamination can be substantial in highly trafficked areas and places where soiled
surgical instruments and other equipment are initially processed. Basic principles of facility
design, traffic flow, and work practices that can be applied to reduce microbial contamination
include:

 Designating appropriate traffic flow for patients, health care workers (HCWs), and
equipment to ensure safe separation between contaminated items and clean/sterile items.
 Developing policies and procedures that establish clear authority, responsibility, and
accountability to ensure that these safe practices are adopted and practiced.
 Regulating the flow of visitors, patients, and staff using signs (e.g., authorized personnel
only), reminders (e.g. red line on the floor), and physical barriers (e.g., closed doors). The
amount of traffic and the number of individuals present in a designated area and their
activities contribute to the number of microorganisms present in that area.
 Using work practices that prevent contaminated items from contacting clean items, such as
working from dirty to clean. This is especially important if separate spaces for dirty and
clean items are not available.
 Ensuring that all staff understand the policies and procedures, for example, through new
staff orientation and ongoing training, to guarantee safe handling of clean and soiled items.
 Ensuring appropriate ventilation of OTs, procedure areas, CSSDs, and instrument
processing areas.
 Using fans in facilities without mechanical ventilation to optimize existing ventilation. The
air should be drawn into the area and should be exhausted outside using one-way exhaust

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 fans. Where mechanical ventilation or fans are not available, the only option is to use
natural ventilation with open windows and doors fitted with mosquito nets.
 Designing new facilities and renovations with these principles in mind. For example,
health care facilities should have a dedicated central location where soiled instruments can
be reprocessed and that is physically separated from procedure areas.

In clinics where only minor procedures are performed, a procedure room with a hand washing
sink is required for examining clients and performing procedures. A separate room with at least
one sink for cleaning and an area for processing instruments and other items is also desirable
(Figure 12.0.1). Ideally, the processing area should include more than one room (e.g. a
dirty room for receiving dirty instruments and a clean room for final processing and storage). If
only a single room is available (Figure 12.0.1 a), soiled equipment should be received and
cleaned in an area of the room distant enough from areas where equipment is high-level
disinfected or sterilized and then stored.

Although the space requirements for performing various minor surgical procedures may not be
different, it may still be quite different to some extent depending on the classification of the
procedure (semi critical or critical), the instrument processing requirements (high-level
disinfection or sterilization). Inserting or removing an IUD, for example, is classified as a semi
critical procedure not normally sterile, or can be made so if necessary (Spaulding, 1968). In
contrast, inserting a laparoscope into the abdomen is classified as a critical procedure because
tissues that are normally sterile are being touched. For the former, either sterile or high-level
disinfected instruments are acceptable, but for the latter, the preferred final processing is
sterilization. To sum up, it should be noted that sterile metal instruments with laparoscopy, calls
for an additional separate area for final processing (high-pressure sterilization by autoclaving).
(Figure 1-12-1 b). This is especially important if the volume of services is high (five or more
procedures per day).

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 Figure 12.0-1. a and b Floor Plans for Instrument Cleaning, High-Level Disinfecting and
Sterilizing Areas in a Clinic and Larger Facility

The space, equipment and need for well-defined traffic flow and activity patterns become
progressively more complex as the type of surgical procedure changes from general surgery and
obstetrics to open heart surgery.

As a guide, the space requirements for the types of surgery typically performed at district
hospitals are roughly the same as that of a busy surgical center or polyclinic. These include:

 Changing room and scrub area for the clinic staff.

 Preoperative area where clients are examined and evaluated prior to surgery.
 Operating room
 Recovery area for observation of patients after surgery (may be combined with the
preoperative area).
 Processing area for cleaning and sterilizing or high-level disinfecting instruments and
other items.
 Space for storing sterile packs and/or high-level disinfected containers of instruments and
other items. 

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Traffic Flow and Activity Patterns

The recommended infection prevention practices for minimizing microbial contamination of

specific areas in healthcare facilities are briefly described below.
ICU and Isolation Room
 Limit traffic to authorized staff and patients at all times.
 Permit only the patient and staff (performing and assisting) only two family members
should be limited at a time in one room for limited period of time in a day (wearing clean
attire and head-cover).
 Patients can wear their own clean clothing.
 Staff should wear attire and personal protective equipment (PPE) according to procedures
performed. Family member who are allowed to inter should wear head cover, face mask,
gown and shoe cover above their clean cloth and shoe.
 Family member who reported to have acute URTI should not be allowed to enter

Procedure Area
 Limit traffic to authorized staff and patients at all times.
 Permit only the patient and staff (performing and assisting) in the procedure room (family
members should be limited with obstetrical procedures).
 Staff should wear attire and personal protective equipment (PPE) according to procedures
performed.
 Place a clean container filled with clean water mixed with enzymatic detergent solution (if
available) for immediately immersing of instruments and other items once they are no
longer needed.
 Have a leak proof and covered waste container for disposal of contaminated waste items
(cotton, gauze, dressings) right after use.
 Have a puncture-resistant container for safe disposal of sharps (e.g. used suture needles,
hypodermic needles and syringes, and disposable scalpel blades) right after use.
 Have storage space in procedure rooms for clean, high-level disinfected and sterile
supplies (Storage shelves should be enclosed to minimize dust and debris collecting on
stored items).

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Surgical Unit
The surgical unit is often divided into four designated areas defined by the activities performed in
each Unrestricted, Transition zone, Semi-Restricted and Restricted area. Environmental
controls and use of surgical attire increase as one move from unrestricted to restricted areas.
Moreover, staff with respiratory or skin infections and/uncovered open sores should not be
allowed in the surgical unit.

Different Areas in Surgical Unit

Post signs in each area to clearly indicate the appropriate environmental control and surgical
attire required.
A. Unrestricted Area

This area is the entrance from the main corridor and is isolated from other areas of the
surgical unit. This is the point through which the staff, patients and materials enter the
surgical unit.

B. Transition Zone

This area consists primarily of dressing rooms and lockers. It is where the staff put on
surgical attire that allows them to move from unrestricted to semi-restricted or restricted areas
in the surgical unit. Thus, only authorized staff should enter this area.

C. Semi-Restricted Area

This is the peripheral support area of the surgical unit and includes preoperative and recovery
rooms; storage space for sterile and high-level disinfected items; and corridors leading to the
restricted area. This is an area where support activities (e.g. instrument processing and
storage) for the operating room are carried out. Therefore it is important to do the following:

 Limit traffic to authorized staff and patients every time.

 Have a work area for processing of clean instruments.
 Have storage space for clean, sterile or high-level disinfected supplies with enclosed
shelves to minimize dust and debris collecting on stored items.

Flip flops or sandals should not be worn as they provide no protection from
dropped sharps.

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  Have doors limiting access to the restricted area of the surgical unit.
 Staff working in this area should wear surgical attire and a cap.
 Staff should wear clean and closed shoes that will protect their feet from fluids and
dropped items.

D. Restricted Area

This designated area consists of the operating room(s) and scrub sink areas.

Never store instruments and other items in the operating room.

 Limit traffic to authorized staff and patients at all times.

 Keep the door closed at all times, except during movement of the staff, patients, supplies
and equipment.
 Scrubbed staff must wear full surgical attire and cover head and facial hair with a cap
and mask.
 Staff should wear clean and closed shoes that will protect their feet from fluids and
dropped items.
 Masks are required when sterile supplies are open and when the scrubbed staffs are
operating.
 Patients entering the surgical unit should wear clean gowns or be covered with clean
linen and have their hair covered.
 Patients do not need to wear masks during transport unless they seek airborne
precautions).

E. Operating Room(s)
 The operating room should be enclosed to minimize dust and eliminate flies; however,
central air conditioning is necessary (If windows are the only ventilation, provide tight-
fitting screens).
 The operating room should be located away from areas of the hospital or healthcare
facility that are heavily staffed with frequent movements of the staff and patients.

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F. Work Area

According to the size and type of the healthcare facility, the work area for processing
instruments (e.g. the Central Sterile Supply Department or CSSD) may be: part of the surgical
unit; or just connected to it; or an independent area somewhere away from it.

This is the area where instruments, surgical gloves and equipment are processed and where
the staff should be specially trained in handling, processing and storing instruments,
equipment and other clean, sterile or high-level disinfected items. The CSSD is considered a
semi-restricted area; hence all the recommendations for traffic patterns and proper attire
described above should be followed.

Permit only authorized personnel to enter this area

How to Conduct Activities at Surgical Unit

A. Before Surgical Procedures

 Place a plastic bag or leak proof-covered waste container for contaminated waste items
(cotton gauze and old dressings).
 Place a puncture-resistant container for the safe disposal of sharps (e.g. suture needles,
hypodermic needles and syringes, and disposable scalpel blades) at the point of use but
without contaminating the sterile field.
 Place a leak proof and covered waste container for soiled linen away from sterile items.
 Organize tables, Mayo and ring stands side by side in an area away from the traffic
patterns and at least 45cm (18 inches) from walls, cabinets and other non-sterile surfaces.
 Place a clean sheet, a lift sheet and arm board covers on the operating room bed.
 Check and set up suction, oxygen and anesthesia equipment.
 Place supplies and packages those are ready to open on the tables, not on the floor.
 Mayo stand and other non-sterile surfaces that are to be used during the procedure should
be covered with a sterile towel or cloth.

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B. During Surgical Procedures:

 Limit the number of staff entering the operating room only to those necessary to perform
procedures and to patients (family members as deemed necessary). Make the surgical
team self-sufficient so that outside help is not required.
 Keep the doors closed at all times, except during movement of the staff, patients, supplies
and equipment.
 Keep the number of people and their movement to a minimum; because, the numbers of
microorganisms is directly proportional to an increase with people‘s activity.
 Keep talking to the minimum in the presence of a sterile field.
 Scrubbed staff should wear full surgical attire including:

o A clean scrub suit covering the bare arm (one or two pieces); if a two piece
pantsuit is worn, the top of the scrub suit should be tucked into the pants;
o A clean surgical cap that covers the head;
o Clean, closed shoes that protect the feet from fluids or dropped items; and
o Sterile (or high-level disinfected) surgical gloves, protective eyewear and a mask
covering the mouth, nose and any facial hair.
 Scrubbed staff should keep their arms and hands within the operative field at all times and
touch only sterile items or areas. Non-scrubbed staff should wear surgical attire including:

o Long sleeved jackets banded at the wrist and that are closed during use;
o A clean surgical cap that covers the head;
o Clean, closed shoes that protect the feet from fluids or dropped items; and
o A mask covering the mouth, nose and any facial hair.

 Non-scrubbed staff should stay at the periphery of the operating room, keeping their
distance from sterile areas. They should not lean or reach over the operative field.
 Clean accidental spills or contaminated debris in areas outside the surgical field with a
0.5% Chlorine solution as promptly as possible (a non-scrubbed staff member wearing
utility gloves should do this).

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C. After Surgical Procedures:

Non-scrubbed staff wearing utility gloves should:

 Collect all waste and remove it from the room in closed leak proof containers.
 Close and remove puncture-resistant containers when they are three quarters full.
 Remove covered containers with a 0.5% chlorine solution with instruments and
surgical gloves from the room.
 Remove soiled linen in closed leak proof containers.
 Remove waste, soiled linen, soiled instruments and equipment and supplies that
have been opened but not used, in an enclosed cart or in a leak proof and covered
waste container. (Be sure that these items do not reenter the restricted area).

Description of Central Sterile Supply Department in a Hospital

A CSSD consists of four areas, as shown in Figure12.0.2. These areas are:

1. The ―dirty‖ receiving/cleanup area,

2. The ―clean‖ work area,
3. The cleaning equipment storage area, and
4. The sterile or high-level disinfected storage area.

Following surgery, place soiled instruments in their original sterile wrap and transport them to the
CSSD where they can be immediately cleaned before further processing.
Separate the ―dirty‖ receiving/cleanup area (1) from the ―clean‖ work area (2) with a physical
barrier (wall and door). If this is not possible, use a screen or paint a red line on the floor to
designate separation between areas.

Note:
Develop flow patterns to help ensure that contaminated items never come
in contact with clean, disinfected or sterile items.

The function and equipment requirements for the four areas of a typical CSSD are summarized
below.

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 Figure 12.0-2. Floor Plan for a Central Supply Department in a Hospital

“Dirty” Receiving/Cleanup Area (1)

In this area, soiled items are received, disassembled, washed, rinsed and dried. Congruently, the
Staff in the receiving/cleanup area should wear plastic aprons, utility gloves and safety goggles
or face shields to protect themselves from spills and splashes. The ―dirty‖ receiving/cleanup area
should have:

 Two sinks if possible (one for cleaning with detergent and one for rinsing) with a
clean water supply; and
 A clean equipment counter for drying.

“Clean” Work Area (2)

In the clean work area, cleaned items are:

 Inspected for flaws or damage;

 Packaged (if indicated) and either sterilized or high-level disinfected; and
 Sent for storage as packaged or air dried and placed in a sterile or high level disinfected
container.

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The clean work area should have

 A large work table;

 Shelves for holding clean and packaged items; and
 A high-pressure steam sterilizer, a dry-heat oven, a steamer or a boiler.

Staff entering the clean work area should wear clean cover gowns.

Clean Equipment Storage Area (3)

Store Clean the equipment in this area. The staff of CSSD should also enter the
department through this area. Equip the area with:

 Shelves (preferably enclosed) for storing clean equipment, and

 An office or desk for record keeping.

Sterile or High-Level Disinfected Storage Area (4)

Store sterilized packs and covered sterile or high-level disinfected containers in this area. This
area should be separated from the central sterile supply area:

 Limit access to the storage area and/or store items in closed cabinets or shelves. (Shelves
or cabinets had better be closed as they protect packs and containers from dust and debris.
Open shelves are acceptable only if the area has limited access and if housekeeping and
ventilation practices are controlled).
 Keep t h e storage area clean, dry, dust-free and lint-free by following a regular
housekeeping schedule.
 Packs and containers with sterile or high-level disinfected items should be stored 20 to 25
cm (8 to 10 inches) off the floor, 45 to 50cm (18 to 20 inches) from the ceiling and 15 to
20cm (6 to 8 inches) from an outside wall.
 Do not use cardboard boxes for storage. (Cardboard boxes shed dust and debris and may
harbor insects).
 Date and rotate the supplies (first in, first out). This process serves as a reminder that the
package is susceptible to contamination and conserves storage space, but it does not
guarantee sterility.

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  Packs will remain sterile as long as the integrity of the package is maintained.
 Sterile or high-level disinfected containers remain so up until they are opened.
 Dispense sterile and high-level disinfected articles from this area.

Shelf Life of Sterile Items

The shelf life of a packaged sterile item is event-related and not time related.

 An event can compromise the integrity and effectiveness of the package.

 Events that can compromise or destroy package sterility include multiple handling, loss
of package integrity, moisture penetration and airborne contamination.
 Sterility is lost when the package has tears in the wrapper, has become wet, has been
dropped on the floor, has dust on it or is not sealed.
 The shelf life of a sterile package will depend on: the quality of packing; conditions
during storage and transport; and the amount of handling prior to use.
 Sealing sterile packs in plastic bags can help prevent damage and contamination.
 Most contaminating events are related to excessive or improper handling of the packages.
The ideal number of times an item should be handled is three:

1. When removing it from the sterilizer cart and placing on a storage shelf,
2. When transporting it to the place where it is to be used, and
3. When selecting it to be opened for use.

Handling and Transporting Instruments and Other Items

 Keep clean and high-level disinfected or sterile instruments and other items separate from
soiled equipment and waste items. Do not transport or store these items together.
 Transport high-level disinfected and sterile instruments and other items to the procedure
or operating room in a closed cart or container with a cover to prevent contamination.
 Remove supplies from all shipping cartons and boxes before bringing such supplies into
the procedure room, the operating room or the clean work area of the CSD. (Shipping
boxes shed dust and harbor insects that may contaminate these areas).
 Transport soiled supplies and instruments to the receiving/cleanup area of the CSD in leak
proof and covered waste containers.

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  Transport contaminated waste to the disposal site in leak proof and covered waste
containers.

Note:
If supplies are being delivered to the surgical area; one person standing
outside should pass them through the door to a person inside the operating
room to reduce traffic.

Summary

Irrespective of the existing layout of the facility, design traffic flow and work practices in such a
way that keeps soiled/contaminated instruments, equipment, and textiles separate from the clean
and sterile instruments, equipment, and textiles, whether in the OT or in the CSSD. Appropriate
traffic flow and work practices prevent accidental contamination of clean items and reduce the
risk of infections to patients, HCWs, and visitors.

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CHAPTER 13: INFECTION PREVENTION AND CONTROL ASPECTS OF
OCCUPATIONAL HEALTH IN HEALTH CARE SETTINGS
Key Topics:
Hazard Identification, Risk Assessment and Risk Control
Occupational health activities for the prevention and management of infections in HCWs
Occupational Health Activities for Management of Job-Related Illnesses and Occupational
Exposures
Prevention Strategies for Infections Relevant to Occupational Health in Health Care
Facilities
Occupational Health Activities for specific groups of health care workers
Post Exposure Prophylaxis for HIV and HBV
Monitoring of occupational health activities

Definition of Key Terms

Hazard: Anything (e.g. condition, situation, practice, behavior) that has the potential to cause
harm, including injury, disease, death, environmental, property and equipment damage. A hazard
can be a thing or a situation

Risk: The likelihood, or possibility, that harms (injury, illness, death, damage etc.) may occur
from exposure to a hazard.

Occupational exposure is an exposure of HCW to an infection while providing care and

treatment services to patients in a health care facility

Occupational health is the discipline that deals with all aspects of work-related health and safety
and has a strong focus on prevention; it is known also as employee health.

Occupational health activities include all aspects of work-related health and safety activities,
including prevention. In this chapter, the term refers in particular to activities that address
infectious hazards at health care facilities.

Occupational health surveillance is the collection, analysis, and dissemination of data on

hazards that have endangered or may endanger HCWs.

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Occupational infection is an infection contracted as a result of an exposure to risk factors arising
from work activity.

Sharps injuries are injuries from a ―sharp‖ penetrating the skin. ―Sharps‖ include syringe
needles, scalpels, broken glass, and other objects that may be contaminated with blood or body
fluids. These injuries potentially expose HCWs to infections from bloodborne pathogens.

Vaccine-preventable diseases are infectious diseases for which effective vaccines are available.
They include but are not limited to hepatitis A and B, influenza, measles, mumps, rubella, tetanus,
diphtheria, pertussis, and varicella (chicken pox)

Post-Eexposure Pprophylaxis (PEP) is a preventive medical treatment that a person may take
following exposure to potentially infectious blood borne pathogens, such as HIV or HBV, to
prevent becoming infected from the exposure. Post-exposure prophylaxis can also be taken
following exposure to non-blood borne pathogens such as invasive Group A streptococcal
infections, invasive meningococcal infections, and pertussis

Non-Occupational Exposure - is an exposure to HIV and other blood borne pathogens outside
the work setting. This term predominantly refers to potential exposure through sexual assault.
Other forms of potential non-occupational exposure include those arising from needle-sharing
among injecting drug users, consensual sex, needle sticks in the community, fights or playground
incidents resulting in bleeding by an HIV-infected child and mass causalities like road traffic
accidents, etc.

Exposed Person - is the person who is potentially at risk of acquiring HIV infection (and or
infection from other pathogens) through exposure to blood or body fluids in his or her
occupation or in another non-occupational situation.

Source Person - is the person who is (either identified or not identified as) the possible source of
contamination through potentially infectious blood or body fluid. If the serostatus of the source
person is unknown, he or she may be asked to provide informed consent to HIV testing. The
source person may be: a patient if a healthcare worker is the one who is exposed (in occupational
ex

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BACKGROUND
Health care facilities around the world employ over 59 million workers who are routinely exposed
to a variety of health and safety risks (WHO 2016a). These risks include exposure to infectious
agents such as blood borne pathogens, tuberculosis (TB), viral respiratory infections, vaccine-
preventable diseases, bacterial infections, and gastro intestinal infections, among others. If an
infection is contracted as a result of an exposure to risk factors arising from work activity, it is
known as an occupational infection. In general, HCWs who have contact with patients, body
fluids, or specimens have a higher risk of acquiring or transmitting infections than those who have
casual contact with patients and the health care environment.
Occupational exposures to sharps injuries are an example of the substantial impact of occupational
infections among HCWs. It is estimated that 39% of hepatitis C virus (HCV), 37% of Hepatitis B
virus (HBV), and 4.4% of HIV infections among HCWs worldwide are attributable to
occupational exposure due to sharps injuries. This amounts to an estimate of 16,000 HCV, 66,000
HBV, and 1,000 HIV occupational infections annually (Prüss-Üstün et al. 2005). It is thought that
more than 90% of these are in limited-resource countries. (IFIC 2003)

It is notable that infection with HBV is 95% preventable with immunization, and the HBV vaccine
has contributed to a significant reduction of HBV in HCWs. However, less than 20% of HCWs in
some regions of the world have received all three doses of vaccine needed for immunity from
HBV infection. (APIC 2014a; IFIC 2003)

In general, Occupational Health deals with all aspects of work-related health and safety and has a
strong focus on prevention, especially for infectious (such as disease exposures) and non-
infectious risks (such as injury). The goals of infection prevention and control (IPC) intersect with
those of occupational health in preventing and addressing infectious hazards at health care
facilities. Therefore, a large portion of occupational health activities at a health care facility are
also IPC activities. (APIC 2014a)

Although the actual risk of infectious exposure for HCWs depends somewhat upon the job
description and the setting, attention to IPC helps protect staff and patients in all settings.
Emerging infectious disease outbreaks, such as severe acute respiratory syndrome (SARS) in
2003, Middle Eastern respiratory syndrome coronavirus (MERS-CoV) in 2012, and Ebola Virus

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Disease (EVD) in 2014, have highlighted the importance of IPC in protecting HCWs, as
transmission of these viruses to HCWs occurred when they cared for infected patients. These
outbreaks have demonstrated that strategies to protect HCWs from exposure to infectious risks in
the workplace are critically important and that facilities must have the infrastructure in place to be
able to adapt to changes in emerging infectious threats. Health care facilities need staff
knowledgeable in IPC to conduct and support sounds occupational health activities to minimize
the risk of occupational infection in HCWs and provide a safe environment for patients and staff.
(APIC 2014a; WHO 2016a; WHO 2016c) posures) or a perpetrator if it is a case of sexual assault.

Hazard Identification, Risk Assessment and Risk Control

Workplace hazard identification, assessment and control is an on-going process. It should be

undertaken at various times, including:
 If it has not been done before.
 When a hazard has been identified
 When a change to the workplace may introduce or change a hazard. Such as when changes
occur to the work equipment, practices, procedures or environment.
 As part of responding to a workplace incident, even where an injury has not occurred.
 Where new information about a risk becomes available or concerns about a risk are raised
by workers
 At regularly scheduled times appropriate to the workplace.

Hazard Identification: This is the process of examining each work area and work task for the
purpose of identifying all the hazards which are ―inherent in the job‖. Work areas include but are
not limited to machine workshops, laboratories, office areas, agricultural and horticultural
environments, stores and transport, maintenance and grounds, reprographics, and lecture theatres
and teaching spaces. Tasks can include (but may not be limited to) using screen-based equipment,
audio and visual equipment, industrial equipment, hazardous substances and/or teaching/dealing
with people, driving a vehicle, dealing with emergency situations, construction. This process is
about finding what could cause harm in work task or area.

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Risk Assessment: Is defined as the process of assessing the risks associated with each of the
hazards identified so the nature of the risk can be understood. This includes the nature of the harm
that may result from the hazard, the severity of that harm and the likelihood of this occurring.

Risk Control: Taking actions to eliminate health and safety risks so far as is reasonably
practicable. Where risks cannot be eliminated, then implementation of control measures is
required, to minimize risks so far as is reasonably practicable. A hierarchy of controls has been
developed and is described below to assist in selection of the most appropriate risk control
measure/s.

Monitoring and Review: This involves ongoing monitoring of the hazards identified, risks
assessed and risk control processes and reviewing them to make sure they are working effectively.

Hazard identification, risk assessment and control are an on-going process. Therefore,
regularly review the effectiveness of your hazard assessment and control measures. Make
sure that you undertake a hazard and risk assessment when there is a change to the
workplace including when work systems, tools, machinery or equipment change. Provide
additional supervision when new employees with reduced skill levels or knowledge are
introduced to the workplace. The effectiveness of control measures can be checked through
regular reviews as well as consultation with workers.

Occupational Health Activities for Preventing Infections among Health Care

Workers

The goal of occupational health activities is to protect HCWs—and thereby their patients—from
acquiring an infection or any other hazard while working in a health care facility. This goal is
achieved by:

 Identifying work-related infection risks and hazards and preventing them

 Ensuring prompt and appropriate management of any occupational exposures to infections
or other hazards
 Training all HCWs on IPC and patient safety practices and how to protect themselves
against the risks of occupational exposures to infections and other hazards

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  Monitoring and investigating potentially harmful exposures and outbreaks among HCWs
 Preventing infections by carrying out occupational health activities (APIC 2014a; CDC
1998; WHO 2016c)

Protection from acquiring infections through occupational exposure is critical to maintaining and
retaining an adequate workforce of trained and healthy HCWs. Protecting HCWs also helps to
contain costs associated with absenteeism, illness, and attrition as a result of incapacity, death, and
fear. In addition, occupational health activities protect patients through prevention, early
identification, and control of infections and other harms among staff. Therefore, protecting HCWs
is integral to maintaining a safe environment for both patients and staff.

Aspects of occupational health should be included in any IPC/PS program; the World Health
Organization‘s (WHO‘s) (2016c) Core Components of IPC emphasize the importance of
collaboration between occupational health/employee safety activities and the IPC program (CDC
1998; WHO 2016a; WHO 2016c).

It is ideal to have an occupational health department and program in a larger health care facility,
depending on the size of the facility and available staffing. In smaller health care facilities, the
IPC team or other appropriate staff may carry out occupational health activities. All occupational
health programs should be coordinated and overseen by a trained health care professional or team
who hold the responsibility for ensuring that all of the program activities, including IPC aspects
are conducted.

A responsible person from various departments, which could include human resources, IPC/PS,
outpatient clinics, administration, and the laboratory, should work in a coordinated manner to
implement occupational health activities such as efficient and prompt screening, immunization,
and follow-up of exposures and outbreaks among HCWs.

Major Occupational Health Activities

The priorities of occupational health activities at any facility will vary depending on factors such
as the type of facility, organizational structure and services provided, geographical location,
characteristics of the patients and HCWs, and diseases that are endemic in the community (APIC

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2014a). This section provides a practical description of the implementation and integration of
occupational health activities.

Activities that should be implemented by staff responsible for occupational health can be divided
into the following categories:

 For newly employed HCWs (see Table 13.0.1)

 For all HCWs on an ongoing basis (see Table 13.0.2)
 Facility-wide activities (see Table 13.0.3)

Table 13.0-1 Occupational Health Activities for Newly Employed HCWs

Activity Key Occupational Health Activities: Newly Employed HCWs

Pre-  Though not recommended in many settings, a baseline medical history and physical
employment examination, if done, can serve as a screening tool and establish a baseline to
evaluation determine if any future diseases are work-related.
 Review history of vaccination for hepatitis B in particular and other vaccinations
recommended as per the national guidelines for vaccination of HCWs.
 Assess for immunity: In low-resource settings, documentation of routine
immunization might be the only source to verify immunity if the records are
available. Follow the national vaccination schedule for HCWs when vaccination
status is not known. In some settings blood titers to determine current immunity to
vaccine preventable diseases may be available.
 Assess for presence of chronic and acute infections, including screening for TB.
Education/  Tailor training to the needs of specific job functions.
training on  Conduct IPC training for newly employed HCWs following the national training
IPC curriculum. At a minimum, all new employee should receive training in:
o Standard Precautions and Transmission-Based Precautions
o Management of occupational exposure to blood-borne pathogens
 Include topics such as risk and prevention of occupational infections, risk of infection
after exposures, and management of exposures, including availability and
effectiveness of post-exposure prophylaxis (PEP) and potential consequences to
family members of exposed HCWs. Also include updates on occupational health and
pregnant HCWs.
Counseling for  Counsel for:
occupational o The risk and prevention of occupational infection
exposure to o Risk of various infections following exposure
infections o Management of exposures, including testing and PEP (where indicated)
o Risks and benefits of PEP
o Long-term consequences of infections
o Potential risks for family members, colleagues, and other patients

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 o The need to be away from the job

 Female HCWs of childbearing age and those who are pregnant should be counseled
on the risks of infections and provided with information on appropriate
Transmission-Based Precautions needed for infections of concern during pregnancy.
 Answer any other questions that the HCW might have.

Table 13.0-2 Occupational Health Activities for all HCWs

Activity Key Occupational Health Activities: All HCWs

Monitoring  Screen for TB using the WHO TB screening tool.
employee health  Ensure that the vaccination status of all HCWs is up to date.
status
 Update employee health records.
 Perform routine monitoring of HCWs with HBV, HCV, and HIV
infection with the goal of assisting infected HCWs to continue to
provide safe health care to patients.
Education/training  Organize periodic refresher training for all HCWs in key IPC
on IPC practices.
 Provide updates on guidelines for monitoring and managing
occupational exposures to blood-borne pathogens and other
infections.
Determining work  Make decisions about work restrictions (the need to be away from
restrictions for the job) for ill HCWs (see Appendix 1-13-9 for disease-specific
employee illness work restrictions).
and exposure
Post-exposure  Follow up immediately those HCWs with job-related exposures and
follow-up make decisions about work restrictions and post-exposure care (see
Appendix 1-13-9 for disease-specific work restrictions). See the
Occupational Health Activities for Management of Job-Related
Illnesses and Occupational Exposures section in this chapter.
Vaccination  Organize vaccination sessions for those staff who need to complete
vaccinations according to national/facility recommendations.

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 Table 13.0-3 Facility-Wide Activities

Activity Key Occupational Health Activities: Facility-Wide

Exposure  Conduct a regular review of occupational exposure reporting in the
reporting facility.
 Ensure that round-the-clock services are available for post-exposure
management as recommended in Volume 1, Chapter 6: Sharps Injuries
and Management of Exposure to Blood borne Pathogens, in this
module.
 Prepare and transmit documentation of occupational exposures to the
authorities as needed.
Occupational  Evaluate effectiveness of occupational health activities for preventing
health program occupational exposure to blood borne pathogens and other risks.
review  Make changes in the selection and implementation of occupational
health program activities as needed.

National guidelines, if available, should be followed to vaccinate HCWs against vaccine-

preventable diseases. WHO has provided information on immunization for the general population
and HCWs (see Table: 13.0.4) to help develop national policies for vaccination of HCWs

Table 13.0-4 WHO-Recommended Immunizations for HCWs

Vaccine Recommendations
Hepatitis B  Routine childhood immunization. No booster needed.
 Incompletely vaccinated HCWs should receive additional doses to
complete the vaccine series. The vaccine series does not need to be
restarted; however, minimum dosing intervals should be followed: 4
weeks between the first and second dose, 8 weeks between the second
and third dose, and 16 weeks between the first and third dose. (CDC
2013)
 Hepatitis B vaccine is affordable and available in many settings and is
an appropriate place to begin when starting a staff immunization
program. (CDC 1998)
Polio  Routine childhood immunization.
 All HCWs should have completed a full course of primary vaccination
against polio.
Diphtheria  Routine childhood immunization.
 Booster for HCWs every 10 years.
Measles  Routine childhood immunization.
 If required by the national policy, all HCWs should produce proof of
immunity or documentation of immunization at the time of employment.

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Rubella  If rubella vaccine has been introduced into the national program, all
HCWs should be immunized for rubella and produce proof of immunity
or documentation of immunization at the time of employment.
Meningococcal  One booster dose 3–5 years after the primary dose may be given to
persons considered to be at continued risk of exposure, including HCWs.
Influenza  Influenza virus changes regularly so annual immunization with a single
dose is recommended if the vaccine is available for HCWs under the
national immunization program.
Varicella  Countries should consider vaccination of potentially susceptible HCWs
(i.e., unvaccinated and with no history of varicella) with two doses of
(Chicken pox) varicella vaccine.
Immunizations with NO Current WHO Recommendation for HCWs
There are no specific recommendations for vaccination specifically for HCWs for TB, pertussis, tetanus,
mumps, hepatitis A (HAV), typhoid, or cholera. These vaccines should be offered as a part of routine
vaccination programs and as overall strategies for preventing outbreaks (typhoid and cholera).
Adapted from: World Health Organization. WHO Recommendations for Routine Immunization-Summary Tables.
Table 4, Summary of WHO Position Papers-Immunization of Health Care Workers. Updated 2015. © World Health
Organization.

Occupational Health Activities for Management of Job-Related Illnesses and

Occupational Exposures

The occupational health team should respond to all potential and confirmed exposures to blood-
borne pathogens and other infectious diseases immediately and collaborate with IPC staff for
follow-up as necessary. Health care facilities should have systems in place for HCWs to report
sharps injuries and blood borne pathogen exposures with prompt evaluation and follow-up (see
Table 13.0.5).

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 Table 13.0-5 Occupational Health Activities for Management of Job-Related Illnesses and
Exposures

Activity Key Occupational Health Activities: Job-Related Illnesses and Exposures

Infectious  Identify infections in HCWs (whether community-acquired or job-related).

disease in  Make decisions about the length and type of work restrictions (related to patient
HCWs care or food handling) and assignment to other duties (see Appendix 1-13-9).
 Report to public health authorities if it is a notifiable disease of public health
interest.
Sentinel  Suspect a job-related infection in an HCW with an infectious disease known to
infections in spread in health care facilities. Certain occupational infections may be the result of
caring for patients with an unidentified infection (such as meningococcal meningitis
HCWs
or novel influenza) or may indicate IPC lapses at the facility. ( see Appendix 1-13-9
for disease-specific risk of transmission to and from HCWs.)
 Ensure infections are managed following clinical guidelines and make decisions
about the length and type of work restrictions (as above).
 Take necessary measures to prevent further spread of the infection through
investigation of possible routes of transmission in the facility and correct any lapses
in IPC.
 Identify and facilitate clinical management and work restrictions of those exposed.
 Monitor closely for additional cases (indicating a hospital or community outbreak).
Post-exposure  Determine what is considered an exposure (exposure definition).
follow-up  Obtain a list of those who have been exposed.
 Counsel those exposed.
 Offer PEP promptly when appropriate and available.
 Determine any work restrictions.
 Conduct medical surveillance for development of disease.
 Determine when the HCW can return to work.
 Maintain adequate and confidential documentation on the event.
 Coordinate all of the above and any other activities such as ongoing monitoring or
follow-up lab testing.
 (See Volume 1, Chapter 6: Sharps Injuries and Management of Exposure to blood
borne Pathogens, in this module for more information on post-exposure
management for HBV, HCV, and HIV and Appendix 1-13-9 for disease-specific
guidance for management of exposed HCWs.)

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Summary of Key Elements of Occupational Health Activities

The following are the key elements for occupational health programs in health care facilities:

 Oversight by a qualified health care professional or team

 Coordination among multiple hospital departments
 Medical evaluation at the start of employment
 Health and safety education and training of all staff
 Immunization programs
 Management of work restrictions and post-exposure treatment for occupational illnesses
and exposures
 Counseling on protection from and management of accidental exposure to blood borne and
other infectious pathogens
 Maintenance of personnel health records
(APIC 2014a; CDC 1998; WHO 2002)

Prevention Strategies for Infections Relevant To Occupational Health in Health Care

Facilities

 Prevent occupational exposure of HCWs by the application of Standard Precautions for

all patients, at all times, as well as disease- or syndrome-specific Transmission-Based
Precautions, to prevent exposures to infectious agents.
 Protect against vaccine-preventable diseases: Having a mandatory program that requires
all HCWs to receive vaccines to protect themselves against vaccine-preventable diseases
has been found to be more effective than a voluntary program in ensuring that all
susceptible staff are vaccinated. In settings with limited resources, priority should be given
to staff who are at high risk of exposure and those without any existing immunity. Select
the vaccines that may provide the most protective effects, such as hepatitis B or influenza.
 Manage occupational exposures following the national guidelines (e.g., national
guidelines for management of occupational exposure to blood and body fluids) (Refer to
Chapter 6, Sharps Injuries and Management of Exposure to Blood borne Pathogens, in this

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 volume for post-exposure management of HBV, HCV, and HIV and (Appendix 1-13-9)
for disease-specific guidance for management of exposed HCWs)
 Keep up to date by seeking additional information on specific diseases and local
epidemiology: Details on specific, key infections relevant to limited-resource settings can
be found in (Appendix 1-13-9)

Occupational Health Activities for Specific Groups of Health Care Workers

Certain groups of workers at a health care facility may require special attention related to
occupational health activities. They include pregnant staff, laboratory staff, emergency response
staff, and HCWs infected with HIV, HBV, or HCV.

Pregnant Health Care Workers

Pregnancy does not increase the risk of acquisition of infection for most occupationally acquired
infections, and clinical manifestations are no more severe in pregnant women than in others
(APIC 2014b). However, pregnant HCWs may be anxious about potential infection and possible
harm to their babies. The staff supporting occupational health activities should address any
questions that pregnant HCWs may have about occupational exposures, how to avoid them, and
the management of exposures, as well as any implications for the baby. Full compliance with
Standard Precautions, such as hand hygiene and appropriate personal protective equipment (PPE),
as well as adherence to Transmission-Based Precautions, should be adequate for pregnant HCWs
in preventing most infectious diseases as well as adherence to Transmission-Based Precautions,
should be adequate for pregnant HCWs in preventing most infectious diseases (see Table 13.0.6).

However, as in the case of non-pregnant HCWs, non-immune pregnant HCWs should not care for
patients with measles, rubella, and varicella (APIC 2014b). Table 13.0.7 provides information on
occupational exposure to infection among pregnant HCWs, risks to their babies, and prevention
strategies. The information provided in the table will guide the occupational health team members
in making appropriate decisions. Table 1-13-7 describes additional pertinent facts to assist with
management of relevant occupational exposures in pregnant HCWs.

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 Infectious Agents of Concern for Pregnant HCWs According to the Risk of
Table 13.0-6
Transmission Associated with Providing Health Care Services and Available Preventive
Measures

Health Care-Associated Health Care- Health Care-Associated Health Care-Associated

Acquisition Possible Associated Infections for Which Standard Infections for Which
and Prevented by Acquisition Is and Transmission-Based PEP Is Effective
Vaccine Unlikely Precautions Are the Only
Preventive Measures
Anthrax, hepatitis Herpes Cytomegalovirus HIV, N. meningitis,
A virus (HAV), simplex virus, (CMV), viral syphilis
HBV, influenza, toxoplasmosis hemorrhagic fever,
Neisseria HCV, parvovirus B19,
meningitis, TB
pertussis, rubella,
measles, varicella,
tetanus, diphtheria

In settings where adequate infection control precautions (including PPE) are available and
immunizations for vaccine-preventable diseases are maintained, there are few instances in which
pregnant HCWs cannot provide the same care as their non-pregnant colleagues; they should not
routinely be restricted from duties on the basis of pregnancy status. However, pregnant HCWs
should not care for patients with parvovirus B16 and certain vaccine-preventable diseases if they
are non-immune. At times of PPE and vaccine shortage, assign pregnant HCWs to other tasks
with no risk for exposure to infectious agents. (APIC 2014b; CDC 2013)

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 Table 13.0-7 Management of Occupational Exposure to Common Infections for Pregnant Staff Members

Agent In-Hospital Source Potential Effect on the Rate of Perinatal Maternal Screening Prevention
Fetus Transmission
Cytomegalo- Urine, blood, semen, Classic cytomegalic Primary Routine screening Efficacy of CMV immune globulin
virus vaginal secretion, inclusion disease infection not recommended; not established.
(CMV) immunosuppressed (5–10%)* (25–50%) antibody is No vaccine available
transplant, dialysis, Hearing loss Recurrent infants incompletely Standard Precautions
day care (10–15%) (52%) protective
Symptomatic
(< 5–15%)
Hepatitis A Feces (most No fetal transmission None Routine screening Vaccine is a killed viral vaccine and
virus common), blood described; transmission not recommended can safely be used in pregnancy.
(HAV) (rare) can occur at the time of Contact Precautions during acute
delivery if the mother phase.
is still in the infectious The safety of HAV vaccination
phase and can cause during pregnancy has not been
hepatitis determined; however, because the
vaccine is produced from
inactivated HAV, the theoretical risk
to the developing fetus is expected
to be low. The risk associated with
vaccination, however, should be
weighed against the risk for HAV in
women who might be at high risk of
exposure to HAV.
Hepatitis B Blood, body fluids, Hepatitis, early onset HbsAg + 10% Routine HBsAg HBV vaccine during pregnancy
virus vaginal secretions, hepatocellular HbeAg + 90% testing advised Neonate: HBIG plus vaccine at birth
(HBV) semen carcinoma Standard Precautions
Hepatitis C Blood, sexual Hepatitis 5% (0–25%) Routine screening No vaccine or immunoglobulin
virus not recommended available; post-exposure treatment
(HCV) with antiviral agents being
investigated.
Standard Precautions
Herpes Vesicular fluid, Sepsis, encephalitis, Primary genital Antibody testing Chemoprophylaxis at 36 weeks
simplex virus oropharyngeal, and meningitis, (33–50%) minimally useful, decreases shedding.
 vaginal secretions mucocutaneous lesions, Recurrent genital genital inspection Standard Precautions
congenital (1–2%) for lesions if in
malformation (rare) labor
HIV Blood, body fluids No congenital Depends on HIV Routine maternal Antiretroviral chemoprophylxis
syndrome; if fetus viral titer and use screening advised available for exposures,
infected, AIDS in 2–4 of ART If exposed, testing postnatal/breastfeeding
years If titer < 1,000 at 3, 6, and 12 chemoprophylaxis for HIV+
virus; rate 2% months mothers and their infants.
If titer ≥ 10,000; Standard Precautions
rate up to 25%
Influenza Sneezing and No congenital Rare None Non-live vaccine (such as trivalent
coughing, syndrome: influenza in inactivated) for all pregnant HCW
respiratory tract mother could cause during influenza season.
secretions hypoxia in fetus Droplet Precautions
Measles Respiratory Prematurity, Rare Antibody test Vaccine contraindicated during
(rubeola) secretion, coughing spontaneous abortion, pregnancy. Vaccination
no congenital recommended prior to conception.
syndrome Airborne Precautions
Neisseria Respiratory Sepsis Unknown None Chemoprophylaxis with ceftriaxone
meningitidis secretion of No congenital or azithromycin
untreated patients or syndrome Vaccine if indicated for outbreak
those patients who control
have received Droplet Precautions, based on
antimicrobials for syndrome and for confirmed cases.
< 24 hours Standard Precautions, especially
mask, face protection for all
intubations
Rubella Respiratory Congenital syndrome 90% in first Routine rubella Vaccine contraindicated during
secretions trimester IgG testing in pregnancy. Vaccine prior to
40–50% overall pregnancy conception
Preconception No congenital rubella syndrome
screening described for vaccine
recommended Droplet Precautions; Contact
Precautions for contact with
congenital rubella patients.
Syphilis Blood, lesion, fluid, Congenital syndrome Variable 10– VDRL RPR Post-exposure prophylaxis with
 amniotic fluid 90%, depends on FTA-ABS penicillin
stage of maternal Standard Precautions, gloves until
disease and 24 hours of effective therapy
trimester of the completed for infants with
infection congenital syphilis and all patients
with skin and mucous membrane
lesions
Tuberculosis Sputum, skin lesions Neonatal TB; liver Rare TB skin test Post-exposure prevention
(TB) most frequently Interferon recommendations vary with
infected gamma-release tuberculin skin test reaction size and
assay (IGRA) chest radiograph result.
blood test; if Airborne Precautions
available. Chest
radiograph
Varicella- Droplet or airborne Malformations (skin, Total 25%: Antibody Vaccine contraindicated during
zoster spread of vesicle limb, central nervous congenital pregnancy. Vaccine prior to
fluid or secretions of system, eye); chicken syndrome conception
the respiratory tract pox (0–4%) Varicella-zoster immune globulin
(scabs are not within 96 hours‘ exposure if
infective) susceptible
Airborne and Contact Precautions
*Congenital syndrome: varying combinations of jaundice, hepatosplenomegaly, microcephaly, thrombocytopenia, anemia, retinopathy, and skin and
bone lesions.
FTA-ABS = fluorescent treponemal absorption test; HbsAg = hepatitis B surface antigen; HbeAg = hepatitis B e-antigen; HBIG = hepatitis B
immune globulin; IgG = immunoglobulin G; RPR = rapid plasma reagin test; VDRL = Venereal Disease Research Laboratory test
Adapted from : APIC 2014b
Laboratory Staff

HCWs in laboratories may be at increased risk of occupational exposure to the pathogens with
which they work. Laboratory staff should receive specific training on the risks and how to avoid
them (such as working under a bio-containment hood, using a closed centrifuge, avoiding mouth
pipetting) and have access to PPE, as required, according to the procedures they perform and the
pathogens with which they have contact. (Volume 2, Section 4, Chapter 3, Clinical Laboratory
Biosafety, provides details on preventing infection among laboratory staff.) In addition to the
vaccines routinely recommended for all HCWs, further vaccinations may be appropriate for
HCWs working in a clinical or research laboratory (CDC 1998). National recommendations
should be consulted and followed if available.

The following vaccines may be relevant for staff working with specific pathogens:
 BCG (Mycobacterium tuberculosis),
 Hepatitis A, Meningococcal (N. meningitidis),
 Polio, Rabies and
 Typhoid
(CDC 1998)

Emergency Response Staff

HCWs who respond to emergencies and transport patients should not be overlooked during
occupational health activities. These HCWs are at a high risk of exposure to blood borne
pathogens and should have access to HBV vaccination, have adequate PPE and thorough
instruction on proper PPE use, and be taught to apply Standard Precautions for all patients at all
times. Furthermore, they may transport patients before the infection status of the patient is known
(e.g., meningococcal meningitis, influenza, novel respiratory viruses, viral hemorrhagic fever) and
thus should be aware of how to apply Isolation Precautions based on disease syndromes, be
informed about patients who later develop infections of occupational health concern and be
included in exposure follow-up and relevant PEP and work restrictions.

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Health Care Workers exposed TO HIV and/or Hepatitis B or C

HIV, HBV and HCV are the primary infectious agents that can be transmitted via exposure to
bodily fluids. In addition to percutaneous injury, contact of mucous membranes or non-intact skin
with blood, fluids containing blood, tissue or other potentially infectious bodily fluids pose an
infectious risk. Potentially infectious body fluids include semen, vaginal secretions, cerebrospinal
fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, amniotic fluid, pus, etc. In
this case, body fluids like feces, nasal secretions, saliva, sputum, sweat, tears, urine, and vomits
are not considered infectious unless they contain blood.

Post Exposure Prophylaxis (PEP) is a preventive medical treatment that a person may take
following exposure to potentially infectious blood borne pathogens, such as HIV or HBV, to
prevent becoming infected from the exposure. Post-exposure prophylaxis can also be taken
following exposure to non-blood borne pathogens such as invasive Group A streptococcal
infections, invasive meningococcal infections, and pertussis

Occupational Exposure - is exposure of individuals to HIV and other blood borne pathogens
occurring in the course of their work. This exposure should not be assumed to be directed solely to
health care workers but also to other workers like emergency rescue staff, waste-disposal workers,
law enforcement personnel and fire-fighters. Because, these staffs are also likely be exposed to
health risk from pathogens in blood and other potentially infectious body fluids while doing their
work.

Occupational exposure to blood and body fluid is the exposure of an HCW to blood or other
potentially infectious materials during the performance of an employee's duties. Exposure to blood
borne pathogens involves skin, eye, mucous membrane, or parenteral contact (e.g., a needle stick).

Non-Occupational Exposure - is an exposure to HIV and other blood borne pathogens outside the
work setting. This term predominantly refers to potential exposure through sexual assault. Other
forms of potential non-occupational exposure include those arising from needle-sharing among
injecting drug users, consensual sex, needle sticks in the community, fights or playground
incidents resulting in bleeding by an HIV-infected child and mass causalities like road traffic
accidents, etc.

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Post Exposure Prophylaxis for HIV

A. Occupational Exposure to HIV

Each day, thousands of people around the world experience accidental exposure to blood and
other body fluids or tissues while performing their work duties. Hence, it could be said that
healthcare workers are especially vulnerable for infections. The risk of acquiring HIV after a
mucous membrane exposure to blood is approximately 0.09 % while the acquisition through a
percutaneous exposure is approximately 0.3% (Cardo DM et al., 1997). The risk of acquiring
HIV percutaneous is associated with deeper injuries, visibly bloody devices, and more advanced
disease (likely due to a higher viral load) in the source patient. Hollow bore needle exposures
have higher risk of transmission than that of solid bore needle exposures.

The use of post exposure prophylaxis against HIV infection dates back to the early 1990s for
both direct and indirect evidence suggested that the treatment with ARVs soon after exposure to
HIV decreases the risk of transmission. Animal studies have demonstrated mixed results on the
efficacy of PEP (Black RJ, 1997).

A retrospective case-control study demonstrated that PEP with AZT for 4 weeks was associated
with an 81% reduction in transmission of HIV in humans. In that study, approximately 70% of
patients received AZT within 4 hours of the exposure (Cardo DM, 1997). It is not known how
long after an exposure PEP would turn to be ineffective. However, the data from animal studies
mentioned above, suggest that PEP is effective when initiated within 72 hours of exposure.
Taking the evidences mentioned above in to consideration, most international guidelines
recommend PEP drugs to be started for exposed persons (based on the indication) as early as
possible preferably within 2 hours of exposure but giving PEP drugs after 72 hours of exposure
is not generally advisable. Measures that should be taken on initial management of exposure
exposed persons are put on Annex 16. 1

The PEP drug recommendations for percutaneous injury and mucous membrane or non-intact skin
exposure are found in (Table 13.0.8 and 13.0.8)

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 Table 13.0-8 Recommended HIV Post Exposure Prophylaxes (PEP) for Percutaneous Injuries

Exposure Code (EC)

Status Code (SC)
EC 2 EC 3
SC 1 Recommend basic 2-drug PEP Recommend expanded 3-drug PEP
SC 2 Recommend expanded 3-drug PEP Recommend expanded 3-drug PEP
Generally, no PEP is warranted; Generally, no PEP is
however, consider basic 2-drug PEP warranted; however consider basic
SC unknown
for source with HIV risk factors. 2-drug PEP for source with HIV
risk factors
HIV-Negative No PEP warranted No PEP warranted.

Table 13.0-9 RecommendedHIV Post Exposure Prophylaxes for Mucous Membrane Exposures
and Non-intact Skin Exposures

Exposure Code (EC)

Status Code (SC)
EC 2 EC 3
SC 1 Consider basic 2-drug PEP Recommend basic 2-drug PEP
SC 2 Recommend basic 2-drug PEP Recommend expanded 3-drug PEP
Generally, no PEP warranted; Generally, no PEP warranted;
If PEP is offered & administered and however consider basic 2-drug PEP
SC unknown the source is later determined to be for source with HIV risk factors.
HIV-negative, PEP should be
discontinued.
HIV-Negative No PEP warranted No PEP warranted
Adapted from Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures
to HIV and Recommendations for Post exposure Prophylaxis. MMWR Recommend Rep 2005; 54 (No RR-9):
1-17 & MMWR 1998; 47(No. RR-7): 1-33.

Adherence

Compliance rates of 95% or greater are required to actually maximize the benefits of
antiretroviral therapy. Although parallel data are not available for PEP, the magnitude of the
positive effects of high levels of adherence to prescribed practices is generally assumed to be
similar.

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Clients who have already started PEP but did not come to the ART clinic on the follow up
appointment date, can be traced by giving a telephone call (or physically for those in the same
health facility, if possible) to remind them to come to follow up visit. The Service given at each
follow up visit should be documented on Potential exposure and PEP follow up forms
(Appendix 13-5) which should be attached to the chart of every patient who reports exposure.

To facilitate counseling and informed decision making for HIV post exposure prophylaxis, the
list of information items to be given for clients on PEP service is summarized in (Appendix 13-
3) Patients given PEP drugs should be counseled on side effects of ARVs. The steps in the
clinical management of HIV PEP are summarized in (Appendix 13-2)

Considerations for Pregnant Women and Women of Childbearing Potential

Because of its potential teratogenicity, Efavirenz should not be used in any nPEP (non-
occupational PEP) regimen during pregnancy or among women of childbearing age at risk of
becoming pregnant during the course of antiretroviral prophylaxis. A protease inhibitor or
nucleoside reverse transcriptase inhibitor-based regimen should be considered in these
circumstances.

Children

Potential HIV exposures in children occur most often by accident (e.g. needle sticks, in the
community, fights, or playground incidents resulting in bleeding by an HIV-infected child) or
by sexual abuse or assaults (Nourse CB et al., 1997). Young children who cannot swallow
capsules or tablets needs to be benefitted by other alternative preparations appropriate for
pediatric dosing (Appendix13-4). Adherence to the prescribed medications will depend on the
involvement of parents or guardians, and support provided to them.

B. Non-Occupational Exposure to HIV

The risk of HIV transmission per-contact from sexual exposure varies according to the nature of
the exposure. The estimated risk is 1 to 30% with receptive anal intercourse; 0.1 to 10.0% with
insertive anal intercourse and receptive vaginal intercourse; and 0.1 to 1.0% with
insertive vaginal intercourse (CDC DHHS guideline on PEP, 2005; Powers KA et al., 2008;
Boily MC et al., 2009). As compared to other forms of intercourse, oral intercourse is

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considered to pose a lower risk of HIV transmission although good risk estimates are
lacking and there are case reports of HIV infections in persons in whom the only reported risk
factor was oral intercourse (Lifson AR et al., 1990).

Evaluation of Persons Seeking Care after Potential Non- Occupational

Exposure to HIV

When deciding whether to recommend the initiation of PEP, the clinician should assess and
carefully weigh the following factors (see Box 1-13-1):

Box 1-13-1: Elements of assessment to determine whether PEP is indicated

Risk Behavior*:
Did exposure to potentially HIV-infected blood or body fluid occur?

If yes, Was the exposure an isolated or episodic event, or result of habitual behavior?

Degree of Transmission Risk Based on Type of Exposure:

What was the route of exposure?

Are factors present that are known to further increase transmission risk?

Exposure Source:

Is the source known to be HIV infected? **

If HIV status of the source is unknown, what is the likelihood of the source being HIV Infected?
* Assessment of the behavioral factors and circumstances that led to HIV exposure includes: emotional,
psychological and social factors that contribute to risk behavior such as depression, history of sexual
abuse, and drug and alcohol use.

**If the source is known to be HIV infected, information about his/her CD4 count, viral load, ARV
medication history, and history of ARV drug resistance should be obtained when possible to assist in
selection of a PEP regimen.

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 Table 13.0-10 Considerations of nPEP According to the type of risk exposure

Types of exposures that do not warrant Types of exposures that should prompt
PEP considerations of PEP
 Human bites not involved with blood  Unprotected receptive and insertive vaginal or anal
 Exposure to sharps and needles not in intercourse with a source that is HIV-infected or at
contact with an HIV infected or at risk risk for HIV infection
person  Unprotected receptive penile-oral contact with
 Mutual masturbation without skin break ejaculation with a source that is HIV infected or at risk
Oral-anal contact of HIV infection
 Receptive penile–oral contact without  Oral-vaginal contact with blood exposure
ejaculation  Needle sharing with a source known to be HIV
 Insertive penile-oral contact infected or at risk for HIV infection
 Oral-vaginal contact without blood  Injuries with exposure to blood from a source known
exposure to be HIV infected or at risk for HIV infection
(including needle sticks, human bites and accidents)
This risk estimate considers many factors, including source viral load, presence of STDs and presence of
ejaculates. It is prudent to recommend PEP for receptive oral sex with ejaculation although discussion about
the conflicting data should occur

II. Exposure to Hepatitis B Virus

HBV infection is a well-recognized occupational risk for HCP (Mast EE et al., 1993). The risk of
HBV infection is primarily related to the degree of contact with blood in the work place and also
to hepatitis B e antigen (HBeAg) status of the source person. In studies of HCP who sustained
injuries from needles contaminated with blood containing HBV, the risk of developing clinical
hepatitis, if the blood was both hepatitis B surface antigen (HBsAg) and HBeAg-positive was

22% to 31%; the risk of developing serologic evidence of HBV infection was 37% to 62%. By
comparison, the risk of developing clinical hepatitis from a needle contaminated with
HBsAg-positive, HBeAg-negative blood was 1% to 6%, while the risk of developing serologic
evidence of HBV infection was 23% to 37% (Werner BG et al., 1982).

Table 13.0-11 Recommended Post-Exposure Prophylaxis for Exposure to Hepatitis B Virus

321
 Vaccination and
antibody response Treatment
status Source Source Source unknown
HBsAg not available for
of exposed workers* HBsAg positive negative testing

Unvaccinated HBIG§ x 1 and initiate HB Initiate HB Initiate HB vaccine series

vaccine series vaccine series
Previously vaccinated

Known responder**
No treatment No treatment No treatment

HBIG x 1 and initiate

If known high risk treat as if
Non responder† revaccination source, or HBIG x No treatment
source were HbsAg positive
2 §§

Test exposed person for

Test exposed person for HBsab
HBsab 1. If adequate**, no
Antibody 1. If adequate**, no treatment is treatment is necessary
No treatment
response unknown necessary 2. If inadequate†,
2. If inadequate, administer administer vaccine and booster
HBIG x 1 vaccine booster and recheck titer in 1 to 2
months

It is recommended that healthcare workers should be vaccinated for HBV

III. Exposure to Hepatitis C Virus

The risk of HCV transmission from a percutaneous exposure is approximately 1.8% (Alter
MJ, 1997; Lanphear et al., BP 1994; Puro V et al., 1995; Mitsui T et al., 1992). HCV is rarely
transmitted from mucous membrane exposure to blood and it has never been documented as
occurring as a consequence of a blood exposure to intact or non-intact skin. Therefore, there
is no known PEP to HCV exposure. Nonetheless, a 2001 NEJM study found that treatment of
patients with acute HCV with interferon alpha-2b led to resolution of HCV viremia in 98% of
patients.

The CDC recommends follow-up testing for an exposure to HCV with anti-HCV
antibody testing within 4 to 6 months. So it is resolved that a positive antibody test should

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prompt HCV viral load and liver function tests. Once exposure is confirmed, the management
and follow up of non-occupational HCV exposure is similar to that of the occupational
exposure.

Post-Exposure Management Steps (HBV, HCV and HIV)

The aim of post-exposure reporting and follow-up is to start PEP as soon as possible, within 72
hours of exposure, if indicated. The key components of managing occupational exposure to
bloodborne pathogens are described below.

STEP 1 Time frame – immediately, within 30 minutes. Person responsible: Exposed HCW.

Provide immediate care to the exposure site:

 Wash the exposed skin and any wound with soap and water.
 Mucous membranes with water for 15 minutes.
 DO NOT use any antiseptic or caustic agents such as bleach.

After washing, immediately report the event to the person in charge of PEP management.
The information reported should include identification of the exposed person, date and
time of exposure, type of fluid and nature of exposure, and details about the source
person as recommended by national PEP guidelines.

STEP 2 Time frame – immediately after reporting. Person responsible: Physician, in-Charge of
PEP management determines the risk associated with exposure (see Table 1-13-5) by:

 Type of fluid (e.g., blood, visibly bloody fluid, other potentially infectious fluid or
tissue)
 Type of exposure (e.g., sharps injury, mucous membrane or non-intact skin
exposure, bites resulting in direct contact with infected blood) (CDC 2001)
 Infectious status of source (presence of HBSAg, HCV antibody, or HIV antibody)
 Susceptibility of exposed person (hepatitis B vaccine and vaccine response status,
HBV, HCV immune status)

Table 13.0-12 HIV Exposure Risk and Type of Exposure

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 Risk Type of Exposure

 Exposure to a small volume of blood or blood-contaminated fluids from

Low-risk asymptomatic HIV-positive patients
exposure  Following an injury with a solid needle
 Any superficial injury or mucocutaneous exposure

 Exposure to a large volume of blood or potentially infectious fluids or blood-

contaminated fluid
High-risk  Exposure to blood or body fluid from a patient with clinical AIDS or early
exposure seroconversion phase of HIV
 Injury with a hollow needle and/or deep and extensive injuries

STEP 3 Time frames – as soon as possible, preferably within 24 hours. Person responsible:
Physician, in-Charge of PEP management, HCW.

Evaluate the exposed HCW:

 Check history of hepatitis B vaccination (currently there is no vaccine for hepatitis C

or HIV).
 Determine immune and infection status of the exposed HCW.
For HBV, if not conducted previously, measure total hepatitis B core antibodies (anti-
HBc) and hepatitis B surface antibodies (anti-HBs)

For HCV, test for HCV antibodies (anti-HCV—a positive test means current or past
infection) and ALT (alanine aminotransferase).

If test is positive, test for viremia to confirm current infections.

For HIV, check status and history of previous HIV testing:

 Provide HIV pretest counseling.

 Offer HIV testing if the exposed HCW
 Provides informed consent.
 Offer HIV post-test counseling per the national counseling and testing guidelines.
 Refer to HIV care and treatment for those who test positive.

STEP 4 Time frame – as soon as possible, preferably within 24 hours, simultaneously with Step 3
above. Person responsible: In-Charge of PEP management, patient‘s treating physician.

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 Evaluate the exposure source:

 Obtain detailed information on clinical status of the source person.

 Determine vaccination and immune status of the source person:
 Test known source person for HBsAg.
 Test known source person for anti-HCV antibodies.
 Check known source person for HIV status and history of previous HIV testing.
 Conduct clinical assessment of known source person for HIV/AIDS.
 Provide HIV pretest counseling.
 Conduct HIV testing if the source person provides informed consent.
 Offer HIV post-test counseling per the national counseling and testing
guidelines.
 Refer to HIV care and treatment for those who test positive.

Table 13.0-13Determinant for Post-Exposure Prophylaxis for Occupational Exposure to HBV

Vaccination and Treatment

Antibody
Response Status
of Exposed Source HBsAga Source HBsAg Source Unknown or Not
Health Care Positive Negative Available for Testing
Worker
Previously vaccinated No treatment No treatment No treatment

HBIGb single dose and

Unvaccinated Full HB vaccination Full HB vaccination
full HB vaccination

Known responders No treatment No treatment No treatment

HBIG single dose and

Known non- If known high-risk source, manage
revaccination or second No treatment
responderd as if source were HBsAg positive
dose of HBIG

Test exposed person for

anti-HBse: Test exposed person for anti-HBs:

If adequate level, no If adequate, no treatment is

Antibody response
treatment is necessary; No treatment necessary;
unknown
if inadequate level, if inadequate, vaccine booster and
HBIG single dose and check titer in 1–2 months
HB vaccine booster
a
HBsAg: hepatitis B surface antigen

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b
HBIG: hepatitis B immunoglobulin
c
Known responder: a person who has an adequate level of serum antibody (anti-HBs ≥ 10 mIU/mL
d
Known non-responder: a person with inadequate response to vaccination (anti-HBs < 10 mIU/mL)
e
Anti-HBs: hepatitis B surface antibody

Source: CDC 2001.

STEP 5 Time frame – as soon as test results return (if any), must be within 72 hours from
exposure. Person responsible: Physician, In-Charge of PEP management, HCW.

Establish eligibility for PEP:

Refer to Table 13.0.12 to determine the PEP required for HBV exposure.

Parenteral or mucous membrane exposure (e.g., sexual exposure, splashes to the eye,
nose, or oral cavity)

Exposure to blood, blood-stained saliva, breast milk, genital secretions, or cerebrospinal,

amniotic, peritoneal, synovial, pericardial, or pleural fluids

PEP is not indicated if:

 The exposed HCW is known to be HIV-positive.

 The source person is HIV-negative.
 Exposure is limited to intact skin.
Testing the source person and the exposed HCW is helpful but it is not mandatory to
have either test results to initiate HIV PEP. The decision is sometimes based on an
individual‘s level of concern as well as background HIV prevalence.

STEP 6 Prescribe PEP: Time frame initiate PEP as early as possible but within 72 hours

 Continue ARVs for HIV for 28 days.

 Continue HBV vaccine schedule over 6 months
 Provide adherence counseling and address any drug interactions.
 Follow national guidelines or WHO recommendations for PEP

STEP 7 Time frame - 72 hours – 6 months after exposure. Person responsible: Physician, In
Charge of PEP Management, HCW.

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 Follow-up:

 Provide follow-up for adherence and any side effects of ARVs and address
questions that the individual may have.
 Arrange for an HIV test at 3 months after the exposure.
 Arrange for HBV vaccine at 1 and 6 months, if indicated.
 Link HIV care and treatment, including prevention measure for protecting others,
in case the HIV test results are positive.
 Provide additional counseling and other preventive interventions, as needed, and if
test results are negative.
Document all PEP provided, following facility and national guidelines.

Monitor PEP provision in the facility.

Documentation of PEP Service Given

Each person with occupational HIV exposure should report the incidence to his immediate
supervisor. Initial PEP management should be given with in the case team and the exposed
person is referred to the ART clinic for further follow up. Documentation of exposure and
management given should be done by using potential HIV exposure documentation and follow
up form (Appendix 1-13-5) which would be attached with the patient chart. The person who
gives PEP service should be trained on PEP service delivery (or a training with a PEP
management component) for he/she is responsible for completing the potential HIV exposure
documentation and follow up form (Appendix 1-13-5), attach it with the patient chart and utilize
the PEP decision- making tools (job aid) to determine indications for PEP and decide on the use
of two or three drug regimens.

If PEP is not indicated, the PEP trained service provider (preferably case team leader) will file
the completed Potential HIV exposure documentation and follow up form (Appendix 1-13-5) with
the patient chart and indicate to the exposed person that no further follow-up is needed. The
incident and the service given should also be documented on service register in the service outlet.

In the ART clinic, the persons getting PEP service will have a minimum of six follow up visits
and each time the patient comes for visit, HIV exposure documentation and follow up form
which is attached with the patient‘s chart and the PEP register (Appendix 1-13-6) placed in the

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ART clinic are updated. Documentation and reporting of PEP service given for non-occupational
exposure will be similar to that of occupational exposure.

Health Care Workers Infected with HIV and/or Hepatitis B or C

HCWs infected with HIV and/or HBV or HCV should inform the facility manager of their status.
The facility IPC team should strive to prevent transmission of infections to patients and at the
same time maintain the livelihood and privacy of the infected staff members. These HCWs
should not be prohibited from providing patient care if they are not performing invasive
procedures, the infection is well-controlled, they fully comply with recommended IPC practices,
and there are no other factors that would prevent them from safely carrying out the patient care
activities.

HCWs with these conditions should be closely followed up by a team of clinicians for periodical
clinical monitoring, to assess treatment response and viral suppression, when appropriate, and to
revise recommendations about duty restrictions accordingly. They should avoid performing
procedures that may result in increased risk of contact with large amounts of blood and body
fluids. There are no restrictions for those staff with viral loads less than designated levels.
(Henderson et al. 2010)

The Society of Healthcare Epidemiology of America (SHEA) has classified patient care and
clinical procedures into three different categories based on the risk of transmission of blood borne
pathogens:

Category I: Procedures with minimum risk of blood borne virus transmission

Clinical procedures and patient care activities that either do not involve touching patients (e.g.,
history taking, counseling) or are limited to touching patients‘ intact skin (e.g., performing
physical examinations) and mucous membranes (e.g., performing vaginal examinations,
performing some dental procedures, phlebotomy). It also includes minor surgical procedures with
very minimal exposure to patients‘ blood and body fluids (e.g., surface stitches, gastrointestinal
endoscopy procedures).

Category II: Procedures for which blood borne virus transmission is theoretically possible
but unlikely.

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Several surgical procedures are examples of such procedures, including ophthalmic surgery,
dental surgery that requires local anesthesia, minor oral surgical procedures, endoscopic and
arthroscopic procedures, provision of contraceptive methods, minor gynecological procedures,
starting of central lines, and medical male circumcisions.

Category III: Procedures for which there is definite risk of blood borne transmission

Procedures for which there is definite risk of blood borne transmission of viruses or that have
previously been classified as ―exposure-prone.‖ All major surgical procedures that involve a high
volume of blood and body fluids are Category III procedures with definite risk of exposure.
Examples of Category III procedures are: general surgery; oral surgery with difficult access for
suturing; emergency surgical procedures involving bleeding and exposure to a high volume of
blood; obstetric procedures, including cesarean section; and orthopedic surgeries. Any major
surgical procedure that goes beyond 3 hours and requires changing gloves should not include
staff members infected with blood borne pathogens.

Managing HCWs infected with HIV and/or hepatitis B or C

HCWs infected with blood borne pathogens whose viral load is below the minimum designated
level should follow a six-point plan described below to safely provide patient care and be
productive.

The HCWs should:

 Not have transmitted infection to any patient.

 Obtain advice from a team of clinicians about continuing to care for patients.
 Undergo testing twice a year to demonstrate the maintenance of a viral burden
below designated levels.
 Receive follow-up by a clinician with expertise in managing blood borne pathogen
infections and consent to share their results with the IPC/occupational health team at
the facility.

Consult closely with experts on the use of optimal IPC procedures:

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 A. This may include guidance on double gloving, changing gloves during procedures,
avoiding digital palpation of needle tips, and performing all procedures under direct
view. It also includes promptly withdrawing from a procedure if they have any injury
that bleeds and informing the IPC/occupational health team about any injuries.
B. Adhere strictly to recommended procedures, including the routine use of double
gloving for Category II (such as minor surgery) and Category III (such as major
surgery) procedures and frequent glove changes during procedures, particularly if
performing technical tasks that have a potential to compromise glove integrity.

Agree in writing to comply with recommendations and guidance of the expert clinicians as well
as the facility IPC/occupational health and management team.
Adapted from: Henderson et al. 2010.

Monitoring Prevention of Occupational Exposures and Injuries

Health care facilities should evaluate the effectiveness of occupational health interventions and
practices on a routine basis. They should conduct surveillance to collect, analyze, and
disseminate data on risks to HCWs. There should be a system to report any occupational
exposure and injury, which should be supported by prompt management and PEP. The rates of
injuries or exposures among HCWs should be routinely reviewed and reported back to the staff
and strategies and action plans to prevent future injuries should be developed and updated. (The
principles of surveillance are discussed in this document please refer Volume 2, Section 2,
Chapter 1)

Surveillance activities can be conducted by the staff organizing occupational health activities at
the facility and/or with the assistance of IPC staff.

Summary

In the course of their duties, millions of HCWs around the world are routinely exposed to a
variety of health and safety hazards, including infectious agents. Infections can be transmitted to
HCWs, who can in turn transmit the infections to patients and others. The goals of IPC intersect
with those of occupational health activities in preventing and addressing infectious hazards at

330
health care facilities. Therefore, IPC staff should be involved in occupational health activities at
the facility, and occupational health staff should be knowledgeable about IPC.

IPC elements of an occupational health program include surveillance, education, immunization,

and exposure prevention and response. Protection of staff by the application of Standard
Precautions to every patient, every time, and use of disease- or syndrome-specific Transmission-
Based Precautions to prevent exposures to infectious agents are essential to prevent occupational
exposures. Recommendations for managing specific occupational exposures and infections in
staff members are based on the epidemiology of infectious disease transmission in health care
facilities and they should target HCWs as potential sources or hosts. Special attention may be
needed for specific groups of employees with potential increased risk of exposure (laboratory,
pregnant, and emergency response personnel, and HCWs infected with HBV, HCV, and HIV).
Finally, the effectiveness of interventions to protect HCWs from occupational infection should be
evaluated. Monitoring progress and identifying causes, with feedback to key persons, can
enhance prevention activities.

CHAPTER 14: CLIENT EDUCATION ON INFECTION PREVENTION

AND CONTROL (IPC)
Key Topics

Significance of client education on IPC

Components of Effective client Education Program
Good Examples of Patient Education Program
Steps in client‘s education on IPC

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 Models of Client Education
Definition of Key Terms
Patient/Client Education: Patient Education is defined as a systematized process of transfer of
knowledge, skills, and attitude which empowers the patient, family, care giver and community to
actively participate in the promotion and maintenance of safe healthcare facility environment
Empowerment: WHO defines empowerment as ―a process through which people gain greater
control over decisions and actions affecting their health‖ and should be seen both as an individual
and a community process.

BACKGROUND
Educating and empowering patients and clients to actively participate in their care help reduce a
patient's risk of hospital acquired infections. Creating an open dialogue, however, can be a
challenge in today's healthcare system. So how can hospitals improve their patient education
programs and help patients become empowered and active in their treatment.

Four components have been reported as being fundamental to the process of patient/client
empowerment:

1. Patient understands of his/her own role;

2. Patient‘s acquisition o f sufficient knowledge on their ability to collaborate or involve
with their healthcare provider;
3. Patient‘s knowledge and skills; and
4. The presence of facilitating environment.

Based on these four components, empowerment can be defined as a process in which patients
understand their role, are given knowledge and skills by their health-care providers to perform
tasks cognizant of the community‘s socio-cultural differences and encourages patient participation

First, hospitals need to understand what accreditation standards require of hospitals. The Joint
Commission established certain standards to protect patients' rights and assist hospitals in patient
education. These standards, while broad, provide the framework for healthcare providers to
establish patient education practices.

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One of the EFDA (Ethiopian Food and Drug Administration) general standards for patient
education requires the hospital to provide patient education and training based on the patient's
needs. This includes conducting a learning needs assessment and then administers training to the
patient based on the assessment. The standard provides examples of what hospitals should train
patients on, including basic health practices and safety.

The information given to the patient should be appropriate for the patient's age, literacy level,
education, and language skills. Patient materials should be geared between sixth and eighth grade
reading levels. Use of medical terminology or jargon should be avoided.

With shorter lengths of stay and limited time for teaching, print and audiovisual materials are
important adjuncts for any discharge teaching plan. They are, however, just adjuncts and should
not replace individualized instruction. Printed materials are useful for reinforcing information
provided to patients while in the hospital and also serve as a ready resource. Printed material is an
important reminder of key points after patients return home.

Family members are the vital links in the transition from hospital to home care. Families must be
included in discussions and demonstrations. Family is any person who plays an important role in
the patient's life.

Every effort must be made to ensure that learning takes place in incremental steps and that
patients are not overwhelmed with too much information at one time.

Significance of Client Education on IPC

Although there are many unanswered questions on how to approach patient involvement in this
part of the guidelines, the WHO and World Alliance for Patient Safety are actively highlighting
the role that patients and their families could play in the improvement of healthcare.

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Actionable strategies are being developed with a strong emphasis on working in partnership with
healthcare authorities, partners and professionals.

They are the basis of infection control precautions which are to be used as a minimal expectation
in the care of all patients. For example, Hand hygiene is a major component of standard
precautions and one of the most effective methods to prevent transmission of pathogens
associated with healthcare. In addition to that, the use of personal protective equipment should be
guided by risk assessment and the extent of contact anticipated with blood and body fluids, or
pathogens. Supplementary to the practices carried out by health workers when providing care, all
individuals (including patients and visitors) should comply with infection control practices in
health care settings. The control of spread of pathogens from the source is the key to avoid
transmission. Among source control measures, those like respiratory hygiene/cough etiquette
which developed during the severe acute respiratory syndrome (SARS) outbreak have now been
considered part of standard precautions.

Worldwide escalation of the use of standard precautions would reduce unnecessary risks
associated with healthcare promotion of an institutional safety climate helps to improve
conformity with recommended measures. Thus, subsequent risk reduction, provision of adequate
staff and supplies, together with leadership and education of health workers, patients and visitors
are critical for an enhanced safety climate in healthcare settings.

Healthcare associated infection is a major issue in patient safety. Hand hygiene is one of the
primary measures to prevent healthcare associated infection and limit the spread of antimicrobial
resistance. However, for Hand hygiene to be promoted and practiced, patient participation is
quite an important element of the strategy. Studies undertaken on the effects of patient education,
confirmed that health education is a dependable instrument to increase staff adherence with hand
washing. Given that support from healthcare workers is crucial for success, the first and most
important step is to enlist their full and enthusiastic support. A major educational campaign using
expressive patients when possible may be needed to convince physicians and nurses of the
value of patient participation.

The objective is to help healthcare workers recognize the contribution of patients and their
families to the healing process and to be receptive to patient input. This campaign must be

334
designed to take into account the numerous healthcare providers related obstacles to patient
participation (e.g. perception of lack of time and their level of training in the patient-care giver
relationship). Once healthcare workers are ―on board,‖ educational programs for patients must be
offered so that they have the knowledge required to participate.

The strategy also emphasizes that while educating patients, the healthcare provider needs to
understand the legitimacy and relevance of patient involvement and be convinced of the
effectiveness of involving patients. While involving patients, numerous patient-related factors
known to influence patient participation must be addressed and overcome. Although they are not
modifiable, socio- demographic factors (e.g. age, disease severity, and ethnicity) must also be
taken into account. When both the healthcare worker`s and the patient‘s support are secured,
positive feedback will emerge from the patients and contribute to the safety of healthcare.

Components of Effective Client Education Program

1. Have clear policies and procedures in place that guide proper implementation of patient
education and empowerment.
2. Have a clear assignment of roles and responsibilities for all steps in patient education
process to qualified individuals within a context of shared responsibility and accountability.
The list is inclusive of the patient‘s primary care provider, other physicians, nurses,
pharmacists and other clinicians. The qualifications of the responsible individuals should
be determined by the healthcare organization within the limits of applicable law and
regulation.
3. Incorporate training on procedures and basic principle for patient education into the
educational curricula, orientation and continuing professional development activities for
healthcare professionals.
4. Develop and include an evaluation component that includes using both qualitative and
quantitative measures to determine not only what works, but under what conditions and
within which organizational context the program works.
5. Background of evidences on effective patient/client education program

335
A program in which there is some evidence of empowering of patients and HCWs are usually
part of the multifaceted approach and it includes one or all of the following: educational tools,
motivation tools, and role modeling.

For example, education on Hand hygiene on admission to the hospital could be designed in such
a way that it encompasses the above four components. With respect to hand-hygiene,
educational program for patient/staff empowerment and improvement can be categorized as:
educational (can include Internet), motivational (reminders/posters), and role modeling within the
context of a multimodal approach.

Good Example of Patient Educational Program

Example 1

In addressing infection prevention through Hand hygiene, it is very important that the
administration ensure they have clear policies and procedures in place which require:

• Provision of education on the Hand hygiene on admission of the patient to the hospital,
• Display of reminders of Hand hygiene in a consistent and conspicuous location (for
example, the patient‘s sink) so that it is easily accessible to patients and their family care
givers.
• Information on Hand hygiene for patients can be designed in the form of printed matter,
an oral demonstration, or audiovisual means. Hand hygiene and other educational
reminders should be displayed in a consistent and highly noticeable location.

Example 2

The steps of patient participation orientation in the hospital following surgery are:

336
 • Wash your hands carefully after handling any type of soiled material. This is especially
important after you have gone to the bathroom.
• Since you are part of your healthcare team, do not be afraid to remind doctors and nurses
about washing their hands before working with you.
• If you have an intravenous catheter, keep the skin around the dressing clean and dry. Tell
your nurse promptly if the dressing become loose or gets wet.
• Likewise, if you have a dressing on the wound, let your nurse know promptly if it became
loose or gets wet.
• If you have any type of catheter or drainage tube, let your nurse know promptly if it
becomes loose or dislodged.
• Carefully follow your doctor‘s instructions regarding breathing treatments and getting out
of bed. Don‘t be afraid to ask for help, advice, or sufficient pain medications!
• If possible, ask your friends and relatives not to visit you if they themselves feel ill.

Six Key points that allow patients to be more actively involved in their own care

1. Share vit al information with all caregivers, including all medicines, allergies, and
ailments.
2. Ask questions about health problems and care.
3. Ask for help from family and friends.
4. Express your concerns.
5. Alert caregivers if your symptoms change.
6. Pay close attention to instructions.

Advised techniques for patient Educators (HCWs/community workers):

1. Slow down communication can be improved by speaking slowly and by spending just
a small amount of additional time with each patient. This will help foster a patient-centered
approach to the clinician-patient interaction.
2. Use plain, non-medical languages explain things to patients as you would explain them
to your grandmother.
3. Show or draw pictures because visual images can improve the patient‘s recall of ideas.

337
4. Limit the amount of information provided and repeat it. Information is best
remembered when it is given in small pieces that are pertinent to the tasks at hand.
Repetition further enhances recall.
5. Use of the “teach-back” technique re-confirms that patients really understood
learning items taught before by asking them to repeat back your instructions.
6. Create a shame-free environment make patients feel comfortable to ask questions.
Include other supporters of patients (patient‘s family or friends) to promote understanding.
In spite of the fact that a great deal of attention focuses on written materials suitable for low
literacy audiences, non-written materials can also be effective patient education tools. These
non- written materials include graphic illustrations such as pictures, pictographs, and
models, along with audiotapes, videotapes, and various forms of computer-assisted learning
applications. Studies in the area tend to be supportive of the use of this alternative and are
stressing on the effectiveness of these non-written modalities and their supremacy
over written materials for patients with limited literacy.

Steps in Clients Education

1. Make the patient comfortable

The general standard on patient education also requires that the hospital provide the patient
with education on how to communicate concerns about patient safety issues. Patients may feel
cautious or apprehensive about asking questions because they do not want to be considered a
tough patient but encouraging them to speak up can go a long way in preventing infections.

Healthcare providers can help ease some of that apprehension by routinely asking patients if
they have any questions or concerns, they want to discuss. By asking them first you open a
whole new line of communication, making the patient more willing to come forward if he or
she notices a change.

It is very difficult for the patient to have the courage to speak up unless they are invited to
speak up by the system. When patients do speak up thank them for raising a concern even if it
leads to nothing. Once again this will help them feel more at ease and comfortable bringing up
issues in the future.

338
 Encourage patients to also advocate either a family member or someone else who can help
look out for potential risks. These advocates can also look out for variations in practice and
may notice changes in the patient before healthcare providers see a difference.

Very often the patient is not only reluctant to speak up but they're not feeling well, or they
may have trouble communicating for a variety of reasons, so that third party is vital.

2. Help the patient become an active participant

Talk to the patient about what he or she can do to optimize care, instead of focusing solely on
what the healthcare provider is going to do for the patient. Patients want to be involved in their
care. They want to be an active participant. And family members want to be involved in any
way they can.

Encourage the patient to ask questions regarding his or her treatment. Urinary tract infections
and central line infections are common in hospitals and can be costly to the patient. When it
comes to certain things like catheters assure patients that they can ask doctors and nurses, like
"Is it essential for my care? Educating the patient on these practices may reduce the risk of
infection by eliminating a potential threat.

3. Let patients know what their care should look like as well

"A lot of bad things in healthcare happen because of the variation in practice," "If we can
encourage patients to know what to expect then they can identify a variation in practice that is
exposing them to a potential risk."

Educate the patient on what dressings or catheters need to be changed on a daily basis and
what the process looks like. Showing the patient what to expect and what techniques help
prevent infections empowers him or her to look out for potential risks when shifts change and
someone else begins changing his or her dressings.

4. Don't forget about high-risk patients.

Hospitals need to improve their patient education and infection control training with high risk
patients.

339
 "There are a number of patients out there who have diabetes, and if there are significant
changes in their blood sugar that can increase their chances of infection, whether they are in
the hospital or not.

For patients at a higher risk of infection, such as those who are diabetic, taking immune
suppressive drugs, overweight or smokers, healthcare providers need to discuss how these
issues heighten their risk for infection. Patients in the intensive care unit are also considered
high risk. Healthcare providers should encourage ICU patients to get up and out of bed.

5. Understand the patient's rights of education

According to EFDA standards, the patient possesses the right to receive information in a
manner in which the patient understands. In certain cases the hospital may need to provide
interpreting or translation services to accommodate the patient's communication needs. These
needs should be determined during the initial learning needs assessment.

Models of Client Education:

Reminders and Motivational Messages

Patient empowerment models often include visual reminders for both the HCW and the patient.
These visual reminders usually include small badges or stickers worn by patients with a message
such as ―did you wash/sanitize your hands?‖ If the message is framed correctly, posters can serve
as a visual reminder and encouragement for both the patient and the HCW to participate in
hygiene practices of the hands. Educational videos, posters, brochures, and visual reminders
targeting on the education of HCWs and patients were evaluated in three long-term care facilities
as part of a comprehensive program of Hand hygiene. This combination of HCW education and
patient empowerment resulted in an aggregate increase in the compliance with Hand hygiene to
bring about 52% and 32% of decrement in infections.

Role modeling

340
Role modeling in which the HCW‘s behavior towards Hand hygiene or other positive behavior is
influenced by either peers or superiors has been observed to influence compliance and motivation
of the patient to be empowered.

Graphic illustrations (pictures, pictographs, models)

Research has shown that using pictures including cartoons or pictographs with verbal
explanations and use of models can greatly increase patient‘s understanding and retention of
information. In a recent study, the mean correct recall of information was found to be 85% with
pictographs and 14% without it. Another study found that patients receiving wound care
instructions with cartoons were able to answer questions correctly 46% of the time when tested
three days later compared to only 6% of patients who received only written instructions and
answered questions correctly.

Summary
Educating and empowering patients and clients to actively participate in their care help reduce a
patient's risk of hospital acquired infections. Actionable strategies are being developed with a
strong emphasis on working in partnership with healthcare authorities, partners and professionals.
They are the basis of infection control precautions which are to be used as a minimal expectation
in the care of all patients. For example, Hand hygiene is a major component of standard
precautions and one of the most effective methods to prevent transmission of pathogens associated
with healthcare. In addition to that, the use of personal protective equipment should be guided by
risk assessment and the extent of contact anticipated with blood and body fluids, or pathogens.
Supplementary to the practices carried out by health workers when providing care, all individuals
(including patients and visitors) should comply with infection control practices in health care
settings.

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341
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APPENDIX

Appendix 4A: Sample Hand Hygiene Observation Form: World Health

Organization
Source: WHO 2009e.

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Source: WHO 2009e.

363
Source: WHO 2009e.

364
Source: WHO 2009e.

Appendix 4B Sample Hand Hygiene Observation Form Modified for Room

Entry and Exit
FOUR rules for conducting Hand Hygiene Observations
1. Observe for hand hygiene upon ENTRY and EXIT from Patient Environment
Patient Environment definition:
Private or semi-private room: Crossing room door
Between patients and multi-patient rooms setting: Crossing the ―curtain line‖
2. A provider may use the Alcohol-Based Hand Rub (ABHR) dispenser just outside the room door, inside the
room, at the sink, or the health care worker‘s personal ABHR bottle.
3. DO NOT GUESS. If your view is blocked and you cannot confirm if provider performed hand hygiene, simply
check ―Unsure‖ box.
4. Do not exceed 3 observations per provider in one session.

UNIT:______________________ DATE:____/_____/____ DAY OF

WEEK:_______________
TIME: ________ TO OBSERVER NAME:
__________ __________________________________________
Role of Observed Person Hand Observed Behavior
Hygiene
Other
Other Providers (nursing,

1=Unknown
Hand wash with soap and
Pharmacist/Laboratory

students, and residents)

Physicians (all doctors)

2=Clinical
Hand cleaning with
medical and other
CO/PA/Dentist**

No hand hygiene
procedure
Support Staff

Area location
Not observed

3=Transport
Technician
Midwife
Nurse*

Circle
ABHR

4=Nursing
water
Obs #

care ONE
5=Blood
sample
collection
6= Nutrition
7= Admin
ENTRY
EXIT
ENTRY
EXIT
ENTRY
EXIT

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 ENTRY
EXIT
ENTRY
EXIT
ENTRY
EXIT
ENTRY
EXIT
* All types of nursing staff including diploma, degree, post-graduate, supervisor, and assistant.
** CO=Clinical Officer, PA=Physician Assistant.
Adapted from: Johns Hopkins Medicine. Hospital Epidemiology and Infection Control. JHH Hand Hygiene
Compliance Data Collection Form. http://www.hopkinsmedicine.org/heic/docs/HH_observation_form.pdf

Appendix 4C: Implementation of a Multimodal Hand Hygiene Improvement

Strategy
As discussed in this Hand Hygiene chapter, the WHO Multimodal Hand Hygiene Improvement
Strategy identifies five key steps to implement a hand hygiene improvement strategy (see Steps 1–
5 below). The implementation strategy was developed based on a literature review of the
implementation science, behavioral change, spread methodology, diffusion of innovation, and
impact evaluation (WHO 2009a). For detailed information on assessing the economic impact of
hand hygiene promotion, refer to WHO Guidelines on Hand Hygiene in Health Care.

It is important to note that although each step within the process builds upon activities occurring in
previous steps, it should be considered a cyclical process rather than a linear one. Each step of the
cycle should be repeated, refined, and enhanced at least every 5 years in order to maximize the
impact of the hand hygiene program. (WHO 2009a; WHO 2009f)

Step 1: Facility Preparedness

Suggested duration: 3 months

Step 1 in the hand hygiene improvement strategy is to evaluate and prepare the facility for the
program. To have a successful hand hygiene program, careful planning is required from the start of
the program. During Step 1, it is imperative to map out a clear strategy for the entire program.

Step 1: Key Activities in Facility Preparedness

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 Key Activities
Identify coordinator.
Identify key individuals/groups.
Undertake a situation analysis of hand hygiene practices at the facility.2
Complete ABHR production, planning, and costing tool.
Train observers/trainers.
Procure raw materials for ABHR (if necessary).
Collect data on costs/benefits of hand hygiene improvement program: costs of program
versus reductions in costs of managing hospital acquired infections.
Undertake training on data entry and analysis.
Steps 1–5 Reproduced from: WHO Guidelines on Hand Hygiene in Health Care, page 119. © World Health (2009):
http://apps.who.int/iris/bitstream/10665/44102/1/9789241597906_eng.pdf. Accessed May 6, 2016.

Step 2: Baseline Evaluation

Suggested duration: 2–3 months

Step 2 includes the baseline evaluation of hand hygiene practices, perceptions, knowledge, and
available infrastructure within the health care facility.

Hand hygiene is the most effective way of preventing the transmission of infections and it is
imperative to collect data on HCWs‘ perception on the importance of hand hygiene. These
perceptions, as well as other factors influencing compliance, will provide valuable information for
strategy development. Changing perceptions can be the means by which improvements in hand
hygiene practices are achieved. Similarly, assessing the infrastructure of the health care facility
may help explain current hand hygiene practices and will guide improvement efforts. Lack of
access to sinks, running water, and ABHR may all contribute to low hand hygiene compliance and
should be addressed during the implementation planning step.

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Step 2: Key Activities in Baseline Evaluation

Key Activities
Undertake baseline assessments:
Senior manager perception survey
HCW perceptions survey
Ward structure survey
HCW knowledge survey
Begin local production or market procurement of ABHR.
Conduct hand hygiene observations.
Monitor use of soap and ABHR.
Perform data entry and analysis.

Step 3: Implementation
Suggested duration: 3–4 months

Step 3 is implementation of the planned program. Availability of ABHR at the point of care and
education and training for HCWs are crucial to the success of this step. Health care facilities may
choose to hold a high-profile launch event to coincide with the start of the program‘s
implementation. Publicizing leadership endorsement and support also helps foster a successful
implementation stage (WHO 2009a). During implementation, it is also important to evaluate
HCWs‘ tolerance and acceptance of ABHR. Monthly collection of hand hygiene observations
should continue during implementation, if possible. If time and resources are limited, observations
should occur only during Step 2 and Step 4.

Step 3: Key Activities in Implementation

Key Activities
Launch the strategy.
Provide feedback on baseline data.
Distribute posters.
Distribute ABHR.
Distribute other WHO materials from the Pilot Implementation Pack.
Educate HCWs.

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Undertake practical training of HCWs.
Undertake ABHR tolerance tests.
Complete monthly monitoring of usage of products.

Step 4: Follow-Up Evaluation

Suggested duration: 2–3 months

Step 4 is the evaluation of the short-term impact of the hand hygiene improvement strategy. By
performing a follow-up evaluation, facilities will gain information they can use to make future
decisions and take actions related to the hand hygiene program. Compliance with hand hygiene
practices among HCWs is the main indicator that should be evaluated. It is important to note that
hand hygiene improvement activities should continue in the health care facility according to the
local action plan, even during this evaluation step.

WHO has identified the following as key success indicators in the evaluation of the short-term
impact of a hand hygiene program:

 Increase in hand hygiene compliance

 Improvement in infection control/hand hygiene structures
 Increase in usage of hand hygiene products
 Improved perception of hand hygiene
 Improved knowledge of hand hygiene

The data collected during this evaluation will help shape future actions and the steps the health
care facility may take to maintain high hand hygiene compliance rates over time.

Step 4: Key Activities in Follow-Up Evaluation

Key Activities
Undertake follow-up assessments:
HCW knowledge survey
Senior executive manager perception survey
HCW perception and campaign evaluation survey
Facility situation analysis

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Conduct data entry and analysis.
Conduct hand hygiene observations.
Continue monthly monitoring of use of products.

Step 5: Developing Ongoing Action Plan and Review Cycle

Suggested duration: 2–3 months

Step 5 is to develop an ongoing action plan and review cycle. The goal of the hand hygiene
program is to create an environment in which performing appropriate hand hygiene is central to the
facility‘s culture. Reviewing the results of the data and creating a final report detailing the results
of the improvement program will help condense the findings and will aid in creating a future
action plan. Enthusiasm and motivation for the program must remain high in order to have long-
term impacts.

Step 5: Key Activities in Developing an Ongoing Action Plan and Review Cycle

Key Activities
Study all results carefully.
Provide follow-up data.
Develop a 5-year action plan.
Consider scale-up of the strategy.

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Appendix13A: Initial Management of a Person Reporting Exposure to
Potentially Infectious Body Fluids
The initial management should aim at reducing time of contact with the source person‘s blood, body
fluids or tissues and to clean and decontaminate the site of the exposure.

If the skin is broken following an injury with a used needle or sharp instrument, the following is
recommended:

 Do not squeeze or rub the injury site.

 Wash the site immediately using soap or a mild disinfectant solution (like
Chlorhexidine Gluconate solution or 70 to 80% alcohol solution) not irritating to the skin. If
running water is not available, clean the site with a gel or other hand-cleaning solution or whatever
is customarily available.
 Do not use strong solutions, such as bleach or Iodine to clean the site as these may irritate the
wound and make the injury worse.

After a splash of blood or body fluids, the following is recommended. After a splash contacts with
unbroken skin, do the following:

 Wash the area immediately.

 If, running water is not available, clean the area with a gel or other hand rub solution or whatever is
customarily available.
 Do not use strong disinfectants.

After a splash contacts with the eye, do the following:

 Irrigate the exposed eye immediately with water or normal saline.

 Sit in a chair, tilt the head back and have a colleague gently pour water or normal saline over the
eye pulling the eyelids up and down to make sure the eye is cleaned thoroughly.
 If contact lenses are worn, leave these in place while irrigating the eye as they form a barrier
over the eye and will help protect it. Once the eye has been cleaned, remove the contact lenses and
clean them in the normal manner. This will make them safe to wear again.
 Do not use soap or disinfectant on the eye.

After a splash contacts with the mouth, do the following:

 Spit the fluid out immediately.

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  Rinse the mouth thoroughly using water or saline, and spit again. Repeat this process several times.
 Do not use soap or disinfectant in the mouth.

Appendix 13B: Summary of Steps in Clinical Management of HIV Post-

Exposure Prophylaxis
Item Recommended action and notes
 First aid, assess the type and severity of exposure, use decision making tools to assess the
 exposure and decide eligibility for PEP
Person reports  Fill the Potential HIV exposure documentation and PEP follow up form (Appendix 1-13-6).
Exposure  This form should be filled for every exposure despite the eligibility for PEP

 Eligible if the following four criteria are fulfilled:

Eligibility  Exposure within 72 hours
 Exposed individual not known to be infected with HIV Significant exposure
 Person who was the source of exposure is HIV infected or has unknown HIV status
 Information about risks and benefits of PEP
Informed consent  Health education and counseling on adherence; side effects; risk reduction; trauma or
for  mental health problems; and social support and safety (both occupational and non-
occupational)
post-exposure  Consent may be given verbally
 Base line HIV testing of the exposed person
Prophylaxis,  Give IEC materials with local language

 Rapid HIV test of the source person, if feasible and based on informed consent and
 standard operating procedures, also
Additional  consider testing the source patient for HBV and HCV (if available)
laboratory  Pregnancy testing of exposed person if there the person is female in reproductive age group
 Hemoglobin (for zidovudine-containing PEP regimens) Hepatitis B and C screening if available
evaluations

 Medicine Two nucleoside-analogue reverse-transcriptase inhibitors + /- boosted protease

Medicine inhibitor
 Give doses of ARVs enough for 3 to 5 days (starter packs)

 The initial dose of antiretroviral medicines should be given as soon as possible but not later than
Time to initiation
72 hours after exposure
Duration of  28 days
herapy

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  The person started on PEP need to be informed report to the ART clinic in the next working
day for further follow up.
 The exposed person should have a minimum of 6 visits to the ART clinic up to the sixth month
HIV testing.
Link to ART clinic
 In the ART clinic: Assess and manage side effects, Assess and support adherence
and subsequent
 Give continued health education and counseling on side effects; on the importance of treatment
follow up there
completion with good adherence, risk reduction; trauma or mental health problems; and social
support and safety (both occupational and non-occupational) in the first ART clinic visit, at 2
weeks and at 4 weeks.
 Do Follow-up HIV testing 6 weeks, 3 months and 6 months after exposure

Referral  Intra facility and inter facility referrals as appropriate

Record-keeping  Maintain accurate and confidential records

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Appendix 13C: Facilitating Informed Patient Decision Making For HIV Post-
Exposure Prophylaxis
In the process of giving health education and counseling for HIV post-exposure prophylaxis, people
who have been exposed to HIV must be made fully aware of the following:

 The risk of acquiring HIV infection from the specific exposure;

 About the efficacy of PEP;
 The importance of taking a HIV test and of receiving appropriate post-test counseling before
starting PEP drugs;
 The possibility that they might already be infected with HIV will need to be assessed if they have
not already had an HIV test;
 People already living with HIV should be referred to the ART clinic for treatment of their
infection, and if they had started PEP, the medicine should be stopped when the diagnosis is
confirmed;
 The importance of adhering to medicine;
 The duration of the course of medicine (four weeks);
 The common side effects that may be experienced while taking PEP medicine and possible drug
interactions.
 Exposed persons should be advised to avoid blood or tissue donations, breastfeeding, or
pregnancy to prevent secondary transmission, especially during the first 6 to 12 weeks post
exposure.
 PEP medicine can be taken during pregnancy and may protect the mother from getting HIV
infection after exposure;
 That continuing to breastfeed while taking PEP is safe although the risk of transmitting HIV
through breastfeeding is higher at the early stage of infection if the women get infected by HIV
while breastfeeding; appropriate counseling.
 Discuss safe alternatives to breastfeeding if they are acceptable, feasible, affordable and
sustainable; and
 Exclusive breastfeeding is strongly recommended whenever alternatives are not possible.
 Information provided as part of the informed consent process should be appropriate to the person‘s
age, literacy skills and level of education and should take into account the context of the exposure.
 The consenting person must be able to understand the risks and benefits of the proposed
intervention (PEP).

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Appendix 13D: Pediatrics PEP Doses
Regimen Pediatrics PEP Doses
1. Two drug PEP:
A AZT + 3TC
B D4T + 3TC (if HB is < 7gm/dl)
2. Three drug PEP:
A AZT + 3TC + LVP/r
B D4T + 3TC + LPV/r (if HB < & 7 gm/dl)
Dose Formulation
0-4 wks: 4 mg/kg/dose PO BID Syrup: 10mg/ml
Capsules: 100mg
4wks-12yrs: 180-240mg/m2/dose PO BID Tablet: 300mg
1. AZT Combvir (AZT/3TC):
>/=13yrs: 300mg PO BID 300mg/150mg

0-4wks: 2mg/kg/dose PO BID

Syrup: 10mg/ml
Tablet: 150mg
2. 3TC >/=4wks: 4mg/kg/dose PO BID Combvir (AZT/3TC):
300mg/150mg
>13 yrs: 150 mg PO BID

< 30 Kg: 1mg/kg/dose PO BID

Syrup: 1mg/ml
3. D4T >/= 30mg: 30mg PO BID Capsules: 15mg, 30mg

Syrup:
LPV:m230mg/m2/dose LPV/r=400mg/100mg in
5ml
4. LPV/r r: 57.5mg/m2/dose PO BID LPV/r = 80mg/ml/2omg/ml
Capsule: LPV/r=133.3/33.3

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Appendix 13E: Post Exposure Prophylaxis Follow up Card Legend
Facility Name: Write the name of the hospital or health center. Date: Date clients‘ exposure reported in Ethiopian calendar (dd/mm/yyyy). Medical Record
Number/Card Number: A number given by the facility main chart room. For HMIS sites, this number is medical record number and for the other sites it is card
number. Patient Name: Write patient full name. Age: Write age of the client in years Sex: Put a check mark on F for female and on M for Male. Occupation: Occupation
of the exposed client (e.g. Nurse, physician, teacher, etc.). Address: This information is helpful for tracking patients. Write the full address of the client in the
spaces provided Visits: A follow up visits in the ART clinic. First the baseline information on the heading portion will be completed by the health worker who first
encountered the exposed cases. The visits days/weeks are estimated from the first date the exposed person appears to the health facility. E.g. first visit is 1-3 days after
initial presentation of the exposed case to the health facility. Write the number of hours elapsed between time of exposure and time of reporting in hours

Date of Visit HIV status of source case Exposure status

Enter date of visit in Ethiopian Calendar in Put a check mark on Reactive or Non- c) Hollow needle deep prick
dd/mm/yyyy format Reactive if the HIV status of the source case is d) Hollow needle superficial prick
known. If Unknown select Unknown e) Solid needle deep prick
f) Solid needle scratch
g) Splash to the conjunctivae
Circumstance of injury: h) Splash to the oral cavity
i) Splash to intact skin
a) Trying to secure intravenous line j) Splash to broken skin
b) Needle stick injury during surgery Source code k) Other (specify) cut injury with a surgical blades etc.....
c) Needle stick while disposing of SC negative: HIV Negative
waste SC1: HIV positive; Asymptomatic/High CD4
d) Amniotic fluid splash during SC2: HIV positive: Advanced disease/patient
on antiretroviral therapy/primary Exposure type: Non-Occupational
delivery
1. Sexual assault
e) Splash with body cavity fluids infection/low CD4
2. Pediatric exposures
during procedure SC unknown: HIV status unknown or source 3. Non HCW care givers
f) Other (specify: Cut injury with a unknown 4. Unanticipated high risk exposure (consensual
surgical blade while doing a sexual activity)
surgical procedure 5. Condom tears
Exposure code: Occupational 6. Road traffic accident
Exposure Code Mucous 7. Other (specify) e.g. Community fight, bite
Membrane
EC1= Few drops and short duration Adherence grading

EC2= Several drops /long duration/

major blood splash
Percutaneous
EC2= Solid and Superficial scratch
EC3= Hollow needle deep puncture

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Appendix 13F: Post Exposure Prophylaxis Follow up Card Legend (Cont‟d…)
General counseling on PEP includes Adherence % of missed/mon # of missed
dose per month
The risk of acquiring HIV infection due
exposure
The efficacy of PEP
The importance of having a base line and
follow up HIV test
The importance of adherence to PEP drugs
Advice to avoid secondary transmission to
other people in case the exposed person
becomes HIV positive due to exposure G(good) >95 ≤ 3 doses
F(fair) %
85‐94% 5‐8 dose
P(poor) <85 ≥ 9 doses
Counseling on: %
Types of regimen given:
d4T/3TC or AZT/3TC (CBV) or
The risk of acquiring HIV infection due TDF/3TC
exposure d4T/3TC/LPV/r
The efficacy of PEP
AZT/3TC/LPV/r
The importance of having a base line
and follow up HIV test Drug side effectsTDF/3TC/LP
The importance of adherence to PEP drugs; 1. Nausea 7.V/r
Anemia
The duration of the course of medicine 2. Diarrhea 8. Abdominal pain
(four weeks); 3. Fatigue AZT/3TC/E
9. Jaundice
The common side effects of PEP drugs 4. Headache 10.
FVFat changes
Advice to avoid secondary transmission 5.Numbness/tingling 11. Dizzy, anxiety, night
6. Rash mare
to other people in case
12. Other(specify)

Remark: one may use the table to show any other additional information (e.g. linkage to HIV care or other support, tracking, lost
dead etc.)

377
Appendix 13G: Post Exposure Prophylaxis Follow up Card Legend (Cont‟d…)
Post Exposure Prophylaxis Follow up Card:
Patient Name: Age: Sex: □M □F Occupation
Address: Region: Sub-city/Woreda:
Kebele: House # Tel:
Exposure status:(a-i) Other specify: Circumstance of injury: Select a letter from the lists(a-e)
other(specify): Number of hours elapsed after exposure: hrs
HIV status of source case: □ Reactive □Non-Reactive □ Unknown, If Reactive, Source code □ 1 □ 2 Exposure code: □1 □ 2 □ 3
Baseline HIV status of exposed person: □ Reactive □ Non-Reactive □ Not done If female, pregnancy test: □ Positive □ Negative
For Non-occupational exposure: □Sexual violence/rape □ Other(specify)
PEP Eligibility: □ Eligible □ Not Eligible Type of PEP regimen provided :
Visits Follow up information
Measures taken in e.g.
cases of poor adherence and Remark (tracking
Fill the pt and Next
drug side effect, additional PEP of clients lost to
service status as Appointment date
drugs prescribed for 2 weeks, follow up, etc)
indicated
linkages to other services etc.
Baseline info complete (Y/N)
General counseling on PEP(Y/N)
st
1 Visit Adherence (G/F/P)
( 2-3 days) Drug side effects (1-12)
Adherence (G/F/P)
nd
2 visit Drug side effects (1-12)
(2 weeks) General counseling on PEP
Adherence (G/F/P)
Visits in the ART
Drug side effects (1-12)
Clinic
rd
3 visit Treatment completed(Yes/No)
(4 weeks) Reinforce counseling on PEP
th
4 visit General counseling on PEP
(6weeks) HIV test result(N/NR)
th
5 visit HIV test result(N/NR)
(3 month) General counseling on PEP
th
6 visit HIV test result(N/NR)
(6 month) General counseling on PEP

378
Appendix 13H: Occupational and Non-Occupational HIV Post Exposure Prophylaxis Register
Instructions for PEP register:
Serial Number (SN): A number assigned to patients on the register (e.g. 1, 2, 3, etc)
MRN/Card Number: A number given by the facility main chart room. For HMIS sites, this number is medical record number and for the other sites it is card
number.
Date: Use Ethiopian Calendar and a format of DD/MM/YYYY to register when patient is enrolled in PEP service
Age: Enter client‘s age in year
Sex: Enter ‗M‘ for male and ‗F‘ for Femal
Occupation: Enter Client current Occupation (e.g. health worker, teacher, daily laborer, etc)
Department/case team: Enter the Department or case team in which the client works (e.g. ANC, OPD, etc) for occupational exposures
Non-occupational Exposure: Put a check mark ―√‖ under the Non-Occup-sexual assault/rape column if the client is exposed due to sexual assault/rape. Specify if
the client is exposed to other non-occupational reasons under ‗other-Non-Occup‘ column.
Occupational exposure: Put a check mark ―√‖ under the ‗Occup column‘ if the patient is exposed occupationally
Exposure Code/type: Put the exposure code types among the lists provided under the foot note of the PEP register. E.g. If a client is exposed to few drops of blood
for short duration of time, write ―EC1‖ under the ‗Exposure code/type‘ column.
Source patient HIV Status code: Put the source patient HIV status code listed under the foot note of the PEP register under ‗source patient HIV status code‘ column.
E.g. If a client is exposed to a patient whose HIV status is negative after testing then write ‗SC negative‘ under the ‗source
patient HIV status code‘ column.
PEP Eligibility: If the client is eligible for PEP Write ‗Eligible‘ otherwise write ‗Not eligible‘.
Drug regimen provided: Put the PEP drug regimen provided to the client among the drug regimen listed under the foot note of PEP register. E.g. if a client is
prescribed ―AZT/3TC (CBV)‖ put ‗AZT/3TC (CBV‘ under the ‗drug regimen column‘.
Treatment completed: Put ‗Yes‘ if completed, ‗No‘ if not completed the treatment under ‗treatment completed‘ column.
HIV status of exposed Person: Write ‗R‘ for reactive) or ‗NR‘ for non-reactive depending or ‗Unknown‘ for unknown status on the patient‘s HIV status at base
line, 6 weeks, 3month, and 6 month
* Remark: Use the ‗remark column‘ to document events like lost, stopped, linkage to HIV care and other (specify) as applicable

379
Appendix 13I: Occupational and Non-Occupational HIV Post Exposure Prophylaxis Registers (Continued…)
HIV status of
Exposed person
(R or NR)
Non-occupational

Date
Age

Sex
Occupat Source
exposure Exposure PEP
ional patient

Base line
MRN/Card Occu Case team/ Code/ type Eligibility Drug Treatment

3m

6m
6w
exposur HIV
Number patio Department (Eligible/ regimen complete d
e(√) status
SN n Not Provided (Y/N) Remark
Rape/Sexu Other Non- code
occupation Eligible)
al assault(√)
al (specify)

Occupational exposure code Non-occupational HIV status code of the source

Mucus membrane exposure SC negative: HIV Negative
Sexual assault SC1: HIV positive; Asymptomatic/High CD4
EC1= Few drops and short duration
Pediatric exposure SC2: HIV positive: Advanced disease/patient on antiretroviral
EC2= Several drops /long duration/ major blood splash
Un-anticipated high risk therapy/primary infection/low CD4
Percutaneous exposure SC unknown: HIV status unknown or source unknown
EC2= Solid and superficial scracthes Community fight
EC3=Hollow needle deep puncture Road traffic accident
Other(specify

Drug Regimen Code Remark

d4T/3TC or AZT/3TC (CBV) or TDF/3TC Lost
d4T/3TC/LPV/r or AZT/3TC/LPV/r or TDF/3TC/LPV/r or AZT/3TC/EFV Dead
Stopped
Other (Specify)

380
 Appendix 13 J: PEP Facility Assessment
Form
Facility:
Completed by:
Date of Visit [Ethiopian Calendar] (dd/mm/yy)
Checked by:

A. Set up of PEP Service 5. Is the PEP focal person a member of the MDT committee and
IP committee?
1. Is there a PEP Service (both for occupational and non-
occupational exposures) in the facility? Yes No

Yes No
6. Does PEP focal person regularly (weekly) follow, if the
PEP service is given according to the standard management?
2. Is the PEP service in 24 hours available?
Yes No
Yes No

C. Materials available in the PEP service outlets:

3. Are PEP drugs accessible 24 hours where?
1. Do the PEP service outlets have standard reference
Emergency case team L &D case team
materials? (Check box when available)
In Patient case team OPD case team
National infection prevention and patient safety
Others specify

4. Is there follow up of patients on PEP in the ART clinic

Yes No
Others specify
5. Are the staffs in the health facility aware of PEP service?
2. Standard IEC materials available in PEP service areas for
HIV Yes No
Yes No
PITC Yes No
ART Yes No
B. Human Resource
PEP Yes No
1. Number of staff trained in trainings that includes PEP (ART,
IMAI/IMNCI, IP, STI/PEP) D. Equipment/Supplies/Furniture available in the
facility:
MD Nurse HO_ HA/Junior Nurse Other
1. Is there adequate supply and appropriate use of personal
2. At least one PEP trained personnel assigned in each case team on protective equipment‘s in every service outlet of the
duty hours to give PEP service (as an additional responsibility) hospital?
Yes
MD Nurse HO_ Junior Nurse/HA
No, specify
3. At least one PIHCT trained personnel assigned in each case
team on duty hours to give CT service for PEP purpose (as 2. Is there clean water supply in the rooms?
additional responsibility)
Yes No
MD Nurse HO_ Junior Nurse/HA
3. Are the recommended ARVs for PEP available in PEP
service delivery areas at least one pack from each?
4. Is there PEP Focal Person?
Yes No
Yes No
 4. Are condoms available in the service outlets? 3. Adherence counseling and follow up of side effects done for
PEP patients according to the standard
Yes No
Yes No sometimes
5. Is there a penile model to demonstrate about condom use?
4. Completing of PEP drugs is followed and documented in the
Yes No PEP register.

6. Are HIV test kits available in the PEP service outlets? Yes No sometimes

5. HIV testing of source patient (if required for decision making)

Yes No done after taking consent.

7. Are pregnancy test kits available in the PEP service outlets? Yes No sometimes

Yes No 6. Do the health facility MDT and IP committees use PEP

data generated in hospital to improve PEP service
8. Safety boxes available in every service outlet for safe disposal delivery and IP practice of the facility in general?
of sharps
Yes No sometimes
Yes No
7. Do health facility MDT and IP committees have monthly
9. In the pharmacy, are enough stock of recommended ARV meetings and monitor the PEP service delivery and IP
drugs for PEP available? practice of health facilities

Yes specify Yes No Sometimes

E. Standard M&E Tools 8. Does the Health facility have a mechanism for
incorporating the IP and MDT reports (which includes
Are the following formats available in the ART clinic? PEP)

1. Potential HIV exposure documentation and follow up form Yes No

Yes No In to a final report that is given to the CEO and MD at least

quarterly?
2. PEP register

Yes No

3. Intra facility referral?

COMMENTS, RECOMMENDATIONS & FOLLOW-UP
Yes No
Follow-up - Describe actions since last visit:
4. Service outlet HMIS register (in facilities that have not started
the HMIS)

Yes No

Comments about this visit

F. Service Practice

1. Do healthcare workers follow IP protocol (like using appropriate

personal protective equipment‘s, safe disposal of sharps….)

Yes No sometimes

2. Is HIV testing and counseling (base line and follow up at 3 & Recommended actions, persons responsible, time frame
6 months) done for patients who take PEP?

Yes No sometimes
Appendix 13K: Checklist for PEP at Site Level PEP Service Delivery
The below mentioned human resources, materials and supplies need to be 24 hours
available in each case of health facilities

1. Healthcare provider who is trained on PEP service delivery

2. National infection prevention and patient safety reference manual

3. National PITC guideline

4. PITC protocol

5. PITC cue card

6. Decision making tool for PEP wall charts

7. IEC materials on HIV, PITC, ART and PEP

8. Potential HIV exposure documentation and follow up form

9. PEP register

10. ARVs (recommended PEP drugs available in EOPD)

11. Condoms

12. Penile models

13. Gloves

14. Syringe with needle

15. Lancet

16. Safety box

17. Soap and water supply

18. HIV test kits

19. Pregnancy test kit

20. Post pill

Appendix 13L: Risk and Work Restriction for Health Care Workers Exposed to or Infected With Infectious
Diseases of Importance in Health Care Settings
This information is to be used in the absence of local regulations.

Disease/ Infection/ Mode of Transmission Risk Incubation Main Risk in Prevention Vaccine Post-
Syndrome Transmission Period Health Care Available Exposure
Staff to Patient to Prophylaxis
Patient Staff Facility (PEP)
Available

Cholera Fecal-oral Rare Rare Hours to 5 days, Stool contact, Hand hygiene, Contact Yes; No
contaminated water Shedding up to unwashed hands Precautions, clean
10 days after environment No
cessation recommend-
ation for
HCWs

Work restrictions: No duty. Restrict from food handling.

Duration of restrictions: Until 48 hours after last episode of diarrhea except for food handlers: 2 consecutive negative fecal specimens at least 48 hours apart and at
least 48 hours after stopping antibiotics are required.*

Conjunctivitis due Contact with eye High High 5–12 days, Surfaces, Hand hygiene, Contact No No
to adenovirus secretions and shedding from equipment, Precautions, clean
contaminated incubation unwashed hands instruments and
surfaces and period until 14 equipment
equipment days after onset

Work restrictions: No contact with patient or patient environment.

Duration of restrictions: Until discharge from eye ceases.

Cytomegalovirus Contact with urine, Rare Rare Unknown Contact with body Hand hygiene, No No
(CMV)⁰ saliva, breast milk, fluids, especially Standard Precautions
cervical secretions, saliva, blood, and
and semen from urine, possibly
infected person who unwashed hands
 is actively shedding
virus

Work restrictions: No restriction.

Duration of restrictions: None.

Diarrheal diseases Contact with infected Varies Varies Varies by Stool contact, Hand hygiene, Contact See specific No
person‘s stool, pathogen unwashed hands, Precautions, clean disease
consumption of causing diarrhea contaminated environment
contaminated food or environmental
water, contact with surfaces,
objects or contaminated food
environment or water
contaminated with
stool

Work restrictions: Acute (diarrhea with or without other symptoms): No contact with patient or the patient environment, or food handling.

Duration of restrictions: Until symptoms resolve (check the need for negative stool cultures for specific diarrheal etiologies).*

Diphtheria By respiratory No data Rare 2–5 days, Close contact, face- Hand hygiene, Droplet Yes, and PEP with
droplets, contact with infectious for 2 to-face exposure, Precautions for booster every antibiotic
skin lesions weeks cough pharyngeal lesions, 10 years† should be
Contact Precautions discussed,
for skin lesions vaccination if
none within 5
years

Work restrictions: Active disease: No duty; Asymptomatic carriers: No duty.

Duration of restrictions: Until antibiotic therapy completed and 2 negative cultures more than 24 hours apart.

Hemorrhagic Bloodborne; possible Negligible Moderate 5–21 days Exposure of mucous Hand hygiene, Barrier No Antivirals
fever contact transmission to high membranes or Precautions to achieve should be
respiratory tract, full skin coverage to discussed
(e.g., Ebola, through broken skin be used with training
Marburg, Lassa or sharps injury and trainer observer to
virus) monitor
Caring for EVD patients with adequate PPE and no known exposure: Active monitoring for fever and symptoms twice per day. Off duty if any symptoms. Work
restrictions: Active suspected or confirmed: Off duty. Post-exposure: Off duty. With active monitoring for fever and symptoms twice per day.

Duration of restrictions: Active: Until cleared by medical staff. Post-exposure: Until 21 days after last exposure.

Hepatitis A Person-to-person by Rare Rare 15–50 days Stool contact, Hand hygiene, Contact Yes; HCWs Immune
fecal-oral route; unwashed hands, Precautions, especially are not globulin
infected food eating or drinking in with babies and considered at
handlers with poor patient care area incontinent patients increased riskᶧ
personal hygiene can
contaminate food

Work restrictions: No contact with patient or the patient environment, or food handling.

Duration of restrictions: Until 7 days after the onset of jaundice.

Hepatitis B Via sharps, mucosal, Low Moderate, 45–180 days Sharps injury, blood Hand hygiene, Yes; Recom- Depends on
(HBV)⁰ and non-intact skin, 2–40% after (average 60–90 and serum-derived Standard Precautions, mended for all HCW
contact with blood, percutan- days) including prevention HCWs† immune
semen, vaginal eous injury body fluid splashes of sharps injury, status and
secretions, and from to mucous vaccination source
bloody fluids infected membranes patient‘s
patient status;§

for non-
immune
HCWs with
HBsAg,
positive
source HBIG
and
vaccination
series§

Work restrictions: Acute or chronic HBV: Do not exclude from duty but restrictions apply depending on circulating viral levels and procedures performed by HCW.
Requires review by occupational health/IPC personnel and possibly an expert review panel. #

Duration of restrictions: Different recommendations if HepB antigen is positive or negative and if HBV is < 10 4 GE/mL (genome equivalents/milliliter plasma) or >
104 GE/mL.#
Hepatitis C⁰ Via sharps, mucosal, Low Moderate, 6–7 weeks Sharps injury, Hand hygiene, No No
and non-intact skin 0–10% splash on mucous Standard Precautions,
contact with blood, (average membranes or non- including prevention
semen, vaginal 1.8%) after intact skin of sharps injury
secretions, and percutane-
bloody fluids ous injury
from
infected
patient

Work restrictions: Acute or chronic HCV: Do not exclude from duty but restrictions apply depending on circulating viral levels and procedures performed by HCW.
Requires review by occupational health/IPC personnel and possibly an expert review panel.# Post-exposure:§

Duration of restrictions: Different recommendations if HCV is < 104 GE/mL or > 104 GE/mL.#

Hepatitis E Person to person by — — 2–9 weeks Contaminated food Hand hygiene, No No

fecal-oral route, or water, unwashed Standard Precautions
contaminated water, hands
contaminate food

Work restrictions: Off duty.

Duration of restrictions: Duration of illness, viral shedding in stool occurs 7–30 days after onset of jaundice.

Herpes simplex⁰ Contact with virus in Rare Low 2–14 days Contact with Hand hygiene, No No
saliva of carriers, infected site or Standard Precautions⁰
contact with vesicle saliva, vaginal (Contact Precautions
fluid secretions, or in disseminated
amniotic fluid infection)

Work restrictions: Genital: No restriction. Hands (herpetic whitlow): No contact with patient or the patient environment. Orofacial: No contact with high-risk
patients.◊

Duration of restrictions: Genital: None. Hands (herpetic whitlow): Until lesions heal.

Human Primarily via sharps Rare Low, 0.2– Within 6 months Sharps injury, Hand hygiene, No Depends on
immunodeficiency contact with blood; 0.4% after splash on mucous Standard Precautions type of body
virus (HIV)⁰ mucosal or non-intact sharps membranes or non- including prevention fluid, type of
skin contact with exposure to intact skin of sharps injury exposure and
blood; semen, infected source
 vaginal secretions, person patient
and bloody body status;§ when
fluids less likely to indicated,
transmit initiate
antiretroviral
treatment as
soon as
possible
(within 72
hours)§

Work restrictions: Acute or chronic HIV: Do not exclude from duty but restrictions apply depending on circulating viral levels and procedures performed by HCW.
Requires review by occupational health/IPC personnel and possibly an expert review panel. # Post-exposure:§

Duration of restrictions: Different recommendations if circulating HIV viral burden is < 5x10 2 GE/mL or > 5x102 GE/mL.#

Influenza⁰ Droplet spread; direct Moderate Moder 1–5 days Close contact with Hand hygiene, Droplet Yes; annual Antivirals
droplet transmission ate patient (within 1–2 Precautions, annual immunization may be
or droplet-to-contact meters from vaccine with a single recom-
transmission of coughing/ sneezing) dose recom- mended in
respiratory secretions mended yearly certain
of infected patients for HCWᶧ situations

Work restrictions: No contact with high-risk patients◊ during community outbreaks.

Duration of restrictions: Until acute symptoms resolve.

Measles⁰ Airborne; direct High High 5–21 days Inhaling droplets Hand hygiene, Yes; all Immune
airborne transmission and airborne virus Airborne and Contact HCWs should globulin
or airborne-to- or contact with the Precautions, vaccine be immune to
contact transmission patient‘s respiratory measles, proof
of respiratory secretions of immunity
secretions of infected or
person immunization
required pre-
patient
contact†

Work restrictions: Active: Off duty. Post-exposure in non-immune people: Off duty.
Duration of restrictions: Active: 7 days after rash appears. Post-exposure: From 5th day after first exposure through 21st day after last exposure and/or 4 days after
rash appears.

Meningococcal Droplet spread; direct — Rare 2–10 days Close contact (face to Hand hygiene, Droplet Yes; recom- Antibiotic
infectious droplet transmission face) with respiratory Precautions mended for after close
or droplet-to-contact secretions HCWs at risk contact‡
N. meningitides transmission of of exposure†
respiratory secretions of patients with (tetravalent A,
of infected patients meningococcemia or C, W135, and
meningococcal Y)
meningitis

Work restrictions: Active: No duty. Post-exposure: No restrictions. Recommended prophylaxis includes: rifampin (600 mg twice a day for 2 days), a single dose of
ciprofloxacin (500 mg), or a single dose of ceftriaxone (250 mg) IM.

Duration of restrictions: Active: Until 24 hours after start of effective antibiotic therapy. Post-exposure: No restrictions.

Mumps Droplet spread; direct Moderate Modera 12–25 days Close contact with Hand hygiene, Droplet Yes; HCWs No
droplet transmission te patient (within 1–2 Precautions are not
or droplet-to-contact meters from coughing/ indicated as a
transmission of group at
respiratory secretions sneezing) increased
and saliva of infected risk†
patients

Work restrictions: Active: Off duty. Post-exposure in non-immune people: Off duty.

Duration of restrictions: Active: 9 days after onset of parotitis. Post-exposure: From 12th day after first exposure through 26th day after last exposure or 9 days after
onset of parotitis.

Methicillin- Direct and indirect Rare Rare Depends on the Unwashed hands, Hand hygiene, Contact No No
resistant S. aureus contact type of contaminated surfaces, Precautions
(MRSA) infection infection contaminated
equipment

Work restrictions: Active, draining skin lesions: No contact with patient or the patient environment, or food handling. Carrier: No restriction unless
epidemiologically linked with transmission of the organism.

Duration of restrictions: Until lesions have resolved.

Norovirus Fecal-oral (direct or High High 12–48 hour Stool or vomit Hand hygiene, Contact No No
indirect contact with contact, possibly Precautions, clean
patient‘s stool or aerosol transmission equipment, clean
vomit), contaminated during vomiting environment
surfaces,
contaminated food or
water

Work restrictions: Acute: No contact with patient or the patient environment, or food handling.

Duration of restrictions: Until symptoms resolve, viral shedding in stool may occur.

Parvovirus B19 Contact with infected — Rare 6–10 days Respiratory Droplet Precautions No No
(erythema persons, fomites, or secretions for patients with fever
infectiosum or respiratory secretions and anemia or aplastic
fifth disease) crisis or chronic B19,
others Standard
Precautions

Work restrictions: Acute: Off duty. Exposed: no restriction.

Duration of restrictions: 7 days after onset of illness.

Pertussis Droplet spread; direct Moderate Moderate 7–10 days Respiratory Hand hygiene, Droplet Yes; recom- Macrolides
(whooping cough) droplet transmission secretions and Precautions mendation for
or droplet-to-contact respiratory droplets HCWs
transmission of currently
respiratory secretions under review†
of infected patients

Work restrictions: Active: Off duty. Post-exposure asymptomatic: No restriction if PEP received. Post-exposure symptomatic: Off duty.

Duration of restrictions: Active: from beginning of catarrhal stage through 3 rd week after onset of paroxysms. Post-exposure: Until 5 days of effective antibiotic
therapy.

Poliomyelitis Contact with feces or Rare Rare 3–21 days, Feces, respiratory Hand hygiene, Contact Yes; all No
urine of infected vaccine- secretions, lab Precautions HCWs should
person, respiratory associated polio specimens have
secretions and (oral vaccine): completed a
7–21 days after full course of
 fomites vaccination primary
vaccination
against polio†

Work restrictions: Active: Off duty. Post-exposure: Vaccination series or booster.

Duration of restrictions: Duration of illness.

Rabies Animal bite, saliva, Rare Rare 1–3 months Lab samples, saliva Hand hygiene, Yes; HCWs Yes
tissue and organ of infected patients Standard Precautions are not at
transplants (theoretical) increased risk

Work restrictions: Active: Off duty. Post-exposure: No restriction, consider post-exposure treatment.

Duration of restrictions: Rabies is mostly fatal.

Respiratory Droplet contact or Moderate Moderate 2–8 days Respiratory Hand hygiene, Contact No No
syncytial virus direct contact with secretions, hands, Precautions
(RSV) respiratory secretions and fomites

Work restrictions: No contact with high-risk patients◊ during community outbreaks.

Duration of restrictions: Until acute symptoms resolve.

Rotavirus Person-to-person via Moderate Moderate 2–3 days Stool contact, Hand hygiene, Contact Yes; adults No
fecal-oral route; food unwashed hands, Precautions, clean including
handlers may environmental environment, clean HCWs are not
contaminate food surfaces, fomites equipment at increased
risk of severe
disease†

Work restrictions: Acute: No contact with patient or the patient environment, or food handling.

Duration of restrictions: Until symptoms resolve.

Rubella⁰ Droplet contact or Moderate Moderate 12–23 days Respiratory droplets Droplet Precautions Yes; all No
direct contact with and secretions (acute infection), HCWs should
respiratory Contact Precautions be immune to
secretions; airborne (congenital rubella) rubella and
transmission not proof of
demonstrated immunity or
immunization
required pre-
patient
contact†

Work restrictions: Active: Off duty. Post-exposure in non-immune people: Off duty.

Duration of restrictions: Active: Until 5 days after rash appears. Post-exposure: From 7th day after first exposure through 21st day after last exposure.

Salmonella or Person-to-person via Low Low 1–3 days Stool contact, Hand hygiene, Contact Yes (typhoid), No
shigella fecal-oral route, via unwashed hands Precautions for currently no
contaminated food or incontinent patients recommen-
water; food handlers and babies dation
with poor personal regarding
hygiene can HCWs†
contaminate food

Work restrictions: Acute: No contact with patient or the patient environment, or food handling. Carrier: No restriction from patient care unless staff member
handles food* or is epidemiologically linked with transmission of the organism.

Duration of restrictions: Until symptoms resolve unless food handler,* in which case a specific number of negative cultures is required.

Novel respiratory Droplets, contact Medium Medium Varies Small droplets from Hand hygiene, Droplet No No
viruses (SARS, (possibly airborne) respiratory and Contact
bird flu, MERS- secretions, Precautions, use
CoV, etc.) possibility of Airborne Precautions
airborne if possible
transmission

Work restrictions: Acute: No duty.

Duration of restrictions: Until acute symptoms resolve.

Staphylococcus Direct and indirect Rare Rare Foodborne: 30 Unwashed hands, Hand hygiene, Contact No No
aureus contact minutes–6 days contaminated Precautions
surfaces,
infection Impetigo: 1–10 contaminated
days equipment
(see also MRSA)
Toxic shock
syndrome: 2
days

Work restrictions: Active, draining skin lesions: No contact with patient or the patient environment, or food handling. Carrier: No restriction unless
epidemiologically linked with transmission of the organism.

Duration of restrictions: Until lesions have resolved.

Scabies Direct skin-to-skin Low Low 2–6 weeks Prolonged skin-to- Hand hygiene, Contact No No
contact with infested (typical (typical skin contact (typical Precautions, clean
person scabies) to scabies), scabies), skin-to- environment, clean
moderate moderate skin contact during equipment
(crusted (crusted daily care (crusted
scabies) scabies) scabies),
infrequently fomites

Work restrictions: Active: No patient contact. Post-exposure: No restriction.

Duration of restrictions: Active: Until after 1 st treatment and cleared by medical evaluation. Post-exposure: Prophylactic treatment not indicated except in outbreak
situations.

Streptococcus, Droplet contact or Rare No data Pharyngitis 2–5 Contact with Hand hygiene; No No
Group A (GAS) direct contact with days, impetigo infected secretions; precautions depend on
oral secretions or 7–10 days, other HCWs are rarely type of infection –
drainage from infections carriers Minor skin and
infected wounds variable endometritis: Standard
Precautions,

Major skin: Contact

Precautions,

Respiratory tract,
scarlet fever and
invasive disease:
 Droplet Precautions

Work restrictions: Active: No contact with patient or the patient environment, or food handling. Carrier: No restriction unless linked with transmission.

Duration of restrictions: Until 24 hours after effective treatment is started.

Tuberculosis Airborne Low to Low to high Weeks to years Incomplete Airborne Precautions Yes, BCG; Isoniazid
(TB)⁰ transmission from high implementation of There is no (INH) for
sources with active recommend control recommenda- treatment of
pulmonary or measures, including tion for HCWs latent TB
laryngeal patient placement, in routine infection;
tuberculosis; facility ventilation, circumstances
susceptible person and personal 4-drug
must inhale airborne respiratory regimen for
droplet nuclei to protection active TB
become infected

Work restrictions: Active pulmonary or laryngeal: Off duty. Active extra-pulmonary: No restriction once pulmonary or laryngeal involvement is excluded. Latent:
No restriction. PPD (tuberculin skin test) conversion (> 10 mm induration): No restriction; consider isoniazid prophylaxis depending on local recommendations.

Duration of restrictions: Active: Until proven non-infectious (by sputum acid-fast bacilli [AFB] culture culture).

Varicella, chicken Contact with High High 10–21 days (up Contact with lesions Airborne and Contact Yes; consider VZIG
pox, disseminated vesicles; droplet or to 28 days in and aerosols even Precautions vaccination of
zoster⁰ airborne spread from person who without direct potentially
respiratory tract receives contact with the susceptible
varicella-zoster infected patient HCWs (i.e.,
immune unvaccinated
globulin and with no
[VZIG]) history of
varicella)ᶧ

Work restrictions: Active: Off duty. Post-exposure in non-immune people: Off duty.

Duration of restrictions: Active: Until all lesions are dry and crusted. Post-exposure: From 10th day after first exposure through 21st day (28th if VZIG is given) after
last exposure.

Localized Contact with Moderate Moderate Years after Contact with lesions Contact Precautions Yes; see VZIG
varicella-zoster vesicles; perhaps acute infection and perhaps aerosols and Airborne above;
(shingles) droplet or airborne from respiratory Precautions for shingles
spread from tract from disseminated zoster vaccine not
respiratory tract from disseminated zoster recommend-
disseminated zoster ed specifically
for HCWs

Work restrictions: Localized in healthy person: Cover lesions, no contact with high-risk patients.◊ Generalized or localized in immunosuppressed person: No patient
contact. Post-exposure in non-immune people: No patient contact.

Duration of restrictions: Active and generalized: Until all lesions are dry and crusted. Post-exposure: From 10th day after first exposure through 21st day (28th if VZIG
is given) after last exposure or if varicella occurs, until all lesions dry and crusted.

Viral respiratory Respiratory Moderate Moderate 1–7 days Droplet contact or Respiratory etiquette, Yes (influenza No
infections, acute secretions direct contact with hand hygiene, Droplet only)
febrile respiratory Precautions, annual
secretions, close vaccine
contact (1–2 meters)
with patient

Work restrictions: No contact with high-risk patients◊ during community outbreaks.

Duration of restrictions: Until acute symptoms resolve.

§ PPE—Post-exposure prophylaxis; see Chapter 3, Sharps Injuries and Management of Exposure to Bloodborne Pathogens, in this module for details about PEP for bloodborne
pathogens.
#
See section above on Health Care Workers Infected with HIV and/or Hepatitis B or C.

⁰ For information relevant to exposure of pregnant personnel, see Table 2-7 in this chapter.

◊ Definition of high-risk patient: neonates and immunocompromised persons of any age. For influenza, also those > 65 years, residents of nursing homes, persons with chronic
pulmonary or cardiac conditions, diabetes. (CDC 1998)

‡ Definition of close contact: Direct, mouth-to-mouth contact as in resuscitation attempts, endotracheal intubation, endotracheal tube management, or close examination of
oropharynx of patients. (CDC 1998; WHO 2002)

† For vaccine recommendations for HCWs (WHO 2016b), see Table 2-4.

* For management of illness in food handlers, see Volume 1, Chapter 12: Food and Water Safety.
Appendix13M: Decision Making Tools for PEP
Appendix 13M: Decision Making Tools for PEP (Continued…)

397
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