Standard Infection Control Principles

Standard infection control principles and droplet precautions must be used if patients have or are suspected of having influenza. Standard infection control principles are a set of broad statements of good practice to minimize exposure to and transmission of a wide variety of micro-organisms.

These principles should be applied by all healthcare practitioners to the care of all patients all of the time.

Standard infection control principles include policies on hospital environmental
hygiene, hand hygiene, use of PPE and safe use and disposal of sharps.

Hand hygiene

Hand hygiene is the single most important practice needed to reduce the transmission of infection in healthcare settings and is an essential element of standard infection control principles. In any outbreak of pandemic influenza strict adherence to hand hygiene recommendations should be enforced.

Patients’ hands will be heavily contaminated, because of frequent contact with their nose, mouth and the tissues they have used in respiratory hygiene. Their hands will also make frequent contact with their immediate environment. Therefore good hand hygiene among staff before and after contact with patients or their close environment is vital to protect both themselves and other patients. Good hand hygiene among patients should also be encouraged.

Hand hygiene includes:

• hand washing with soap and water and thorough drying, and
• the use of alcohol-based products containing an emollient that do not require the use of water. If hands are visibly soiled or contaminated (eg with respiratory secretions), they should be washed with soap and water and dried. When an alcohol handrub is used to decontaminate hands, the hands should be free of visible dirt and organic material. The handrub must come into contact with every part of the hand’s surface. Hands must be decontaminated immediately before each and every episode of direct care of or contact with patients and after any activity or contact that potentially results in hands becoming contaminated, including the removal of protective clothing and cleaning of equipment. Hands should be decontaminated between caring for different patients and between different care activities for the same patient, even if gloves have been worn. After hand washing, paper towels should be used to dry the hands thoroughly and should then be discarded in the nearest waste bin. Lined waste bins with foot-operated lids should be used whenever possible.

In addition to the placement of alcohol handrub at the point of use (eg at patients’ beds, in examination rooms, etc), consideration should also be given to distributing personally carried alcohol handrub to certain groups of transient or migratory staff (eg hospital medical staff and community staff who undertake home visits).

All staff, patients and visitors should clean their hands when entering and leaving areas where care is delivered with either soap and water followed by drying or alcohol handrub.

Applying droplet precautions in the mitigation phase of the H1N1 pandemic 2009

In addition to the standard infection control principles, droplet precautions should be used if a patient is known or suspected to be infected with influenza and is at risk of transmitting droplets while coughing, sneezing or talking and during some procedures.

Placement of patients within the facility

• Ideally patients with influenza should be placed in single rooms, but during pandemics this may not be possible. Therefore patients can be ‘cohorted’ (grouped together with other patients who have influenza and no other infection) in a segregated area. This is esp. useful while waiting for the H1N1 throat swab results. If the throat swab result is negative, the patient maybe transferred back to the standard wards.
• Where patients are cohorted on the basis of epidemiological and clinical information rather than on laboratory-confirmed diagnosis, beds should be at least 3 feet apart.
• Special ventilation is not necessary, and the doors of segregated areas can remain open. Designated cubicles at the ends of the wards maybe used so as to minimize exposure from regular patient and staff traffic. (unless a patient is being isolated for another reason in addition to influenza that requires the doors to be shut).

Surgical masks (3-ply) & its Use

• In addition to wearing a surgical mask in situations as outlined under standard infection control principles, staff must wear surgical masks when working in close contact (within 3 feet) with a symptomatic patient. For practical reasons, this is likely to mean wearing a surgical mask at all times within cohorted areas.
• Patients with ILI should also wear a surgical mask when not in isolation in a single room and stay at least 3 feet distant from others.
• It is important to ensure that surgical masks are worn and disposed of correctly. Make sure the mask is correctly fitted by ensuring that it covers your nose and mouth and that it is secured at the back of your head.
• Avoid touching your face while wearing the mask. Replace the mask whenever it is moist. A mask that has been removed should not be reused.
• Remove the mask by only touching the straps and put the used mask in a bin. Wash your hands well with soap and water straight away and dry with a paper towel.

Transport of patients

• The movement and transport of patients from their rooms or the cohorted area should be limited to essential purposes only.
• If transport or movement is necessary, minimize the dispersal of droplets from the patient by masking them, if possible. The surgical mask should be worn during transport until the patient returns to the segregated area.
• If a surgical mask cannot be tolerated by the patient, then good respiratory hygiene should be encouraged.

Use of Personal Protective Equipment (PPEs)

° Wherever possible, aerosol-generating procedures should be performed in side rooms or other closed single patient areas with minimal staff present. Aerosol-generating procedures include endotracheal intubation, nebulized medication administration, airway suctioning, bronchoscopy, diagnostic sputum induction, positive pressure ventilation via face mask, and high frequency oscillatory ventilation. These procedures should preferably be performed in a single room with the door closed.
°° Gloves and apron should be worn during certain cleaning procedures.
** Surgical masks (3-ply) are recommended for use at all times in cohorted areas for practical purposes.
# Formal Fit Testing for N95 masks is recommended where available.
@ Use eye protection if splashes can be expected during that particular procedure

Reference 1:

Aerosol-generating procedures

Several medical procedures have been reported to generate aerosols, and it has been suggested that some of these are associated with an increased risk of pathogen transmission.

However, the risk associated with many aerosol-generating procedures is not yet well defined, and the understanding of the aerobiology involved in such procedures may change as further studies in this area are carried out. In a 2007 revised WHO document, Infection prevention and control of epidemic-and pandemic-prone acute respiratory diseases in health care, based on epidemiological studies on tuberculosis (TB) and/or SARS, the following aerosol-generating procedures were considered to be associated with a documented increase in risk of pathogen transmission in patients with acute respiratory disease:

• intubation and related procedures, eg manual ventilation and suctioning
• cardiopulmonary resuscitation
• bronchoscopy
• surgery and post-mortem procedures in which high-speed devices are used.

The authors of the WHO document make the comment that there are other procedures that may be associated with an increased risk of pathogen transmission, but due to methodological flaws in some of these studies, preclude using their conclusions to make recommendations.

They categorise these as procedures with only a ‘possible’ increase in risk of respiratory pathogen transmission. The controversial/possible procedures specified by WHO are non-invasive positive pressure ventilation, bi-level positive airway pressure, high frequency oscillating ventilation and nebulisation.

Health Care Workers at Increased Risk of Complications from H1N1 Influenza 09
Infections

• Health care workers who are at increased risk of complications from Influenza A/H1N1 (ie. co-morbidities) and who are likely to be in direct contact with patients who have influenza A / H1N1 infections, should be considered for redeployment to lower risk activities.
• If redeployment is not possible, health care workers who are at increased risk of complications from Influenza A / H1N1 infection should maintain a distance of 3 feet from Influenza A / H1N1 patients and not participate in procedures with these patients that may generate small particles or aerosols of respiratory secretions.

Management of Visitors

• Limit visitors for patients who are in isolation to those persons who are necessary for the patient's emotional wellbeing and care. Visitors should also be masked and instructed on hand hygiene policies.

Duration of Precautions

Persons with influenza a/H1N1 infection should be considered potentially contagious from 1 day before to 7 days following illness onset. Persons who continue to be ill longer than 7 days after illness onset should be considered potentially contagious until fever has resolved. Children, especially younger children, might be contagious for longer periods.

• Isolation precautions should be continued for 7 days from symptom onset or until the resolution of fever, whichever is longer.
• Isolation precautions may also be discontinued when patient has had 3 days of influenza antiviral treatment provided they have no fever for 24 hrs in the absence of antipyretics.

Cleaning H1N1 Influenza 09 In-Patient Rooms / Areas

Daily and on discharge - clean with a neutral detergent. The room can be used immediately following cleaning.

Management of laundry and utensils should be performed in accordance with procedures followed for seasonal influenza.

Waste

• Treat waste as general medical waste.
• Used tissues are disposed of in general waste.

Management of Ill Health Care Workers

• Health care workers who develop influenza-like illness (ILI) should be assessed and treated as recommended for the general public. They should be excluded from work for the duration of the symptoms esp. until fever resolution.
• Testing for H1N1 is not necessary as a routine. The recommendation for H1N1 screening / testing for the public can be applied.

Surveillance and management of healthcare personnel

• Health care workers should be monitored for illness and those who develop acute respiratory illness (ARI) should be instructed not to report to work, or if at work, should cease patient care activities and notify their supervisor and infection control personnel.
• Surveillance of ILI and work absenteeism among healthcare workers must be maintained by the Occupational Health Unit of the health facility / institution in accordance to their current guidelines.