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TRAINING ON OUTBREAK INVESTIGATION

TOPIC 4

INFECTION CONTROL

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TOPIC 4

INFECTION CONTROL
During outbreak investigation

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LEARNING OBJECTIVES

At the end of the session, the participants will be able to: Explain the importance of promoting culture of safety Identify common situations during an outbreak investigation when the investigator is likely to be exposed to sources of infection Describe standard precautions and transmission-based precautions Explain the uses of different types of personal protective equipment (PPE) Demonstrate hand washing, putting on and removing PPE and particulate respiratory seal check Identify challenges in the use of PPE

RECOMMENDED ACTIVITIES

Below is the summary table of recommended activities for the topic Infection control, their objectives and suggested timing in the training.
Table 51. Summary of recommended activities

Activity Number

Timing Title Objective

Before During After

Skills Station
(should have all the posters available)

To practice participants on donning of PPE, hand hygiene, disinfection, chlorine solution preparation, particulate respirator seal check, etc. To show difference between droplet and aerosol To enumerate safety precaution components To identify appropriate mask for specific transmission To demonstrate wearing and taking off PPE and hand hygiene

+++

+++

+++

Droplet vs Aerosol

+++

++

Mime-Precaution

+++

+++

Match the mask Video on Donning PPE and hand hygiene

++

+++

++

++

+++

++

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SUMMARY CONTENTS

During an outbreak investigation, it is important that staff/investigators try their best to prevent self from being infected by patients or other possible sources. This topic is about protecting you and your staff from infections caused by dangerous pathogens and its immediate environment. Standard precautions require that health workers in the field assume that the blood and the body substances of all patients are potential sources of infection, regardless of the diagnosis, or presumed infectious status. Additional precautions are needed for diseases transmitted by air, droplets and through contact.

A culture of Safety
Improving worker safety requires an organization-wide commitment to creating, implementing, evaluating and maintaining effective and current safety practices a culture of safety. Establishing an effective culture of safety also requires that both personal safety and safety of others are responsibilities inherent to both the managers and the staff. This means respecting and adhering to the standards and protocols, being aware of personal safety and safety of others by providing immediate feedback or correcting incorrect behaviour positively.

Risk of infection during an outbreak

During an outbreak, staff can be infected in many ways. More notably are the following situations when staff are the most at risk: a. needle stick injury during specimen collection and other procedures b. breach in the use of PPE not using PPE, improperly fitted PPE or reusing single-use PPE c. from aerosol-generating procedures d. being exposed to an asymptomatic but infected patient

In hospital setting, recapping of needles after taking blood samples is the most common cause of needle stick injury.

Standard Precaution
Standard precautions are precautionary measures that help limit infections to health workers, patients and relatives. Experiences from previous outbreaks have shown that further disease transmissions e.g., nosocomial transmission, could

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have been prevented if basic level of infection control precautions are followed. Treating all patients with the standard precautions involves work practices that are essential to provide a high level of protection to patients, health care workers, relatives, etc. These are: Hand hygiene Respiratory hygiene and cough etiquette which are added to standard precautions to control transmission of respiratory infections if a patient has respiratory symptoms. Use of personal protective equipment (PPE) based on risk assessment to avoid direct contact with patient's blood, body fluids, secretions and nonintact skin Prevention of needle sticks/sharps injuries and Cleaning and disinfection of the environment and equipment

Standard precautions should be: in PLACE ALL the time whether or not there is recognized outbreak practiced for ALL PATIENTS regardless of diagnosis

Transmission-based precaution
For certain transmissible or highly pathogenic infections, transmission-based precautions are used IN ADDITION to standard precautions. These are: a. Contact precaution, b. Droplet precaution and, c. Airborne precautions

Since the infecting agent may not be known at the time of admission to a health care facility, transmission-based precautions are used empirically, according to the clinical syndrome and the likely aetiologic agent (based on a risk assessment), and then modified when the pathogen is identified or stopped if a transmissible infectious disease etiology is ruled out.

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Transmission based Precautions Contact

Transmission Example

Organisms Commonly implicated shigellosis, Ebola hemorrhagic fever, MRSA

Recommended PPE

Direct indirect contact with patient/ environment

Gloves, gowns

Droplet

Cough, sneeze

Neisseria meningitidis, pertussis, Surgical mask, pneumonias, diptheria, influgoggles + standard enza, mumps precaution N 95, goggles + standard precaution

Airborne

Particle suspended in the air TB, measles, varicella, and vari(<5) ola

Table 52. Transmission-based precautions, organisms implicated and recommended PPE.

Personal Protective Equipment (PPE)

Personal protective equipment or PPE is designed to act as a barrier to hazardous agents encountered by health workers in the hospital or while conducting outbreak investigation. Personal protective equipment reduces, but does not completely eliminate, the risk of acquiring an infection. It is important that it is used effectively, correctly and at all times where contact with blood and body fluids of patients may occur.

Staff must also be aware that use of personal protective equipment does not replace the need to follow basic infection control measures such as hand hygiene.
Personal Protective Equipments (PPE) are comprised of:

MEDICAL MASK

GOWN

PROTECTIVE EYEWEAR

GLOVES

Figure 51. Personal protective equipment (PPE)

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Items that are not PPE include caps for hair which function more for staff comfort and closed footwear or boots. Boots are used only to avoid accidents and sharp objects.

How tos
The accompanying PowerPoint presentation on Infection Control provides us with steps on the following: a. Wearing and taking off PPE b. Particulate respirator seal check c. Hand-rub with alcohol d. Hand washing with soap and water

Hand Hygiene
Hand washing is the simplest and most effective way of preventing the transmission of infection. Hand washing should be performed during these circumstances:
Immediately Upon arriving at work Before Direct contact with patient Putting on gloves for clinical and invasive procedures Preparing handling, serving, or eating food Leaving work Between Procedures on the same patient where soiling of hands is likely After Contact with patient Removal of gloves Removal of other personal protective equipment Contact with blood, body fluids, secretions, excretions, wounds exudates, contaminated items Contact with items/surfaces known or likely to be contaminated Personal body functions such as using the toilet, and wiping or blowing one's nose

Table 53. When to perform hand hygiene

Availability of alcohol-based hand rubs is critical in promoting effective hand hygiene practices especially in setting without access to running water. This approach has led to increased compliance in hand hygiene and decreased health care-associated infection.

Wash hands with soap and water when visibly dirty or soiled with blood or other body fluids, or if exposure to potential sporeforming organisms is strongly suspected or proven or after using the restroom. Preferably use an alcohol-based hand rub for routine hand antisepsis.

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Challenges in using PPE and strategies to improve safety

PPE is one of the vital components of a system of safety controls and preventive measures in health facilities or in the field. Recent studies have shown that despite expert recommendations and high risk conditions, health care workers tend to use PPE less. Below are some of the challenges in PPE use. Studies were conducted in a hospital setting although the findings can also be noted in field setting: Too busy or no time to wear PPE Health staff do not consider themselves high risk in contracting the disease Patient did not appear high risk Interference with skills Discomfort Perception that precautions are ineffective Availability of supply and ready access to it Cost of the PPE Community/patient perception e.g., alien looking, creates fear Strategies to improve safety (after Goldfrank, 2008) Leadership and commitment to safety Emphasis on education and training Improving feedback and enforcement Clarify relevant work practices

DETAILS OF RECOMMENDED ACTIVITIES

Activity 1 Skills Station

Objectives: To practice participants on donning of PPE, hand hygiene, disinfection, chlorine solution preparation, particulate respirator seal check, etc. Estimated Time Throughout the session. Participants can go and try to practice during breaks, lunch time, etc Materials (see Annex B page 8 31) 1. PPEs, particulate respirator mask, soap and water, alcohol hand rub, chlorine solution 2. Posters showcasing steps in wearing and taking off PPE, particulate respirator seal check, hand washing, alcohol hand rub, chlorine solution preparation

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3. Containers for water, soap, water receiver (when performing hand washing, etc.) Process 1. Provide stations (desks) for each topics: PPE, respirator seal check, hand washing, chlorine solution 2. Train organizing team member or participant on specific skills and allow them to oversee skills practice by participants. 3. Participants can practice several times. (Note: In case of limited supplies of PPE, participants maybe requested to keep one e.g., mask and share others e.g., gown for practice purpose with clear explanation that this should not be the case in actual investigation.)

Figure 52. Skills station set-up

Activity 2 Droplet vs Aerosol

Objectives To show difference between droplet and aerosol Estimated Time 5 minutes Materials 1. Video clip on aerosol vs droplet production 2. LCD/ DVD player Process 1. Run the video clip on aerosol and droplet 2. Let patient discuss when aerosol and droplets are generated. This can be followed by discussion on example of disease with transmitted through aerosol or droplet as well as the PPE to use.

Activity 3 Mime Precaution

Objectives To enumerate safety precaution components Estimated Time 30 minutes

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Standard Precautions Hand hygiene Respiratory hygiene and cough etiquette have been added to standard precautions to control transmission of respiratory infections. Use of personal protective equipment (PPE) based on risk assessment to avoid direct contact with patient's blood, body fluids, secretions and non-intact skin Prevention of needle sticks/sharps injuries and Cleaning and disinfection of the environment and equipment

Materials Small pieces of paper to draw group who will perform the activity Process 1. In a small piece of paper, write Silent Movie Actors and leave the other pieces blank. The group who picked the paper with Silent Movie Actors on it will perform the activity 2. Ask the participants to guess what standard precaution is being acted out by the silent movie actors 3. Write down the standard precautions correctly guessed. 4. Encourage participants to create mnemonics or any easy-to-remember action to illustrate standard precautions.

Activity 4 Match the Mask

Objectives To identify appropriate mask for specific transmission Estimated Time 30 minutes Materials (see Annex B page 8 32) 1. Slides containing scenario and question whether mask is needed and what particular mask 2. LCD/ Computer 3. Score sheet Process 1. Divide the group into four. Flash the scenario and ask the group to discuss and provide the answer. Allow time for the group to give reason to their answers 2. Score correct answers on displayed score sheet. 3. The group with the most correct answer wins.

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Activity 5 Video on donning PPE and performing hand hygiene

Objectives To demonstrate a) wearing and taking off PPE and b) hand hygiene Estimated Time 15 minutes Materials 1. Video clips on a) wearing and taking off PPE and b) performing hand hygiene 2. LCD/ DVD player Process 1. Run the video clips 2. Allow discussion on variations in wearing and taking off PPE and draw conclusions/ summary.

REFERENCES

Goldfrank, L.R., Liverman, C.T., eds. Preparing for an influenza pandemic: personal protective equipment for healthcare workers. Washington, D.C., The National Academies Press, 2008 Infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in health care. Interim Guidelines. Geneva, World Health Organization, 2007 (WHO/CDS/EPR/2007.6) Laboratory biosafety manual. 3rd ed. Geneva, World Health Organization. 2004. (WHO/ CDS/CSR/LYO/2004.11) WHO Guidelines in hand hygiene in health care (Advanced Draft): A summary. Geneva. World Health Organization, 2005 (WHO/EIP/SPO/QPS/05.2)

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THOUGHTS, COMMENTS, NEW GAMES AND VARIATIONS

NOTE: The following pages contain transcripts of the presentations included in this topic. The embedded transcripts aim to assist facilitators in explaining the content of the slides. The slides and transcripts (slide notes) can be modified and adapted based on facilitators objectives and needs of the trainees. Karaoke-type presentation (directly reading the contents of the slides and transcripts) is strongly discouraged.

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INFECTION CONTROL Transcript

Infection control During an outbreak investigation, it is important that staff/investigators try their best to prevent self from being infected by patients or other possible sources. This presentation is about protecting you and your staff from infections caused by dangerous pathogens. S L I D E 1 Standard precautions require that health workers in the field assume that the blood and the body substances of all patients are potential sources of infection, regardless of the diagnosis, or presumed infectious status. Additional precautions are needed for diseases transmitted by air, droplets and through contact. In the field, it is important that maximum protection is provided to staff. Most of the time, staff are faced to work in resource limited settings. It may happen that discrepancies exist between what is ideal and what can be achieved/ provided in terms of staff protection. Aside from limited resources, there might be cases whereby wearing bulky items may limit movement hence further increase danger and lead to a situation where a breach of methods is more likely to occur.

Infection Control
A good epidemiologist is a safe epidemiologist

SEARO CSR Training onon Outbreak Investigation E P Outbreak I D E M I C A Investigation L E R T A N D R E S P O N S E SEARO CSR Training

Learning objectives At the end of the session, the participants will be able to:
Learning Objectives

S L I D E 2

At the end of the session, the participants will be able to:

Explain the importance of promoting culture of safety Identify common situations during an outbreak investigation when the investigator is likely to be exposed to sources of infection Describe standard precautions and transmissionbased precautions Explain the uses of different types of personal protective equipment (PPE) Demonstrate putting on and removing PPE Demonstrate hand washing
Infection Name of Control Presentation E P I D E M I C A L E R T A N D R E S P O N S E SEARO CSR Training onon Outbreak Investigation SEARO CSR Training Outbreak Investigation

Explain the importance of promoting culture of safety Identify common situations during an outbreak investigation when the investigator is likely to be exposed to sources of infection Describe standard precautions and transmission-based precautions Explain the uses of different types of personal protective equipment (PPE) Demonstrate putting on and removing PPE Demonstrate hand washing

A culture of safety In infection control, for overall safety, it is important to ensure the following:

A Culture of Safety
S L I D E 3
Follow standard protocols Always be aware of your safety Change incorrect behavior in a positive way
Infection Name of Control Presentation E P I D E M I C A L E R T A N D R E S P O N S E SEARO CSR Training onon Outbreak Investigation SEARO CSR Training Outbreak Investigation

Follow organizational protocols, standard guidelines should be regularly practiced. Awareness of staff/ health workers on safety measures (attitude) as well as the organizations commitment to safety Commitment of the team leader to identify, correct and change erroneous behavior of staff and co-workers to minimize and avoid risk of infection

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Raise awareness Before going to the field, staff should be able to reflect on the importance of safety culture/ behaviour/ attitude. This means:

Raise Awareness!
S L I D E 4
Stop and think Assess the risk Prepare appropriate precautionary measures Use PPE Dont expose yourself or your staff to danger!
Infection Name of Control Presentation E P I D E M I C A L E R T A N D R E S P O N S E SEARO CSR Training onon Outbreak Investigation SEARO CSR Training Outbreak Investigation

Collect as much information as possible regarding the possible situation (or infection, if this is known) you are to deal with. This includes consideration of staff vaccination status in relation to the kind of disease to be investigated. Assess the risk Prepare appropriate precautionary measures before moving self/ staff for investigation/ sample collection Use personal protective equipment Strike a balance between the overall benefit of the action and the safety of self/staff. Do not expose yourself or your staff to unnecessary danger.

Risk of infection when assisting in an outbreak During an outbreak, staff can be infected from the following:

Risk of infection when assisting in an outbreak

S L I D E 5
Staff may become infected because of:
needle stick injury breach in the use of PPE during an aerosol-generating procedure before a patient is recognised as infectious
Infection Name of Control Presentation E P I D E M I C A L E R T A N D R E S P O N S E SEARO CSR Training onon Outbreak Investigation SEARO CSR Training Outbreak Investigation

Injuries by needle stick during specimen collection. This occurs most commonly when trying to RECAP the needles after taking blood samples. Use of PPE that has not been properly fitted e.g., gloves, masks. Staff should wear PPE that is appropriate for the degree of patient contact and the type of infection (if this is known). All personnel who may need to use an N-95 respirator (face mask) should be trained and fit-tested in use. Most PPE should not be re-used. Failure to perform hand hygiene From aerosol-generating procedures e.g., intubation, suctioning, nebulisation, cough-inducing procedures e.g. in SARS clusters identified in Toronto, Hong Kong, Singapore and Hanoi (http:// www2a.cdc.gov/PHTN/webcast/SARSII/Chiarello5-8.pdf) An infected patient who is not recognized as an infection risk (for example, a person who is not yet manifesting signs and symptoms)

Standard precautions Standard precautions should be followed routinely for all types of patient contact that may involve exposure to blood or body fluids irrespective of whether or not there is a recognized infectious risk or outbreak. Standard precautions are used for all patients regardless of their diagnoses to ensure protection of the health care worker and the patient.

Standard Precaution
S L I D E 6
SHOULD be: IN PLACE ALL of the time
Whether or not there is a recognized outbreak

PRACTICED for ALL patients

Regardless of diagnosis Standard precautions limit health care workers contact with secretions, skin lesions, mucus membranes, blood and other body fluids.
Infection Name of Control Presentation E P I D E M I C A L E R T A N D R E S P O N S E SEARO CSR Training onon Outbreak Investigation SEARO CSR Training Outbreak Investigation

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Standard precautions Treating all patients by applying standard precaution measures involve work practices that are essential to provide a high level of protection to patients, health care workers and visitors. These are: Hand hygiene

Standard Precaution
S L I D E 7
Infection Name of Control Presentation E P I D E M I C A L E R T A N D R E S P O N S E SEARO CSR Training onon Outbreak Investigation SEARO CSR Training Outbreak Investigation

Standard Precautions include

Hand hygiene Respiratory hygiene and cough etiquette Use of personal protective equipment (PPE) Prevention of needle sticks/sharps injuries Cleaning and disinfection of the environment and equipment

Respiratory hygiene and cough etiquette which are added to standard precautions to control transmission of respiratory infections if a patient has respiratory symptoms. Use of personal protective equipment (PPE) based on risk assessment to avoid direct contact with patient's blood, body fluids, secretions and non-intact skin Prevention of needle sticks/sharps injuries and Cleaning and disinfection of the environment and equipment

Transmission-based precautions For certain transmissible or highly pathogenic infections, transmissionbased precautions are used in addition to standard precautions. Contact, droplet, and airborne precautions are meant to prevent exposure to pathogens contracted through these means. Since the infecting agent may not be known at the time of admission to a health care facility, transmission-based precautions are used empirically, according to the clinical syndrome and the likely aetiologic agent (based on a risk assessment), and then modified when the pathogen is identified or stopped if a transmissible infectious disease etiology is ruled out. Its important to note that these guidelines are for clinical patient care and investigation in the field. Procedures in the laboratory or autopsy suite, etc. where mechanical generation of fine aerosols might occur, require different types or degrees of protection.

Transmission-based Precautions

S L I D E 8

USED for certain transmissible or highly pathogenic infections Contact, droplet, and airborne precautions each aim to block different routes of transmission USED in addition to standard precautions

Infection Name of Control Presentation E P I D E M I C A L E R T A N D R E S P O N S E SEARO CSR Training onon Outbreak Investigation SEARO CSR Training Outbreak Investigation

Transmission-based precautions Contact: Diseases which are transmitted by this route include MRSA, enteric infections and most skin infections. Gloves and gowns must be worn and contaminated surfaces cleaned Apply for infections that are spread through direct or indirect contact with patients or patient-care environment (e.g., shigellosis, Ebola hemorrhagic fever, MRSA). Droplet: droplets are usually generated from the infected person during coughing, sneezing, talking or when health care workers undertake procedures such as tracheal suctioning. Wear surgical mask and goggles in addition to standard precautions. Apply for infections spread by large droplets generated by coughs, sneezes, etc. (e.g., Neisseria meningitidis, pertussis, pneumonias, diptheria, influenza, mumps). Airborne: Airborne transmission when particles < 5 micron in size are disseminated into the air. These particles can remain suspended into the air for long periods of time, especially when bounded to dust particles. Use mask N95 and goggles in addition to standard precautions Apply for infections spread by particles <5 that remain infectious and suspended into the air (TB, measles, varicella, and variola).

Transmission-Based Precautions
Transmission Example

S L I D E 9

Organisms commonly implicated

Recommended PPE Gloves, gowns

Contact

Direct indirect shigellosis, Ebola contact with hemorrhagic fever, MRSA patient/ environment Cough, sneeze Neisseria meningitidis, pertussis, pneumonias, diptheria, influenza, mumps

Droplet

Surgical mask, goggles + standard precaution

Airborne

Particle suspended in the air (<5)

TB, measles, varicella, N 95, goggles + and variola standard precaution

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Personal protective equipment (PPE) PPEs are comprised of: gloves

Personal Protective Equipment

S L I D E 1 0
Infection Name of Control Presentation E P I D E M I C A L E R T A N D R E S P O N S E SEARO CSR Training onon Outbreak Investigation SEARO CSR Training Outbreak Investigation

gowns eye protection medical masks

Items that are not PPE: Caps for the hair only for the comfort of HCWs

Closed footwear only to avoid accidents with sharp objects

Personal protective equipment (PPE) Personal protective equipment reduces but does not completely eliminate the risk of acquiring an infection. it is important that it is used effectively, correctly and at all times where contact with blood and body fluids of patients may occur. Staff must also be aware that use of personal protective equipment does not replace the need to follow basic infection control measures such as hand hygiene.

Personal Protective Equipment

S L I D E 1 1

Reduces but does NOT completely eliminate the risk of acquiring infection Important that it is used
Effectively Correctly At all times

where contact with blood and body fluids may occur

DOES NOT replace basic infection control measures like HAND HYGIENE.
Infection Name of Control Presentation E P I D E M I C A L E R T A N D R E S P O N S E SEARO CSR Training onon Outbreak Investigation SEARO CSR Training Outbreak Investigation

Putting on PPE There has been much discussion regarding the order of putting on and taking off personal protective equipment. The order for putting on personal protective equipment is not important, what is important is the staffs knowledge on how contamination while wearing PPE be prevented. The following sequence is an example of one of the order when full personal protective equipment is worn: 1. Wash hands. 2. Wear scrub suit or old set of thin clothes before entering the designated changing room or area (optional) 3. Put the gown on. 4. If required, wear boots /or shoe covers with trousers tucked inside. (optional) 5. Wash hands. 6. Put the cap on. 7. Put the mask on. 8. Wear an impermeable apron if necessary. (optional) 9. Wear protective eye wear/ goggles. 10. Wash hands and dry them. 11. Wear gloves with gown sleeve cuff tucked into glove.

Putting on PPE (if all is needed)

S L I D E 1 2

Wash hands

Wash hands

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Taking off PPE The order in which personal protective equipment is removed is not as important as the principle behind choosing such an order. The key principle is that when removing personal protective equipment the wearer should avoid contact with blood, body fluids, secretions, excretions and other contaminants. When hands become contaminated they should be washed or decontaminated with 70% alcohol solution. An example of how to remove personal protective equipment is given.
Taking off PPE

1. 2. 3. 4. 5. 6. 7. 8.

S L I D E 1 3
Infection Name of Control Presentation E P I D E M I C A L E R T A N D R E S P O N S E SEARO CSR Training onon Outbreak Investigation SEARO CSR Training Outbreak Investigation

Using gloved hands, untie the gown string if tied in front and remove shoe covers. Remove gown and apron, without contaminating clothing underneath. Touch only inside of gown and apron while removing. Place in appropriate disposal bag. Remove gloves (fingers under cuff of second glove to avoid contact between skin and outside of gloves) and discard in an appropriate manner. Wash hands. Remove cap. Remove eye protection from behind. Put eye protection in a separate container for reprocessing Remove mask from behind Wash hands up to elbows thoroughly with soap and water, dry or decontaminate in 70% alcohol before leaving facility.

PPE materials: Gloves First we will discuss gloves. Gloves protect the user against contamination with infectious material, but it is important to realize that gloves may become sources of contamination if they are not used properly. There are different kinds of gloves that are used for different purposes. Thick rubber gloves may be used for cleaning or household purposes in a patients room. Clean gloves can be used for general contact in the room or with the patient, while sterile gloves should be used when collecting specimens or conducting any type of medical procedure on the patient.
PPE Materials

S L I D E 1 4

Gloves
Different kinds of gloves
Household gloves Clean gloves (protect yourself) Sterile gloves (also protect the patient from infection use for sterile sites)

Here are some dos of glove use: Work from clean to dirty. This is a basic principle of infection control. In the context of working with possible or confirmed avian influenza patients, it refers to touching clean body sites or surfaces before you touch dirty or heavily contaminated areas. Limit opportunities for touch contamination - protect yourself, others and environmental surfaces. An example of touch contamination is when someone wearing gloves touches his or her face or adjusts glasses with gloves that have been in contact with a patient. Touch contamination can potentially expose a person to infectious agents. Think about environmental surfaces, too, and avoid unnecessarily touching them with contaminated gloves. Surfaces such as light switches and door and cabinet knobs can become contaminated if touched by soiled gloves. Change gloves as needed, if this is possible. If gloves become torn or heavily soiled and additional patient care tasks must be performed, then change the gloves before starting the next task. Always change gloves after use on each patient, and discard them in the nearest appropriate receptacle. Patient care gloves should never be washed and used again. Washing gloves does not necessarily make them safe for reuse; it may not be possible to eliminate all microorganisms and washing can make the gloves more prone to tearing or leaking.

Dos
Work from clean to dirty Avoid touch contamination
Eyes, mouth, nose, surfaces

Change gloves between patients

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PPE materials: Gowns

PPE Materials: Gowns

S L I D E 1 5

Gowns
Fully cover torso Have long sleeves Fit snuggly at the wrist

Gowns are generally the preferred PPE for clothing, but aprons occasionally are used where limited contamination is anticipated. If contamination of the arms can be anticipated, a gown should be selected. Gowns should fully cover the torso, fit comfortably over the body, and have long sleeves that fit snuggly at the wrist.

Infection Name of Control Presentation E P I D E M I C A L E R T A N D R E S P O N S E SEARO CSR Training on on Outbreak Investigation SEARO CSR Training Outbreak Investigation

PPE materials: Masks Masks are another type of PPE. Wear masks that fully cover your nose and mouth to prevent fluid penetration. Masks should fit snugly, so ones with a flexible nose piece and that can be secured to the head with string ties or elastic are preferable. Respirators that filter the air before it is inhaled have been designed to protect the respiratory tract from airborne transmission of infectious agents. A commonly used respirator in healthcare settings is the N95 particulate respirator. The device has a sub-micron filter capable of excluding particles that are less than 5 microns in diameter. Prior to use, respirators should be fit tested for the appropriate size. And you should always check your respirator before use to make sure it has a proper seal. If surgical masks and respirators are not available, other materials such as tissues and cloth may be used to cover the nose and mouth. While the efficacy of these materials has not been scientifically evaluated, they are probably better than no mouth covering at all.

PPE Materials: Masks

S L I D E 1 6

Masks and Respirators: Barriers and Filtration

Surgical masks
Cotton, paper

Particulate respirators (N95)

Fit testing essential

Alternative materials (barrier)

Tissues, cloth

Infection Name of Control Presentation E P I D E M I C A L E R T A N D R E S P O N S E SEARO CSR Training on on Outbreak Investigation SEARO CSR Training Outbreak Investigation

Performing a particulate respirator seal check

Performing a particulate respirator seal check The slide presents step-wise manner in performing a particulate respirator seal check.

S L I D E 1 7
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PPE Materials
S L I D E 1 8
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PPE materials: Goggles Eye protection is important. Goggles provide barrier protection for the eyes. Personal prescription lenses do not provide optimal eye protection and should not be used as a substitute for goggles. Goggles should fit snuggly over and around the eyes or personal prescription lenses. You can use a face shield as a substitute to wearing a mask or goggles. The face shield should cover the forehead, extend below the chin, and wrap around the side of the face.

Eye Protection
Face shields Goggles

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Pointers on how to safely use PPE

Pointers on how to safely use PPE
PPE does not provide 100 % protection

S L I D E 1 9

Ensure you have everything you require before starting a task Ensure that no mucosal surface is exposed Check PPE is being correctly put on ( mirror / observer) Avoid self contamination while using the PPE Do not touch face, mask, eye wear etc Avoid self contamination on removal of the PPE Remember where you could be contaminated Avoid contamination of others Avoid contamination of the environment Dispose of PPE immediately and safely

Personal protective equipment reduces but does not completely eliminate the risk of acquiring an infection. it is important that it is used effectively, correctly and at all times, where contact with blood and body fluids of patients may occur. Staff must also be aware that use of personal protective equipment does not replace the need to follow basic infection control measures such as hand hygiene.

Infection Name of Control Presentation E P I D E M I C A L E R T A N D R E S P O N S E SEARO CSR Training onon Outbreak Investigation SEARO CSR Training Outbreak Investigation

Hand hygiene when to perform

Hand hygiene when to perform

S L I D E 2 0

Immediately
Upon arriving at work

Before
Direct contact with patient Putting on gloves for clinical and invasive procedures (e.g. administering intravascular injections, intravenous injections) Preparing handling, serving, or eating food Leaving work

Hand washing is the simplest and most effective way of preventing the transmission of infection. Hand washing should be performed during these circumstances: Immediately Upon arriving at work

Before Direct contact with patient Putting on gloves for clinical and invasive procedures (e.g. administering intravascular injections, intravenous injections) Preparing handling, serving, or eating food Leaving work

Infection Name of Control Presentation E P I D E M I C A L E R T A N D R E S P O N S E SEARO CSR Training onon Outbreak Investigation SEARO CSR Training Outbreak Investigation

Hand hygiene when to perform (continuation)

Hand hygiene when to perform

S L I D E 2 1

Between
Procedures on the same patient where soiling of hands is likely

After
Contact with patient Removal of gloves Removal of other personal protective equipment Contact with blood, body fluids, secretions, excretions, wounds exudates, contaminated items Contact with items/surfaces known or likely to be contaminated Personal body functions such as using the toilet, and wiping or blowing one's nose

Between Procedures on the same patient where soiling of hands is likely After Contact with patient

Removal of gloves Removal of other personal protective equipment Contact with blood, body fluids, secretions, excretions, wounds exudates, contaminated items Contact with items/surfaces known or likely to be contaminated Personal body functions such as using the toilet, and wiping or blowing one's nose

Infection Name of Control Presentation E P I D E M I C A L E R T A N D R E S P O N S E SEARO CSR Training onon Outbreak Investigation SEARO CSR Training Outbreak Investigation

Hand hygiene how to hand rub with alcohol-based formulation S L I D E 2 2

How to hand rub with alcoholbased formulation
Infection Name of Control Presentation E P I D E M I C A L E R T A N D R E S P O N S E SEARO CSR Training onon Outbreak Investigation SEARO CSR Training Outbreak Investigation

The slide provides a step-wise manner in performing hand rub with alcohol-based formulation. An alcohol-based hand product should be used if hands are NOT visibly soiled or contaminated and when access to soap and water are not available at the moment.

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DRAFT Version

Hand hygiene how to hand wash The slide provides a step-wise manner in performing hand washing with soap and water. S L I D E 2 3
How to perform hand washing

Hands that are visibly dirty or contaminated with body fluids should be washed with soap and water.

Infection Name of Control Presentation E P I D E M I C A L E R T A N D R E S P O N S E SEARO CSR Training onon Outbreak Investigation SEARO CSR Training Outbreak Investigation

Typical parts missed

Typical parts missed

S L I D E 2 4
Infection Name of Control Presentation E P I D E M I C A L E R T A N D R E S P O N S E SEARO CSR Training onon Outbreak Investigation SEARO CSR Training Outbreak Investigation

Washing hands should be done properly so as to ensure that no major parts are missed. Typical parts missed are shown in the slides when hand washing is not done properly.

PPE use: Challenges PPE is one of the vital components of a system of safety controls and preventive measures in health facilities or in the field. Recent studies have shown that despite expert recommendations and high risk conditions, health care workers tend to use PPE less. Below are some of the challenges in PPE use. Studies were conducted in a hospital setting although may apply in the field setting: Too busy or no time to wear PPE

PPE Use: Challenges

S L I D E 2 5

Reasons for not wearing PPE:

Too busy or no time Do not consider themselves high risk Can tell which patients are high risk Interference with skills, dexterity, communicating Physical discomfort Perception that precautions are ineffective
Infection Name of Control Presentation E P I D E M I C A L E R T A N D R E S P O N S E SEARO CSR Training onon Outbreak Investigation SEARO CSR Training Outbreak Investigation

Health staff do not consider themselves high risk in contracting the disease Patient did not appear high risk. Some staff even expressed that they can tell which patient are high risk Interference with skills particularly dexterity, communicating, health worker patient relationship and in recognizing people Physical discomfort Perception that precautions are ineffective

PPE use: Challenges (continuation)

PPE Use: Challenges

S L I D E 2 6

Reasons for not wearing PPE:

Availability of supply and ready access to it Cost of the PPE Community/patient perception e.g., some staff are careful not to upset patient

Below are some of the challenges in PPE use. Studies were conducted in a hospital setting although may apply in the field setting (continuation) Availability of supply and ready access to it

Cost of the PPE Community/patient perception - alien looking, creates fear, some staff are careful not to upset patient - pressure from community as they do not want to be handled by ghosts - a case during Ebola outbreak in recent period

Infection Name of Control Presentation E P I D E M I C A L E R T A N D R E S P O N S E SEARO CSR Training onon Outbreak Investigation SEARO CSR Training Outbreak Investigation

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DRAFT Version

Strategies for improving safety Promoting culture of safety necessitate strong management leadership and commitment. This includes providing opportunity to enhance understanding of staff in the importance of safety adherence. This can be done through continued education and training, improving feedback and enforcement of safety procedures among staff.

Strategies for improving safety

S L I D E 2 7

Leadership and commitment to safety Emphasis on education and training

Risk perception

Improving feedback and enforcement Clarify relevant work practices

Infection Name of Control Presentation E P I D E M I C A L E R T A N D R E S P O N S E SEARO CSR Training onon Outbreak Investigation SEARO CSR Training Outbreak Investigation

Be alert/ vigilant Finally infection control can be summarized as ABCDE:

Be Alert / vigilant

S L I D E 2 8

A Be Alert B Use Barrier protection C Clean and Disinfect D Dispose of waste E Evaluate and Feed back

A Be Alert be conscious of your environment and the situation you are in B Use Barrier protection use appropriate PPE/ immunization if necessary C Clean and Disinfect perform hand hygiene all the time D Dispose of waste dispose waste properly E Evaluate and Feed back review infection control measures and further improve

Infection Name of Control Presentation E P I D E M I C A L E R T A N D R E S P O N S E SEARO CSR Training onon Outbreak Investigation SEARO CSR Training Outbreak Investigation

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Permanent Secretary Building No. 3, 4th Floor Ministry of Public Health, Tiwanon Road Nonthaburi 11000 Thailand

SEARO CSR Subunit in Bangkok

Telephone No.: +66 2 580 7534 to 35 Email Address: csrsubunitbkk@searo.who.int Website: www.searo.who.int/csrsubunitbkk Facsimile: +66 2 580 7537