Infection Control

Commercial in Confidence
Infection control workbook
Last Updated December 2010

Table of contents
Principles of infection prevention and control ...............................................................5

Hand hygiene ..................................................................................................................5
The National Hand Hygiene Initiative (NHHI) ......................................................................... 5
5 Moments for Hand Hygiene .........................................................................................5
Putting on and removing PPE.........................................................................................6
Removing aprons and gowns ................................................................................................. 7
Removing and cleaning reusable face and eye protection ..................................................... 8
Changing and removing gloves .............................................................................................. 8
Cleaning: How much is enough? .......................................................................................... 10
Appropriate selection and use of chemical agents for environmental cleaning ....................... 10
Disinfection and sterilisation ................................................................................................. 10
Principles of aseptic technique ................................................................................................ 10
Contact precautions ................................................................................................................ 12
Hand hygiene and personal protective equipment ............................................................... 12
Droplet precautions ................................................................................................................. 12
Airborne precautions ............................................................................................................... 12
Personal protective equipment to prevent airborne transmission ......................................... 13
Basic epidemiology and statistics .................................................................................14

Formula examples ........................................................................................................14
Incidence .............................................................................................................................. 14
Incident rate.......................................................................................................................... 14
Prevalence ........................................................................................................................... 14
Study examples ............................................................................................................15
Ecological study ................................................................................................................... 15
Cross sectional study ........................................................................................................... 15
Case control study................................................................................................................ 15
Cohort study ......................................................................................................................... 15
Experimental study ............................................................................................................... 15
Randomized controlled trials (RCT) ..................................................................................... 15
Bias examples...............................................................................................................15
Selection bias ....................................................................................................................... 15
Information bias .................................................................................................................... 15
Confounding example ...................................................................................................16
Statistics examples .......................................................................................................16
Mean .................................................................................................................................... 16
Median ................................................................................................................................. 16
Percentiles............................................................................................................................ 16
Normal distribution ............................................................................................................... 16
Range ................................................................................................................................... 17
Standard deviation ............................................................................................................... 17
Confidence intervals ............................................................................................................. 17
Other common statistical tests......................................................................................18
Epidemiology and statistics exercise you can work through ........................................19
Bibliography ..................................................................................................................21
Surveillance and quality improvement ..........................................................................22

Resources for further information on surveillance definitions and activities .................22
Scenario examples developed as additional material only to assist with
understanding surveillance activities. ...........................................................................25
Infection control workbook 2 of 90

Facility-wide.......................................................................................................................... 25
Ongoing surveillance ............................................................................................................ 25
Point prevalence surveillance: .............................................................................................. 25
How long should SSI surveillance continue? ........................................................................ 26
Process surveillance ............................................................................................................ 26
Basic microbiology and multi-resistant organisms (MRO) .........................................27

Basic microbiology ........................................................................................................27
Terminology.......................................................................................................................... 27
Normal flora of the respiratory tract ...................................................................................... 30
The normal flora of the gastrointestinal tract ........................................................................ 30
Environmental organisms ..................................................................................................... 31
Gram positive bacteria ......................................................................................................... 32
Gram negative bacteria ........................................................................................................ 32
Viruses ................................................................................................................................. 32
Aspergillus ............................................................................................................................ 32
Aspergillosis symptoms and transmission ............................................................................ 32
Aspergillosis risk factors and management .......................................................................... 33
Staphylococcus aureus treatment ........................................................................................ 33
Clostridium difficile ............................................................................................................... 34
Multi-resistant Gram negative bacteria (MRGN)................................................................... 35
Extended spectrum beta-lactamases (ESBL) ....................................................................... 35
Risk management systems for infectious agents and infectious diseases ..............36
Infectious agents ...........................................................................................................36
Group A Beta-Haemolytic Streptococcus (GAS) ..........................................................36
Meningococcal disease ................................................................................................37
Tuberculosis (TB) .........................................................................................................38
Legionella......................................................................................................................39
Clostridium difficile ........................................................................................................40
Clostridium difficile or other gastroenteritis diseases............................................................ 41
Pertussis .......................................................................................................................42
Hepatitis A.....................................................................................................................43
Hepatitis B.....................................................................................................................44
Hepatitis C ....................................................................................................................45
Measles .........................................................................................................................46
Rubella ..........................................................................................................................47
Mumps ..........................................................................................................................48
Varicella ........................................................................................................................49
Influenza .......................................................................................................................50
Respiratory Syncytial Virus (RSV), Parainfluenza and Adenovirus ..............................51
Gastroenteritis...............................................................................................................52
Creutzfeldt Jacob Disease ............................................................................................53
Infectious agent screening and immunisation of healthcare workers .......................54

An example of risk assessment table for health screening and immunisation of HCW ........ 55
Bibliography ..................................................................................................................57
Outbreak management ....................................................................................................59

Appropriate selection and use of chemical agents for environmental cleaning ....................... 59
Bibliography .....................................................................................................................61

Renovation, repairs and redevelopment risk management ........................................62

Documented significant outbreaks of construction related infection ..................................... 62
Risk rating matrix.................................................................................................................. 64
Description of activities and classification by class............................................................... 65
An example of a construction/project survey tool .................................................................... 68
Roles and responsibilities for planning, consultation, implementation and monitoring of
infection prevention activities................................................................................................ 69
Management of occupational exposures ......................................................................74

Transmission risk .................................................................................................................... 74
Risk of transmission following exposure to HIV, HBV, HCV infected person ....................... 74
Factors affecting transmission risk ....................................................................................... 74
Sample occupational exposure management poster .............................................................. 76
Factors to consider in assessing the need for follow-up of occupational exposures ............ 77
Immediate management flow chart – source identity known – SAMPLE ONLY ................... 78
Immediate management flow chart – source identity unknown - SAMPLE ONLY ................ 79
Bibliography .....................................................................................................................80
Cleaning, Disinfection and Sterilisation ........................................................................81

Spaulding classification ................................................................................................81
Cleaning .................................................................................................................................. 81
Cleaning agents ................................................................................................................... 81
Respiratory equipment ......................................................................................................... 82
Disinfection.............................................................................................................................. 82
Thermal disinfection ............................................................................................................. 82
Ortho-phtaladehyde (OPA) ................................................................................................... 82
Further information on endoscopes ...................................................................................... 82
Monitoring ............................................................................................................................... 83
Bowie Dick type test ............................................................................................................. 83
Using biological/enzymatic monitoring indicators ................................................................. 83
Bibliography .....................................................................................................................84
Glossary ............................................................................................................................86

Principles of infection prevention and control

Hand hygiene
The Australian Commission on Safety and Quality in Health Care (ACSQHC) has
engaged Hand Hygiene Australia (HHA) to implement the National Hand Hygiene
Initiative (NHHI).
Healthcare associated infections (HAIs) have been nominated as a priority area by the
ACSQHC. Improved healthcare worker hand hygiene is an important priority to reduce
the risk of HAIs. Reliable indicators of hand hygiene compliance are important, as are
mechanisms for wider implementation and monitoring
Hand hygiene is a key infection control measure discussed throughout this module to
be utilised with all infectious agents or diseases to minimise risk of transmission to
other patients, visitors or HCW.
The National Hand Hygiene Initiative (NHHI)
HHA works closely with existing State and Territory projects and campaigns to
maximise the success of the NHHI. This work includes the establishment of a standard
national system of outcome measures to assess the effectiveness of the NHHI.
5 Moments for Hand Hygiene
Source: Hand Hygiene Australia

To learn more about the NHHI, go to the Hand Hygiene Australia website by clicking
on the 'Hand Hygiene Australia' link, which also has more information on:
• alcohol-based handrubs
• hand care issues
• The 5 Moments of Hand Hygiene
• resources for healthcare workers
• online learning packages, and
• contact details.
Examples of evidence supporting practice:
• World Health Organization (2009) Guidelines on Hand Hygiene in Health Care

• Boyce JM & Pittet D, Healthcare Infection Control Practices Advisory C, Force
HSAIHHT (2002) Guideline for Hand Hygiene in Health-Care Settings.
• Recommendations of the Healthcare Infection Control Practices Advisory
Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
• Society for Healthcare Epidemiology of America/Association for Professionals
in Infection Control/Infectious Diseases Society of America. MMWR Recomm
Rep 51: 1–45
Hand Hygiene Australia
Putting on and removing PPE
Health care workers should follow the sequence for putting on and removing PPE,
taking care to perform hand hygiene between each step, especially when the next step
is to touch the face.

Source: Australian Guidelines for the Prevention and Control of Infection in Healthcare
Removing aprons and gowns
Apron and gowns should be removed in a manner which avoids contaminating clothes
or skin. This can be done by pulling from shoulders and turning gown inward, rolling it
into a bundle for disposal or, if reusable, laundering.
Characteristics of aprons and gowns that will assist with risk assessing use and
application in clinical settings are as per the following table.

Removing and cleaning reusable face and eye protection
Only touch the back of the mask, goggles or face shield when removing. The front is
considered contaminated and, if reusable, should not be touched with bare hands prior
to cleaning.
Changing and removing gloves
When removing gloves, care should be taken not to contaminate the hands.
Hand hygiene must be performed immediately after the removal and disposal of
gloves, in case infectious agents have penetrated through unrecognised holes, or
have contaminated the hands during glove removal.


Cleaning: How much is enough?
The Australian Guidelines for the Prevention and Control of Infection in Healthcare
classify a range of risks and include detailed guidance on specific items and settings.
For more information, refer to Australian Guidelines for the Prevention and Control of
Infection in Healthcare (AICG).
Appropriate selection and use of chemical agents for environmental cleaning
Appropriate selection and use of chemical agents for environmental cleaning and
disinfection should be risk assessed for:
• correct and safe use

• PPE – especially the use of gloves that are removed immediately once activity
has been completed and changed between cleaning and disinfection activities
• compatibility
• contact time
• dilution, and
• scope of activity.
If using a combined cleaner/disinfectant product – follow manufacturer’s instructions

once the risk assessment has been completed. If using separate cleaning agents and
disinfectants, cleaning must be completed prior to use of disinfectants. Follow
manufacturer’s instructions for use.
The selection of a disinfectant must include confirmation that its characteristics will
ensure it is effective against infectious agent(s) involved.
Disinfectants to be used in healthcare settings may vary according to National/ State/

Territory recommendations and also between acute and non-acute patient care areas.
A risk assessment should be completed.
Disinfection and sterilisation
Information on the Spaulding classification of items (critical, semi-critical and non-

critical) and comprehensive information on cleaning, disinfection and sterilisation is
included in the 'Cleaning, disinfection and sterilisation' module.
If it cannot be cleaned, then it cannot be adequately disinfected or sterilised
Principles of aseptic technique
Aseptic non-touch technique (ANTT) provides a framework and principles that can be
applied in acute care or community health care setting to support the reduction in
healthcare associated infections.
Aseptic technique aims to prevent infectious agents from being introduced to

susceptible sites by hands, surfaces and equipment in sufficient quantity to cause
infection.

ANTT is a technique used to prevent contamination of key parts and key sites by
infectious agents that could cause infection. In ANTT, asepsis is ensured by identifying
and then protecting key parts and key sites by hand hygiene, non-touch technique,
using new sterilised equipment and/or cleaning existing key parts to a standard that
renders them aseptic prior to use (Rowley et al 2010).
ANTT involves undertaking a risk assessment for procedures and this will assist in
determining what equipment or PPE is required for the activity, e.g. selection of sterile
of non-sterile gloves for a specific procedure.
ANTT also requires consideration of sequencing within the activity or procedure to

ensure that there is a safe, efficient and logical order to the procedure.
The basic principles of aseptic technique include:
• hand hygiene immediately before and after procedures

• using barriers, such as a sterile gown, gloves and drapes
• using masks and eye protection
• skin antisepsis
• using sterile equipment
• maintenance of a sterile field
• correct technique, and
• methodology that minimises the risk of contamination of the sterile field.
Minimising the risk of contamination with infectious agents remains the same for all
procedures. ANTT allows for clean and dirty environments, addressing how the aseptic
field will be maintained and whether an aseptic field is critical or general, based on the
risk assessment for that procedure.
E.g. in a high risk procedure like inserting a central venous catheter, a critical aseptic
field is required, which means a surgical scrub, sterile gloves and sterile gown would
be utilised.
In a lower risk procedure, like inserting a peripheral venous catheter, a general aseptic
field is required, which means sterile equipment, hand hygiene and non-sterile gloves
would be utilised.
Refer to the Australian Guidelines for the Prevention and Control of Infection in
Healthcare and www.antt.org.uk for more information on the use and application of
these principles.

Contact precautions
Contact precautions should be used for diseases such as:
• Clostridium difficile
• gastroenteritis – bacterial
• viral gastroenteritis, such as norovirus and rotavirus
• hepatitis A
• Methicillin- resistant Staphylococcus aureus (MRSA)
• Vancomycin Resistant Enterococcus (VRE)
• highly contagious skin infections, such as impetigo, and
• infestations, such as scabies.
Contact precautions should also be considered in the presence of any excessive

wound drainage or faecal incontinence.
Hand hygiene and personal protective equipment
Follow these steps:
• perform hand hygiene

• put on gloves and gown upon entry into the room or cubicle
• before leaving the patient care environment, remove gloves, perform hand
hygiene and remove gown, and
• ensure that clothing and skin do not contact potentially contaminated
environmental surfaces before leaving the patient care environment.
Droplet precautions
Infection and conditions which require droplet precautions include:
• influenza virus (by direct or indirect transmission)

• meningococcal infection
• whooping cough
• rubella
• adenovirus
• rhinovirus
• respiratory syncitial virus, and
• streptococcal infection (Group A) respiratory infection.
Airborne precautions
Some common infections which require airborne precautions include:
• Rubeola virus (Measles)

• Varicella zoster virus (Chickenpox)
• active pulmonary Mycobacterium tuberculosis, and
• disseminated herpes zoster (shingles).

Personal protective equipment to prevent airborne transmission
To minimise the risk of exposure to suspected or confirmed airborne infectious agents

or particles, all health care workers who enter a patient care area where airborne
precautions are in place must wear a correctly fitted P2 (N95) mask. Click on the
following link for details.
http://www.flupandemic.gov.au/internet/panflu/publishing.nsf/Content/safeuse-dvd-1--)
The filtration efficiency of P2 (N95) masks protects the wearer from inhaling small
respiratory particles, but to be effective they must fit so that inhaled and exhaled air
travels through the filter medium.
Considerations when using P2 (N95) masks include:
• if a good facial seal cannot be achieved, e.g. if the intended wearer has a
beard or long moustache, an alternative respirator such as a powered air-
purifying respirator (PAPR) should be used
• masks should be changed when they become moist
• masks should never be reapplied after they have been removed
• masks should not be left dangling around the neck, and
• hand hygiene should be performed upon touching or discarding a used mask.
Differences between surgical and P2 masks are outlined in the table below:

Basic epidemiology and statistics

Formula examples
Incidence
5 newly colonised patients with MRSA were detected on a weekly screening in Ward
B. A total of 30 patients were screened on this day:
• 23 did not have MRSA

• 2 were known to have MRSA from last week’s screening, and
• 5 were the newly detected cases.
Therefore: Incidence ratio = 5/30 =0.17

Incidence percentage = 17%
Incident rate
In the following example, 5 patients were identified with S.aureus blood stream
infections from Ward A in a 30 day period. Ward A had another 16 patients coming in
and out of the ward during these 30 days with a total of 257 patient-days of bed
occupation in the ward.
Therefore: Incidence ratio = 5/257 = 0.02

Incidence rate = 20 per 1,000 patient-days
The incidence rate was 20 patients with S.aureus blood stream infections per 1,000
patient-days.
This rate can then be compared to the rates:
• in other wards within the same hospital

• in other similar sized hospitals for the same specialty units, and
• before and after infection control intervention.
When comparing rates, consideration should be given to variable risk as patients may
have different risk factors or be undergoing procedures that change their risk factors.
The risk affecting the rates can be used to identify higher or lower rates and how they
impact upon patient safety.
Prevalence
In the following example, 5 newly colonised patients with MRSA were detected on
screening in Ward B on one day. A total of 30 patients were screened on this day:
• 23 patients did not have MRSA

• 2 were known to have MRSA from last week’s screening, and
• 5 were the newly detected cases.
Therefore: Prevalence ratio = 7/30 = 0.23

Prevalence percentage = 23%

Study examples
Ecological study
An example of an ecological study would be a comparison of hospital-wide use of

vancomycin with prevalence of VRE in the hospital. Additional studies would be
required to further explore the data.
Cross sectional study
An example of a cross sectional study would be an investigation of all patients

currently in hospital with VRE and whether they have received vancomycin. This study
then can lead to analysis of the population as either a case control or cohort study.
Case control study
An example of a case control study would be an investigation of risk factors in patients

with central venous catheters who had S.aureus bacteraemia (cases) and those that
did not (controls) in the intensive care unit over the same time period.
Cohort study
An example of a cohort study would be an investigation of risk factors in patients with

central venous catheters who had S.aureus bacteraemia (cases) and those that did not
(controls) in the intensive care unit over the same time period.
Experimental study
An experimental study may look at the effectiveness of an antibiotic by which a group

of people are given the new antibiotic while the others receive the current treatment. All
other factors are kept constant while the antibiotic is the only experimental factor
(variable) that will or will not show an effect.
Randomized controlled trials (RCT)
An example of a randomized controlled trial would be where patients in the intensive

care unit are randomly assigned to the new anti-Staphylococcal antibiotic daptomycin
or the current antibiotic vancomycin for treatment of MRSA bacteraemia and then
compared for mortality and length of hospital stay outcomes.
Bias examples
Selection bias
Selection bias occurs where volunteers may not be representative of a true population
as these are patients who want free treatment and they may differ to non volunteers.
Information bias
Information bias can occur if patients are aware of their infection status as they may try
to identify possible reasons for obtaining a resistant infection. This group would be
more likely to remember recent antibiotics that they have been given.

Confounding example
In assessing the association between VRE infection and mortality in a gastro-surgical

unit, we need to consider complexity of surgery as a potential confounder. Complex
surgical patients are more likely to be on vancomycin and develop VRE but these
patients are also more likely to die. As complexity of surgery is associated with both
exposure and outcome it is a potential confounder.
Statistics examples
Mean
To calculate the mean for the set of 10 numbers displayed here:
10.5, 10.8, 10.9, 11.9, 12.4, 12.8, 15.2, 11.1, 11.7, 10.1
Total sum X = 117.4 and number of observations n = 10.
Therefore: 117.4/10 = mean 11.7.
Median
To calculate the median for the following set of numbers:
10.5, 10.8, 10.9, 11.9, 12.4, 12.8, 15.2, 11.1, 11.7, 10.1
Arrange them in numerical order:
10.1, 10.5, 10.8, 10.9, 11.1, 11.7, 11.9, 12.4, 12.8, 15.2
The median is between 11.1 and 11.7 and therefore 11.4
Percentiles
If we use our previous set of numbers:
10.5, 10.8, 10.9, 11.9, 12.4, 12.8, 15.2, 11.1, 11.7, 10.1
10.1, 10.5, 10.8, 10.9, 11.1, 11.7, 11.9, 12.4, 12.8, 15.2
Therefore:
th
• 25 percentile = (10.5, 10.8) = 10.65
th
• 50 percentile = (11.1-11.7) = 11.4
th
• 75 percentile = (12.4-12.8) = 12.6.
Normal distribution
The height of adults in Australia follows a normal distribution with a mean (µ) of 174 cm
and a standard deviation (σ) of 6 cm.

Therefore:
• 68.2% of observations will be between + 1 standard deviation (168-180cm)

• 95.4% of observations will be between + 2 standard deviations (162-186cm),
and
• 99.6% of observations will be between + 3 standard deviations (156-192cm).
Range
Using the set of numbers from our previous sample:
10.5, 10.8, 10.9, 11.9, 12.4, 12.8, 15.2, 11.1, 11.7, 10.1
We would rearrange them in numerical order:
10.1, 10.5, 10.8, 10.9, 11.1, 11.7, 11.9, 12.4, 12.8, 15.2
Therefore, the range is (10.1 – 15.2).
Standard deviation
To use the set of numbers from our previous example:
10.5, 10.8, 10.9, 11.9, 12.4, 12.8, 15.2, 11.1, 11.7, 10.1
We would again arrange them into numerical order.
10.1, 10.5, 10.8, 10.9, 11.1, 11.7, 11.9, 12.4, 12.8, 15.2
Therefore:
• mean = 11.7, and

• calculated SD = 1.5.
This means that 95% of results will be between (11.7-1.5) to (11.7+1.5), that is, 10.2 to
13.2.
If the distribution is "normal", 95% of all observed results will be located between the
mean +/- 1.96 SD.
Confidence intervals
The incidence rate for acquiring VRE from another patient in a four bed room has a
Relative Risk of 2.9 [95% CI, 1.3-4.4], p = 0.01.
This means that the risk of acquiring VRE from another patient sharing the four bed
room is 2.9 times increased with the true value in 95% of the time being as low as 1.3
or as high as 4.4. As it does not cross 1, the p value of 0.01 is supported as significant.

Other common statistical tests
Anova: Tests for statistical significance between means of several subgroups (multiple
testing).
Chi-square: Tests the relationship between the frequencies of two factors.
Correlation coefficient: A measure of association that indicates the degree to which

two variables have a linear relationship. Results can be between -1 and +1.
Fisher’s exact: Used to test association of 2X2 frequency table for sparse data or
small numbers (<20).
Kruskall-Wallis: Extension of Wilcoxon for comparing more than 2 groups
Mann-Whitney: Used when sample data are not normally distributed. Test compares
two groups of ordinal scores.
McNemar’s Test: A form of Chi- square test for matched pair’s data.
Multivariate Analysis: Involves the observation and analysis of more than one
statistical variable at a time.
Pearson Correlation: Used to determine if the values of two normally distributed

variables are linearly associated.
Regression: Determines the relationship between one dependent (response) variable

and one or more independent variables.
T-test: Used to test the hypothesis involving numerical data that is normally
distributed. It determines whether the mean observations differ significantly from a test
value.
Univariate Analysis: Explores each variable in a dataset separately.
Wilcoxon: Used instead of the T-Test, when sample data are not normally distributed.
It is the same as a Mann-Whitney test.

Epidemiology and statistics exercise you can work through

The following exercise has been based on an article by Huang et al published in
Journal of Infectious Disease. 2007: Vol 195 (1 Feb), 339-346 titled “Improving the
Assessment of Vancomycin-Resistant Enterococci by Routine Screening”.
It is to be used to understand how data is presented in infection control peer review

journals. You do not need to understand how the study was conducted. It is only to
show how all elements of this module appear in publications. The following questions
are in sequential reading order. Complete your response to the questions. Correct
answers are available for you to check your response against.
Question Your Response
Q1: What type of study was conducted?
Q2: How was monthly VRE prevalence

measured?
Q3: How was monthly VRE incidence

measured?
Q4. What summary statistics were used?
Q5.What type of analyses was used to

evaluate predictors of monthly admission
prevalence and incidence?
Q6. What is the incidence rate

denominator?
Q7. What was the overall compliance

with collection of admission swabs?
Q8. How much did imported VRE

increase with screening on admission?
Q9. VRE incidence decreased monthly

by 0.22% (p=0.004). Was this
significant?
Q10. How was misclassification of

imported carriers as incident ones
prevented?
Q11. How much did surveillance cultures

add (average and range) on additional
precaution days per unit month?
Q12.What percentage of patients

admitted within 60 days of their last
positive VRE culture tested positive for
VRE?

Correct answers to the questions are as follows:
Question Correct Response
Q1: What type of study was Retrospective cohort study

conducted?
Q2: How was monthly VRE The number of patients in the unit ever known
prevalence measured? to be VRE positive before or during that month/
total patients in unit that month
Q3: How was monthly VRE The number of patients newly detected to be
incidence measured? VRE positive before or during that month/
number of patients at risk of VRE detection
Q4. What summary statistics were Mean standard deviation and range
used?
Q5.What type of analyses was used Multivariate analysis

to evaluate predictors of monthly
admission prevalence and
incidence?
Q6. What is the incidence rate 1000 patient-days at risk for new VRE
denominator? detection
Q7. What was the overall compliance 82%

with collection of admission swabs?
Q8. How much did imported VRE Increase 3.3 fold (unit range, 2.2-17.0 fold)
increase with screening on
admission?
Q9. VRE incidence decreased Yes

monthly by 0.22% (p=0.004). Was
this significant?
Q10. How was misclassification of By collecting admission surveillance cultures

imported carriers as incident ones
prevented?
Q11. How much did surveillance 44.2 (Range 29.3-83.7)

cultures add (average and range) on
additional precaution days per unit
month?
Q12.What percentage of patients 76.4%; 301/394

admitted within 60 days of their last
positive VRE culture tested positive
for VRE?

Bibliography
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Basic and Clinical Biostatistsics.3 Edition. Edited by B. Dawson, RG. Trapp. McGraw-
Hill Higher Education, Singapore, (2001)
nd
Epidemiology. 2 Edition. Edited by L. Gordis. W.B. Saunders Company, USA (2000)
Essential Epidemiology. An introduction for students and health professionals. Edited

byP Webb, C Bain and S Pirozzo. Cambridge University Press, UK (2008)
th
Hospital Infections. 5 Edition. Edited by WR. Williams. Lippincott Williams & Wilkins,
Philadelphia, USA (2007)
Medical calculator (Last accessed 20.07.09 )http://www.medcalc.be/manual/index.php
th
Microbiology an Introduction. 9 Edition. Edited by GJ Tortora, BR Funke and CL
Case. Pearson International Edition, San Francisco, US (2007)

Surveillance and quality improvement

Resources for further information on surveillance definitions and
activities
Australian Infection Control Association (AICA) This link provides details about the National
Advisory Board (NAB), standardised definitions
http://www.aica.org.au/default.asp?PageID=46 for infection prevention surveillance activities for
SSI, MRO, C.difficile, and additional resources
for surveillance activities.
Australian Council for Healthcare Standards Provides member organisations with risk
(ACHS) management tools and clinical indicators.
http://www.achs.org.au
Healthcare Infection Control Special Interest Group Provides a website for discussion, sharing of
(HICSIG) resources, guidelines and patient information
material for healthcare workers especially
http://www.asid.net.au/hicsigwiki/index.php relating to risk management, infection
prevention and antibiotic stewardship.
Aged Care Accreditation Provides aged care information relating to risk

management and infection prevention control in
http://australia.gov.au/directories/australia/aged- this specialised area of healthcare.
care-accreditation
http://www.accreditation.org.au/
Victorian Hospital Acquired Infection Surveillance Collects and analyses data from acute care
System (VICNISS) facilities in Victoria. Provides data on results
and resources for these activities.
http://www.vicniss.org.au/
The Victorian Quality Council A useful guide on the quality improvement cycle
and using data
http://www.health.vic.gov.au/qualitycouncil/pub/imp
rove/data_guide.htm
Centre for Health Related Infection Surveillance Provides guidance and support for Queensland
and Protection (CHRISP) health care facilities in surveillance activities
aggregating and analysing data.
http://www.health.qld.gov.au/chrisp/default.asp
Clinical Excellence Commission (CEC) Resources and publications relating to quality

http://www.cec.health.nsw.gov.au/ and safety including surveillance activities, e.g.

the CLAB-ICU project.
NSW Health/Quality and Safety - HAI Provides resource information, publications and
data on Infection Prevention and Control
http://www.health.nsw.gov.au/quality/hai/index.asp activities including HAI and surveillance
activities.
Hand Hygiene Australia (HHA) Provides data on hand hygiene and resources
for health care at utilise to assess and improve
http://www.hha.org.au/ compliance in line with the 5 Moments.
An independent resource centre that provides

Institute of Healthcare Improvement information and resources on improvement of
health care world-wide.
http://www.ihi.org/IHI/Topics/Improvement/

Surveillance activities are an important tool for use by infection prevention and control
professionals. They need to be practical, uniform, and have the ability to be collected
rapidly.
Figure 1:
The PDSA Cycle
ACT – communicate PLAN – define the

the findings to surveillance
relevant people
STUDY – analyse
DO – systematic
and interpret
collection of data
Types of surveillance are outlined in the following diagram.

Scenario examples developed as additional material only to assist with

understanding surveillance activities.
Facility-wide
Ongoing surveillance
Scenario: The ICP at a rural aged care facility decides to undertake hospital wide
surveillance. They are able to perform this surveillance because the facility has only 12
residents and all are cared for by the local GP. Close liaison with the GP allows the
capture all infections and identify possible trends. After twelve months of data
collection and analysis, the ICP feels that patients with indwelling urinary catheters
have a high infection rate. The ICP consults other like facilities that collect data and
confirms that the rate is high. A reassessment of the surveillance plan and available
time for the activity shows that surveillance will be refined to concentrate on reducing
urinary catheter related infections. Surveillance now targets hand hygiene, aseptic
technique, and urinary catheter insertion and maintenance until infection rates have
decreased significantly.
Who would you report these findings to?
Answer - Management, Medical officer, clinical staff.
Point prevalence surveillance:
Scenario: The ICP at a small rural hospital undertakes a point prevalence survey of
patients colonised with MRSA because several patients have had MRSA isolated from
infected surgical wounds over the last month. Nose and groin swabs are collected from
every patient on a particular day, but MRSA is not detected in any specimens.
To conclude that MRSA was no longer a problem based only on these results may not
be an accurate assessment. In this case, it would be more beneficial to undertake
surgical site infection surveillance for a period to determine if a link between the
infections was identifiable, e.g. all patients with MRSA infected wounds had the same
surgeon or were operated on in the same theatre etc.
Examples for specific high risk clinical areas: Intensive Care Units (ICU) and High
Dependency Units, including Neonatal and Paediatric, usually utilise both process and
outcome surveillance methods and focus on identified risk areas or sites, including:
• central line associated blood stream infections (CLABSI), which account for
approximately 87% of primary blood stream infections (BSI)
• ventilated associated pneumonia (VAP), which accounts for up to 86% of
pneumonia cases associated with mechanical ventilation
• catheter related urinary tract infections, which account for up to 97% of ICU
cases of urinary tract infections (UTI) associated with indwelling urinary
catheters
• anti microbial use and antimicrobial resistance in infectious agents, which
create morbidity and mortality issues, especially in ICU [refer to module 4], and
• surgical site infections (SSI) following an invasive surgical procedure, which
are associated with significant morbidity, mortality and cost to the organisation
and patient.

How long should SSI surveillance continue?
Example 1: Hospital A has conducted SSI surveillance on Cholecystectomies for

twelve months. Twenty procedures were performed and the infection rate was 0%. The
ICP decides to change activity and conduct SSI surveillance on caesarean sections for
the next 12 months.
Example 2: Hospital B has conducted surveillance on caesarean sections for the last
12 months because this procedure was the most commonly performed at the facility.
The hospital also performed about 10 hip replacements per year. The caesarean
infection rate after twelve months was 6%, half of which were deep infections (non-risk
adjusted). The ICP contacted several similar facilities in other regions to compare
rates. The ICP did not want to cease surveillance of caesareans due to the deep
infection rate but also wanted to conduct surveillance on hip replacements, and, in
particular, adherence to the surgical antibiotic prophylaxis protocol. Infection control
was not allocated any more resources so the plan for the next 12 months was to
continue caesarean surveillance for the first six months and evaluate following
interventions aimed at reducing the 6% infection rate. The ICP would conduct
surveillance on the hip replacements for the second half of the year to ensure that
infection rates were acceptable. If the SSI rate for the caesareans had not decreased
after six months, the surveillance of hip replacements might need to be delayed or the
IC committee might need to review the availability of additional infection control
resources to support the extended surveillance activities.
Example 3: SSI surveillance has been conducted at Hospital C, a regional hospital, for
the last three years. Data has been collected on three different procedures which are
most commonly performed. One procedure was targeted each year. After three years,
the infection rate for all procedures was very low. The surgical procedures performed
did not require the patients to remain in hospital for longer than a few days, so
detecting infections unless readmitted to the hospital was not possible. The ICP
decided that SSI surveillance was not the best use of infection control resources and
decided to devote more her time to hand hygiene activities and staff education. This
would include a three month snapshot of one of the surgical procedures each year for
the next three years. If infection rates increased in any of these procedure groups, the
ICP would adjust the plan accordingly.
Process surveillance
Monitoring
In the ICU of a large hospital, the ICP has been feeding back high infection rates for
central line associated bacteraemia (outcomes) to the appropriate people but the rates
have not improved, despite introducing a “bundle” of interventions to prevent the
infections. The ICP decides to monitor/audit adherence to the “bundle protocol” by staff
and feedback these results.
In this case, the process method has a twofold effect. Firstly, the staff are aware that
they are being observed and they usually correct bad habits, or if they are unaware of
the correct protocol they can be advised accordingly. Secondly, the results are fed
back to the people who can create or enforce change. The information enables them to
address poor work practices, lack of technique or resources and so on.

Basic microbiology and multi-resistant organisms (MRO)

Basic microbiology
Terminology
The following table provides explanation of terms utilised in this module and terms that
an ICP should be aware of to ensure they have an understanding of this topic.
Infection The invasion, growth and multiplication of pathogenic

microorganisms in the body, e.g. Streptococcus sp.
Disease Harmful alteration in the physiological or metabolic state of the
host, e.g. pulmonary tuberculosis
Virulence Degree of pathogenicity of an organism. This varies between
microorganisms in the same species, e.g. Streptococcus sp.
Pathogenic The ability for microorganisms to cause disease
Pathogens These are microorganisms that are capable of causing disease
in a susceptible host. The intact skin and mucous membranes
lining the respiratory, gastrointestinal and genitourinary tract
provide a protective barrier against these organisms. If this
barrier is damaged or penetrated, the organisms can potentially
gain entry to the body, e.g. Escherichia coli (E. coli) is normally
found as normal flora of the gastrointestinal tract where it usually
causes no evidence of disease and offers benefits to the host.
However, it can also cause bacteraemia, septicaemia and
urinary tract infections when it is allowed to enter other body
areas/systems, thereby becoming an opportunistic pathogen.
Signs Measurable changes in the patient as a result of infection, e.g.
temperature and vomiting
Symptom Changes felt by the patient, e.g. hot flushes, nausea
Syndrome Combination of signs and symptoms, e.g. inflammation
Sepsis Poisoning due to infection by microorganisms
Endogenous Infection caused by organisms from the hosts own body, e.g.
infection Streptococcus sp.
Exogenous Infection caused by organisms external to the host, e.g.
infection Pseudomonas aeruginosa
Iatrogenic infection Infection resulting from medical treatment or procedure, e.g.
post operative wound infection
Carrier Person that harbours and has the ability to continuously shed or
transmit an infection without showing any symptoms of the
disease, e.g. MRSA and hepatitis B
Colonisation Microorganisms which normally inhabit and reproduce in or on
the human body without causing disease. Some of these
organisms are also identified as pathogens, such as S.aureus,
which can be carried on the skin without causing disease, but if
it is provided with an entry point or suitable environment can be
pathogenic (disease/infection producing). There are many health
factors that can provide protection against infection by these
colonising pathogens.
Host Human, or other providing a home for the organism
Resident (normal) Organisms that live on the host without causing disease
flora

Transient flora Organisms found on the host for a short time, not causing
disease
Incubation period Time between exposure to organism and appearance of
symptoms, e.g. food poisoning – 4-24 hrs; tetanus – 24-24 hrs;
chicken pox – 2-3 weeks; Hepatitis B – 1-3 months
Infective dose The number of organisms which must gain entry in order to
cause infection, e.g. Shigella - <100 organisms, Salmonella -
6
>10
Immunisation Exposure to an antigen in order to create an immune response
which then develops antibodies to that particular disease
Epidemic A sudden rapid rise in a disease in a given population or area,
e.g. H1N1 influenza
Endemic Always present in a given population, e.g. Streptococcus sp.
Erythema Reddened skin, usually due to inflammation
Serotypes Different antigenic strains of a microorganism
Subclinical infection No recognisable signs or symptoms but an immune response
occurs, e.g. glandular fever.

Eyes:
Staphylococcus aureus,
Staphylococcus epidermidis Skin:
Diphtheroids Staphylococcus aureus,
Staphylococcus epidermidis,
Mouth: propionibacterium acnes
Streptococcus spp. Corynebacterium spp.
Lactobacillus,
Bacteroides,
Candida spp. (yeast) Upper Respiratory Tract:
Staphylococcus aureus,
Staphylococcus epidermidis
Nose and throat:
Streptococcus spp.
Streptococcus pneumoniae,
Diphtheroids (mainly in the nose)
Haemophilus influenzae,
Neisseria sp. (in the throat)
Micrococcus spp.
Stomach:
Lactobacilli
Candida spp. (yeast)
Small intestine:
Lactobacilli
Streptococcus spp
Corynebacteria
Enterococci
Escherichia coli
Genital/Urinary tract: Bacteroides spp.
Lactobacillus spp. Candida spp. (yeast)
Corynebacteria
Enterococcus spp.
Enterobacter spp. Large intestine (colon):
Escherichia coli Lactobacilus spp.
Staphylococcus spp. Corynebacterium spp.
Streptococcus spp. Enterococcus spp.
Diphtheroids Enterobacter spp.
Proteus spp. Escherichia coli
Klebsiella spp. Fusobacterium spp.
Candida albicans (yeast) Clostridium spp.
(In females – flora exists in the lower Bacteroides spp.
part of the urethra and vagina, in Proteus spp.
males, flora in the urethra is found in
Bifidobacterium spp.
much lower populations)
Candida albicans (yeast)
Normal flora of the skin
The normal flora of the skin includes:
• Staphylococcus epidermidis, a type of coagulase negative staphylococcus

(CoNS). Other examples include Staphylococcus capitis and Staphylococcus
hominis
• Staphylococcus aureus, found in moist areas, that is, axillae, groin, perineum
• Propionibacterium acnes, found in hair follicles and sebaceous glands
• Corynebacterium spp, found on the skin surface, and
• Candida spp, found in the female genital tract.

Normal flora of the respiratory tract
Normal flora of the respiratory tract includes:
• Streptococcus spp, including S.mutans, S.mitis and S.salivarius

• Neisseria spp, including N.sicca and N.pharyngitidis
• Staphylococcus spp, including S.epidermidis, and
• Haemophilus spp, including H.parainfluenzae.
Normal human flora also includes some Gram negative bacilli, such as E.coli,
Klebsiella spp in low numbers in the elderly, and some anaerobic bacteria, such as
Peptostreptococcus spp.
The normal flora of the gastrointestinal tract
From “Infectious Diseases” edited (D. Armstrong and J Cohen)
The normal flora of the gastrointestinal tract includes:
• Enterococcus spp, such as E.faecium and E.faecalis

• some anaerobic bacteria, such as Bacteroides spp

• the anaerobic Gram positive bacillus Clostridium perfringens, and

• Gram negative bacilli, including E.coli, Serratia spp, Klebsiella spp and
Pseudomonas spp.
Gram positive cocci: Enterococcus faecalis from ASM Microbe Library
Environmental organisms
There are several significant microorganisms that are linked to transient flora and
environmental origins, including:
• animals
• soil
• buildings and air conditioning units
• vegetation
• foods, and
• water.
Healthcare facility areas that pose a risk of being contaminated by environmental

microorganisms include:
• food preparation areas

• air handling systems
• warm water systems
• inanimate surfaces and objects, like curtains, shelving or storage units
• equipment, like ventilators and humidicribs, and
• wet areas.
Examples of common environmental microorganisms are: S. aureus, P.aeruginosa,

L.longbeachiae, L.pneumophilia, L. monocytogenes, Pasteurella spp., and
Enterococcus spp. Aspergillus fumigatus.

Gram positive bacteria
Examples of Gram positive bacteria include Staphylococcus aureus, S. epidermidis,

Enterococcus spp, Streptococcus pyogenes, S.pneumoniae, Clostridium difficile,
Lactobacillus spp and Listeria spp.
Gram negative bacteria
Examples of Gram negative organisms include Neisseria meningitidis, N.gonorrhoeae,

E. coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter spp, Serratia
spp and Bacteroides spp.
Viruses
Some examples of important viruses include:
• respiratory viruses, such as respiratory syncytial virus (RSV),

influenza A and B, measles, rubella, herpes, and varicella
zoster
• faecal viruses, such as rotavirus or norovirus, and
• blood borne viruses, such as hepatitis B and C, and HIV.
Aspergillus
Aspergillus is a fungal organism found on plants and in soil, dust and building
materials. They have also been linked to air-conditioning ducts. While A.fumigatus is
the most common species of Aspergillus, others include A.flavus, A.niger and
A.terreus.
Aspergillus fumigatus courtesy of Mycology online-Kaminski collection
Aspergillus spp causes a disease known as Aspergillosis.
Aspergillosis symptoms and transmission

Aspergillosis symptoms range from allergic reactions, like wheezing and coughing, to
invasive symptoms resulting from infected bodily organs and compromised immune
systems. The disease commonly affects the lungs, and can spread throughout the
body, including the brain.
Aspergillus is transmitted via spores, which are breathed in from the environment.
There is no harm for healthy people as the immune system can get rid of the spores.
However, inhalation by compromised people from a dusty environment can lead to
infection.
This means the risk is greatest for immunocompromised patients, including bone
marrow or solid organ transplant patients, leukemia patients, or cystic fibrosis patients.
Invasive aspergillosis is very serious and requires early treatment with antifungals.
Aspergillosis risk factors and management
Risk factors associated with aspergillosis include:
• transplantation
• corticosteroids, and
• chemotherapy.
Staphylococcus aureus treatment
Treatment depends on the type of S.aureus.
Terminology used for the types of S. aureus will vary between laboratories and
clinicians. It includes:
• penicillin sensitive S.aureus (PSSA)

• methicillin (flucloxacillin) sensitive S. aureus (MSSA)
• methicillin (flucloxacillin) resistant S. aureus (MRSA)
• healthcare associated (HA-MRSA)
• community associated (CA-MRSA)
• vancomycin-intermediate/resistant S.aureus (VISA/ VRSA)
• endemic methicillin-resistant S.aureus (EMRSA)
• multi-resistant methicillin-resistant S.aureus (mMRSA), and
• multi-resistant oxacillin resistant S.aureus (MORSA).

Examples of S. aureus sensitivity patterns
PSSA MSSA CA-MRSA HA-MRSA VISA/VRSA
Penicillin S R R R R
Methicillin S S R R R
Gentamicin S S S R R
Cephazolin S S R R R
Erythromycin S S S R R
Clindamycin S S S R R
Ciprofloxacin S S S R R
Vancomycin S S S S I/R
Rifampicin S S S S S
Fucidic acid S S S S S
S=Sensitive, I=Intermediate, R=Resistant
Please note that if recommended, rifampicin and fucidic acid should always be used in
combination therapy for the treatment of MROs. This reduces the risk of resistance to
one or both of these agents.
Clostridium difficile
The Clostridium difficile organism grows anaerobically and is capable of causing:
• diarrhoea, referred to as Clostridium difficile-associated diarrhoea (CDAD)

• pseudo membranous colitis
• toxic megacolon
• colonic perforation
• peritonitis, and
• death.
Clostridium difficile and spores source - CDC/Dr. Gilda Jones

Multi-resistant Gram negative bacteria (MRGN)
Many of the common Gram negative bacteria can develop resistance. Examples that
have developed multi-drug resistance include:
• Pseudomonas spp,
• Acinetobacter spp
• E. coli
• Proteus mirabilis
• Klebsiella spp
• Serratia spp
• Enterobacter spp, and
• Burkholderia spp.
Extended spectrum beta-lactamases (ESBL)
The major classes hydrolysed by these enzymes are:
• penicillins, including benzyl penicillin, cloxacillin, flucloxacillin, amoxicillin and

piperacillin, and
• cephalosporins, including cephalexin, cefaclor, cefazolin, cefotaxime,
ceftazidime and ceftriaxone.
Beta lactam antibiotics
Beta lactam groups Examples
Penicillins Penicillinase sensitive: penicillin G, penicillin

Penicillinase resistant: methicillin, oxacillin, cloxacillin
Aminopenicillins: ampicillin, amoxycillin
Carboxypenicillins: ticarcillin
Ureidopenicillins: piperacillin
Cephalosporins First generation: cefazolin, cephalothin, cephalexin
Second generation: cefaclor, cefamycin, cefotetan, cefoxitin
Third generation: cefotaxime, ceftriaxone, ceftazidime
Fourth generation: cefepime, cefpirome
Carbapenems imipenem, meropenem, ertapenem

Monobactams aztreonam

Risk management systems for infectious agents and

infectious diseases
Infectious agents
Group A Beta-Haemolytic Streptococcus (GAS)
Disease or Infective Single Infection Duration of Requirements for
Infectious agent material, Room Control Precautions HCW and additional
transmission Needed Precautions comments
(causative route and type To Be
organism) of infection Applied on
Clinical
Suspicion
Scarlet fever, Bacterial Yes, if the Droplet and Cease 24 HCW with GAS
streptococcal infection patient has contact hours after respiratory
pharyngitis, transmitted by respiratory precautions commencing infections should
pneumonia, skin respiratory infection or effective take precautions to
infections like secretions or in extensive antibiotic limit possible
erysipelas, impetigo exudate from lesions or treatment. transmission to
and cellulites. lesions draining others and not
Puerperal and wounds. work until 24 hours
neonatal infections Carriers of this after commencing
require immediate infectious agent Also effective antibiotic
antibiotic treatment. can also consider treatment.
In severe cases transmit the risks for
necrotizing fasciitis, infection. burns HCW with GAS
acute rheumatic fever, patients. lesions must have
post-streptococcal OR poor lesions covered
glomerulonephritis hygiene and be on effective
and toxic shock can antibiotic treatment
occur. for at least 24 hrs
before direct
patient care or
food preparation
(Streptococcus
pyogenes)
This infectious
agent has been
associated with
high morbidity and
mortality unless
treated early.
Consultation with
Infectious
Diseases is
recommended if
purpural sepsis is
suspected.

Meningococcal disease
Disease or Infective material, Single Infection Duration of Requirements for
Infectious agent transmission route Room Control Precautions HCW and
and type of Needed Precautions additional
(causative infection To Be comments
organism) Applied on
Clinical
Suspicion
Severe fulminant Bacterial infection Yes or Droplet Cease 24 Immunisation as
disease can present transmitted by cohort if precautions hours after part of
as meningitis and/ respiratory droplets. multiple commencing employment
or septicaemia and cases effective should be
result in death This infectious antibiotic considered with
within hours of the agent can be treatment. some HCW
onset of symptoms. carried groups , e.g.
It can also be asymptomatically in laboratory staff.
identified as a the throat of healthy However, it is
bacteraemia, septic individuals and be more commonly
arthritis (especially transmitted to used in the
weight bearing others causing community
joints) and disease during outbreaks
conjunctivitis but
immunisation
will not cover all
possible
(Neisseria serotypes
meningitidis) associated with
this infectious
agent.
Post-exposure
prophylaxis for
staff who have
had significant
contact with the
patients
naso/oropharyng
eal secretions
prior to droplet
precautions
being
implemented.
Colonised
individuals are
usually not
treated with
antibiotics.
This disease is most significant during Australian autumn and winter, however,
epidemiologically it has been identified as occurring throughout the year. This is a rare
but significant disease that is often difficult to diagnose and it can cause significant
morbidity and mortality if not managed effectively in a timely manner. Often these
patients require complex prolonged inpatient care. However, if identified and treated
early patients may avoid many complications.

Tuberculosis (TB)
Disease or Infective material, Single Infection Duration of Requirements for HCW
Infectious transmission route Room Control Precautions and additional comments
agent and type of Needed Precautions
infection To Be
(causative Applied on
organism) Clinical
Suspicion
Pulmonary Bacterial infection Yes – Airborne Precautions HCW should all be
tuberculosis caused by an Negative precautions must not be assessed by specialist
organism that is pressure on clinical ceased clinicians as part of the
Tuberculosis can identified as an acid room with the suspicion of before 3 employment process for
present in any fast bacilli (AFB) door closed TB. consecutive risk factors for exposure
organ/tissue of when stained. at all times if negative to TB or infection due to
the body (extra- available. These sputum ethnographic, travel or
pulmonary The infectious agent If not – a precautions smears have past exposure risks.
disease). is usually found in single room must be been Vaccination with Bacillus
respiratory with the door reviewed collected Calmette-Guérin (BCG)
However, lungs vaccines are generally not
(pulmonary secretions or sputum closed at all when OR
where it is capable times. diagnosis is 1-2 weeks given to HCWs as it
disease) are the affects some screening
most common of being infectious to confirmed. after initiation
others but can of effective tests (tuberculin skin tests
presenting If negative – TST) but is sometimes
organ. occasionally also be pressure air HCW who treatment.
identified in other used for children to
handling is have not protect against meningeal
body tissues. not received Consultation TB or miliary TB.
operational or training or with an
not available: been Infectious
Other assessed for Diseases or HCW who work in
Mycobacterium sp. competence Respiratory identified high risk areas
can also cause in putting on Physician (e.g. bronchoscopy units,
infection but are and removing and infection Chest Clinics) should
not infectious and P2 masks control undertake follow-up
should not professional screening as required by
OR need to be
access the recommende local policy in relevant
eliminated during State/Territory.
diagnostic phase. patients room d prior to
whilst ceasing
Once infection has airborne precautions. HCW requiring treatment
occurred many precautions or management should be
years can pass are in place, managed by Infectious
before the disease e.g. food Diseases or Respiratory
presents with service staff. physicians or in a Chest
signs and Clinic.
symptoms. Onset
of symptoms is Immunocompromised
usually slow and HCW or patients should
insidious, often not have contact with
going unnoticed by suspected cases of
pulmonary TB.
patient or others.
Extra-pulmonary Exudate or pus. No Standard No aerosol generating
tuberculosis Precautions procedures to be
performed on the site of
the extra-pulmonary TB
(Mycobacterium
without airborne
tuberculosis)
precautions being
implemented.

Legionella
Disease or Infective material, Single Infection Control Duration of Requirements
Infectious transmission route Room Precautions To Precautions for HCW and
agent and type of infection Needed Be Applied on additional
Clinical comments
(causative Suspicion
organism)
Legionnaires Bacterial infection No Standard For the Nil
DIsease affecting the lungs Precautions duration of
causing pneumonia the
(often associated with admission
community acquisition
(Legionella
however can be health
pneumophila) care associated
most commonly disease).
associated with
water from water
supply (hot, Organisms are inhaled
warm or cold) or from aerosols
from cooling generated from
towers for air- contaminated water,
conditioning e.g. cooling towers or
units. drinking fountains, or
soil/potting mix.
Most commonly
(Legionella
causing diseases in
longbeachiae) is
patients who are
most commonly
immunocompromised
associated with
or have significant co-
potting mixes or
morbidities.
soil.

Clostridium difficile
Infectious transmission route Room Control Precautions HCW and additional
agent and type of infection Needed Precautions comments
To Be Applied
(causative on Clinical
organism) Suspicion
Antibiotic Bacterial infection or Yes or Contact For the Alcohol-based
associated colonisation. cohort if precautions duration of hand rub is
pseudomembra multiple the illness or effective in
nous colitis Toxin and spore cases for at least 48 destroying the
producing infectious hours after vegetative forms of
Recent agent. the cessation C. difficile, but not
emergence of of symptoms effective at
an international Newborns often carry (diarrhoea) removing spores.
hyper-virulent and normal
this organism without bowel
strain has been having disease. All patients
identified. function has receiving antibiotic
returned. therapy should be
Associated with use of considered at risk
(Clostridium antimicrobial agents.
difficile) If stool of C.difficile and
Especially cultures are monitored
cephalosporins (second performed accordingly as
and third generation), they need to symptoms of
ampicillin/amoxicillin be negative disease can vary
and clindamycin for organism from no symptoms
or spores. to severe
Transmitted in faeces diarrhoea and
and often associated Toxin may be systemic toxic
with diarrhoea. present after syndrome.
diarrhoea
has resolved. In patients with
identified C.difficile
antibiotic review of
current
antimicrobial
agents is required
and administration
of effective agents
to control C.difficile
need to be used,
e.g. either oral
metronidazole or
oral vancomycin).
HCWs with
C.difficile infection
should be
excluded from
clinical areas
whilst symptomatic
and for 48 hrs after
symptoms have
resolved.

Clostridium difficile or other gastroenteritis diseases
Additional information to be considered when cleaning and disinfecting patient

care areas

• PPE – especially the use of gloves when undertaking activity that are removed
immediately once activity has been completed and changed between cleaning
and disinfection activities
• compatibility with item or surface
• contact time
• dilution, and
If using a combined cleaner/disinfectant product for environmental cleaning, follow

manufacturer instructions once the risk assessment has been completed.
If using separate cleaning agents and disinfectants, surfaces should be cleaned first
with a detergent solution, then a disinfectant. This means that surfaces are cleaned
twice.
When using disinfectants, ensure staff, patients and items are not harmed by exposure
to the disinfectant agents. Follow manufacturer’s instructions for use.
to the disinfectant agents.
Disinfectants to be used in healthcare settings for environmental cleaning may vary

according to National/ State/ Territory recommendations and also vary between acute
and non-acute patient care areas. A risk assessment should be completed.

Pertussis
Infectious transmission route Room Control Precautions HCW and additional
agent and type of infection Needed Precautio comments
ns To Be
(causative Applied
organism) on Clinical
Suspicion
Whooping Respiratory secretions Yes – if Droplet For acute Pre-employment
Cough or are the infective available. precautions infection - vaccination
Pertussis material transmitted If not, then maintain assessment
during paroxysmal risk assess precautions until required for health
Bacterial coughing. the 5 days after the care workers in
infection of placement of commencement direct patient care.
the respiratory This disease is highly the patient. of effective Refer to State/
airways. infectious. antibiotic therapy. Territory
requirements.
Most at risk population
is babies <6months of If symptomatic for
age who are not fully greater than 3 HCW with
(Bordetella
vaccinated. In this weeks Pertussis must be
pertussis)
population death can precautions may excluded from
result from Pertussis not be required. work for at least 5
or its complications. days after starting
Consultation with effective antibiotic
clinician and/or therapy or for 3
Any age group can weeks after the
contract this infection Infection Control
recommended onset of symptoms
and transmit it to if no receiving
others if exposed to a prior to ceasing
precautions. antibiotic therapy.
case and not
protected by
vaccination or This disease can
immunity has waned. affect adults,
however, it is often
a milder disease.
The duration of
coughing will be
the same as in
babies and can
last for extended
periods of about 4
months
(sometimes
referred to as the
100 day cough)
Post exposure
prophylaxis may
be required for
HCW if exposed
esp. if pregnant .

Hepatitis A
Disease or Infective Single Room Infection Duration of Requirements for
Infectious material, Needed Control Precautions HCW and additional
agent transmission Precautions To comments
route and type Be Applied on
(causative of infection Clinical
organism) Suspicion
Hepatitis A Acute viral Yes, if patient Contact For children Infection is usually
infection is incontinent precautions – maintain self limiting but it
(non- (sometimes then single especially precautions can last for several
enveloped asymptomatic) room and important with for duration weeks and confers
RNA virus that is transmitted dedicated children and of admission. life long immunity
classified as a by the faecal-oral bathroom incontinent to further infection
picornavirus) route, either by facilities patients. For adults - with this virus.
person-to-person should be maintain
contact or utilised. precautions This disease has a
(Hepatitis A ingestion of
virus) for one week long incubation
contaminated Yes, if patient (7 days) after period (15-50
food/water. requires the onset of days) so
hospitalisation jaundice. determining the
Occurs where and contact source of infection
there is incidence precautions is often difficult.
of the disease are
combined with implemented. Infected food
poor food handlers must not
handling or prepare food for
sanitation. others for at least
Often associated 7 days after the
with community onset of jaundice
outbreaks , e.g. or 14 days after
child care the onset of
centres, refugee symptoms.
camps.
Vaccination of high
risk HCW, e.g.
paediatric staff,
plumbers,
laboratory staff,
HCW working in
rural and remote
indigenous
communities.

Hepatitis B
Infectious agent transmission route Room Control Precautions HCW and additional
and type of Needed Precautions comments
(causative infection To Be Applied
Suspicion
Hepatitis B Viral infection that No Standard Duration of Pre-employment
can be seen as precautions admission assessment to
(an enveloped acute, include past
DNA virus asymptomatic, or infection and
belonging to the chronic. natural immunity or
family Complications of carrier status as
Hepadnaviridae) Hepatitis B can well as vaccination
include cirrhosis of assessment and
liver or confirmation of an
(Hepatitis B virus) hepatocellular adequate antibody
carcinoma. response required
for health care
Blood and body workers in direct
substances are the patient care or
infective material. those who handle
However, blood has human tissue or
the highest viral body fluids. Refer
load. to National/ State/
Territory
requirements.
Transmission
occurs
occupationally by This disease has a
percutaneous long incubation
injures, mucosal period (40-180
exposure to blood days) and is often
or body substances insidious and
from an infected asymptomatic in
person. clinical
Transmission can presentation.
also occur
perinatally, during HCWs infected
sexual contact. with Hepatitis B
Internationally, it need to be risk
has been reported assessed and
to have been managed
transmitted from according to
contaminated blood infection risks. This
products or organ should be
donation. undertaken by
specialist clinicians
and scope of
practice must be
considered
especially for
exposure prone
procedures (EPP).

Hepatitis C
Disease or Infective material, Single Infection Duration of Requirements
Infectious transmission route and Room Control Precautions for HCW and
agent type of infection Needed Precautions additional
To Be Applied comments
(causative on Clinical
organism) Suspicion
Hepatitis C Viral infection that can be No Standard Duration of This disease
seen as acute, precautions admission has a long
(Hepatitis C asymptomatic, or chronic. incubation
virus is an Complications of Hepatitis period (2-24
enveloped RNA C can include chorisis of weeks) and is
virus of the liver or hepatocellular often insidious
Flaviviridae carcinoma. and
family) asymptomatic
Blood and body in clinical
substances are the presentation.
(Hepatitis C
virus) infective material.
However, blood has the HCW infected
highest viral load. with Hepatitis
C need to be
risk assessed
Transmission occurs and managed
occupationally by according to
percutaneous injures, infection risks.
mucosal exposure to blood This should be
or body substances from undertaken by
an infected person. specialist
Transmission can also clinicians and
occur in people who have scope of
substantial or repeated practice must
percutaneous exposures to be considered
blood including injecting especially for
drug users and persons exposure
with haemophilia. prone
Internationally, it has been procedures
reported to have been (EPP).
transmitted from
contaminated blood
products.

Measles
Infectious agent transmission route Room Control Precautions HCW and
and type of infection Needed Precautions additional
(causative To Be comments
organism) Applied on
Clinical
Suspicion
Measles Acute viral illness Yes – with Airborne Until 4 days Pre-employment
Or transmitted by negative precautions after the rash vaccination
airborne respiratory pressure appears. assessment
Rubeola secretions that are ventilation required for
aerosoled as droplet if possible Any room health care
(Measles is an nuclei and can stay and the used by a workers in direct
enveloped, single suspended in the door patient with patient care.
stranded RNA atmosphere and closed at measles Refer to
virus of the survive for several all times whilst NHMRC/ State/
Paramyxovirus hours. Direct contact precautions Territory
family) with the infected are in place requirements.
respiratory secretions must be left
can also allow for vacant for a Immunity to
transmission. period of 2 measles is
hrs after the obtained by
The measles virus is patient has vaccination or
highly transmissible left it. natural infection.
and non-immune
individuals are at high Incubation period is
risk of contracting the usually 10-12 days.
infectious agent if
exposed.
Only HCW with
demonstrated
Usually presents as a immunity should
mild disease care for a patient
characterised by a with measles
generalised infection.
maculopapular rash,
fever and
conjunctivitis. Healthcare
However, workers who are
complications of otitis not immune and
media, pneumonia or have not
measles encephalitis received training
can occur and can or been
lead to death. assessed for
competence in
putting on and
removing P2
masks should
not access the
patients room
whilst airborne
precautions are
in place, e.g.
food service
staff

Rubella
Infectious agent transmission route Room Precautions To Precaution for HCW and
and type of Needed Be Applied on s additional
(causative infection Clinical Suspicion comments
organism)
Acute viral illness Yes – or Droplet and Contact Until 7 days Pre-
Rubella or German transmitted in saliva cohort of precautions after the employment
Measles and respiratory multiple onset of the vaccination
secretions and cases. rash. assessment
acquired by direct required for
(the Rubella virus contact with infected health care
is an enveloped droplets, saliva or workers in
virus and a contaminated direct patient
member of the fomites. care. Refer to
Togavirus family) NHMRC/
Rubella is usually a State/
mild, self limiting Territory
illness and many requirements.
infections are
subclinical. Immunity to
However, if the Rubella is
disease is obtained by
contracted whilst vaccination or
pregnant, the virus natural
can cause infection.
significant birth
defects if disease Incubation period
occurs early in is usually 10-17
foetal life. days.
Only HCW
with
demonstrated
immunity
should care
for a patient
with Rubella
infection.
Any pregnant
healthcare
workers
(clinical or
non-clinical)
should not
have contact
with patient if
immune
status is
unknown or
negative.

Mumps
Disease or Infective material, Single Infection Duration of Requirements
Infectious agent transmission route Room Control Precautions for HCW and
and type of Needed Precautions additional
(causative infection To Be Applied comments
Suspicion
Mumps or Acute viral infection Yes – or Droplet and Until 9 days Pre-
Infectious Parotitis transmitted in saliva cohort id Contact after the onset employment
and respiratory multiple Precautions of swelling vaccination
secretions and cases (parotitis). assessment
(The mumps virus
acquired by direct required for
is an enveloped
contact with infected health care
virus and is a
droplets, saliva or workers in
member of the
contaminated direct patient
Paramyxovirus
fomites. care. Refer to
family)
NHMRC/
In children, Mumps State/
is generally a mild, Territory
self-limited illness, requirements.
but may be
debilitating and Immunity to
severe Mumps is
complications of obtained by
meningitis and vaccination or
encephalitis have natural
been reported. In infection.
post pubertal
individuals can have Incubation period
complications is usually 16-18
including days.
epididymo-orchitis
(males), mastitis
and/or oophoritis Only HCW
(females). with
demonstrated
immunity
should care
for a patient
with Mumps
infection.
Non-immune
people
exposed to
Mumps should
be considered
infectious from
th th
the 12 -25
day after
exposure (with
or without
symptoms)

Varicella
Disease or Infective material, Single Infection Duration of Requirements for HCW and
Infectious transmission route Room Control Precautions additional comments
agent and type of Needed Precautions
infection To Be
Applied on
Clinical
Suspicion
Varicella or Acute viral infection is Yes – Airborne and During Pre-employment history of
Chicken transmitted by direct with the contact prodromal infection or vaccination is required
Pox contact with the door precautions phase for health care workers in direct
exudate from lesions closed at patient care. Refer to NHMRC/
also or by droplets from all times. State/ Territory requirements.
includes respiratory
Shingles secretions. It can also Immunity to Varicella is obtained
be airborne as droplet and then Until all
Contact lesions are by vaccination or natural infection.
nuclei in the
(the prodromal phase of precautions dry and
Varicella infection. only crusted. Incubation period is usually 13-17
Zoster Virus days.
is an
enveloped Shingles can occur in
some individuals who Only HCW with a personal
virus and is memory of disease, evidence of
a member have had previous
infection with VZV. It complete, appropriate age related
of the vaccination or serology for an IgG
herpes virus presents as a painful
rash along a response to show demonstrated
family) immunity should care for a patient
dermatome that is a
reactivation of the with Varicella infection.
VZV that has been
dormant in the nerve Shingles should be treated with
dorsal ganglia since antiviral agents if diagnosed early
primary infection to help reduce the severity of post
occurred. Shingles is herpetic neuralgia.
able to transmit the
VZV and can cause
HCW who develop shingles should
primary Varicalla
be excluded from work if the
infection (Chicken
lesions cannot be covered. If the
pox) in someone
lesions can be covered they can
exposed who has no
(Varicella work but should be excluded from
immunity to the virus.
Zoster Virus caring for pregnant women,
– VZV) neonates, immunocompromised
The disease is more patients or patients with extensive
severe in adults than eczema.
children and is
characterised by
Non-immune people exposed to
fever, headache, a
varicella should be considered
rash that crops and
infectious from the day 10–21 post
develops into vesicles
contact.
that then crust.
Complications include
secondary bacterial Healthcare workers who have not
infection of lesions, received training or been assessed
pneumonia, for competence in putting on and
encephalitis and removing P2 masks should not
death. access the patients room whilst
airborne precautions are in place,
e.g. food service staff

Influenza
Disease or Infective material, Single Infection Control Duration of Requirements for
Infectious transmission route Room Precautions To Precautions HCW and additional
agent and type of infection Needed Be Applied on comments
Clinical
Suspicion
Seasonal Acute abrupt onset Yes – or Droplet and 7days from Annual vaccination is
human viral infection cohort if contact the onset of recommended for at-
influenza associated with there are precautions symptoms (3 risk groups including
outbreaks. multiple days if HCW. Pre-
The influenza virus confirmed Airborne, droplet treated with employment
cases anti-viral assessment may be
(Influenza is changes its antigenic and contact
agents). required for health
an makeup frequently precautions for
(often annually) and novel strains of care workers in direct
enveloped patient care. Refer to
virus) increase susceptibility influenza (e.g. Children will
of the population to H1N1, H5N1) and require NHMRC/ State/
outbreaks if exposed influenza like longer and Territory
(Influenza A as the levels of disease (sudden this should requirements.
or Influenza immunity will be acute respiratory be assessed
B) inadequate to the syndrome - by Infectious HCW with influenza
changed viral antigens SARS) that can Disease receiving antiviral
New/Novel with attack rates of 10- cause epidemics Physician or treatment should be
influenza 20% of the population. or pandemics. clinician. excluded for 2 days
strains after the
Transmission occurs commencement of
by droplets of treatment. If not
respiratory secretions being treated then
from an infected they are excluded for
person being inhaled 5-6 days or until
by susceptible recovered.
individuals. Direct
contact with Influenza incubation
contaminated surfaces period is usually
is also responsible for between 1-4days
transmission. with symptomatic
disease lasting 2-5
Influenza is usually a days and recovery
self limiting systemic can take several
disease characterised weeks.
by fever, malaise,
cough, sore throat, Anti-viral medications
joint pain. should be considered
Complications include for treatment if
pneumonia, otitis identified early.
media, encephalitis
and death.
Novel strains of
influenza and
influenza–line illness
require outbreak and
disaster risk planning
for each facility and
health care
providers. Refer to
State and Territory
guidelines for further
information relating
to this.

Respiratory Syncytial Virus (RSV), Parainfluenza and Adenovirus

Infectious agent transmission route Room Precautions To Precautions for HCW and
and type of infection Needed Be Applied on additional
Clinical comments
Suspicion
Respiratory Viral infection causing Yes – or Droplet and Whilst Outbreaks are
Syncytial Virus acute respiratory cohort of contact symptomatic. often
(RSV) infections most multiple precautions associated
Parainfluenza and problematic in infants cases. with these
Adenovirus and children but can infectious
affect all ages. agents and
community
Transmitted by direct outbreaks can
contact with oral or impact upon
respiratory secretions healthcare
or exudate from eyes, services with
droplet transmission. an influx of
Contact with admissions.
contaminated surfaces
or equipment can also Outbreaks are
allow spread of these usually
infectious agents. seasonal.
Infections can be Infected HCW

minor but more severe should be
complications include excluded from
pneumonia, contact with
bronchiolitis, susceptible
conjunctivitis, and patients until
croup. all symptoms
have resolved.

Gastroenteritis
Disease or Infective Single Infection Control Duration of Requirements for
Infectious material, Room Precautions To Precautions HCW and additional
agent transmission Needed Be Applied on comments
route and type Clinical Suspicion
of infection
Gastroenteritis Gastrointestinal Yes or Contact precautions For the The diagnosis of

(viral) infectious agents Cohort if plus droplet duration of gastroenteritis
are transmitted by multiple precautions whilst the illness requires either:
e.g. rotavirus, the faecal-oral cases. patient is and for 48
norovirus, route from symptomatic and hrs after
• Two or more
adenovirus contaminated HCW are in close symptoms
loose/watery
food, fluid or (<1metre) from have ceased.
stools more than
hands. patient.
what is normal for
Occasionally
a patient in a 24
transmission can
Yes or Contact precautions hour period
occur through
Gastroenteritis Cohort if • Two or more
aerolisation of
(bacterial) multiple episodes of
droplets of
cases. vomiting in a 24
vomitus or
diarrhoea hour period
e.g. Salmonella
sp., • A stool positive
Campylobacter, Infectious agents for an infectious
Shigella, agent PLUS at
are capable of
Cholera, least one
transmission for
Clostridium symptom of
up to 48 hrs after
difficile symptoms have nausea, vomiting,
abdominal pain,
ceased.
diarrhoea
Yes or Contact precautions
Gastroenteritis Cohort if
multiple Incubation period is
Other e.g.
cases. usually 1-4 days but
Protozoa can be as short as
several hours or as
e.g. Giardia long as several weeks
lamblia, after exposure.
Entamoeba
histolytica, HCW who have
Cryptosporidium symptoms of
parvum gastroenteritis should
not come to work and
should be excluded for
work for at least 48
hrs after all symptoms
have resolved if they
contract
gastroenteritis.

Creutzfeldt Jacob Disease

Disease or Infective material, Single Infection Control Duration of Requirements for
Infectious transmission route Room Precautions To Precautions HCW and additional
agent and type of Needed Be Applied on comments
infection Clinical Suspicion
Creutzfeldt Protein based No Standard Duration of CJD has a very long

Jacob transmissible precautions admission incubation period
Disease agents cause rare and the protein is
(CJD) chronic Risk assessment of resistant to heat,
encephalopathy and all patients chemicals and
associated undergoing irradiation. However,
dementia leading to identified higher risk once signs appear
(Prion – death. these lead to rapid
altered host procedures will
assist healthcare progressive
protein) deterioration
They accumulate in facilities to
brain and neural potentially prevent characterised by
cells. They cannot transmission. This dementia and
be cultured and do can be achieved by myoclonus. Death
not trigger an using a screening usually occurs within
immune response. tool to identify risk 1 year of onset of
factors if known. symptoms.
There is no
evidence that CJD Patients with risk Presentation of this
can be transmitted factors for the disease can be sporadic
through normal disease and (most common), familial,
social or sexual undergoing higher iatrogenic (health care
contact or mother to risk surgery require associated with dura-
child transmission transmission based mater grafts and human
precautions to be growth hormone or
implemented to gonadotrophin
This disease is not administration, corneal
infective but it is manage
instrumentation and grafts, use of
transmissible. contaminated surgical
equipment. This
includes disposable instrumentation –
instrumentation, neurological instruments
PPE, drapes, etc. or equipment). These
forms of the disease are
also referred to as
If non-disposable classical (cCJD).
instrumentation or Variant (vCJD) is
equipment is used
another form of the
on high risk tissue
disease with different
and the patient is transmission risk factors
subsequently that are associated with
identified as a case, contact/consumption of
risk management animal product that is
procedures must be affected by this
implemented and a abnormal protein.
look-back may be
required.

Infectious agent screening and immunisation of healthcare

workers
Source: Australian Immunisation Guidelines – current Edition.
Health care workers may be risk identified based on a classification or category that is
determined by their occupational risk of exposure to patients, blood and body
substances or infectious agents. The following example gives two category examples.
Category A – direct contact with patients or blood/body substances or infectious agents

Category B – no direct contact with patients, no greater risk of exposure to infectious
agents than a member of the general public

An example of risk assessment table for health screening and immunisation of

HCW
Infectious HCW HCW And example of evidence that may be

agent or category A category B required
disease
Diphtheria, One documented dose of adult dTpa vaccine

tetanus and Yes Rec
pertussis This dose must identify that the vaccine contained
(Adult dTpa) a Pertussis component in addition to Diphtheria
and Tetanus.
Note: This is not the same as a ‘Tet Tox’ or

ADT vaccine.
Tuberculosis Yes No Assessment of status within 4 weeks of

(TB) commencement of employment
Hepatitis A Selected Selected Offer to selected staff only, for example:

• laboratory services
• plumbers, and
• community, primary and mental
healthcare workers working with
developmentally disabled or indigenous
people.
Hepatitis B Yes No Documented evidence* of completed, age

appropriate, course of vaccine AND documented
evidence of antiHBs>10mIU/ml’
OR
documented evidence of past infection (HBcAb)
Measles, Yes Rec Born before 1966;

Mumps, OR
Rubella documented evidence of 2doses of MMR at least
(MMR) 1 month apart;
OR
documented evidence of immune response (IgG)
to Measles, Mumps, Rubella.
Chickenpox Yes Rec Personal history of chicken pox;

OR
physician diagnosis of shingles;
OR
documented evidence of IgG varicella serology;
OR
documented evidence of age appropriate
vaccination for Varicella.
Influenza Rec Rec Offer annually in autumn

* Hepatitis B – if documented evidence is not available but the HCW has serological
evidence of >10iu/l Hepatitis B surface antibody serology (antiHBs or HBs Ab) then the
following items will assist in determining risk for the HCW:
1. The assessor should document the person’s reported hepatitis B vaccination

history and determine the validity of the information, taking into consideration:
• who provided the vaccines, the number of doses and the timing of the
doses
• the person’s age at the time each dose was received (NB. two adult
doses of hepatitis B vaccine administered 4-6 months apart are
adequate when given to persons aged 11-15 years)
• the time between the last vaccine dose course and serology provided,
and
• the reasons stated for the inability to provide documented evidence of
hepatitis B vaccination.
2. Review a recent serology result (antiHBs).
3. Assess the risk to both the person and clients based on the type of clinical
area/procedures involved.
4. Advise the person of the importance of a completed age-appropriate course of
immunisation to establish long-term protection and the risks associated with
incomplete vaccination, even though sufficient antiHBs levels have been
documented.
5. The person should be offered an additional dose(s) of vaccine if the person
believes that the antiHBs levels could have resulted from an incomplete
course.
There are clinical areas where the risk may be considered too high to allow HCWs
without this evidence to work until all evidence is complete. These include:
• Emergency Department
• Operating Theatres and Recovery Rooms
• Paediatrics
• Maternity
• Adult and Neonatal ICU and Special Care Units
• Respiratory wards/units
• Transplant and Oncology Units with immunocompromised patients

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Outbreak management
Appropriate selection and use of chemical agents for environmental cleaning

• PPE – especially the use of gloves when undertaking activity that are removed
immediately once activity has been completed and changed between cleaning
and disinfection activities
• compatibility with item or surface
• contact time
• dilution, and
If using a combined cleaner/disinfectant product for environmental cleaning, follow

manufacturer’s instructions once the risk assessment has been completed.
If using separate cleaning agents and disinfectants, surfaces should be cleaned first
with a detergent solution, then a disinfectant. This means that surfaces are cleaned
twice.
to the disinfectant agents. Follow manufacturer’s instructions for use.
to the disinfectant agents.
Disinfectants to be used in healthcare settings for environmental cleaning may vary

according to National/ State/ Territory recommendations and also between acute and
non-acute patient care areas. A risk assessment should be completed.

SAMPLE INSTITUTION GASTRO OUTBREAK CASE LIST
Symptom Symptom Description Faecal

Patient Duration (Please tick or cross and briefly describe) Specimen
Occupation
(Resident)
Room No.
NAME unique DOB Floor or
Hospitalise
Onset Date
Abdominal
identifier
Diarrhoea
End Date
Vomiting
or
ward or
Nausea
Y/N Date
& Time
Fever
e.g. UR
Pain
Collected department
d*
NUMBER
or MRN
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www.healthemergency.gov.au
Gravel,D, Garden M, Taylor G, Miller M,Simor A, McGeer A, Hutchinson J, Moore D,
Kelly S, Mulvey and Canadian Nosocomial Infection Suveillance Program (2009).
Infection control practices related to Clostridium difficile infection in acute care
hospitals in Canada. American Journal of Infection Control, 37; 1:9-14
Development of surveillance lists, case lists, checklists and reporting formats should
gather the appropriate data required by the outbreak management team and
state/territory health authorities. Most public health authorities will have formats to
utilise.
Renovation, repairs and redevelopment risk management

Documented significant outbreaks of construction related infection
Most infections of Invasive Aspergillosis are caused by Aspergillus fumigatus,

occasionally Aspergillus flavus, Aspergillus terreus, and Aspergillus niger.
Etiologic Underlying Number of Number of Circumstances Year

agent medical patients patients
condition infected or who died
colonised
A. fumigatus Haematology 6 2 Major hospital Chang et
patients construction work al., 2008
A. fumigatus Lung transplant 8 1 Building construction Raviv et
A. flavus recipients work al., 2007
A. terreus
A. ustus Ophthalmology 3 0 Renovations Saracli et
patients (3 ophthalmology dept al., 2007
enucleations) and operating suite
A. fumigatus Renal 4 4 Building construction Panackal
transplant work et al.,
patients 2003
A. fumigatus Surgical 6 2 Deterioration of Lutz et
A. flavus inpatients insulating material in al., 2003
airflow units
Aspergillus Oncology 36 17 28 cases occurred Loo et
patients (over 69 during construction and al., 1996
(Bone Marrow months) 4 cases after control
Transplant, measures initiated
Acute Myeloid
Leukaemia,
Acute and Chronic
Lymphatic
Leukaemia)
A. fumigatus Respiratory 6 3 (related Spores in fibrous Humphre
failure, Crohns to insulation above ys et al.,
disease, underlying perforated ceiling were 1991
chronic disease) dispersed during minor
bronchitis building in adjacent
offices and stores areas
A. fumigatus Renal disease 3 2 Outbreak coincided Sessa et
– chronic renal with hospital renovation al., 1996
failure in an area near the
renal unit where the
patients were being
accommodated.
Aspergillus Patients on 5 5 Large-scale evacuation Shields
haematology work while hospital et al.,
unit being rebuilt. The 1990
isolation rooms that
housed the patients
overlooked the building
site.

Risk rating Area/Department

Lowest risk Office areas
Public areas
Workshops
Unoccupied wards areas not accommodating patients
Potential risk Nuclear medicine

Non invasive radiology including Magnetic Resonance Imaging (MRI)
and Computerised Tomography (CT)
Preadmission units and discharge clinics
Research laboratories
General outpatient areas except surgery and oncology
Psychiatric services
Allied health, e.g. physiotherapy, occupational therapy, social work,
dietetics and so on
General wards
All other patient care areas unless stated in moderate or highest risk
Moderate risk Emergency Department

Pharmacy
Pathology laboratory
Respiratory units
Physiotherapy respiratory function units
Coronary care unit
Cardiology clinics
Outpatients unit (surgery and oncology)
Invasive radiology
Paediatrics wards
Obstetrics wards including labour ward and delivery suites
Surgical wards
Geriatric and long term care wards
Highest risk Units accommodating immunocompromised patients (e.g. HIV/ AIDS

units)
Intensive care units and high dependency units
Sterilising services unit
Sterile stock store rooms
All operating suites
Day surgery units
Haematology/oncology inpatient and day units
Solid organ transplant units (e.g. renal transplant unit)
Bone marrow transplant units
Neonatal intensive care/special care units
Cardiac catheterisation/angiography units
Haemodialysis unit
Endoscopy units
Anaesthesia and pump areas
Recovery units
Pharmacy clean rooms/aseptic areas/admixture rooms

Classification Type of activity

Type I - Inspection and non invasive activities. These include but are not limited to:
insignificant • activities that require lifting or removal of ceiling tiles for visual
inspection only
• painting (not sanding)
• electrical trim work
• minor plumbing (in a localised area, e.g. patient bathroom), and
• maintenance activities that do not generate dust or require cutting
of walls or access to ceilings other than for visual inspection.
Type II - Minor Small scale short duration, maintenance or renovation activities that create
minimal dust. These include but are not limited to:
• access to duct spaces
• cutting of walls or ceilings where dust migration can be controlled
for the installation of minor electrical work or cables
• sanding to repair small patches
• minor plumbing work in one patient care area (1 patient room),
e.g. disruption to water supply.
Type III - Work that generates a moderate to high level of dust or work that cannot
Moderate/major be completed in a single work shift. This includes but is not limited to:
• sanding of walls for painting or wall covering
• removal of floor coverings and ceiling tiles
• plasterwork, duct work or electrical work above ceilings
• major plumbing work, e.g. interruption of sewerage pipes, and
• removal of fixed building items, e.g. countertops, sinks.
Type IV - Major Major maintenance, demolition/ excavation/ construction projects that

require consecutive work shifts to complete. These include but are not
limited to:
• removal of ceiling tiles and/or ceilings
• major plumbing work in clinical common areas or affecting more
than 2 patient rooms
• removal of plaster walls, block works, bricks, or mortar, and
• new construction involving large areas of open soil.
Risk rating matrix
AREAS OF PROBABILITY OF CONTAMINATION

VULNERABILITY
Insignificant Minor Moderate Major
Lowest risk Class I Class II Class II Class III
Potential risk Class I Class II Class III Class IV

Moderate risk Class I Class II Class III Class IV
Highest risk Class II Class III Class IV Class IV
Baseline air sampling should be considered prior to the commencement of any

activities, especially where there is a disruption of possible contaminants. There are
several methods used to determine baseline levels of dust and microorganisms.
Further information can be obtained from the Australian Institute of Occupational
Hygienists.
Description of activities and classification by class
Class Activity conducted during project
Class I • minimise raising or disturbing dust during activity

• vacuum ceiling as tile is being displaced or removed for inspection
• immediately replace ceiling tiles displaced for visual inspection
• vacuum work areas
• minimize patient’s exposure to construction/renovation area, and
• ensure construction zone is thoroughly cleaned when work is complete.
Class II • restrict access to the work area to essential staff undertaking the activity
• wet mop and/or vacuum to remove visible dust during activity
• use drop sheets to control dust and airborne infectious agents
• water mist work surfaces while cutting or sawing
• seal windows and unused doors with duct tape
• seal air vents in construction/renovation area
• disable ventilation system until the project is complete
• place dust mat at entrance and exit to work areas
• contain debris in covered containers before transporting for disposal
• wipe horizontal surfaces to keep dust free
• identify high risk patients who may need to be temporarily kept away
from construction area
• ensure that patient care equipment and supplies are free from dust
exposure, and
• ensure construction zone is thoroughly cleaned when work is complete
with wet mop with hot water and detergent and /or vacuum with HEPA
filtered vacuum.
Class III In addition to measures introduced in Class 1 and 11:
• ensure that IPC consultation has been completed and infection

prevention measures approved
• erect impermeable dust barrier from true ceiling to floor (e.g. 2 layers of
6mm plastic sheeting)
• ensure windows, doors, plumbing penetrations, electrical outlets and
intake and exhaust vents are sealed with plastic and duct taped
• clean and vacuum air ducts and spaces above ceiling as far as
accessible, if necessary
• ensure construction workers wear protective clothing that is removed
before entering patient areas
• remove dust barrier carefully to minimize spreading dust and other
debris associated with construction
• remove debris at the end of each working day

• increase frequency of cleaning in areas adjacent to construction zone,

and
• design traffic pattern for construction workers that avoid patient care
areas and a traffic pattern for clean or sterile supplies and equipment
that avoids the construction area.

Class IV In addition to measures introduced in Class 1, 11 and 111:
• erect an impermeable dust barrier and anteroom with walk off mat into
patient care area
• check integrity of barriers daily and repair any damage as soon as
identified
• seal holes, pipes, conduits, and punctures appropriately
• ensure negative pressure ventilation systems in construction area is
separate to patient care areas by sealing off or redirecting directly to
outside. Consider HEPA filtration to redirected air
• regularly visit the patient care areas adjacent to the construction zone to
ensure preventative measures are effective, and
• utilise dust monitors in adjacent areas that have been calibrated to the
environment.

An example of a construction/project survey tool
Construction Survey Tool

May be used for documentation of daily inspection of construction area by
Infection Control or delegate.
Barriers
Patient doors adjacent to area closed ❏ Yes ❏ No ❏ N/A
Dust proof plastic sheeting barriers in place ❏ Yes ❏ No ❏ N/A
and sealed at ceiling height
Dust proof rigid barrier walls in place ❏ Yes ❏ No ❏ N/A
and sealed at ceiling height
Ceiling space sealed within the work area ❏ Yes ❏ No ❏ N/A
(between the ceiling tiles and the next slab or roof)
Project Area
Debris removed in covered container ❏ Yes ❏ No
Rubbish in appropriate container ❏ Yes ❏ No
Entry and exit points clearly identified ❏ Yes ❏ No
Traffic Control
Restricted to construction workers ❏ Yes ❏ No
and necessary staff only
All doors and exits free of debris ❏ Yes ❏ No
General public and patient access ❏ Yes ❏ No
diverted
COMMENTS
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Roles and responsibilities for planning, consultation, implementation and

monitoring of infection prevention activities
Planning and consultation Responsibility
Infection prevention staff must be consulted and Architects/ builders

involvement should be sought at the planning Engineering services
stage to assist with: Infection prevention and control
• education
• design of the project to maximise the
safety of staff and patients, and
• review of the schematic design to ensure
all preventative measures to maximise
dust control are in place.
Project design
The ICP in collaboration with facility Infection prevention and control

administration and nursing staff must identify Facility administration
patient population(s) that may be at risk and the
appropriate preventative measures to ensure
their safety. This include providing construction/
renovation workers sole access to ensure they
avoid patient care areas
Patients who are at increased risk or Infection prevention and control

immunocompromised should be moved to an Facility administration
area away from the work area/ construction zone
if the air quality cannot be assured during
construction.
Traffic patterns for construction workers should Architects/ builders

be established that avoid patient care areas and Engineering services
traffic areas for patient services, e.g. food Infection prevention and control
delivery.
Management must identify whose responsibility it Facility administration

is to stop construction projects if breaches in
preventative measures arise.
Education
All personnel involved in the Architects/ builders

construction/renovation activity should be Engineering services
educated and trained in the infection prevention
measures, methods for dust containment and
removal of construction debris should be
outlined.

Dust control Responsibility

Isolation/ventilation
A dust barrier should be created from the floor to Architects/ builders
the true ceiling and edges sealed. Plastic Engineering services
sheeting can be used for short term dust barriers.
All potential sources of air leak should be sealed Architects/ builders

in the work area/ construction zone. Traffic Engineering services
patterns for construction workers should be
established that avoid patient care areas.
If possible, an elevator or staircase should be Architects/ builders

designated for the sole use of construction Engineering services
workers. The ventilation of the elevator or shaft
should not be re-circulated in the facility
When major demolition or excavation is Architects/ builders

undertaken, damping down to limit dust should Engineering services
be considered.
Open ends of exhaust vents should be capped to Architects/ builders

prevent air exhausted from the work area/ Engineering services
construction zone from being drawn back into
patient care areas or released to outdoor streets
around the healthcare facility.
All windows, doors, vents and other sources of Architects/ builders

potential air leak should be sealed in the work Engineering services
area/ construction zone.
The work area/ construction zone should be Architects/ builders

under negative pressure and all exhausted air Engineering services
should be to the outside of the facility. The
exhaust location must not be a risk to other air
intakes or external services/ people.
Consideration should be given to HEPA filtration
for exhausted air from work area.
Environmental cleaning
Areas adjacent to patient areas should be Environmental services

vacuumed with a vacuum fitted with a HEPA filter
and damp dusted daily or more frequently if
needed.
Waste containment Responsibility

If a dedicated lift/ corridor is not available then Architects/ builders

dedicated times should be allocated and cleaning Engineering services
should be completed following these times.
All waste containers should be covered and all Architects/ builders

debris removed daily via a dedicated work area/ Engineering services
construction zone access corridor and/ or lift.
Monitoring
Daily inspection
The ICP should conduct daily inspections of the Infection prevention and control
adjacent patient care areas for breaches in
infection prevention measures. The need for
additional cleaning of adjacent patient areas
should be assessed and confirmation of
adequate dust control can be made by air
sampling during the highest level of demolition
work or during periods of high dust generation.
Laboratory surveillance
A baseline rate of clinical isolates of Aspergillus Infection prevention and control

spp. and other significant infectious agents
should be established prior to the
commencement of construction/ renovation work.
Throughout the project the rate of clinical isolates
should be monitored. An increase in the rate
should be investigated to determine if associated
with the construction/renovation works. All
preventative infection measures should be
reviewed to ensure that a breach has not
occurred and corrective action should be
undertaken immediately.
Air sampling
Air sampling aims to detect Aspergillus spp. Infection prevention and control
colonies in association with the building works.
Sabouraud’s Dextrose Agar (SABG).
Sabouraud’s agar, a selective inhibitory mould
agar (IMA) media for fungi is used for this test to
monitor for Aspergillus spp.

Air sampling detects viable airborne fungal Infection prevention and control
spores. It may form part of a site’s risk
management program before and during
construction. Cumulative data are used to
establish indoor and outdoor background levels
of filamentous fungi for a particular site, enabling
risk profiles for particular locations in and around
the hospital to be established.
Responsibility
Baseline air sampling should be undertaken prior Infection prevention and control
to the commencement of building works. The
sampling is ideally undertaken from a variety of
locations that could be affected by work
area/construction work.
During the building project air sampling should Infection prevention and control
be undertaken during times of greatest
demolition work or during periods of high dust
generation. Monitoring may need to be
undertaken weekly depending on the size of the
project. If the project is of short duration air
sampling may only be undertaken at baseline,
during demolition work and at commissioning of
the building, provided monitoring indicates dust
control is appropriate and there is no indication of
a breach that could jeopardise patient safety.
Commissioning
At the completion of building works, prior to the Environmental Services

accommodation of patients or services, the Infection prevention and control
building is thoroughly cleaned of all visible soil
and dust. Air sampling should be undertaken to
ensure that the air quality is appropriate for
patients and services. Some studies have
reported 1 CFU/ cubic mm of Aspergillus spp. as
being associated with IA in some high risk
patients. The areas accommodating highest risk
patients should be Aspergillus spp. free. These
areas would equate to areas of vulnerability
labelled highest risk such as ICU, Operating
Suites, Sterilising Services etc.
As a guide, areas that accommodate potentially

high risk patients should be free of Aspergillus
spp. colonies and areas that accommodate
patients who are less compromised should have
less than 5 Aspergillus spp. colonies per cubic
metre of air. These guidelines are based on
studies resulting from outbreaks of invasive
Aspergillosis.

Bibliography
Infection Control Principles of the Management of Construction, Renovation, Repairs

and Maintenance in Healthcare Facilities: A Manual for Reducing the Risk of
nd
Healthcare Associated Infection by Dust and Water-borne Micro-organisms, 2
Edition.
Australasian Health facility Guidelines Part D – Infection Prevention and Control.
http://www.healthfacilityguidelines.com.au/
Chang C, Athan E, Morrissey O et al. Preventing invasive fungal infection during
hospital building works. Intern Med J 2008;38(6b):538-41
Chang C, Cheng A, Devitt B et al. Successful control of an outbreak of invasive
aspergillosis in a regional haematology unit during hospital construction works. J Hosp
Infect 2008;69(1):33-8
Saracli M, Mutli F, Yildiran S et al. Clustering of invasive Aspergillus ustus eye
infections in a tertiary care hospital: A molecular epidemiologic study of an uncommon
species. Med Micol 2007;45(4):377-84
Raviv Y, Kramer M, Amital A et al. Outbreak of aspergillosis infections among lung
transplant recipients. Transpl Int 2007;20(2):135-40
Vonberg R, Gastmeier P. Nosocomial aspergillosis in outbreak settings. J Hosp Infect
2006;63(3):246-54
Cornillet C, Camus C, Nimubona S et al. Comparison of epidemiological, clinical and
biological features of invasive aspergillosis in neutropenic and non neutropenic
patients: a 6-year survey. Clinical Infect Dis 2006;43:577-84
Morgan J, Wannemuehler K, Marr K et al. Incidence of invasive aspergillosis following
hematopoietic stem cell and solid organ transplantation: interim results of a prospective
multicenter surveillance program. Med Mycol Supplement 1 2005; 43: S49 – S58
Hope W, Walsh T, Denning D. Laboratory diagnosis of invasive aspergillosis. Lancet
Infect Dis 2005; 5: 609 – 22
Humphreys H. Positive-pressure isolation and prevention of invasive aspergillosis.
What is the evidence? Journal of Hospital Infection 2004;56:93-100
Chow T, Yang X. Ventilation performance in operating theatres against airborne
infection: review of research activities and practical guidance. Journal of Hospital
Infection 2004;56:85-92
Cooper E, O’Reilly M, Guest D, Dharmage S. Influence of building construction work
on Aspergillus infection in a hospital setting. Infect Control Hosp Epidemiol 2003;
24:472-476
Lutz B, Jin J, Rinaldi M et al. Outbreak of invasive Aspergillus infection in surgical
patients, associated with a contaminated air-handling system. Clin Infect Dis
2003;37(6):786-93
Panackal A, Dahlman A, Keil K et al. Outbreak of invasive aspergillosis among renal
transplant recipients. Transplantation 2003;75(7):1050-53
Faure O, Fricker-Hidalgo H, Lebeau B et al. Eight-year surveillance of environmental
fungal contamination in hospital operating rooms and haematological units. Journal of
Hospital Infection 2002; 50: 155-160

Management of occupational exposures

Transmission risk
Risk of transmission following exposure to HIV, HBV, HCV infected person
Type of Exposure Estimated Risk of Estimated Risk of Estimated Risk of

HIV Transmission HBV Transmission HCV Transmission
Use of contaminated injecting 0.67%
equipment
Needlestick injury of HCW 0.3 – 0.8 % 1-6% Approx 1.8%

if source is HBeAg if the source is
negative and health care HCVab positive but
worker is non-immume PCR negative
or unvaccinated
10%
22-40%
if the exposure is a
if source is HbeAg
positive or HBV DNA result of a deep
positive and health care needlestick injury with
worker is non-immume a hollow bore needle
or unvaccinated from a HCV –RNA
positive source
(tested using
Polymerase Chain
Reaction PCR)
Receptive vaginal intercourse 0.1 – 0.2 %

Insertive vaginal intercourse 0.03 – 0.09 %
Insertive anal intercourse No published per-
contact estimates of
risk, but estimated to
be at least as high as
for insertive vaginal
intercourse.
Receptive anal intercourse 0.1 – 3 %
References:
NSW Health Policy Directive 2006-005. Management of Non Occupational Exposures to Blood Borne and
Sexually Transmissible Infections, AIDS and Infectious Diseases Unit, NSW Health, January 2006
NSW Health Policy Directive 2005-311 Management of health care workers potentially exposed to HIV,
hepatitis B and hepatitis C, AIDS and Infectious Diseases Unit, NSW Health, January 2005
Factors affecting transmission risk

Performance of appropriate first aid

• > if first aid delayed
Nature of injury
• Hollow bore > solid sharp
• Penetrating injury > mucosal splash
• Deep > superficial
• Visible blood on instrument/body fluid > No visible blood
• No gloves > gloves
Hepatitis B immune status of recipient
Type and stage of viral infection in source

• > if high viral load in the source
• Early post exposure prophylaxis (PEP) may significantly reduce HIV
transmission risk

Sample occupational exposure management poster
Occupational Exposure to Blood or Body

Substances
COMMENCE FIRST AID
SKIN: EYES:
DON’T SQUEEZE MOUTH:
Remove contact lenses
Wash with soap Spit out any material
With eyes open - rinse
and rinse repeatedly
and water thoroughly with normal
with water
Apply antiseptic saline, water or ‘eye
stream’
IMMEDIATELY NOTIFY SUPERVISOR

&
CONTACT APPROPRIATELY TRAINED
DESIGNATED PROFESSIONAL FOR FURTHER INSTRUCTIONS
(include details on who/how to contact)
‘Eye steam’ is a readily available pre-packaged eye rinse that can be used for rinsing
eyes when contamination has occurred. It is gentle to the eye and does not cause
stinging to eye tissue.

Factors to consider in assessing the need for follow-up of occupational

exposures
Type of Exposure
• Percutaneous injury
• Mucous membrane exposure
• Non-intact skin exposure
• Bites resulting in blood exposure to either person involved
• Other – environmental, zoonotic
Type and Amount of Fluid/Tissue

• Blood
• Fluids containing blood
• Potentially infectious fluid or tissue (semen, vaginal secretions, and cerebrospinal,
synovial, pleural, peritoneal, pericardial, and amniotic fluids or wound exudate)
• Direct contact with concentrated virus or bacteria
Infectious Status of Source

• Can source be identified
• Presence of HBsAg
• Presence of HCV antibody
• Presence of HIV antibody
Susceptibility of Exposed Person

• Hepatitis B vaccine and vaccine response status
Serological testing timeframe for health care workers
Source status Serological tests for HCWs
Baseline 6 weeks 3 months 6 months

HIV+ve or in a
window period HIVab HIVab HIVab HIVab
(if PEP is used)
HB+ve or in a
window period HBsAb HBsAb HbsAg HBsAg
HBsAg HbsAg
HBeAg HBeAg
HBV DNA HBV DNA
HC+ve or in a LFT’s *HCV

window period PCR at HCVab HCVab HCVab
HCVab 3 HCV – PCR HCV – PCR HCV – PCR
weeks
LFT’s LFT’s LFT’s
Reference:
NSW Health Policy Directive 2005_311 Management of health care workers potentially exposed to HIV,
hepatitis B and hepatitis C, AIDS and Infectious Diseases Unit, NSW Health, January 2005
* In high risk exposures consideration should be given to checking Hep C PCR at 3

weeks post exposure if earlier diagnosis is desired.

Immediate management flow chart – source identity known – SAMPLE ONLY
Positive Source Result

Negative Source Result
HIV
Low Risk Increased Risk Source HCV Urgent
Source (? window period) Urgent Infectious
consultation with a Diseases
specialist clinician consultation
Follow-up plan
No further and/or Infectious
follow-up Diseases HBsAg
consultation
Depends on Hep B immunity of exposed person
Immune - No further action
Non-immune – give HBIG ASAP and
commence Hep B course/give booster
Unknown – Await HBsAb level
Commence course/give booster
Unknown – Await HBsAb level
Follow-up serology at 6 weeks, 3 and 6 months or additional time as indicated.

Immediate management flow chart – source identity unknown - SAMPLE ONLY
In all cases, treat as described for a positive HBsAg source result.

If required by designated person, additional support with management should obtained
by contacting Infectious Diseases physician or specialist clinician.
No blood available for testing

Do not test discarded needles or
syringes for virus contamination
Attempt to identify potential

source patient
If identified
Arrange testing and treat
If cannot be identified
as per known source
Take baseline bloods from exposed person complete
risk assessment and refer for Infectious Diseases
consultation if required
Follow-up serology at 6 weeks, 3 and 6

months or additional time as indicated.

Bibliography
Australian National Council on AIDS, Hepatitis C and Related Diseases (ANCAHRD).

The ANCAHRD Bulletin No.29 September 2002. Management of Exposure to
Blood/Body Fluids in a Healthcare Setting (http://www.ancahrd.org).
Centres for Disease Control and Prevention. Updated U.S. Public Health Service
Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and
Recommendations for Postexposure Prophylaxis. MMWR 2001:50 (No.RR-11)
(http://www.cdc.gov/mmwr).
Queensland Health. Guidelines for Management of Occupational and Non-

Occupational Exposures to Blood and Body Fluids. Appendix to Queensland Health
Infection Control Guidelines. Revised April 2009.
Centres for Disease Control and Prevention. Exposure to Blood. What Healthcare
Personnel Need to Know. Updated July 2003
Australian Government Department of Health & Ageing. Infection control guidelines for
the prevention of transmission of infectious diseases in the healthcare setting. Chapter
23 Needlestick and other blood or body fluid incidents. January 2004
King S, Murphy C. Health-care worker bloodborne virus exposure. In Reducing Harm

to Patients from Health Care Associated Infection: The Role of Surveillance. Australian
Council on Safety and Quality in Health Care. July 2008
Public Health Service, US Department of Health and Human Services, Centers for
Disease Control and Prevention, Atlanta, Georgia. Siegel JD, Rhinehart E, Jackson M,
Chiarello L, and the Healthcare Infection Control Practices Advisory Committee,
Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in
Healthcare Settings, June 2007.
NSW Health Policy Directive 2005_311 Management of health care workers potentially
exposed to HIV, hepatitis B and hepatitis C, AIDS and Infectious Diseases Unit, NSW
Health, January 2005

Cleaning, Disinfection and Sterilisation

Spaulding classification
Classification Item use Goal Appropriate Process

Critical items Items entering sterile Objects will be Sterilisation (or use of
tissue, the body cavity, sterile (free of all single use sterile
the vascular system microorganisms product)
and non intact mucous including bacterial • steam sterilisation
membranes, spores) • low temperature
e.g. surgical methods (ethylene
instruments. oxide, peracetic acid,
hydrogen peroxide
plasma)
Semi-critical items Items that make Objects will be free High level disinfection
contact, directly or of all • thermal disinfection
indirectly, with intact microorganisms, • chemical disinfection
mucous membranes or with the exception (glutaraldehyde, OPA)
non intact skin, e.g. of high numbers of
endoscopes, diagnostic bacterial spores *It is always preferable
probes (vaginal/rectal), to sterilise semi-
anaesthetic equipment critical items whenever
they are compatible
with available
sterilisation processes
Non-critical items Objects that come into Objects will be Low level disinfection
contact with intact skin clean • cleaning (manual or
but not mucous mechanical)
membranes,
e.g. crutches, BP cuffs
and bench tops.
Cleaning
Cleaning agents
Agents suitable for instrument cleaning must be:
• biodegradable
• mild alkaline or neutral pH
• low foaming
• non toxic
• non corrosive
• free rinsing and not leave any residue, and
• compatible with the instrument.

Respiratory equipment
Cycle temperatures
required
o o
Rinsing 40 C to 50 C
o o
Washing 50 C to 60 C
o o
Disinfecting 70 C to 95 C
o o
Final rinsing 80 C to 90 C
Disinfection
Thermal disinfection
Surface Min.
Temperature Disinfection
Time
≥ 90º C 1 minute
80º C 10 minutes
75º C 30 minutes
70º C 100 minutes
Ortho-phtaladehyde (OPA)
Ortho-phtaladehyde:
• demonstrates excellent broad spectrum microbiocidal activity

• is non corrosive
• is stable over a wide pH range
• has a relatively short acting cycle time
• does not require activation
• does not fix proteinaceous material to instruments
• is compatible with a wide range of endoscopic instrument models, and
• is non irritating to personnel.
Further information on endoscopes
For more detailed information on care and reprocessing of endoscopes you can refer
to the following as helpful sources of information:
• State or Territory guidelines

• Australian and New Zealand Standards
• the Gastroenterological Society of Australia (GESA) www.gesa.org.au, and
• the Gastroenterological Nurses College of Australia (GENCA) www.genca.org.

Monitoring
Physical monitoring of any method of sterilisation requires certain parameters are met.,
as per the following table.
Process Temperature Pressure Time
o
Steam porous loads 134 C 203-206 KPa 3-3 ½ mins
o
Steam flash 134 C 203 KPa 3 ½ minutes
o
Ethylene oxide 45-60 C 78-168.9 KPa 3-4 hrs
o
Dry heat 160-180 C Ambient ½ -1r
Gamma radiation Ambient Ambient Dose – 25 kGy

o
Peracetic acid 50 – 56 C Concentration 12 minutes
o
Low temperature gas 50 -55 C Varies according 35-40 or 55-75 minutes
plasma to cycle stage Varies according to
(hydrogen peroxide) machine type
Bowie Dick type test
o
The Bowie Dick type test is done daily at 134 C for 3-3 ½ min. It detects air entrapment
and evaluates the removal of residual air from the chamber and load.
Using biological/enzymatic monitoring indicators
The table shown here is a guide showing test organisms appropriate to the method of
sterilisation.
Type of test organism Methods of sterilisation

Geobacillus Steam under pressure
stearothemophilus Peracetic acid
(Bacillus stearothermophilus) Hydrogen peroxide plasma
Bacillus atrophaeus Ethylene oxide
(Bacillus subtilis) Dry heat

Bibliography
1. Australian Government Department of Health and Aging. Infection control

guidelines for the prevention of transmission of infectious diseases in the
health care setting. Revised 2008.
2. AS/NZS 4187:2003. Cleaning, disinfecting and sterilising reusable medical and

surgical instruments and equipment, and maintenance of associated
environments in health care facilities. Standards Australia, 2003, Sydney.
3. AS/NZS 4815:2006. Office-based Healthcare Facilities Not Involved in

Complex Patient Procedures and Processes – Cleaning, Disinfection and
Sterilising Reusable Medical and Surgical Instruments and Equipment, and
Maintenance of Associated Environments in Health Care Facilities. Standards
Australia 2006, Sydney.
4. Australian College of Operating Room Nurses. 2008 ACORN standards for

Perioperative Nursing. (S14: S16: S22: S23). 2008 edition.
5. Australian Infection Control Association. Infection Control Standards. AICA

Standards Review Working Party, Revised 2006.
6. Block,S. Disinfection, Sterilisation and Preservation. Lippincott Williams and

th
Williams, 2001, 5 Edition.
7. Gardner J and Peel M. Introduction to Sterilisation, Disinfection and Infection

rd
Control. Churchill Livingstone, 1998, 3 ed., Melbourne.
8. Gastroenterological Society of Australia and Gastroenterological Nurses

nd
College of Australia. Infection Control in Endoscopy, 2 ed. , Australian
Gastroenterology Institute, Sydney.
9. Rutala, WA, Weber, DJ, HICPAC. CDC:Guidelines for Disinfection and

Sterilisation in Healthcare Facilities, 2008.
10. Queensland Government. Infection Control Guidelines, Queensland Health,

November 2001. www.health.qld.gov.au

National and State Infection Control Organisations Contact Details

Australian Infection Control Australian (AICA)
GPO Box 3254 BRISBANE QLD 4001
Email: admin@aica.org.au
Web: www.aica.org.au
New South Wales

Infection Control Association of New South Wales Inc.
Locked Bag 3030 BURWOOD NSW 1805
Email: ica@nursing.edu.au
Web: www.icansw.org.au
Victoria
Victorian Infection Control Professionals Association
Mailing Suite 22
85 Grattan St, Carlton, 3053
Email: enquiries@vicpa.org.au
Website: www.vicpa.org.au
Queensland
Infection Control Practitioners Association of Queensland
PO Box 6188 BURANDA QLD 4102
Website: www.icpaq.org
Western Australia
Infection Control Association of Western Australia Inc.
PO Box 674 CLAREMONT WA 6910
Website : http://www.aica.org.au/default.asp?PageID=50&n=Western+Australia
Tasmania
Tasmanian Infection Control Association
GPO Box 2041 HOBART TAS 7001
Website: http://www.aica.org.au/default.asp?PageID=51&n=Tasmania
South Australia
Infection Control Association of South Australia Inc
PO Box 118 NORTH ADELAIDE SA 5006
Email: mail@icasa.org.au
Web: www.icasa.org.au
Australian Capital Territory Infection Control Association ACT Inc.

PO Box 5122 GARRAN ACT 2605
Web: http://www.aica.org.au/default.asp?PageID=53&n=Australian+Capital+Territory

Glossary
Acid fast stain: A differential stain use to identify Mycobacteria.
Aerobe: An organism that requires oxygen (O) to grow.
Airborne precautions: Utilised to prevent transmission of aerosoled infectious agents

(small airborne droplets less than 5 microns in size) that can remain infective over time
and distance.
Anaerobe: An organism that does not requires oxygen (O) to grow.
Association: In statistics, this refers to any dependence between two or more events,
characteristics or other variables.
Bacilli: Bacteria with a rod-like shape.
Beta lactamase: An enzyme produced by bacteria that are resistant to antibiotics

containing a b-lactam ring such as penicillin and cephalosporins.
Bias: Any trend in the collection, analysis, interpretation, publication, or review of data
that can lead to conclusions that are systematically different from the truth.
Bioburden: The number and the types of microorganisms present on an item prior to
sterilisation.
Box plot: A graphical method of presenting the distribution of a variable measured on

a numerical scale. Values are divided into quartiles.
Case: In epidemiology, a person in the population or study group identified as having a

particular disease, health disorder, or condition under investigation.
Case control studies: An observational study of people with the disease (or other
outcome variable) of interest and a suitable control (comparison, reference) group of
persons without the disease.
Cell wall: Outer layer of bacteria, plant and fungal cells that provides shape and
structural support for the cell.
Cocci: Bacteria with a spherical or oval shape.
Cohort studies: Observation of a large number of people over a long period of time
(commonly years) who have been or in the future may be exposed to factors
hypothesised and the occurrence of a given disease or outcome.
Colonising: Microorganisms which normally inhabit and reproduce in or on the human

body without causing disease.
Contact precautions: Utilised to prevent transmission of blood, body substances or

infectious agents by hand or via direct or indirect contact with contaminated surfaces or
items.

Confidence interval: The probability, e.g. 95%, that the true value of a variable such
as mean, proportion, or rate is contained within the interval.
Confounding: A situation which distorts the effect of an exposure on risk due to its
association with other factors that can influence the outcome.
Control: In epidemiology, these are subjects with whom comparison is made in case
control studies and Random Control Trials (RCTs).
Cross-sectional studies: Examines the relationship between disease and other

variables of interest as they exist in a defined population at one particular time.
Cytotoxin: A toxin that kills mammalian cells.
Denominator: In a fraction, it is the number below the line that indicates the number of
equal parts into which one whole is divided, e.g., 2/3 - 3 is the denominator.
Dependant variable: Variable of interest which should change in response to

intervention.
Disinfectant: A chemical agent used on inanimate objects and surfaces (e.g. floors,
walls and sinks) to destroy most recognised pathogenic infectious agents but not
necessarily all (e.g. bacterial spores).
Disinfection: Destruction of pathogenic and other kinds of infectious agents by

physical and chemical means.
Droplet precautions: Utilised to prevent direct transmission of infectious agents

(larger than 5 microns in size) from the respiratory tract of the infected person to
susceptible mucosal surfaces of another person. Transmission requires close contact
as the droplets do not remain suspended in the air and generally only travel short
distances, usually one metre or less.
Ecological studies: Studies where the unit of analysis are populations or groups of
people, rather than individuals.
Endemic: Sporadic infections that occur at a background rate.
Enzymatic cleaner: Enzymatic cleaning solutions contain enzymes which are capable
of breaking down biological soils (containing proteins, lipids, carbohydrates and
mucopolysaccharides).
Epidemic: Occurrence of infection at a higher rate than the background rate.
Exposure Prone Procedure (EPP): EPPs are invasive procedures where there is the
potential for direct contact between skin, usually a finger or thumb of the healthcare
worker, and sharp surgical instruments, needles, sharp tissues (e.g. fractured bones)
spicules of bone or teeth in body cavities or in poorly visualised or confined body sites,
including the mouth of the patient.
HAI: Healthcare-associated infection.

Hepatitis B surface antibody (anti-HBs/HBsAb): Indicates previous exposure or

vaccination to Hepatitis B virus. The antibody protects the body from future Hepatitis B
virus infection.
Hepatitis B surface antigen (HBsAg): Is a protein antigen produced by Hepatitis B

virus. This antigen is the earliest indicator of acute hepatitis B and frequently identifies
infected people before symptoms appear.
Hepatitis C PCR: Detects the genetic material (RNA) of the virus in the blood using a
special molecular technique. The amount of RNA can help determine how severe the
infection is and how easily hepatitis C infection can be spread.
Incidence: Number of new cases of infection during a specified period of time.
Independent variable: Variable in the intervention which is being manipulated.
Liver function tests (LFTs): LFTS detect abnormal levels of enzyme production in the
liver, and the enzyme most commonly monitored using this test is alanine
aminotransferase (ALT). When elevated above normal values, the ALT and aspartate
aminotransferase (AST) tests indicate liver damage.
Mean: A measure of central tendency calculated by adding all individual values in the
group and dividing by the number of values in the group.
Median: A measure of central tendency calculated by dividing the lower and upper half
of the measurements. The point on the scale that divides the group in this way is called
the median.
Mould: A fungus that grows on various kinds of damp or decaying matter.
MRSA: A strain of S.aureus that is resistant to methicillin as well as a number of other

antibiotics.
Normal distribution: A graph of continuous measurement whose properties include

continuous symmetrical distribution with both ends extending to infinity, identical
arithmetic mean, median and mode and whose shape is determined by mean and
standard deviation.
Normal flora: A collection of microorganisms that live on or in a normal healthy

individual without causing infection or disease.
Normal body flora: A collection of microorganisms that live on or in a normal healthy

individual without causing infection or disease.
Numerator: In a fraction, it is the number above the line that indicates the number of
parts of a whole, e.g., 2/3 - 2 is the numerator.
Odds Ratio: The ratio of two odds used to compare two groups in case control
studies.
Occurrence: In epidemiology, this describes the frequency of a disease in a

population without distinguishing between incidence and prevalence.

Opportunistic: An organism capable of infecting only when host defences are

compromised.
Organelle: A structure bound by a membrane and found in eukaryotic cells.
P value: A measure ranging from 0-1 of the degree of belief in a hypothesis or

statement.
P2 or N95 particulate masks: Also called respirators, are PPE worn by HCW to
protect them from inhalation exposure to airborne infectious agents that are <5 microns
in size.
Pandemic: An epidemic occurring over a very wide area, crossing international

boundaries and affecting a large number of people.
Percentage: Proportion multiplied by 100.
Percentiles: The set of divisions that produce exactly 100 equal parts in a series of
continuous variables.
Plasmid: A small, circular, double extra-chromosomal DNA molecule which replicates

independently of chromosomal DNA and can carry several genes that control plasmid
or parent cell activity.
Population: In statistics, this refers to all inhabitants of a given country or area

considered together.
Prevalence: The number of new and existing cases with infection over a given period
of time.
Proportion: The number of patients with a given disease divided by the total number
of patients included in the study.
Prospective: Studies that collect data by looking forward in time.
Quartiles: Division of a distribution into equal quarters.
Randomized controlled trails: An epidemiological experiment in which subjects in a

population are randomly allocated into groups called study and control groups.
Range: The difference between the largest and smallest values in a distribution.
Rates: Rates are based on the number of infections that have occurred divided by the
number of patients at risk over a fixed period of time. Similar to proportion but a
multiplier is used (for example 1000, 10000 and 100000)
Ratio: The number of patients in a given group with a given disease divided by the
number of patients without the disease.
Relative Risk: The ratio of the risk of disease among the exposed to the risk among
the unexposed and used in cohort and randomized controlled trials.
Retrospective: Studies that collect data by looking back in time.

Risk factor: Any aspect of behaviour, environment, or inherited characteristic, which

on the basis of epidemiological evidence is known to be associated with health related
conditions considered important to prevent.
Sample population: These are measurements made on a subset of the population.

The sample is intended to give results that are representative of the whole population.
Sensitivity: The proportion of individuals in a population that will be correctly identified

when tested to detect a particular disease/ infection, calculated as the number of true
positive results divided by the number of true positive and false negative results.
Single use item: Single use means the medical device or item is intended to be used
on an individual patient during a single procedure and then discarded. It is not intended
to be reprocessed and used on another patient. If a single use devices or item is
marketed as non-sterile, then it will require processing to make it sterile and ready for
use. The manufacturer of the device or item will include appropriate processing
instructions to make it ready for use.
Specificity: The statistical probability that an individual who does not have the
particular disease/ infection will be correctly identified as negative, expressed as the
proportion of true negative results to the total of true negative and false positive results.
Spores: A reproductive structure formed by some Gram positive bacteria and fungi
which are highly resistant to heat and chemicals.
Standard deviation: A measure of dispersion or variation of values around the centre

of a frequency distribution.
Standard precautions: Work practices to ensure basic infection prevention and

control apply to everyone regardless of perceived or confirmed infectious status. They
are a first line approach to reduce risk relating to potential transmission of infectious
agents.
Transmissibility: Infectious microorganisms capable of being transmitted to another

patient or host.
Transmission: Any mechanism by which an infectious agent is spread from a source

or reservoir to another person.
Variable: Any quantity that varies and can have different values.
Virulence: The degree of pathogenicity of a microorganism.
Virus: An infectious particle consisting of nucleic acid and a protein coat.
Window period: The time from infection to development of detectable antibodies.
Yeast: A unicellular fungus.

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Infection control workbook

Last Updated December 2010

Principles of infection prevention and control ...............................................................5

Basic epidemiology and statistics .................................................................................14

Surveillance and quality improvement ..........................................................................22

Infection control workbook 2 of 90

Basic microbiology and multi-resistant organisms (MRO) .........................................27

Infectious agent screening and immunisation of healthcare workers .......................54

Outbreak management ....................................................................................................59

Infection control workbook 3 of 90

Renovation, repairs and redevelopment risk management ........................................62

Management of occupational exposures ......................................................................74

Cleaning, Disinfection and Sterilisation ........................................................................81

Infection control workbook 4 of 90

Principles of infection prevention and control

The National Hand Hygiene Initiative (NHHI)

5 Moments for Hand Hygiene

Source: Hand Hygiene Australia

Infection control workbook 5 of 90

Examples of evidence supporting practice:

• World Health Organization (2009) Guidelines on Hand Hygiene in Health Care

Hand Hygiene Australia

Putting on and removing PPE

Infection control workbook 6 of 90

Removing aprons and gowns

Infection control workbook 7 of 90

Removing and cleaning reusable face and eye protection

Changing and removing gloves

Infection control workbook 8 of 90

Infection control workbook 9 of 90

Cleaning: How much is enough?

Appropriate selection and use of chemical agents for environmental cleaning

• correct and safe use

If using a combined cleaner/disinfectant product – follow manufacturer’s instructions

Disinfectants to be used in healthcare settings may vary according to National/ State/

Disinfection and sterilisation

Information on the Spaulding classification of items (critical, semi-critical and non-

If it cannot be cleaned, then it cannot be adequately disinfected or sterilised

Principles of aseptic technique

Aseptic technique aims to prevent infectious agents from being introduced to

Infection control workbook 10 of 90

ANTT also requires consideration of sequencing within the activity or procedure to

The basic principles of aseptic technique include:

• hand hygiene immediately before and after procedures

Infection control workbook 11 of 90

Contact precautions should be used for diseases such as:

Contact precautions should also be considered in the presence of any excessive

Hand hygiene and personal protective equipment

Follow these steps:

• perform hand hygiene

Infection and conditions which require droplet precautions include:

• influenza virus (by direct or indirect transmission)

Some common infections which require airborne precautions include:

• Rubeola virus (Measles)

Infection control workbook 12 of 90

Personal protective equipment to prevent airborne transmission

To minimise the risk of exposure to suspected or confirmed airborne infectious agents

Considerations when using P2 (N95) masks include:

Infection control workbook 13 of 90

Basic epidemiology and statistics

• 23 did not have MRSA

Therefore: Incidence ratio = 5/30 =0.17