SARS Infection Control in Healthcare Settings

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SARS Infection Control in Healthcare Settings

• William A. Rutala, Ph.D., M.P.H.
• University of North Carolina (UNC) Hospitals and
  UNC School of Medicine

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Infection Control Considerations

• Hospitals must protect vulnerable patients,
  staff, visitors, and prevent spread to the
  community
• Until SARS epidemiology is better understood,
  infection control measures must target all
  possible modes of transmission
• Interim recommendations that will be periodically
  updated

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The principles are the same.methods of
implementation may differ
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Key Objectives of SARS Prevention

• Early detection of infection
• Containment of infection
• Protection of personnel and the environment of
  care
• Hand hygiene

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Key Elements of SARS Prevention

• Early detection
• Containment of infected persons
• Protection of personnel and the environment of
  care
• Hand hygiene

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Early Detection

• Clinician education
• Information on signs and symptoms of SARS
• Heightened index of suspicion in patients with
  history of travel or exposure to SARS areas or
  patients
• Isolation precautions that should be used
• SARS inservices

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Early Detection

• Information at point of first healthcare
  encounter (ER, information desk, ACC, Pre-Care,
  Family Practice, community-based clinics)
• Visual alerts
• Reporting instructions
• Provision of surgical masks for patients
• Segregation of symptomatic patients

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Early Detection

• Information at point of first healthcare
  encounter (ER, information desk, ACC, Pre-Care,
  Family Practice, community-based clinics)
• Visual alerts
• Reporting instructions (notify Infection Control)
• Provision of surgical masks for patients at point
  of first patient contact (or provide mask to
  patient before enter into hospital)
• Segregation of symptomatic patients (private
  rooms)
• Patients with suspected SARS admitted only if
  medically indicated
• Contact and Airborne Precautions should be
  immediately instituted

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Key Elements of SARS Prevention

• Early detection
• Containment of infection
• Protection of personnel and the environment of
  care
• Hand hygiene

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Containment of Infectionwith Engineering Controls

• Preferred-Airborne Isolation Room
• Private room with engineered negative pressure,
  6-12 AC/hr, and air exhausted to outside
• Door closed except when needed for patient/staff
  access
• Limit access to persons essential for providing
  care

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Limited Patient Contact

• Visitors of patients with suspected SARS should
  be restricted (essential family members) and
  screened
• Visitors should be excluded from the hospital if
  any of the following are present
• Fever and respiratory symptoms
• Travel to a locale with local transmission in
  previous 10 days
• Exposure to the probable SARS case while he/she
  symptomatic within prior 10 days
• Dedicate staff to care for SARS patient

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Key Elements of SARS Prevention

• Early detection
• Containment of infected persons
• Protection of personnel and the environment of
  care
• Hand hygiene

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Consider all Possible Transmission Routes

• Most likely
• Droplet
• Contact
• Direct (contamination of skin)
• Indirect (contaminated fomites)
• Possible
• Airborne

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Containment of Infection

• Contact Precautions
• Private rooms, gloves, gowns
• Airborne Precautions
• Private room, negative pressure, air exhausted to
  outside, 6 AC/hr)
• Personnel should wear N95 and eye protection
  (face shield or goggles)
• Gloves and gown removed just prior to exiting
  the room. Immediately outside the room remove and
  discard N95 respirator and remove goggles or face
  shield. Immediately perform hand hygiene for 15
  sec with CHG or application of alcohol hand rub.
  Wipe goggles with alcohol pad and again perform
  hand hygiene.

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Personal Protective Attire

• Respiratory protection
• N95 mask preferred
• Perform qualitative respirator fit-testing where
  applicable
• Surgical mask if not available
• Apply mask when entering room or ward
• Ensure snug fit over nose and mouth
• Eye protection
• Goggles or face shield as recommended for
  standard precautions

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Effectiveness of Precautions

• Study Design case-control study in 5 Hong Kong
  hospitals
• Staff (241 non-infected, 13 infected) surveyed
  about use of mask, gloves, gowns, and handwashing
• Results 69 staff who reported all four measures
  were not infected all infected staff omitted at
  least one measure. Fewer staff who wore masks
  (N95 and surgical masks), gowns, and washed their
  hands became infected compared to those who did
  not.
• Conclusion practice of Contact and Droplet
  Precautions is effective in reducing risk of
  infection after exposure.
• WH Seto et al. Lancet 20033611519-1520

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Stability of SARS Coronavirus

• Virus is stable in feces and urine at RT for at
  least 1-2 d
• Virus survival in cell-culture supernatant
• Minimal reduction in virus conc after 21 days at
  4oC and 80oC
• 1 log reduction at RT for 2 days
• Heat (56oC) kills SARS coronavirus
• Virus loses infectivity after exposure (to 2 phenol, 75 ethanol, 110 Clorox
• WHO Laboratory Network. May 2003.

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Protect the Environment of Care

• Use hospital-grade disinfectants or 1100
  dilution of household bleach (5.25 - 6.0) and
  water for surface cleaning and disinfection
• Assume environment in which SARS patients are
  housed is heavily contaminated
• Facilitate daily cleaning by limiting clutter in
  patient care area
• Thoroughly clean and disinfect room and equipment
  after patient discharge
• No need to routinely disinfect walls, window
  drapes

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Disinfectants Effective Against Human Coronavirus

• Efficacy criteria of 3 log10 reduction after 1
  min
• 1000 and 5000 ppm chlorine (150 and 110
  dilution of bleach)
• Povidone iodine (1 iodine)
• Ethanol (70)
• Glutaraldehyde (2)
• Phenolics
• Sattar SA et al. Epidem Inf 1989 102493-505

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Key Elements of SARS Prevention

• Early detection
• Containment of infected persons
• Protection of personnel and the environment of
  care
• Hand hygiene

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Hand Hygiene

• Hand hygiene is the cornerstone of prevention!!!
• Perform hand hygiene following all contact with
  suspect SARS patients and their environment
• Methods
• Hand washing with soap and water or CHG and water
• Alcohol-based handrubs when
• Hands are not visibly soiled, or
• Hand washing facilities are not available in
  patient rooms

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Protect the Environment of Care

• Follow standard procedures or regulations for
  handling contaminated (infectious) materials
• Soiled linen/laundry
• Usual warm water and detergent wash cycles
• Bleach may be added but is not needed
• Avoid sorting of linen before washing
• Waste
• Dispose in accordance with local regulations for
  infectious waste
• Eating utensils
• Use standard warm water dishwashing methods

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Other considerations

• Avoid use of nebulizers when possible
• If needed, perform nebulization in protected,
  negative pressure environment
• Limit procedures that generate aerosols
• Limit patient movement
• If transport required for patient care, place
  surgical mask on patient
• Place clean attire on patient or cover with gown
• Transporters should wear N95, gloves, gowns, eye
  protection

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Management of Exposures

• Exposed HCW who develops fever and/or respiratory
  symptoms should not report to work. Should report
  their symptoms to the appropriate health care
  provider
• Exposed unprotected HCW who are asymptomatic must
  be evaluated prior to work each day by OHS.
• Exclude close contacts with SARS cases who have
  fever or respiratory symptoms

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SARS Resources

• http//www.cdc.gov/ncidod/sars/
• http//www.who.int/csr/sars/en/
• Chiarello, Linda. SARS Infection Control. CDC

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Prevention is Primary!
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Key Objectives of SARS Prevention

• Early detection of infection
• Containment of infection
• Protection of personnel and the environment of
  care
• Hand hygiene

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Thank you