PREVENTING%20TRANSMISSION%20%20OF%20RESPIRATORY%20INFECTIOUS%20DISEASES%20IN%20CLINICS%20AND%20OFFICE%20SETTINGS

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PREVENTING TRANSMISSION OF RESPIRATORY
INFECTIOUS DISEASES IN CLINICS AND OFFICE
SETTINGS

• BRENDA J. ROUP, PhD, RN, CIC
• NURSE CONSULTANT IN INFECTION CONTROL
• MARYLAND DEPARTMENT OF HEALTH
• AND MENTAL HYGIENE

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TRANSMISSION OF RESPIRATORY INFECTIOUS DISEASES
AND INFLUENZA

• MUSHER, D. HOW CONTAGIOUS ARE COMMON RESPIRATORY
  TRACT INFECTIONS? NEJM, 34813, MAR 27, 2003
• TELLIER, R. REVIEW OF AEROSOL TRANSMISSION OF
  INFLUENZA A VIRUS. EMERGING INFECTIOUS DISEASES,
  1211, NOV. 2006

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TRANSMISSION OF INFLUENZA

• DEPT OF HEALTH AND HUMAN SERVICES, PANDEMIC
  INFLUENZA PLAN, 2005, SUPPLEMENT 4, INFECTION
  CONTROL, OUTPATIENT MEDICAL OFFICES
• http//www.hhs.gov/pandemicflu/plan/
• http//www.pandemicflu.gov/plan/healthcare/maskgui
  dancehc.html

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TRANSMISSION OF INFLUENZA

• MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE,
  OFFICE OF PREPAREDNESS AND RESPONSE. MARYLAND
  PANDEMIC INFLUENZA PLAN, VERSION 6, DECEMBER
  2006.
• http//flu.maryland.gov/

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TOPICS

1. TRANSMISSIBILITY/COMMUNICABILITY OF INFLUENZA
   VIRUS
2. TRIAGE/SCREENING IN OFFICE/CLINIC ENVIRONMENT
3. CONTAINMENT IN OFFICE/CLINIC ENVIRONMENT
4. DVD WHY DONT WE DO IT IN OUR SLEEVES?
   (www.coughsafe.com)

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TRANSMISSIBILITY OF INFLUENZA VIRUS

• REFERS TO THE CAPACITY OF AN INFECTIOUS AGENT TO
  SPREAD FROM ONE PERSON TO ANOTHER
• FOR INFLUENZA VIRUS, DEPENDENT UPON
• PARTICLE SIZE AND INFECTIVE DOSE
• SUSCEPTIBILITY OF HOST
• TEMPERATURE, HUMIDITY, AIR CURRENTS, VENTILATION
• DOWNWIND OR UPWIND

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INFLUENZA VIRUS
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INFLUENZA VIRUS H N
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PANDEMIC INFLUENZA

• VERY SERIOUS FORM OF INFLUENZA VIRUS THAT MAY
  CAUSE GLOBAL OUTBREAK
• AN INFLUENZA VIRUS MUST MEET THESE THREE
  CONDITIONS IN ORDER TO BECOME A PANDEMIC
• BE A NEW SUBTYPE OF INFLUENZA VIRUS THAT HAS NOT
  PREVIOUSLY OR RECENTLY CIRCULATED IN HUMANS
• CAUSES DISEASE IN HUMANS
• SUSTAINS HUMAN TO HUMAN TRANSMISSION

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SNEEZING
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SNEEZING
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PARTICLE SIZE OF INFLUENZA VIRUS

• LARGE DROPLETS (50-100 µm diameter)
• DO NOT REMAIN SUSPENDED IN AIR
• BALLISTIC TRAJECTORY OF A FEW FEET
• INFECT BY DIRECT CONTACT WITH MUCOUS MEMBRANES OF
  MOUTH, EYES, UPPER NASAL PASSAGES

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PARTICLE SIZE OF INFLUENZA VIRUS

• INTERMEDIATE SIZE PARTICLES (10-50 µm)
• TRANSMISSION OF THESE PARTICLES INFLUENCED BY
• TEMPERATURE OF AIR IN YOUR OFFICE
• HUMIDITY
• AIR CURRENTS
• AIR VELOCITY
• REACH UPPER RESPIRATORY TRACT

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PARTICLE SIZE OF INFLUENZA VIRUS

• INCLUDES SMALL PARTICLE AEROSOLS AND DROPLET
  NUCLEI (lt10 µM)
• DROPLET NUCLEI INTERMEDIATE SIZE PARTICLES THAT
  HAVE DESICATED AND SHRUNK
• TRANSMISSION PRIMARILY INFLUENCED BY AIR CURRENTS
• REACH LOWER RESPIRATORY TRACT

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SURVIVAL OF VIRUS ON ENVIRONMENTAL SURFACES

• ON CLOTH OR PAPER 8 - 10 HOURS
• ON NON-POROUS SURFACES (STAINLESS STEEL) 24 -
  48 HOURS
• ON POROUS SURFACES ??

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TRANSMISSION OF INFLUENZA A

• VIRUS INTRODUCED INTO A
• HOME 50 CLINICAL SYMPTOMS
• ENCLOSED SPACE OUTSIDE HOME 50 CLINICAL
  SYMPTOMS
• NAVAL CRUISER 42 CLINICAL SYMPTOMS
• AIRPLANE WITH FAILED AIR CIRCULATION SYSTEM 73
  CLINICAL SYMPTOMS

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TOPICS

• TRANSMISSIBILITY/ COMMUNICABILITY OF INFLUENZA
  VIRUS
• TRIAGE/SCREENING IN OFFICE/CLINIC ENVIRONMENT
• CONTAINMENT IN OFFICE/CLINIC ENVIRONMENT
• DVD WHY DONT WE DO IT IN OUR SLEEVES?

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TRIAGE/SCREENING

1. KEEP YOUR WAITING ROOM AS EMPTY AS POSSIBLE
2. CANCEL NON-ESSENTIAL PATIENT APPTS (EXAMPLE
   CHRONIC DISEASE FOLLOW UP)
3. TRAIN FRONT DESK WORKERS IN SCREENING FOR
   INFLUENZA SYMPTOMS
4. MAXIMUM USE OF TELEPHONE TRIAGE/SCREENING

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TRIAGE/SCREENING

• DISCOURAGE VISITS TO OFFICE
• SEE RESPIRATORY INFECTION PATIENTS AT END OF DAY
• FRONT DOOR ALERT TO PATIENTS
• Please cough or sneeze into your upper sleeve or
  tissue-throw the tissue into the trash can wash
  your hands!
• If you are coughing sneezing, please inform the
  front desk staff!
• MOVE SYMPTOMATIC PATIENTS INTO EXAM ROOMS AS
  QUICKLY AS POSSIBLE

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TOPICS

• TRANSMISSIBILITY/ COMMUNICABILITY OF INFLUENZA
  VIRUS
• TRIAGE/SCREENING IN OFFICE/CLINIC ENVIRONMENT
• CONTAINMENT IN OFFICE/CLINIC ENVIRONMENT
• DVD WHY DONT WE DO IT IN OUR SLEEVES?

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RESPIRATORY HYGIENE/COUGH ETIQUETTE

• http//www.cdc.gov/flu/professionals/infectioncont
  rol/resphygiene.htm
• EMPHASIZES COUGHS AND SNEEZES AND CLEANING OF
  HANDS
• POSTERS IN WAITING AREAS
• CONSIDER PAMPHLETS HANDED OUT BY RECEPTIONIST
  (FREE FROM CDC)
• IF PATIENT IS ACTIVELY COUGHING, HAND A PROCEDURE
  MASK (EAR LOOPS) AND MAKE SURE THEY PUT ON

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MASK WITH EAR LOOPS
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CONTAINMENT

1. IF PATIENT HAS TO COME TO OFFICE, ONLY ONE PERSON
   MAY ACCOMPANY THAT PERSON IN THE WAITING ROOM
2. PROVIDE BOXES OF DISPOSABLE TISSUES IN WAITING
   ROOM, NOT JUST AT RECEPTION WINDOW
3. PLACE LARGE JUGS OF ALCOHOL-BASED HAND CLEANER
   (60 70 ISOPROPYL OR ETHYL ALCOHOL) IN WAITING
   ROOM
4. PROVIDE AT LEAST ONE CLOSED TRASH CAN WITH
   FOOT-OPERATED PEDAL

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CONTAINMENT

• REMOVE ALL MAGAZINES AND TOYS FROM WAITING ROOM
  (FOMITES)
• ASSIGN SOMEONE TO CLEAN HIGH-TOUCH SURFACES EVERY
  1-2 HOURS WITH A DISINFECTANT
• DOOR KNOBS
• LIGHT SWITCHES
• PENS
• COMPUTER KEYBOARDS
• TELEPHONES
• CHAIR ARMS

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OFFICE ARRANGEMENT 1
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OFFICE ARRANGEMENT 2
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OFFICE ARRANGEMENT 3
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OTHER CONTAINMENT STRATEGIES

• CHECK WITH BUILDING MANAGER RE NUMBER OF AIR
  EXCHANGES IN OFFICE (12 OR MORE BEST) AND
  HUMIDITY LEVELS
• HIGH AIR FLOW WILL DILUTE INFLUENZA VIRUS AND
  DESSICATE
• INCREASED HUMIDITY (gt40) WILL DECREASE VIRUS
  INFECTIVITY

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N95 RESPIRATORS

• THERE IS NO RECOMMENDED ROLE FOR THE USE OF N95
  RESPIRATORS IN THE OFFICE/CLINIC SETTING
• USE THESE OTHER STRATEGIES, ESPECIALLY
• TELEPHONE TRIAGE
• KEEP WAITING ROOM EMPTY
• GET COUGHING PATIENTS INTO EXAM ROOMS QUICKLY
• MASK COUGHING PATIENTS

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TOPICS

• TRANSMISSIBILITY/ COMMUNICABILITY OF INFLUENZA
  VIRUS
• TRIAGE/SCREENING IN OFFICE/CLINIC ENVIRONMENT
• CONTAINMENT IN OFFICE/CLINIC ENVIRONMENT
• DVD WHY DONT WE DO IT IN OUR SLEEVES?
  (www.coughsafe.com)

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WEBSITES

• www.cdc.gov
• www.panflu.gov
• www.montgomerycountymd.gov/apc

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QUESTIONS

• www.montgomerycountymd.gov/apc

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STOPTHE SPREAD!

• This publication was supported by Cooperative
  Agreement Number U50/CCU302718 from the CDC to
  NACCHO. Its contents are solely the
  responsibility of the Montgomery County, Maryland
  Advanced Practice Center for Public Health
  Emergency Preparedness and Response and do not
  necessarily represent the official views of CDC
  or NACCHO.
• This publication is in the public domain. It may
  be reproduced in whole or in part by any
  individual or organization without permission, as
  long as the following citation is given
  Montgomery County, Maryland Advanced Practice
  Center for Emergency Preparedness and Response
  Stop the Spread! A Toolkit for Preventing the
  Spread of Germs in Clinics and Office Settings.
  If a part or all of the publication is
  reproduced, the Montgomery County APC would
  appreciate knowing how it is used. Please use the
  form at our website, http//www.montgomerycountymd
  .gov/apc.