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Essential Infection Control for Infectious Disease Emergency Readiness

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Essential Infection Control for Infectious Disease Emergency Readiness CIDER Spring Lecture Series, 2005 Roz Potter RN MA CIC Public health is often invisible and ... – PowerPoint PPT presentation

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Title: Essential Infection Control for Infectious Disease Emergency Readiness


1
Essential Infection Control for Infectious
Disease Emergency Readiness
  • CIDER Spring Lecture Series, 2005
  • Roz Potter RN MA CIC

2
  • Public health is often invisible and unremarked
    when it works well when it fails, our neighbors
    sicken and die.
  • Glasser RJ, We are Not Immune. Harpers Magazine
    July 2004

3
  • Unprecedented Infectious Disease Risks
  • Emerging Infectious Diseases SARS, WNV, Avian
    influenza, MDROs, Monkeypox. Bioterrorism
    Threats Smallpox, Anthrax, Plague, Tularemia,
    Botulinum toxin, Viral hemorrhagic fevers, Q
    fever, Brucellosis. Sociopolitical Pressures
    Limited Access to Healthcare (45 million
    uninsured in the US), Increasing Poverty and
    Homelessness, Shortages of Hospital Beds,
    Healthcare Workers and Airborne Isolation Rooms
    Climate Change Overpopulation Ecological
    Devastation High Numbers of Immunocompromised
    Individuals. Declining Public Health Budgets and
    Infrastructure, Shortages of Vaccines

4
Infection Control and PreventionWhat is
infection control?
  • Infection Control encompasses the processes and
    activities that identify and reduce the risks of
    acquiring and transmitting endemic or epidemic
    infections among individuals

5
Chain Model of Infectious Disease
  • Source Transmission Mode Host Portals
  • human Indirect contact skin
    openings
  • zoonotic hands upper respiratory
    environment surfaces lungs
  • equipment mucous membranes
    airborne GI tract droplet
  • vector
  • vehicle
  • Direct contact
  • From source to host portal

6
Chain Model of Infectious DiseaseInfectious
Disease Control Points
  • 1. Contain the source
  • 2. Interrupt transmission
  • 3. Reduce susceptibility of the host and/or of
    susceptible hosts

7
Chain Model of Infectious DiseaseControl Points
  • 1. Control/contain the SOURCE
  • Case finding with rapid identification/isolation
    of sources includes screening/triage of high-risk
    cases
  • Pest/vector control
  • Environmental disinfection
  • Behavior change
  • Respiratory hygiene/cough etiquette
  • Frequent Handwashing
  • Self-limiting of contacts
  • Contain secretions/excretions
  • Use of barrier protection (surgical mask,
    dressings)
  • Rapid delivery of effective treatment/vaccination

8
Chain Model of Infectious DiseaseControl Points
  • 2A. Interrupt transmission
  • In Community Settings
  • Promote personal infection control
  • handwashing, cough hygiene, reduce risk factors,
    personal habits
  • Contact management
  • Isolation and quarantine
  • Individual and mass prophylaxis
  • Activity restrictions
  • close schools other public venues suspend
    public gatherings restrict travel
  • Cordon Sanitaire

9
Chain Model of Infectious DiseaseControl Points
2B. Interrupt TRANSMISSION In Healthcare (Includin
g Home And Community Treatment) Settings
  • Respiratory Hygiene/Cough Etiquette
  • Education
  • Cover coughs, using tissue or surgical mask
  • Hand hygiene
  • Spatial separation
  • Standard precautions
  • Handwashing
  • Personal Protective Equipment
  • Standard Precautions
  • (continued)
  • Patient Placement
  • Safe work practices
  • Medical waste handling
  • Environmental cleaning and disinfection
  • Expanded precautions
  • Contact
  • Droplet
  • Airborne infection isolation
  • Empiric

10
Chain Model of Infectious DiseaseControl Points
  • 3. Reduce host SUSCEPTIBILITY
  • Vaccination
  • Immune globulin
  • Prophylaxis
  • Self-isolation

11
Recap
  • Infection Control focus
  • Reduction of risk factors
  • Chain Model of Infectious Disease
  • epidemiologic
  • Infectious disease control points
  • Contain/control the source
  • Interrupt transmission
  • Reduce host susceptibility

12
Methods to Limit Transmission Community
Settings Isolation and Quarantine
  • Isolation the separation, restriction of
    movement and activities of ill infected persons
    with contagious disease, to prevent transmission
    to others
  • Quarantine the separation and restriction of
    movement or activities of persons not ill but
    believed exposed to infection, to prevent
    transmission of disease
  • Source CDC. SARS. Supplement D Community
    Containment Measures, Including Non-Hospital
    Isolation and Quarantine

13
Methods to Limit Transmission Community Settings
  • Contact management
  • Focused measures to increase social distance
  • Community-wide measures to increase social
    distance
  • Quarantine
  • Cordon Sanitaire

14
Methods to Limit Transmission Community Settings
  • Contact management for individuals
  • Prophylaxis/Immunization
  • Passive or active monitoring of symptoms and
    needs
  • Quarantine
  • Home
  • Designated community facilities
  • Working quarantine
  • Institute appropriate IC precautions for
    symptoms
  • The contact remains separated from others for a
    specified period, during which daily assessment
    for signs and symptoms of disease occurs
  • Can be voluntary or mandatory

15
Methods to Limit Transmission Community
Settings
  • Contact management for individuals (contd)
  • Treat and Isolate ill Contacts
  • Isolate in hospital if clinically indicated
  • Isolate in community or residence if appropriate
    care can be given and household members are safe
  • During home isolation, non-essential household
    members should be relocated or contact should be
    minimized
  • Use appropriate isolation precautions
  • Close contacts must monitor symptoms
  • Monitor, prophylax and/or treat contacts contact

16
Methods to Limit Transmission Community Settings
  • Focused measures to reduce community
    interactions
  • Closure of particular schools or office buildings
  • Suspension of large public gatherings
  • Restriction of travel in designated area
  • Suspension of out-of-home child care
  • Interventions designed to reduce interactions and
    transmission risk within the targeted group or
    area

17
Methods to Limit Transmission Community Settings
  • Community-wide measures to increase social
    distance
  • Work sites, schools, transportation systems,
    bridges and tunnels are closed (e.g. snow day)
  • Some restrictions, e.g. travel, may require use
    of physical measures such as checkpoints.

18
Methods to Limit Transmission Community Settings
  • Community measures to increase social
    distance
  • Quarantine
  • Legally enforceable order that restricts movement
    into or out of the designated area of quarantine
    of a large group or community
  • Staff and supplies needed to maintain access to
    and availability of essential services and goods
    including food, water, medicine, medical care
    etc.
  • Reduces need for urgent evacuation
  • Requires excellent communications to inform
    affected persons and maintain public confidence

19
Methods to Limit Transmission Community Settings
  • Community-wide measures to increase social
    distance
  • Cordon Sanitaire (sanitary barrier) Quarantine
    that is applied to all inhabitants of an area.
  • Staff and supplies are needed to maintain access
    to and availability of essential services and
    goods including food, water, medicine, medical
    care etc.
  • Requires excellent communications to inform
    affected persons and maintain public confidence
  • Reduces need for urgent evacuation

20
Methods to Reduce Number of Susceptibles
  • Prophylaxis
  • Vaccination
  • Limit contacts
  • Reverse Isolation
  • Isolate susceptibles to prevent transmission
  • May occur voluntarily

21
Susceptible Hosts
  • What is the level of susceptibility in the
    population at risk?
  • Who is at risk of becoming infected after
    exposure to an infectious case?
  • Individual susceptibility varies
  • Prior immunity
  • WBC migration response
  • Age
  • Underlying immunosuppressive disease, e.g.
    HIV/AID, diabetes mellitus, chronic renal
    failure, malnourishment, CA
  • External pressures
  • Corticosteroids
  • Antirejection drugs
  • Antineoplastic drugs
  • Surgical procedures and radiation therapy
  • Invasive devices
  • Implants

22
Personal Risks for Infection
  • Number, type and duration of social contacts
  • Personal habits, e.g. lack of frequent
    handwashing, touching mucous membranes of eyes,
    nose and mouth w/o first handwashing, poor
    personal hygiene, inappropriate and inconsistent
    use of PPE, lack of sanitary living conditions
  • Personal attitudes, e.g. risk-taking instead of
    risk-aversive
  • Crowed living conditions
  • High risk environments, e.g. homeless shelters,
    correctional facilities
  • Medically underserved

23
Limitations of Control MeasuresThe Infected
Source/Infectious Period
  • Sources can transmit disease
  • 1) Without disease symptoms (in colonized,
    chronic carrier, sub-clinical or asymptomatic
    disease states), and/or
  • 2) Before symptoms appear (incubation period),
    and /or
  • 3) In the clinical disease state, and/or
  • 4) In the convalescent period

24
Limitations of Control MeasuresImportance of the
Infectious Period
  • For sources who transmit disease without
    exhibiting symptoms, controlling an epidemic may
    be as dependent upon reducing the number of
    susceptible hosts or removing them, as upon
    measures to limit transmission, such as isolation
    and quarantine.

25
Limiting the Number of Persons Exposed to a
Communicable Disease
  • The Episims (social network simulation) model
    provides information about the social paths a
    disease could take, giving clues about what
    interventions would be most effective in
    decreasing transmission
  • Source Barrett CL, Eubank SG, Smith JP If
    Smallpox Strikes Portland
  • Scientific American, March 2005

26
The Episims Model
  • The models of social interactions and
    networks derived from Episims are based upon
    present day culture. Estimates of a particular
    diseases reproductive number relies on
    historical situations.
  • Results from a variety of simulations show that
    the speed at which people self-isolated or were
    isolated by health officials was the strongest
    determinant of the (simulated) outbreaks extent.
    The next most influential factor was the length
    of delay in officials response
  • Source Barrett CL, Eubank SG, Smith JP If
    Smallpox Strikes Portland
  • Scientific American, March 2005

27
Recap
  • Isolation and Quarantine defined
  • Methods to limit transmission
  • Community settings
  • Contact management
  • Focused measures to increase social distance
  • Community-wide measures to increase social
    distance
  • Quarantine
  • Cordon Sanitaire

28
Recap
  • Methods to reduce the number of susceptibles
  • Prophylaxis
  • Vaccination
  • Reverse isolation (?)
  • Limitations of control measures
  • Asymptomatic transmission
  • Control measures should focus on reducing the
    number of susceptible persons, rather than on
    measures to limit transmission
  • Episims model shows that speed of isolation was
    strongest determinant of outbreaks extent
  • Personal risks for infection

29
  • Healthcare Settings

30
Draft Guideline for Isolation Precautions
  • Recommendations of the Healthcare Infection
    Control Practices Advisory Committee (HICPAC)
    2004
  • For the PREVENTION of infections throughout
    the entire spectrum of healthcare delivery
    settings

31
Transmission Of Infectious Agents In All Settings
Requires 3 Interrelated Elements
Source
Mode of Transmission
Susceptible Host
32
Transmission of Infectious Agents in Healthcare
Settings
  • Individuals are exposed to human sources of
    microorganisms by three primary routes
  • Contact transmission
  • Direct organism is transferred directly from
    one person to another, e.g. scabies or herpetic
    whitlow
  • Indirect- organism is transferred through
    contaminated intermediate object or person, e.g.
    hands or contaminated patient care equipment
  • Droplet Transmission- relatively large ( gt5
    microns) droplet heavy with moisture that are
    propelled relatively short distances from the
    source (3-6 feet) onto the mucous membranes of
    the nose, mouth or eyes, of the host and
    environmental surfaces
  • Airborne Transmission- droplet nuclei (lt5
    microns) that remain suspended in the air for
    long periods, that may be inhaled by the host
    into the alveoli of lungs

33
Fundamental Elements to Prevent Transmission of
Infectious Agents in Healthcare Settings
  • Administrative measures
  • Education of HC workers, patients and families
  • Hand Hygiene
  • Personal Protective Equipment
  • Safe Work Practices
  • Patient Placement
  • Transport of Patients
  • Environmental measures
  • Patient Care Equipment
  • Textiles and Laundry
  • Dishware and eating utensils
  • Adjunctive measures

34
Methods to Prevent Transmission of
InfectionsHealthcare Settings
  • Standard Precautions Basic preventive measures
    to be used with all patients at all times.
  • Gloves for contact except perspiration and intact
    skin
  • Hand Hygiene
  • Patient Placement
  • Other PPE based upon anticipated exposure
  • Safe Work Practices
  • Environmental measures

35
Expanded PrecautionsTo Be Used In Addition to
Standard Precautions
  • Syndromic or empiric
  • Contact Precautions
  • Droplet Precautions
  • Airborne Infection Isolation

36
Expanded PrecautionsSyndromic or Empiric
Precautions
  • Certain clinical conditions carry a sufficiently
    high risk to warrant use of expanded precautions
    while awaiting laboratory confirmation of
    infection
  • Diarrhea standard plus contact precautions
  • Meningitis- droplet for 1st 24 hrs. Mask/face
    protection
  • Rash or exanthems- consult table 6 for specifics
  • Respiratory infections- consult table 6 for
    specifics
  • Skin or wound infection- standard plus contact
    precautions

37
Expanded PrecautionsContact Precautions
  • To reduce the risk of transmission by direct or
    indirect contact with patient or environment
  • Place patient in a private room
  • Wear gloves and gown for all contact with patient
    or with potentially contaminated surfaces or
    items
  • Limit transport of patient
  • Use disposable patient care items whenever
    possible
  • If patient care items must be shared, disinfect
    between patients
  • Clean patient room at least daily and disinfect
    high touch surfaces

38
Expanded PrecautionsDroplet Precautions
  • To reduce risk of infection from patients known
    or suspected to be infected with organisms
    transmitted by respiratory droplets generated
    when coughing, sneezing, or talking or during
    cough-inducing procedures
  • Private room
  • Wear a surgical mask for close patient contact
  • For SARS and Avian influenza, wear N-95
    respirator and also wear eye protection
  • Limit patient transport
  • Instruct patient to wear a surgical mask and
    follow respiratory hygiene/cough etiquette.
    Notify receivers of precautions

39
Expanded PrecautionsAirborne Infection Isolation
  • Requirements
  • All persons who enter room must wear respiratory
    protection (NIOSH approved N-95 or higher
    respirator)
  • Private room and bath with special air handling
    and ventilation capacity (negative pressure to
    surrounding area)
  • 12 air exchanges per hour (6 for existing
    facilities)
  • Air exhausted directly outside or recirculated
    through HEPA filtration
  • Non immune HCW do not care for patients with
    measles, chickenpox or smallpox, regardless of
    use of PPE
  • In settings where AII cannot be implemented, use
    physical separation, mask (surgical) the patient,
    provide fresh air if possible, provide N-95 or
    higher respirators for healthcare personnel until
    transfer to a facility with AII.

40
  • The following slides (some have been adapted)
    are courtesy of Rosie Sokas, MD MOH at UIL
    Chicago School of Public Health and her friends
    at the CDC.
  • Thank you.

41
What are Infectious Aerosols?
What are Infectious Aerosols?
  • Particle size (HICPAC, 1996)
  • Droplets particles larger than 5µm
  • Droplet nuclei particles 5µm or less
  • Term first proposed by Wells, 1934
  • Other authors large droplets vs. small
    droplet
  • Working definition "dispersions of airborne
    particles capable of causing infection."
  • Particle size (HICPAC, 1996)
  • Droplets particles larger than 5µm
  • Droplet nuclei particles 5µm or less
  • Term first proposed by Wells, 1934
  • Other authors large droplets vs. small
    droplet

42
Droplets from a Sneeze
Source Jennison, 1942
43
Droplets from a Cough
Source Papineni RS, Rosenthal FS 1997. The
Size Distribution of Droplets in the Exhaled
Breath of Healthy Subjects. Journal of Aerosol
Medicine. 10(2)105-116.
44
Droplet and Airborne Transmission
  • Droplet Deposit of large infective droplets
    onto the nasal, conjunctival or oral mucosal
    membranes
  • Airborne Deposit of airborne droplet nuclei
    onto the alveoli of susceptible persons

45
Role of Surgical Masks?
  • A surgical mask is NOT respiratory protection
  • 1º intent preventing wound contamination by
    infectious droplets from HCWs respiratory tract
  • 2º use barrier protecting HCWs nose and mouth
    from large droplet splashes, sprays of infectious
    material
  • Particles can enter at edges of mask
  • Some not constructed using particulate filter
    media

46
Assumptions for Respirator Use
  • Need to protect HCWs from possible secondary
    transmission from ill patients (not 1º release)
  • 2. Respirators will be used in the context of a
    complete respiratory protection program

47
N-95 Filtering Facepiece Respirators
48
Benefits of fit testing
  • Study 25 volunteers, 21 models of N-95
    respirators
  • Without fit testing, 95 of the tests had up to
    33 leakage
  • With fit testing, 95 of the tests had no more
    than 4 leakage

49
Powered Air-Purifying Respirator(PAPR)
50
Full Facepiece Elastomeric Respirator (FFR)
51
Assigned Protection Factors
52
Infection Control Lessons
  • The details of prevention and control measures
    always matter
  • Personal habits may make the difference between
    acquiring or evading an infection
  • Multiple factors of modern society may make
    predictions of transmission rates tenuous, at
    best
  • We are living in a time of unprecedented
    infectious disease risks.
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