Annexure C : Precautions For Workplaces

[Regulations 10(1)(b), 15(a) and 16(a), (b) and (c)]

Five Main Routes Of Transmission

1) Contact

1. direct contact with an infected or contaminated body surface or fluid; and
2. indirect contact via contact with an object previously contaminated with organisms from an infected person or animal.

2) Droplet Transmission

Droplets may carry organisms that can infect a new host if they are deposited on conjunctivae, nasal mucosa or the mouth.

Droplets do not remain suspended in the air.

Droplets do not travel more than one metre.

3) Airborne Transmission

Few organisms are carried by this route, the most important being Mycobacterjum tuberculosis and the viruses causing measles and chickenpox.

Prevention of spread requires an enclosed area with at least six air changes per hour, or an open window that provides adequate ventilation.

4) Common Vehicle Transmission

Normal hygienic practices and proper sterilisation or disinfection of equipment should make this type of spread a rare event in certain workplaces, e.g. hospitals.

5) Vector-Borne Transmission

In areas where there is a problem the appropriate measures, e.g. screens on windows and the use of insecticides must be instituted.

Two levels of precautions are recommended:

• Standard Precautions

  These are applied at all times to all patients irrespective of their diagnosis. All body fluids (except sweat) are regarded as potentially infectious.

• Transmission-Based Precautions

  These are applied when a specific infectious disease is diagnosed or suspected.

  The route by which the disease is transmitted will determine the category of precautions that must be applied.

Precautions

A) Administrative Controls

1) Education and Training
2) Adherence to precautions

B) Precautionary measures

1) Standard Precautions
2) Airborne Precautions
3) Droplet Precautions
4) Contact Precautions
5) Formidable Epidemic Disease (e.g. viral haemorrhagic fevers) Precautions

Administrative Controls:

1) Education And Training

A system must be developed to ensure that hospital patients, employees, contractors and visitors are educated about:

• the use of precautions.
• their responsibility for adhering to the precautions.

2) Adherence To Precautions

Periodic evaluation of adherence to precautions must be carried out. The findings are to be used to implement improvements.

Precautionary Measures

1) Standard Precautions

Standard precautions are used for the protection of all people exposed to HBA.

1.1 Hand Washing

• Wash hands after touching blood, body fluid, secretions, excretions and contaminated items, whether or not gloves are worn.

• Wash hands (when working with patients):

  • immediately after gloves are removed.
  • between patient contact.

  • where indicated to prevent cross-contamination of different body sites.

• Use plain (non-antimicrobial) soap for routine hand washing.
• Use an antimicrobial agent or an alcohol hand disinfectant for specific circumstances (e.g. control of outbreaks or hyperendemic infections) as defined by the infection control program. (See contact precautions.)

1.2 Gloves

• Wear gloves (clean, intact non-sterile gloves are adequate) when touching blood, body fluid, secretions, excretions and contaminated items.
• Put on clean intact gloves just before touching mucous membranes and non-intact skin.

• Change and dispose of gloves between tasks and procedures -

  • on the same person.

  • after contact with material that may contain high concentration of micro-organisms.

• Remove gloves promptly after use -

  • before touching non-contaminated items and environmental surfaces.

  • before attending to another person.

• Wash hands immediately to avoid transfer of micro-organisms to other persons and environments.

1.3 Mask, eye protection, face shield

• Wear a mask and eye protection or a face shield -

  • to protect mucous membranes of the eyes, nose and mouth.
  • during procedures and activities that are likely to generate splashes or sprays of blood or body fluid, secretions and excretions.

1.4 Protective Clothing

• Wear appropriate protective clothing to protect skin and to prevent soiling of clothing during procedures and activities that are likely to generate splashes or sprays of blood, body fluid, secretions and excretions.
• Select protective clothing that is appropriate for the activity and amount of fluid likely to be encountered.
• Remove soiled protective clothing as promptly as possible and consider it contaminated.
• Wash hands immediately after removal of protective clothing to avoid transfer of micro-organisms to other people or environments.

1.5 Patient-care equipment

• Handle patient-care equipment soiled with blood, body fluids, secretions and excretions in a manner that prevents -

  • skin and mucous membrane exposures.
  • contamination of clothing.

  • transfer of micro-organisms to other environments.

• Ensure that reusable equipment is not used for the care of another patient until -

  • it has been cleaned.

  • it has been reprocessed appropriately.

• Ensure that-

  • sufficient disposable syringes and needles are at all times available for 3 provision is made for their safe disposal.

1.6 Environmental Control

• Ensure that adequate procedures are in place for routine care, cleaning and disinfection of environmental surfaces, and other frequently used or potentially contaminated surfaces.
• Disinfection of environmental surfaces is not routinely required. Simple cleaning is adequate unless there has been significant soiling by potentially infectious body fluids.

1.7 Linen

• Process, handle and transport used linen contaminated with blood, body fluid, secretion and excretions in colour coded, impervious containers and all possible measures should be observed to prevent

  • skin and mucous membrane exposure.
  • contamination of clothing.
  • transfer of micro-organisms to other persons and environments.

1.8 Occupational Health

1.8.1. Injuries

• Take care to prevent injuries when -

  • using needles, scalpels and other sharp instruments or devices.
  • handling sharp instruments after a procedure.
  • cleaning instruments.
  • disposing of used needles.

Never

• Re-cap needles or manipulate them using both hands, if it is absolutely necessary to resheath a needle. A variety of mechanical devices that are commercially available must be used.
• Use any other technique that involves directing the point of a needle toward any part of the body.

Do not

• Remove used needles from disposable syringes by hand.
• Bend or break or otherwise manipulate needles by hand.

Do

• Place used disposable syringes and needles, scalpel blades and other sharp objects in appropriate puncture-proof containers that are as close as possible to the area in which the procedure is carried out.
• Transport them safely to the disposal area.

1.8.2. Resuscitation

Use mouthpieces, resuscitation bags or other ventilation devices as an alternative method to mouth-to-mouth resuscitation in areas where the need for resuscitation is predictable.

1.9 Patient Placement

• Place in an isolation area (single or private room) patients who -

  • contaminate the environment.
  • do not or cannot be expected to assist in maintaining appropriate personal hygiene or environmental control.
  • If an isolation area is not available, consult infection control professionals regarding patient placement or other alternatives.

2) Airborne Precautions

In addition to Standard Precautions, use Airborne Precautions for -

• patients known or suspected of being infected with micro-organisms transmitted by airborne droplet nuclei, i.e. small particle residue of evaporated droplets containing micro-organisms that -

  • remain suspended in the air;
  • can be widely dispersed by air currents within a room or over a long distance.

2.1 Patient Placement

Ideally place patients in a private room that has -

• monitored negative air pressure in relation to the surrounding areas.
• 6 - 12 air changes per hour.

• Appropriate discharge of air outdoors or monitored high-efficiency filtration of room air before the air is circulated to other areas of the hospital.

  Where this is not possible

• Use -

  • a room with a simple extraction fan providing at least six air changes per hour.

  • a room with an open window, and adequate ventilation.

• When an isolation area is not available, place the patient in a room with another patient who has active infection with the same micro-organism, and no other infection, unless otherwise recommended.
• When a private room is not available and cohorting is not desirable, consultation with infection control professionals is advised before patient placement.
• Keep the patient in the room and keep the door closed.

2.2 Respiratory Protection

Tuberculosis:

• Respiratory protection may be worn when entering the room of a patient known or suspected to have infectious pulmonary tuberculosis.

Measles (rubeola) and chickenpox (varicella).

• Susceptible personshould not enter the room of patients known or suspected of having measles or varicella if other immune caregivers are available.
• if susceptible persons must enter the room they must wear respiratory protection.
• Persons immune to measles or varicella need not wear respiratory protection,

2.3 Patient Transport

Movement and transport of the patient should be kept to a minimum.

• If transport or movement is necessary, the patient must wear a surgical mask to minirnise dispersal of droplet nuclei.

2.4 Additional precautions for preventing transmission of tuberculosis

• Respirators -

  • must be worn by all who enter the room.

  • must be able to filter particles 1 micron or less in size with a filter efficiency of 95%.

• Effective treatment of the patient

• Isolation -

  • there is significant clinical improvement in the patient's condition.
  • ideally, two negative acids fast bacilli smears must be obtained.
  • ideally a smear positive patient will require isolation for a minimum of two weeks.

3) Droplet Precautions

In addition to Standard Precautions, use Droplet Precautions for patients known or suspected to be infected with micro-organisms transmitted by droplets (large particle droplets that can be generated during coughing, sneezing, talking or respiratory therapy).

3.1 Patient Placement

Place the patient in an isolation area, e.g. private or single room

• When a private room is not available and cohorting is not achievable, maintain spatial separation of at least one metre between the infected patient and other patients and visitors.
• Additional ventilation measures are not necessary and the door may remain open.

3.2 Masks

Wear a mask when working within one metre of the patient. However, logistically some hospitals may want to implement the wearing of a mask to enter the room.

3.3 Patient Transport

Movement and transport of the patient from the room should be kept to a minimum. If transport or movement is necessary, minimise dispersal of droplets by masking the patient.

4) Contact Precautions

In addition to Standard Precautions use Contact Precautions for specified patients known or suspected to be infected or colonised with epidemiologically important micro-organisms that can be transmitted by direct contact with the patient (hand to skin contact occurs when performing patient care activities that required touching the patient's dry skin) - or indirect contact (touching) environmental surfaces or patient care items in the patient's environment.

4.1 Patient Placement

Place the patient in an isolation area, e.g. private or single room

• When a private room is not available, place the patient in a room with patients who have active disease with the same microorganism but no other infection (cohorting).
• When either a private room nor cohorting is achievable, consider the epidemiology of the microorganism and the patient population when determining patient placement.

Consultation with infection control professionals is advisable before patient placement.

4.2 Gloves And Hand Washing

In addition to wearing gloves and washing hands as outlined in Standard Precautions -

• Wear clean gloves when entering the room.
• Change gloves after having contact with infective material,
• Remove gloves before leaving the patient's environment.
• Wash hands immediately after glove removal with an antimicrobial or an alcohol hand rub.
• Ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient's room to avoid transfer of micro-organisms to other patients or the environment.

4.3 Protective Clothing

In addition to wearing a gown or plastic apron as outlined in Standard Precautions -

• Wear a clean, non-sterile gown and/or plastic apron as appropriate -

  • when entering a room where soiling of clothing is anticipated.
  • following substantial contact with the patient.
  • following contact with environmental surfaces or items in the patient's room.
  • if the patient is incontinent or has diarrhoea, an ileostomy or a colostomy.

  • where wound drainage is not contained by a dressing.

• Remove the gown or plastic apron before leaving the patient's environment.
• After gown or plastic apron removal, ensure that clothing does not make contact with potentially contaminated environmental surfaces to avoid transfer of micro-organisms to other patients or environments.

4.4 Patient Transport

• Movement and transport of the patient from the room should be minimised.
• Ensure that precautions are maintained to minimize the risk of transmission of micro-organisms to other patients and contamination of environmental surfaces or equipment.

4.5 Patient-Care Equipment

Where possible dedicate the use of non-critical patient-care equipment to a single patient (or cohort of patients infected or colonised with the pathogen requiring precautions).

Avoid sharing equipment between patients

• If the use of common equipment or items is unavoidable, then these must be cleaned and disinfected before use for another patient.

4.6 Additional Precautions For Preventing The Spread Of Multi-Drug-Resistant Micro-Organisms

Limit antibiotic use and prevent misuse.
• Educate staff.
• Detect multi-drug-resistant micro-organisms early by laboratory and infection control surveillance.
• Consult an Infection Control Practitioner regarding further management.

5) Formidable Epidemic Disease (Fed) Isolation

• Standard and contact precautions plus additional items such as respirators, visors, water repellent gowns and boots, caps, double gloves are required.
• Standard precautions are adequate during the non-haemorrhagic phase in cases of haemorrhagic fevers, such as Ebola and Congo-Crimean haernorrhagic fever.

5.1 Isolation Area

• This may be a dedicated viral haemorrhagic fever (VHF) unit or a dedicated sideward or private room, preferably with an anteroom.
• The door must be kept closed, and strict access control must be implemented.

5.2 Gowns

• Impervious disposable gowns must be worn over a theatre scrub suit.

5.3 Gloves

• Two pairs are worn, the one pair on top of the other.
• Sterile latex gloves are used because of the thicker quality and longer nori-roll cuff.

5.4 Boots

• Impervious boots or overshoes are worn in the isolation room.

  They must be -

  • high enough to cover the area of skin below the trouser legs.
  • strong enough to withstand wear and tear.

5.5 Theatre Capsigoggles Or Visors

• Worn inside the isolation room.
• Theatre caps.

  A theatre cap worn with a visor providing full protection of the head and neck is preferred.

5.6 Masks an Respirators

• Masks - good quality, high-filtration respirators are necessary.

5.7 Formidable Epidemic Disease Pack (FED Pack)

A FED pack contains all the isolation gear necessary, must be safely stored in an area not accessible to unauthorised persons. The FED pack must be immediately replenished after every usage.

This pack is available immediately, is portable and is used until the patient is diagnosed or transferred to an isolation unit or an infectious diseases hospital. The pack is kept in a box or in a trolley. The box (or trolley) is distinctive and kept in an easily accessible place. The pack contents are replenished as required by the infection control staff.

Instruction posters provide instructions for untrained personnel until infection control professionals arrive to provide guidance and instruction in VHF procedures.

Contents -

• Sterile latex gloves of varying sizes.
• Disposable impermeable gowns.
• Goggles or visors.
• Masks.
• Shoe covers (half-leggings).
• Theatre caps.
• Blood tubes, labels, bio-hazard plastic specimen bags, a rigid, walled container for transportation of specimens and bio-hazard stickers.

• Masking tape used for -

  • sealing boxes of refuse.
  • fixing instruction posters to the wall.

  • securing tops of plastic shoe covers,

• Plastic refuse bags for contaminated refuse.
• Autoclavable bags for non-disposable items.
• Clear plastic bags.
• Sodium-hypochlorite sachets of powder (NaOCI) and liquid 1 % hypochlorite.

• Plastic-covered instruction posters containing detailed instructions on how to -

  • put on isolation gear.
  • undress safely.
  • collect and handle specimens safely.
  • mix disinfectants.
  • disinfect and handle contaminated equipment.
  • dispose of linen and refuse.
  • deal with a blood spill.

5.8 The infection control professionals must ensure that staff follows correct procedures and that equipment is available for disposal of refuse.

• All refuse bags are colour coded, double bagged and are placed into cardboard boxes.
• Refuse bags are sealed and labelled with bio-hazard stickers and tape.
• Containers are escorted to the incinerator.
• Their immediate incineration is ensured.

5.9 Transporting VHF specimens

• These specimens require a special container and packaging:

  • The specimen is placed in a bio-hazard bag.
  • The patient's label is placed in the outer pouch.
  • The specimen is then wrapped in absorbent material and placed in an unbreakable screw-top container.
  • The container is labelled with a bio-hazard sticker and the destination (name of the receiving laboratory).
  • It is preferably delivered by hand.
  • If the specimen has to be posted or sent by courier a second unbreakable container is used and labelled accordingly.

5.10 Management of soiled linen, refuse and equipment

Bedding

• All bedding used is either disposable or condemned linen that is subsequently incinerated.

• Mattresses must be covered with durable plastic covers

  • The covers are disposable.
  • If the mattress becomes soiled with blood or body substance it must be destroyed.

Linen and Refuse

• All linen (disposable and condemned) is placed into plastic refuse bags

  • The person inside the cubicle or room takes the sealed bag and places it in a second bag held by another person outside the room.
  • This bag is then sealed and sent for incineration.

Terminal disinfection of equipment

• All equipment is washed down well with a hypochlorite-detergent.
• It is then dried, using a paper towel.

• If the equipment is not autoclavable, it must .be wrapped in clear plastic bags, then -

  • double bagged into a clean bag held by a second person outside the cubicle.
  • clearly labelled with the contents and a biohazard sticker attached.

  • sent to Central Sterilizing Service Department (CSSD) for ethylene oxide gas sterilization.

• Autoclavable items must be placed in Asepto type bags -

  • labelled as above.
  • sealed in clean plastic bags for transport to CSSD.
  • autoclavable plastic bags may be used if available.

Furniture or environment

• All furniture, walls and floors are washed down well with hypochlorite-detergent.

TABLE I

Abbreviations used

Type of precautions:

Standard precautions (S) are applied at all times in addition to either

   A Airborne
   C Contact
   D Droplet
   VHF Viral haemorrhagic fever

Duration of precautions:

   CN until antibiotics are discontinued and culture-negative
   DH duration of hospitalisation
   Dl duration of illness (with wound lesions, Dl means until they stop draining)
   U until time specified in hours (hrs) after initiation of effective therapy.
   F footnote number under type

Meaning of superscript number (i.e. FE Standard precaution is applied at all times)

^a No dressing, or dressing does not contain drainage adequately.
^b Dressing covers and contains drainage adequately.
^c Also see syndromes or conditions listed in Table 2.
^d Install screens in windows and doors in endemic areas.
^e Maintain precautions until all lesions are crusted. The average incubation period for varicella is 10 to 16 days, with a range of 10 to 21 days. After exposure, use varicella-zoster immune globulin (VZIG) when appropriate and discharge susceptible patients if possible. Place exposed susceptible patients on Airborne Precautions beginning 10 days after exposure and continuing until 21 days after last exposure (up to 28 days if VZIG has been given). Susceptible persons should not enter the room of the isolated patient on precautions if other immune caregivers are available.
^f Isolate all infants on precautions during any admission until one year of age, unless - nasopharyngeal and urine cultures are negative for virus after age three months of age.
^g Additional special precautions are necessary for handling and decontamination of blood, body fluids and tissues, and contaminated items from patients with confirmed or suspected disease.
^h until two cultures are taken at least 24 hours apart are negative,
ⁱ Consult the National Institute of Virology for guidelines issued by provincial health departments. Use Contact Precautions for diapered or incontinent children less than six years of age for duration of illness. Maintain precautions in infants and children under three years of age for duration of hospitalisation; in children three to fourteen years of age, until two weeks after onset of symptoms; and others, until one week after onset of symptoms. For infants delivered vaginally or by Caesarean section and if mother has active infection and membranes have been ruptured for more than four to six hours.
^m Persons susceptible to varicella are also at risk for developing varicella when exposed to patients with zoster lesions: therefore, susceptibles should not enter the room if other immune caregivers are available. ⁿ Many hospitals encounter logistic difficulties and suspected or diagnosed limitations when admitting multiple patients with suspected influenza during community outbreaks. If sufficient private rooms are unavailable, consider cohorting patients or, at the very least, avoid room sharing with high-risk patients.
^o Patients should be examlned for evidence of current (active) pulmonary tuberculosis, If evidence exists, additional precautions are necsssary (see tuberculosis 3).
^p Resistant bacteria judged by the infection control program, based on current state, regional or national recommendations, to be of special clinical and epidemiologic significance. For nine days after onset of swelling. Maintain precautions for duration of hospitalisation when chronic disease occurs in an immunodeficient patient. For patients with a transient plastic crisis or red cell crisis, maintain precautions for seven days. Maintain precautions for five days after patient is placed on effective therapy. Avoid cohorting or placement in the same room with a cystic fibrosis (CF) patient who is not infected or colonised with B. cepacia. Persons with CF who visit or provide care and are not infected or colonised with B. cepacia may elect to wear a mask when within one metre of a colonised or infected patient. Avoid pjacement in the same room with an immunocompromised patient. Until seven days after onset of rash. Discontinue precautions only when TB patient is improving clinically and has three consecutive negative sputum smears collected on different days or TB is ruled out. Maintain all precautions until the patient stops bleeding.

TABLE II

* Infection control professionals are encouraged to modify or adapt this table according to local conditions. To ensure that appropriate empiric precautions are always implemented, hospitals must have systems in place to evaluate patients routinely according to these criteria as part of their pre-admission care.

** Patients with the syndromes or conditions listed below may present atypical signs or symptoms (e.g. pertussis in neonates and adults may not have paroxysmal or severe cough). The clinician's index of suspicion should be guided by the prevalence of specific conditions in the community, as well as clinical judgement.

*** The organisms listed under "Potential Pathogens'' are not intended to represent the complete, or even the most likely, diagnosis, but rather possible etiologic agents that require additional precautions beyond Standard Precautions until they can be ruled out.

Synopsis of types of precautions and patients requiring the precautions

Abbreviations used in list of precautions.