Annexure C : Precautions For Workplaces

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

Five Main Routes Of Transmission

1) Contact
The most important route of transmission in a workplace is by -

  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 are generated during coughing, sneezing, talking and during procedures such as suctioning.

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
Small particles (droplet nuclei) that remain suspended in air for long periods of time have a far greater potential for spreading disease than large droplets.

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
Transmission by items such as food, water, devices and equipment.

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
Vectors such as mosquitoes, flies, fleas, etc. are hopefully not frequently encountered in workplaces as a cause of outbreaks.

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:

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:

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

1.2 Gloves

1.3 Mask, eye protection, face shield

1.4 Protective Clothing

1.5 Patient-care equipment

1.6 Environmental Control

1.7 Linen

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

2) Airborne Precautions

In addition to Standard Precautions, use Airborne Precautions for -

2.1 Patient Placement

Ideally place patients in a private room that has -

2.2 Respiratory Protection

Tuberculosis:

Measles (rubeola) and chickenpox (varicella).

2.3 Patient Transport

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

2.4 Additional precautions for preventing transmission of tuberculosis

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

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

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 -

4.3 Protective Clothing

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

4.4 Patient Transport

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

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

5) Formidable Epidemic Disease (Fed) Isolation

5.1 Isolation Area

5.2 Gowns

5.3 Gloves

5.4 Boots

5.5 Theatre Capsigoggles Or Visors

5.6 Masks an Respirators

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 -

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

5.9 Transporting VHF specimens

5.10 Management of soiled linen, refuse and equipment

Bedding

Linen and Refuse

Terminal disinfection of equipment

Furniture or environment

TABLE I

Infection / Condition Precautions Type* Duration

Abscess
Draining. major
Draining, minor or limited
AIDS'
Actinomycosis
Adenovirus infection, in infants and young children
Amebiasis
Anthrax
   Cutaneous
   Pulmonary
Antibiotic-associated colitis (see C dificile)
Arthropodborne viral encephalitides (eastern. western, Venezuelan equine encephalomyelitis: St Louis,
California encephalitis)
Arthropodborne viral fevers (dengue, yellow fever, Colorado tick fever)
Ascariasis
Aspergillosis
Babesiosis
Blastomycosis, North American, cutaneous or pulmonary
Botulism
'NO dressing or dressing does not adequately contain damage
'Dressing covers and adequately contains drainage.
Bronchiolitis (see respiratory infections in infanis and young children)
Brucellosis (undulant, Malta, Mediterranean fever)
Camp!lobacfer gastroenteritis (see gastroenteritis)
Candldiasis, all forms including mucocutaneous
Cat-scratch fever (benign inoculation lymphoreticulosis)
Cellulitis, uncontrolled drainage
Chancroid (soft chancre)
Chickenpox (varicella) (see F" for varicella exposure)
Chlamydia trachomatis
Conjuctivitis
Genital
Respiratory
Cholera (see gastroenteritis)
Closed-cavify infection
Draining, limited or minor
Not draining
Clostridium spp
C. botulium
C. difficile
   C. perfringens
   food poisoning
   Gas gangrene
Coccidiodomycosis (valley fever)
   Draining lesions
   Pneumonia
Colorado tick fever
Congenital rubella
Conjunctivitis
   Acute bacterial
   Chlamydia
   Conococcal
   Acute viral (acute hermorhagic)
Coxsackie virus (see enteroviral nfection)
Creutzfeldt-Jakob disease
Croup (see respiratory in infants and young children)
Cryptosporidiosis (see gastroenteritis)
Cysticercosis
Cytomegalovirus infection neonatal or immunosuppressed
Decubitus ucler. infected
Crypiococcosis
   Major
   Minor or Iimited
Dengue
Diarrhea acute-infective etlology suspected (see gastroenteritis)
Diptheria
   Cutaneous
   Pharyngeal
Ebola viral hemorrhagic fever
Echnococcosis (hydatidosis)
Echovirus (see enteroviral enfection)
Encephalitis (see enteroviral infection)
Encephalitis or encephalomyelitis (see specific etiologic agents)
Endometritis
Enterobiasis (pinworm disease, oxyuriasis)
Enterococcus species (see multidrug-resistant organisms if epdidemiologically
significant or vancomycin resistant
Enterocolitis. C. difficile
Enteroviral infctions
   Adults
   Infants and young children
Epiglottitis caused by H. influenzea
Epstein-Barr virus infection, including infectious mononucleosis
Erythema infectiosum (also see Parvovirus B 19)
Escherichia coli gastroenteritis (see gastroenteritis)
Food poisoning
   Botulism
   Clostridium perfringens or welchii
   Staphylococcal
Furunculosis-staphylococcal
   Infants and young children
Gangrene (gas gangrene)
Gastroenteritis
   Campylobacter sp
   Cholera
   C. difficile
   Cryptosporidium species
   E. coli
   Enternhemorrhagic 0157.H7
   Diapered or incontinent
   Other species
   Giardia lamplia
   Rota virus
   Diapered or incontinent
   Salmonelia species (including S. fyphil
   Shigella species
   Diapered or incontinent
   Vibrio paraharnolyticus
   Viral (if not covered elsewhere)
   Yersinia enterocolitica
German measles (rubella)
Giardiasis (see gastroenteritis)
   Gonococcal ophthalmia neonatorum (gonorrheal ophtalmia acute conjunctivitis of newborn)
Gonorrhea
Granuloma inguinale (donovanosis, granuloma venereum)
Guillain-Barre syndrome
Hand, foot and mouth disease (see enterviral infection)
Hantavirus pulmonary syndrome
Helicobacter pylori
Hemorrhagic fevers (for example Lassa and Ebola)
Hepatitis, viral
   Type A
   Diapered or incontinent patients
   Type B-HBsAg positive
   Type C and other unspecified, non-A, non-B
   Type E
Herpangina (see enteroviral infection)
Herpes simplex (Herpesvirus horninis)
   Encephalitis
   Neonatal' (see F' for neonatal exposure)
   Mucocutaneous disseminated or primary severe
   Mucocutaneous, recurrent (skin, oral, genital)
Herpes zoster (varicella zoster)
   Localized in immunocompromised patient or disseminated
   Localized in normal patient
Histoplasmosis
HIV (see human immunodeficiency virus)
Hookworm disease (ancyclostomiasis, uncinariasis)
Human immunodeficiency virus (HlV) infectioe
Impetigo
Infectious mononucleosis
Influenza
Kawasaki syndrome
Lassa fever
Legionnaires disease
Leprosy
Leptospirosis
Lice (pediculosis)
Listeriosis
Lyme disease
Lymphocytic choriomeninggitis
Lymphogranuloma venereum
Malaria
Marburg virus disease
Measles (rubeola) all presentations
Meliodiosis all forms
Meningitis
   Aseptic (non bacterial or viral meningitis) (also see enteroviral infections)
   Bacterial, gram-negative enteric in neonates
Fungal
   H. influenzea, known or suspected
   Listeria monocytogenes
   Neisseria meningitidis (meningococcal) known or suspected
   Pneumococcal
   Tuberculosis
   Other diagnosed bacterial
Meningococcal pneumonia
Meningococcal (meningococcal sepsis)
Molluscum contagiosum
Mucormycosis
Multidrug resistant organisms, infection or colonizatior?
   Gastrointestinal
   Respiratory
   Pneumococcal
   Skin, wound or burn
Mumps (infections parotitis)
Mycobacteria non tuberculosis (atypical)
   Pulmonary
   Wound
Mycopiasma pneumonia
Necrotizing enterocolitis
Nocardiosis draining lesions or ther presentations
Norwalk agent gastroenteritis (see viral gastroenteritis)
Orf
Parainfluenza virus infection, respiratory in infants and young children
Parvovlrus B 19
Pediculosis (lice)
Pertussis (whooping cough) '
Pinworm infection
Plague
   Bubonic
   Pneumonic
Pleurodynia (see enterovival infection)
Pneumonia
   Adenovirus
   Bacterial not listed elsewhere (including gram -negative bacterial)
   Burkholderia cepacia in patience with CF including respiratory tract colonization
   Clarrydia
   Fungal
   H. influenzae
   Adults
   Infants and children (any age)
Legionella
   Meningococcal
   Multidrug - resistant bacterial (see multidrug- resistant organisms)
   Mycoplasma (primary atypical pneumonia)
   Pneumococcal
   Multidrug- resistant (see multidrug -resistant organisms)
   Pneumocystis carinii
   Pseudomonas cepacia (see Burkholderia cepacia)
   Staphylococcus aureus
   Streptococcus, Group A
   Adults
   Infants and children
Viral
   Adults
   Infants and young children (see respiratory infectious disease, acute)
Poliomyelitis
Psittacosis (ornithosis)
Q fever
Rabies
Rat-bite fever (Streptopacillus moniliformis disease. Spirillum minus disease)
Relapsing fever
Resistant bacterial infection or colonization (see multidrug resistant organisms)
Respiratory infectious disease acute (if not covered elsewhere)
   Adults
   Infants and young childrenE
Respiratory Syncitial Virus infection in infants and young children and immunocompromisedadults

APPENDIX A.
Reye's syndrome
Rheumatic fever
Rickettsiai fever, tickborne (Rocky Mountain spotted fever, tickborne typhus fever)
Rickettsiaipm (vesicular rikeftsiosis)
Ringworm (dermatophytosis, dermatomycosis, tinea)
Ritter's disease (staphylococcal scalded skin syndrome)
Rocky Mountain spotted fever
Roseola infantum (exanthum subitum)
Rotavirus infection (see gastroenteritis)
Rubella German measles) (also see congenital rubella)
Salmonellosis (see gastroenteritis)
Scabies
Scalded skin syndrome, staphylococcai (Ritter's disease)
Schistosomiasis (bilharzias)
Shigellosis (seegastroenterihi)
Sporom'ckosis
Spirillium minus disease (rat-bite fever)
Staplylococcal disease (S aureus)
   Skin wound or burn
      Major
      Minor or limited
   Enterocolitis
   Endometritis (puerperal sepsis)
   Pharyngitis in infant and young children
   Pneumonia in infant and young children
   Scarlet fever in infant and young children
Streptococcal disease (group B Streptococcus) neonatal
Streptococcal disease (not group A or B) unless covered elsewhere
   Multidrug-resistant bacterial (see multidrug-resistant organisms)
Strongyloidiasis
Syphilis
   Skin and mucous membrane including congenital primary secondary
   Latent (tertiary) and seropositivity without lesions
Tapeworm disease
   Hymenolepis nana
   Taenia solium (pork)
   Other
Tetanus
Tinea (fungus infection dermatophytosis dermatomycosis ringworm)
Toxoplasmosis
Toxic shock syndrome (staphylococcal disease)
Trachoma acute
Trench mouth (Vincent angina)
Trichinosis
Trichomoniasis
Trichuriasis (whipworm disease)
Tuberculosis
   Extrapulmonary draining lesion (including scrofula)
   Extrapulmonary mengitis
   Pulmonary confirmed or suspected or laryngeal disease
   Skin-test positive with no evidence of cument pulmonary disease
Tularemia
   Draining lesion
   Pulmonary
Typhoid (Salmonella typhii) fever (see gastroenteritis)
Typhus endemic and epidemic
Urinary tract infection (including pyelonephritis) with or without urinary catheter
Varicella (chickenpox)
Vibrio parahaemolyticus (see gastroenteritis)
Vincent's angina (trench mouth)
Viral deceases
   Respiratory (if not covered elsewhere)
   Adults
   Infants and young children (see respiratory infectious disease acute)
Whooping cough (pertussis)
Wound infections
   Major
   Minor or limited
Yersinia ettrercolitica gastroenteritis (see gastroenteritis)
Zoster (varicella-zoster)
   Localized in immunocompromised patient, disseminated
   Localized in normal patient
Zygomycosis (phycomycosis mucormycosis)

   

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

Clinical Syndromes Or Conditions Warranting Additional Empiric Precautions To Prevent Transmission Or Epidemiologically Important Pathogens Pending Confirmation Of Diagnosis*
Clinical Syndrome or Condition** Potential Pathogens Empiric Precautions
Diarrhoea
Acute diarrhoea-like infections:
Contact cause in an incontinent or diapered patient
Enteric pathogens*** Contact
Diarrhoea in an adult with a history of recent antibiotic use Rash or exanthems, generally, etiology unknown Clostridium Droplet
Petechial or ecchymotic with fever Neisseria meningitidis Droplet
Vesicular Varicella Airborne and contact
Maculopapular with coryza and fever Measles Airborne

Respiratory infections
Cough/fever/upper lobe pulmonary infiltrate in an HIV-negative patient or a patient at low risk for HIV infection


Mycobacterium tuberculosis


Airborne
Cough/fever/pulmonary infiltrate in any lung location in an HIV-infected patient or a patient at high risk of HIV infection Mycobacterium tuberculosis Airborne
Paroxysmal or severe persistent cough during periods of pertussis activity Bordella pertussis Droplet
Particularly bronchiolitis and croup in infants and young children

Respiratory syncytial virus or parainfluenza virus Contact
Risk of multidrug-resistant micro-organisms
History of infection or colonisation with multidrug- resistant organisms
Resistant bacteria Contact
Skin and wound if urinary tract infection in a patient with a recent hospital or nursing home stay in a facility where multidrug-resistant organisms are prevalent. Resistant bacteria Contact
Skin and wound infection
Abscess or draining wound that can not be covered

Staphylococcus aureus, Group A streptococcus

Contact

* 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.
a See Table I for a complete list of infections requiring precautions, including appropriate footnotes.

b Certain infections require more than one type of precaution.

r See "Guidelines for Preventing the Transmission of Tuberculosis in Health-Care Facilities" available from the Department of Health.

1) Standard Precautions

Use Standard Precautions for the care of all patients.

2) Airborne Precautions

In addition to Standard Precautions, use Airborne Precautions for patients known or suspected to have serious illnesses transmitted by the airborne droplet nuclei. Examples of such illnesses include -

3) Droplet Precautions>/p>

In addition to Standard Precautions, use Droplet Precautions for patients known or uspected to have illnesses transmitted by large-particle droplet.

Examples of such illnesses include

Other serious bacterial respiratory infections spread by droplet transmission, including

Serious viral infections spread by droplet transmission, including

4) Contact Precautions

In addition to Standard Precautions, use Contact Precautions for patients known or suspected to have serious illnesses easily transmitted by direct contact or by contact with terms in the patient's environment. Examples of such illnesses include-

5) Formidable Epidemic Disease (FED) Precautions

In addition to Standard Precautions and Contact Precautions, use FED precautions for persons proven or suspected of having a viral haemorrhagic fever. Examples of such diseases are:

Annexure D : Bio Hazard Sign

Regulations 10(2)(f), 11(4)(b) and 14(b)]

The CHM file was converted to HTML by chm2web software.