6 Infection Prevention and Control in EVD
Introduction Effective IPC is central to providing quality care for patients, a safe working environment and for EVD control Any person working in or entering a healthcare facility is at risk of transmitting infection or being infected So IPC is everybody s business Healthcare-associated infection is a potentially preventable adverse event rather than an unpredictable complication Effective IPC can significantly reduce the rate of Healthcare Acquired Infections
Methods of reducing spread of infection Standard precautions: Practices applied to all cases, regardless of their perceived or confirmed infectious status to ensure a basic level of IPC First-line approach to IPC to minimise risk of transmission of infectious agents from person to person, even in high-risk situations Transmission-based precautions: Additional practices for specific situations where standard precautions are not sufficient to interrupt transmission These are tailored to: Infectious agent Mode of transmission
Precautions for Ebola Standard precautions + Additional transmission based precautions [Contact precautions & Droplet precautions]
Standard precautions At all times, for all patients Hand washing before & after any direct patient contact Use of PPE: gloves, mask, gown Routine cleaning of frequently touched surfaces Prompt and careful cleaning up of spills of body fluids Safe handling and disposal of needles & other sharps Safe systems for waste segregation & disposal Disinfection, sterilisation of patient care equipment, linen contaminated with infective material
Hand Hygiene Cornerstone to infection control Single most effective method to prevent the spread of many communicable diseases Includes Hand washing: use of plain soap & water to mechanically remove bacteria, viruses and debris Hand antisepsis: use of antimicrobial soap & water, or waterless hand gel to kill bacteria and viruses on hands 6
Additional Precautions: Contact Health worker: Use of PPE Gloves : non-sterile, clean, disposable gloves Gowns: Appropriately-sized disposable or reusable gown which is worn once before disposal or laundering Apron Patient: Use disposable equipment or dedicated reusable equipment for each patient (clean and disinfect between each patient use). Single room or cohorting of patients (+ves in one room) Limit patient movement and minimize contact with other non-infected persons
Additional Precautions: Droplet Health worker: Use of PPE Medical-surgical/N95 mask when within 1 metre (3 feet) of patient Wear face shield or goggles Patient Place patients in single room If not possible, cohort patients with same suspected etiology in same room If not possible, place patient beds at least 1 m apart and arranged to keep a distance between patients. Limit patient movement out of the hospital room Have patient use a medical-surgical mask when outside the hospital room
Who should Wear PPE? All doctors, nurses, and health workers who provide direct patient care All support staff: cleaners, handle contaminated supplies and equipment, laundry and dispose of infectious waste All laboratory staff Laboratory support staff Burial teams Family members who care for EVD patients
PPE
Tips for Safe Use of PPE? Ensure you have everything before starting a task Ensure that no mucosal surface is exposed Check PPE is correctly put on (mirror / observer) Avoid self contamination while using the PPE Do not touch face, mask, eye wear etc Avoid self contamination on removal of the PPE Remember where could be contaminated Avoid contamination of others Avoid contamination of the environment Dispose of PPE immediately and safely Help each other while wearing or removing PPE
Remember! Isolation of patients with strict PPE will not protect against all person-to-person transmission to health workers if basic standard precautions are not in place at all times in the outpatient clinic and general wards. This is where patients first present
Injection Safety and Management of Sharps Use care when handling, using, cleaning & disposing of needles, scalpels & other sharps Do not bend, break, or manipulate used needles, scalpels, or other sharp instruments Do not recap needles Have a sharps container nearby when giving injections Discard needles and syringes immediately after use without passing to another person Close, seal & send sharps containers for incineration before they are completely full
Environmental Cleaning Clean & disinfect surfaces or objects contaminated with body fluids, secretions or excretions ASAP Application of disinfectants should be preceded by cleaning to prevent inactivation of disinfectants by organic matter If locally prepared, prepare cleaning and disinfectant solutions daily Clean floors & work surfaces at least once a day with clean water and detergent. Moistened cloth helps to avoid contaminating the air and other surfaces with air-borne particles
Environmental Cleaning Allow surfaces to dry naturally before using them again Dry sweeping with a broom should NEVER BE DONE Rags holding dust should not be shaken out and surfaces should not be cleaned with dry rags Clean from clean areas to dirty areas, in order to avoid contaminant transfer DO NOT spray (i.e. fog) occupied or unoccupied clinical areas with disinfectant. This is potentially dangerous & has no proven disease control benefit
Linen Management Washing contaminated linen by hand is discouraged If washing machines are not available, soak linen in large container of hot soapy water and ensure it is totally covered with water Use a stick to stir Throw out water and refill drum with clean water and add chlorine 1% and allow to soak for 15 minutes Rinse in clean water, remove excess water & spread out to dry. Avoid splashing as much as possible If safe cleaning and disinfection of heavily soiled linen is not possible then burn to avoid unnecessary risks to the handlers
Disinfection with Chlorine Concentration Activity 1% Disinfection of heavily soiled linen 0.5% Disinfection of body fluids Disinfection of corpses Disinfection of toilets and bathrooms Disinfection of gloved hands Disinfection of floors Disinfection of beds and mattress covers Footbaths 0.05% Disinfection of Bare hands and skin Disinfection of medical equipment Disinfection of laundry Disinfection of eating utensils
How to make chlorine solutions for environmental disinfection
For disinfection, remember! Always dilute disinfectants according to manufacturers instructions Add chlorine compounds to water not the other way round Change in-use solution every 24hrs Disinfectants do not sterilise. Cannot be used for surgical instruments. Use gloves when mixing chlorine
Waste Management 1 Waste should be segregated at point of generation Collect all solid, non-sharp, infectious waste using leakproof waste bags & covered bins. Bins should never be carried against the body (e.g. on the shoulder). Waste should be placed in a designated pit of appropriate depth: 2 meters and filled to a depth of 1 1.5 m. After each waste load, the waste should be covered with a layer of soil 10 15 cm deep
Waste Management 2 An incinerator may be used for short periods to destroy solid waste It is essential to ensure total incineration has taken place Placenta and anatomical samples should be buried in separate pit Control area for final treatment & disposal to prevent entry by animals, untrained personnel or children Waste: faeces, urine, vomit and liquid waste from washing, can be disposed of in sanitary sewer or pit latrine. No further treatment is necessary.
Safe Burial Practices
Local Burial Beliefs, Habits and Practices 1 All people have their own behavior related to death Certain practices and rituals can introduce enormous risks for people involved Corpses and body fluids are highly infectious There is need for burial teams The burial team members must be: Well trained and supervised Able to provide information and education to communities Able to withstand pressure from family members and local community to change procedures that could result in unsafe practices
Local Burial Beliefs, Habits and Practices 2 Try to conform to the local burial customs while observing effective public health practices and respect for local laws Reassure community that necessary public health practices are observed with the aim to protect the whole community from further spreading of the disease
Burial Procedures 1 To limit risk, the ideal would be to bury: Immediately after the patient has died Closest possible to the isolation unit Without family members intervening With a specialized, full time burial team Due to family wishes, logistical problems and local community fears and resentments, it will often be difficult to follow ideal procedure Compromises will be made, but must never result in risky practice whatever pressure from family or community
Burial Procedures 2 Grave must be at least 2 meters deep, the bottom must be at least 1.5 meter above ground water Graves must be marked with person s name & date of death Grave site should be ideally situated in a location with limited access An existing graveyard can be used if separate area has been identified It is unclear how long a body remains infectious after being buried, and thus must be in a area that is unlikely to be disturbed
Burial Procedures Roles Role of health staff Health staff should be present during the entire burial process and supervise/assist in handling the body to minimize risk of infection of persons present during the burial rites Burial team The burial team will receive similar training with regard to use of protective clothing
7 Isolation and Referral of EVD cases
Screening at Treatment Center Most patients are referred to the treatment center from community healthcare facilities through the alert system Some patients will show up at the treatment center by their own A screening area should be set up at the treatment center to evaluate suspected cases along the same lines as in healthcare facilities in communities
Features of Treatment Centre Suitable site/location: Water, electricity, sewage, waste disposal, away from build-up areas or populated areas Patient flow arrangement within the isolation unit Orientation of staff working at isolation unit Changing rooms for medical staff Availability of supplies for changing rooms e.g. PPEs Availability and proper storage of supplies for patient care Plan and orient staff on management of waste Plan for safe burial practices
Screening Area at Treatment Center Screening Area C l e a n i n g A r e a W a t e r R e s e r v e s Hand Washing Station ZONE PPE S u s p e c t C a s e s C o n f i r m e d C a s e s Zone without PPE (Only Scrubs with BOOTS) Entrance ambulance, visiting family members Entrance Staff H a z a r d o u s W a s t e M g n t C o r p s e p r e p a r a t i o n Removal of PPE Medical Staff PPE Changing Room ZONE WITHOUT PPE Changing Area (Scrubs) Mobile LAB Toilet IPC Staff Pharmacy storage of material
Precautions during Screening Use masks and gloves Respect 1-2 m distance with patient at all time Position patient properly during interview Insert thermometer from the patient back Use the local case definition Do not perform physical exam If the patient fulfills the case definition: Educate the patient on what is happening and reason for isolation Transfer patient to the suspect case area where he will be seen by the clinical team (physical exam, EVD testing, malaria RDT) Encourage ORS Clean surface and chair between patients
Patient Placement If isolation rooms are unavailable: Cohort these patients in specific confined areas while rigorously keeping suspected and confirmed cases separate Ensure the items listed here for isolation rooms are readily available Make sure that there is at least 1 meter (3 feet) distance between patient beds
Staff Allocation Ensure that clinical and non-clinical personnel are assigned exclusively to HF patient care areas Ensure that members of staff do not move freely between the HF isolation areas and other clinical areas during the outbreak. Restrict all non-essential staff from HF patient care areas
Visitors Stopping visitor access to the patient is preferred If this is not possible, limit their number to include only those necessary for the patient s well-being and care, such as a child s parent Do not allow other visitors to enter the isolation rooms/areas Ensure that any visitors wishing to observe the patient do so from an adequate distance (approximately 15 m or 50 feet). Before allowing visitors to HF patients to enter the facility, screen them for signs and symptoms of haemorrhagic fever
Plan Disinfection for Contaminated Items Disinfectants: ensure availability of disinfectants/bleach solution Soap and clean water: Disinfect before washing and sterilisation for reusable equipment or linen. Sterilization: Heat sterilisation requires special equipment, such as autoclave or steam sterilizer Where not available boiling for 20 minutes will kill VHF viruses
Plan for Supplies and Security Supplies. Gather supplies for the patient area Gather supplies for the Changing Room Arrange for storing of supplies outside the Changing Room Security around Isolation. Restrict general public access to the isolation area Place signs around the isolation area stating that access is restricted
Kenema Treatment Centre, Sierra Leone Entrance for Ambulance View from outside Screening Area Cleaning area and water storage
Gueckedou Treatment Center, Guinea View of the tents with confirmed cases and area for safe removal of PPE Entrance for staff Medic
Referral and transport of Ebola suspected Patients
Reaching decision on transfer of patients Indications for transfer of patients Meeting case definition (as agreed) The need for more sophisticated medical care To achieve greater security in isolation and barrier nursing The needs of the patient must be balanced against the availability of facilities The existence of a conveniently located facility which has been specifically designated and equipped The official at a primary H/Facility who is seeking transfer of a patient should contact by telephone the referral H/Facility
Local transport of VHF patients Before the possibility of diagnosis of Ebola is recognized, patients are usually transported to hospital without special precautions If a VHF is suspected, it becomes necessary to use a trained VHF transport team
Immediately VHF is suspected: The primary hospital should review the case in committee and decide reasons for/against referral Simultaneously, place the patient in preliminary isolation and apply the basic principles of barriernursing until further decisions are made Arrange transfer of the patient in consultation with the County Health Director and the relevant clinical staff at the secondary hospital concerned
Immediately the decision to transfer a patient has been reached: Provide information to family explaining reason for referral It should be known or made known to all members of the County and sub-committee All subordinate and superior officers in the secondary hospital must be informed The secondary hospital officials and staff should take all necessary actions to prepare the receiving of the transferred patient Spray room where patient was staying and advise family to burn clothes and bedclothes used by patient
Planning the transportation Select ground route which is the shortest in distance, that is safe, smooth and provides the fewest risks to local population Local authorities may be involved in the planning Protect attendants (s) and driver The attendants should wear full PPE The driver need not have any protective clothing as long as he does not have any contact with the patient So driver should wear a mask and gloves Ambulance team (ideal): 2 people that handle the stretcher with patient, 1 nurse, 1 spray man who carries out the disinfection, and 1 driver of the car
Decontamination of the vehicle Person conducting the decontamination should wear protective clothing Use the liquid disinfectant for the decontamination Decontaminate removed temporary plastics covers Spray or pour disinfectant over the surface of the interior parts of the vehicle Rinse surfaces with copious quantities of clean water