Principles of Infection Control

and
Personal Protective Equipment

May, 2007
 Learning Objectives
• Demonstrate knowledge of the principles of
infection control

• Recognize gaps in infection control

infrastructure

• Recognize ways to address gaps in infection

control infrastructure in different situations

• Demonstrate proper selection and use of

personal protective equipment
 Session Overview
• Disease transmission

• Introduction to personal protective

equipment (PPE)
– How to use PPE
– Demonstration

• Infection control precautions

– In health care facilities
– In the community
Routes of Disease
Transmission
 Chain of Infection

+
Quantity of Virulence Route of Port Sensitive
pathogen transmission host
 Routes of Transmission

• Respiratory
– Cough
– Sneeze

• Fecal-oral
– Feces contaminate food, environment, or
hands

• Vector-borne
– Transmitted by insects
 Routes of Transmission
Contact
Examples:

Direct Contact Indirect Contact

• Host comes into • Disease is carried from
contact with reservoir reservoir to host

• Kissing, skin-to-skin • Contaminated surfaces

contact, sexual (fomites)
intercourse

• Contact with soil or

vegetation
 Routes of Transmission
Droplet
Large droplets within ~1 meter (3 feet)
transmit infection via:
– Coughing, sneezing, talking
– Medical procedures
Examples:
• Diphtheria
• Pertussis (Whooping Cough)
• Meningococcal meningitis
 Routes of Transmission
Airborne (droplet nuclei)
Very small particles of evaporated
droplets or dust with infectious agent
may…
– Remain in air for a long time
– Travel farther than droplets
– Become aerosolized during procedures
Examples:
• Tuberculosis
• Measles (Rubeola)
Transmission of Influenza Viruses
Seasonal Current Avian
Influenza in Influenza in Humans
Humans
Droplet most likely possible
route

Airborne possible at possible at close

close distances distances

Contact possible Most likely

(bird to human), and
possible (human to
human)
 Infection Control Methods
and
Personal Protective Equipment
 Hand Washing
Method
• Wet hands with clean (not hot)
water
• Apply soap
• Rub hands together for about
20 seconds
• Rinse with clean water
• Dry with disposable towel or
air dry
• Use towel to turn off faucet
 Alcohol-based Hand Rubs
• Effective if hands not visibly soiled
• More costly than soap & water
Method
• Apply appropriate (3ml) amount to
palms
• Rub hands together, covering all
surfaces until dry
 Personal Protective Equipment
(PPE)
• When used properly
can protect you
from exposure to
infectious agents

• Know what type of

PPE is necessary
for the duties you
perform and use it
correctly
 Types of PPE
• Gloves

• Gowns

• Masks

• Boots (for agricultural settings, not used for

human healthcare)

• Eye protection
 Types of PPE
Gloves
• Different kinds of gloves
– Housekeeper gloves
– Clean gloves
– Sterile glove

• Work from clean to dirty

• Avoid “touch contamination”

– Eyes, mouth, nose, surfaces

• Change gloves between patients

 Types of PPE
Gowns

• Fully cover torso

• Have long sleeves

• Fit snuggly at the wrist

 Types of PPE
Masks and Respirators: Barriers and Filtration
• Surgical masks
– Cotton, paper
– Protect against body fluids and large
particles

• Particulate respirators (N95)

– Fit testing essential
– Protect against small droplets and
other airborne particles

• Alternative materials (barrier)

– Tissues, cloth
 Types of PPE
Particulate Respirators
• Three types: disposable, reusable, powered
air purifying respirators

• Disposable Particulate Respirators

– Classified N95, N99, N100, R95, R99, R100, P95,
P99, P100
– Letter indicates oil resistance: N = not resistant, R
= somewhat resistant, P = strongly resistant
– Number is percent of airborne particles filtered
(e.g. N95 filters 95% of particles)
 Types of PPE
Boots
(non-hospital settings) Eye Protection
– Face shields
– Goggles
 PPE Supplies
• Maintain adequate, accessible supplies

• Creative alternatives (studies not done to

asses effectiveness)
– Mask: tissue, scarf
– Gown: laboratory coat, scrubs
Working with Limited Resources
• Avoid reuse of disposable PPE items
– Consider reuse of some disposable items
only as an urgent, temporary solution
– Reuse only if no obvious soiling or
damage

• When prioritizing PPE purchase

– Masks
– Gloves
– Eye protection
Infection Control Precautions
 Precaution Levels
All levels require hand hygiene

• Standard

Transmission based precautions:

• Contact
• Droplet
• Airborne
 Standard Precautions

• Prevent the transmission of

common infectious agents

• Hand washing key

• Assume infectious agent could

be present in the patient’s
– Blood
– Body fluids, secretions, excretions
– Non-intact skin
– Mucous membranes
PPE for Standard Precautions
Wear: If:
• Gloves • Touching
– Respiratory secretions
– Contaminated items or surfaces
– Blood & body fluids
• Gowns
• Soiling clothes with patient body
fluids, secretions, or excretions

• Eye • Procedures are likely to generate

Protection splashes / sprays of blood, body
and / or Mask fluids, secretions, excretions
 Contact Precautions

Taken in addition to Standard Precautions

• Limit patient movement

• Isolate or cohort patients

• Gown + gloves for patient / room contact

– Remove immediately after contact

• Do not touch eyes, nose, mouth with hands

• Avoid contaminating environmental surfaces

 Contact Precautions

• Wash hands immediately after patient

contact

• Use dedicated equipment if possible

– If not, clean and disinfect between uses

• Clean, then disinfect patient room daily

– Bed rails
– Bedside tables
– Lavatory surfaces
– Blood pressure cuff, equipment surfaces
 Cleaning and Disinfection for
Contact Precautions
• Detergents
– Remove dirt, soiling
– Mechanical force essential
– Flush with clean water

• Disinfectants
– Kill viruses, bacteria
– Decontaminate surfaces
– Type depends on infectious agent
– Use after detergent
 Droplet Precautions
• Prevent infection by
large droplets from
– Sneezing
– Coughing
– Talking

• Examples
– Neisseria meningitidis
– Pertussis
– Seasonal influenza
 Droplet Precautions
Taken in addition to Standard Precautions

• Place patients in single rooms or cohort 3 feet apart

• Wear surgical mask within 3 feet or 1 meter of patient

• Wear face shield or goggles within 3 feet or 1 meter of

patient

• Limit patient movement within facility

– Patient wears mask when outside of room
 Airborne Precautions
Taken in addition to Standard Precautions

• Prevent spread of infection through inhalable

airborne particles

• Examples
– Tuberculosis
– Measles
– Varicella
– Variola
 Airborne Precautions
• Use for confirmed or suspected avian
influenza cases
 Airborne Precautions for Avian
Influenza
• N95 respirator (or equivalent) for personnel
– Check seal with each use

• Patient in isolation

• Airborne isolation room, if available

– Air exhaust to outside or re-circulated with HEPA
filtration

• Patient to wear a surgical mask if outside of

the isolation room
Negative Pressure Isolation Room
Natural Ventilation
Cohorting Room

1 meter
 Aerosol-generating Procedures
(Example; Endotracheal intubation)

• N95 particulate respirator

– If not available, wear tight fitting surgical mask
and face shield
• Eye protection
• Gloves and hand washing
• Gown and waterproof apron
• Isolation room with negative pressure, if
available
• Hair cover optional
Choosing the Appropriate
PPE
 Avian Influenza
• Currently not easily transmitted human
to human
• Routes of transmission to humans not
known, cannot rule-out any routes
• Current transmission from poultry to
human or human to human for H5N1
requires very close contact
 Interviewing - Asymptomatic
Exposed Persons and Contacts
• Low-risk activity

• Routine use of PPE not recommended

• Maintain 3 feet distance between interviewer

and interviewee

• Use proper hand hygiene

– May use hand sanitizer (at least 60% alcohol) if
hands not visibly soiled
 Interviewing - Symptomatic
Exposed Persons
• Higher risk activity

• PPE recommended in community and

healthcare facility
– Contact precautions
– Droplet precautions
– N95 respirator

• In healthcare facility, person should be

placed in airborne isolation room

• Maintain a distance > 3 feet if possible

Specimen Collection – Exposed
Persons and Birds
• High-risk aerosol-generating procedure

• PPE recommended
– Gloves
– Gown
– Goggles or face-shield
– N95 or better respirator
 Avian Influenza
Infection Control in
Health Care Facilities
 Influenza Transmission
Effective Infection Control
Prevents Transmission From
...

• Patients to health care

workers

• Patients to patients

• Patients to family members

providing care
Avian Influenza Precautions

Standard precautions

Droplet precautions

Airborne Precautions
 Precautions for Suspected or
Confirmed Cases of Influenza A
(H5N1)
• Place patient in a negative air pressure room

• To create a negative air pressure room:

– Install exhaust fan and direct air from inside to an
outside area where no people are located

• Place patients in rooms alone

– Alternative: cohort patients away from other
patient care areas with beds > 3 feet apart
– Avoid placement in rooms with stagnant
air and poor airflow/ventilation
 Precautions for Suspected or
Confirmed Cases of Influenza A
(H5N1)
• Limit number of health care workers, family
members and visitors

• Designate experienced staff to provide care

• Limit designated staff to avian influenza

patient care

• Teach family and visitors to use PPE

 Precautions for Suspected or
Confirmed Cases of Influenza A
(H5N1)
• Keep isolated from others as much as possible until:
– At least 7 days after symptom onset AND
– At least 48 hours after fever has subsided without taking fever-
reducing medicines

(Whichever is longer)

• Depending on the specific circumstances suspect or

confirmed cases that have completed isolation for at
least 7 days,and who are no longer symptomatic, may
not be considered a source of exposure to others.
 Precautions for Collecting
Specimens
• Notify laboratory in advance

• Health care worker collecting specimen

should wear full barrier PPE

• Place specimen in leak-proof bag

• Hand deliver, if possible

• Label specimen clearly as “suspected avian

influenza”
Precautions for Suspected or Confirmed Cases
Patient Infection Control Precaution

Acute influenza symptom + Surgical mask for patient, use

travel to AI country in 10 respiratory hygiene
days
Isolation room, use of PPE
Test for influenza A/H5
Apply all infection control precautions

Confirmed Influenza A/H5 Different Re-evaluate

diagnosis the precaution
measures
Maintain required infection control
precautions

Adults and adolescents > 12 years: Continue for 10 days after resolution of
fever unless case is ruled-out through confirmatory laboratory methods
Environmental Decontamination

• Cleaning MUST precede decontamination

• Disinfectant ineffective if organic matter is

present

• Use mechanical force

– Scrubbing
– Brushing
– Flush with water
Environmental Decontamination:
Disinfecting
• Household bleach • Peroxygen compounds
(diluted)
• Phenolic disinfectants
• Quaternary ammonia
compounds • Germicides with a
tuberculocidal claim on
• Chlorine compounds label
(Chloramin B, Presept)
• Others
• Alcohol
– Isopropyl 70% or
ethyl alcohol 60%
 Using Bleach Solutions
• First clean organic material from
surfaces or items

• Wipe nonporous surfaces with sponge

or wet cloth
– Allow to dry

• Use fresh diluted bleach daily!

 Waste Disposal
• Use Standard Precautions
– Gloves and hand washing
– Gown + Eye protection

• Avoid aerosolization

• Prevent spills and leaks

– Double bag if outside of bag is contaminated

• Incineration is usually the preferred method

 Managing Linens and Laundry
• Use Standard Precautions
– Gloves and hand hygiene
– Gown
– Mask

• Avoid aerosolization – do not shake

• Fold or roll heavily soiled laundry

– Remove large amounts of solid waste first

• Place soiled laundry into bag in patient room

• Wash with normal detergent

Avian Influenza Infection
Control in the Community
Preventing Transmission
in the Community

• Respiratory
etiquette
– Cover nose / mouth
when coughing or
sneezing

• Hand washing!
 Avian Influenza and Food
• Heat poultry meat to > 70°C to kill the avian influenza
virus

• Consumption of any raw / undercooked poultry

ingredients is risky
– Runny eggs
– Meat with red juice
– Uncooked duck blood

• Separate raw meat from cooked or ready-to-eat foods

to avoid cross-contamination

• Wash hands before and after preparing food

 Patients Cared for at Home
• Potential for transmission

• Must educate family caregivers

• Fever / symptom monitoring

• Infection control measures

– Hand washing
– Use of available material as PPE
 Patients Cared for at Home

• Handle laundry with gloves; do not shake to

prevent aerosolization

• Use disposable or dedicated dishes, utensils

• Decontaminate the home environment

– Frequent cleaning before disinfection
 Autopsy Precautions for
Influenza A (H5N1)

• Follow normal PPE procedures for

autopsies

• Anyone handling a corpse should follow

standard precautions for blood and body
fluids
Application of Infection Control
Activities during an
Investigation
 Location Influences Actions

• Medical facilities

• Homes

• Farms

• Markets

• Rural versus Urban areas

 Anticipate Exposures
Contact with. . .
• Infected individuals
• Individuals suspected to be infected
• Potentially contaminated substances
• Potentially contaminated surfaces /
items
• High-risk procedures
• Animals
 Assess Existing Infection
Control Infrastructure
• Policies and procedures

• Authority

• Human resources

• Financial resources

• Engineering resources
 Assess Existing Infection
Control Infrastructure
• Do policies describe PPE for health care
workers?

• Are procedures in place for patient room

cleaning?

• Are there negative air pressure rooms?

• Will you need to promote respiratory and

hand hygiene in the community?
 Assessing Infection Control
Needs During an Investigation
 Overview

• Components of infection control

infrastructure

• Infection control in healthcare facilities

• Infection control in the community

 Components of
Infection Control Infrastructure

• Policies • Human resources

• Procedures • Financial resources

• Authority
• Engineering
resources
 Assessing
Infection Control Infrastructure

Example: cleaning patient rooms

• Policies
– When to clean, what to clean

• Procedures
– Cleaning products, order of surfaces to clean

• Authority
– Enforcing policies and procedures
 Assessing
Infection Control Infrastructure
Example: Cleaning patient rooms (continued)

• Human resources
– Staff to clean rooms

• Financial resources
– Money to buy cleaning products

• Engineering resources
– Cleaning equipment
– Hand hygiene facility (sink)
 Sustainability

• Evaluate infection control knowledge

• Evaluate infection control procedures

• Develop a sustainable program

• Encourage routine practice

• Build local capacity

 Sustainability Example
• Hospital outside a large city

• Has basic infection control program

• You notice healthcare personnel

– Recapping needles
– Not wearing eye protection when doing invasive
procedures

• Help staff develop appropriate policies and

procedures
 Authority
• Communication with various
administrative levels

• Policies may already exist

– National
– Regional
– Local

• Adapt to the facility you are working in

 How to Put on and Remove
Personal Protective Equipment
 Sequence for Donning PPE

1. Hand hygiene
2. Gown
3. N95 Particulate respirator
– Perform seal check

4. Hair cover
5. Goggles or face shield
6. Gloves
 Gown
• Select appropriate type and size

• Opening may be in back or front

• Secure at neck and waist

• If too small, use two gowns

– Gown #1 ties in front
– Gown #2 ties in back
 Surgical Mask

• Place over nose, mouth and chin

• Fit flexible nose piece over nose bridge
• Secure on head with ties or elastic
• Adjust to fit
 N95 Particulate Respirator
• Pay attention to size (S, M, L)
• Place over nose, mouth and chin
• Fit flexible nose piece over nose bridge
• Secure on head with elastic
• Adjust to fit and check for fit:
Inhale – respirator should collapse
Exhale – check for leakage around face
 Eye and Face Protection
• Limited human to human
transmission of H5N1 has
occurred to date

• Position goggles over eyes and

secure to the head using the ear
pieces or headband

• Position face shield over face and

secure on brow with headband

• Adjust to fit comfortably

 Gloves

• Don gloves last

• Select correct type and size

• Insert hands into gloves

• Extend gloves over gown cuffs

 Key Infection Control Points

• Minimize exposures
– Plan before entering room

• Avoid adjusting PPE after patient contact

– Do not touch eyes, nose or mouth!

• Avoid spreading infection

– Limit surfaces and items touched

• Change torn gloves

– Wash hands before donning new gloves
 Duration of PPE Use

Surgical Masks (if N95 not available)

– Wear once and discard
– Discard if moist

N95 Particulate Respirators

– May use just one with cohorted patients

Eye Protection
– May wash, disinfect, reuse
 Sequence for Removing PPE

Remove in anteroom when possible

1. Gloves
2. Hand hygiene
3. Gown (and apron, if worn)
4. Goggles
5. Mask
6. Cap (if worn)
7. Hand hygiene
Removing Gloves (1)

• Grasp outside edge near wrist

• Peel away from hand, turning

glove inside-out

• Hold in opposite gloved hand

Removing Gloves (2)

• Slide ungloved finger

under the wrist of the
remaining glove

• Peel off from inside,

creating a bag for both
gloves

• Discard
 Removing A Gown
1. Unfasten ties
2. Peel gown away from neck and shoulder

3. Turn contaminated outside toward the inside

4. Fold or roll into a bundle
5. Discard
Removing Goggles or
A Face Shield
• Grasp ear or head
pieces with ungloved
hands

• Lift away from face

• Place in designated
receptacle for
disinfecting or
disposal
 Removing a Mask
• Lift the bottom elastic
over your head first

• Then lift off the top

elastic

• Discard

• Don’t touch front of

mask
 If You MUST Reuse PPE..
• Use during one shift and for one patient
• Discard at the end of each shift

GOWN
• Hang gown with outside facing in

MASK OR RESPIRATORS
• Put the mask into the sealable bag
• May touch the front of the mask, but wash
hands immediately after removing
 Hand Washing

• Between PPE item removal, if hands

become visibly contaminated

• Immediately after removing all PPE

• Use soap and water or an alcohol-

based hand rub
 Summary
• Influenza transmission occurs mainly through
respiratory droplets
– Contact can be prevented using PPE
– Virus can be inactivated with infection control procedures
– Hand washing is key

• PPE must be donned and removed appropriately to

prevent contamination of wearers and environments

• Guidelines for using PPE and infection control

measures for avian influenza in humans should be
practiced until they are routine
 Glossary
Decontamination - The removal of harmful substances
such as chemicals, harmful bacteria, or other
organisms, from exposed individuals, rooms, and
furnishings in buildings or in the outside
environment.

Disease transmission - The process of the spread of a

disease agent through a population

Infection control - Measures practiced by health care

personnel in health care facilities to prevent the
spread of infectious agents

Personal protective equipment - Specialized clothing or

equipment worn by a worker for protect from a
hazard
 References and Resources
• Avian influenza, including influenza A (H5N1), in humans: WHO
interim infection control guideline for health care facilities
Revised 24 April 2006.
[Link]
ontrol1/en/[Link]

• Practical Guidelines for Infection Control in Health Care Facilities.

SEARO Regional Publication No. 41; WPRO Regional Publication.
2004.
[Link]
sunami_infection-[Link]

• US Centers for Disease Control and Prevention. “Cover Your

Cough” [Link]

• Elizabeth A. Bolyard, et al. Centers for Disease Control and

Prevention. Guideline for infection control in health care personnel,
1998.
[Link]