SARS Infection Control in Healthcare Settings William A. Rutala, Ph.D., M.P.H. University of North Carolina (UNC) Hospitals and UNC School of Medicine
Infection Control Considerations Hospitals must protect vulnerable patients, staff, visitors, and prevent spread to the community Until SARS epidemiology is better understood, infection control measures must target all possible modes of transmission Interim recommendations that will be periodically updated
The principles are the same.methods of implementation may differ
Key Objectives of SARS Prevention Early detection of infection Containment of infection Protection of personnel and the environment of care Hand hygiene
Key Elements of SARS Prevention Early detection Containment of infected persons Protection of personnel and the environment of care Hand hygiene
Clinician education Early Detection Information on signs and symptoms of SARS Heightened index of suspicion in patients with history of travel or exposure to SARS areas or patients Isolation precautions that should be used SARS inservices
Early Detection Information at point of first healthcare encounter (ER, information desk, ACC, Pre-Care, Family Practice, community-based clinics) Visual alerts Reporting instructions Provision of surgical masks for patients Segregation of symptomatic patients
Early Detection Information at point of first healthcare encounter (ER, information desk, ACC, Pre-Care, Family Practice, community-based clinics) Visual alerts Reporting instructions (notify Infection Control) Provision of surgical masks for patients at point of first patient contact (or provide mask to patient before enter into hospital) Segregation of symptomatic patients (private rooms) Patients with suspected SARS admitted only if medically indicated Contact and Airborne Precautions should be immediately instituted
Key Elements of SARS Prevention Early detection Containment of infection Protection of personnel and the environment of care Hand hygiene
Containment of Infection with Engineering Controls Preferred-Airborne Isolation Room Private room with engineered negative pressure, 6-12 AC/hr, and air exhausted to outside Door closed except when needed for patient/staff access Limit access to persons essential for providing care
Limited Patient Contact Visitors of patients with suspected SARS should be restricted (essential family members) and screened Visitors should be excluded from the hospital if any of the following are present: Fever and respiratory symptoms; Travel to a locale with local transmission in previous 10 days; Exposure to the probable SARS case while he/she symptomatic within prior 10 days Dedicate staff to care for SARS patient
Key Elements of SARS Prevention Early detection Containment of infected persons Protection of personnel and the environment of care Hand hygiene
Most likely Droplet Contact Possible Consider all Possible Transmission Routes Direct (contamination of skin) Indirect (contaminated fomites) Airborne
Containment of Infection Contact Precautions Private rooms, gloves, gowns Airborne Precautions Private room, negative pressure, air exhausted to outside, >6 AC/hr) Personnel should wear N95 and eye protection (face shield or goggles) Gloves and gown removed just prior to exiting the room. Immediately outside the room remove and discard N95 respirator and remove goggles or face shield. Immediately perform hand hygiene for 15 sec with CHG or application of alcohol hand rub. Wipe goggles with alcohol pad and again perform hand hygiene.
Personal Protective Attire Respiratory protection N95 mask preferred Perform qualitative respirator fit-testing where applicable Surgical mask if not available Apply mask when entering room or ward Ensure snug fit over nose and mouth Eye protection Goggles or face shield as recommended for standard precautions
Effectiveness of Precautions Study Design: case-control study in 5 Hong Kong hospitals Staff (241 non-infected, 13 infected) surveyed about use of mask, gloves, gowns, and handwashing Results: 69 staff who reported all four measures were not infected; all infected staff omitted at least one measure. Fewer staff who wore masks (N95 and surgical masks), gowns, and washed their hands became infected compared to those who did not. Conclusion: practice of Contact and Droplet Precautions is effective in reducing risk of infection after exposure. WH Seto et al. Lancet 2003;361:1519-1520
Stability of SARS Coronavirus Virus is stable in feces and urine at RT for at least 1-2 d Virus survival in cell-culture supernatant Minimal reduction in virus conc after 21 days at 4 o C and 80 o C 1 log reduction at RT for 2 days Heat (56 o C) kills SARS coronavirus Virus loses infectivity after exposure (<5 min) to 2% phenol, 75% ethanol, 1:10 Clorox WHO Laboratory Network. May 2003.
Protect the Environment of Care Use hospital-grade disinfectants or 1:100 dilution of household bleach (5.25% - 6.0%) and water for surface cleaning and disinfection Assume environment in which SARS patients are housed is heavily contaminated Facilitate daily cleaning by limiting clutter in patient care area Thoroughly clean and disinfect room and equipment after patient discharge No need to routinely disinfect walls, window drapes
Disinfectants Effective Against Human Coronavirus Efficacy criteria of >3 log 10 reduction after 1 min 1000 and 5000 ppm chlorine (1:50 and 1:10 dilution of bleach) Povidone iodine (1% iodine) Ethanol (70%) Glutaraldehyde (2%) Phenolics Sattar SA et al. Epidem Inf 1989: 102:493-505
Key Elements of SARS Prevention Early detection Containment of infected persons Protection of personnel and the environment of care Hand hygiene
Hand Hygiene Hand hygiene is the cornerstone of prevention!!! Perform hand hygiene following all contact with suspect SARS patients and their environment Methods Hand washing with soap and water or CHG and water Alcohol-based handrubs when Hands are not visibly soiled, or Hand washing facilities are not available in patient rooms
Protect the Environment of Care Follow standard procedures or regulations for handling contaminated (infectious) materials Soiled linen/laundry Usual warm water and detergent wash cycles Bleach may be added but is not needed Avoid sorting of linen before washing Waste Dispose in accordance with local regulations for infectious waste Eating utensils Use standard warm water dishwashing methods
Other considerations Avoid use of nebulizers when possible If needed, perform nebulization in protected, negative pressure environment Limit procedures that generate aerosols Limit patient movement If transport required for patient care, place surgical mask on patient Place clean attire on patient or cover with gown Transporters should wear N95, gloves, gowns, eye protection
Management of Exposures Exposed HCW who develops fever and/or respiratory symptoms should not report to work. Should report their symptoms to the appropriate health care provider Exposed unprotected HCW who are asymptomatic must be evaluated prior to work each day by OHS. Exclude close contacts with SARS cases who have fever or respiratory symptoms
SARS Resources http://www.cdc.gov/ncidod/sars/ http://www.who.int/csr/sars/en/ Chiarello, Linda. SARS Infection Control. CDC
Prevention is Primary!
Key Objectives of SARS Prevention Early detection of infection Containment of infection Protection of personnel and the environment of care Hand hygiene
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