infection prevention and control (ipc) update | key measures for prevention and control of ebola...

Infection prevention and

control (IPC) update

B. Allegranzi, SDS, HIS

on behalf of the Ebola IPC team

2 | Key Measures for Prevention and Control of Ebola Virus Disease

WHO updates on PPE, procedures for PPE putting on

and removal, hand hygiene, environmental cleaning in

Ebola facilities

Results and lessons learned from a WHO project on

IPC assessments and quality improvement in Ebola

facilities

Suggestions for transitioning the FMTs expertise in IPC

to other functions and activities in the context of

recovery

Outline

WHO Interim IPC guidance for EVD Interim

Infection Prevention and Control

Guidance for Care of Patients with

Suspected or Confirmed Filovirus

Haemorrhagic Fever

in Health-Care Settings,

with Focus on Ebola

December 2014

http://who.int/csr/resources/publications/ebola

/infection-prevention/en/

http://who.int/csr/resources/publications/ebola/infection-prevention/en/




New WHO Guidelines on Personal

Protective Equipment (PPE) Guideline development process

Development of key research

questions

Systematic literature reviews

Literature review and an online

survey on values and

preferences of health workers

Evidence-to-recommendations

exercise using the GRADE

framework

Expert consultation

WHO Guideline Review

Committee

Issued on

31 October 2014

What are the benefits and harms of double

gloves, full face protection, head cover,

impermeable coveralls, particulate respirators,

and rubber boots as PPE when compared with

alternative less robust PPE for HCWs caring for

patients with filovirus disease?

http://who.int/csr/resources/publications/

ebola/infection-prevention/en/





New WHO Guidelines on Hand Hygiene

In Health Care in the Context of Filovirus

Disease Outbreak Response Guideline development process


questions




framework

Expert consultation


Committee

Issued in December 2014

http://www.who.int/mediacentre/news/

releases/2014/ebola-ppe-guidelines/en/

1. Are chlorine solutions effective for hand hygiene in health care?

2. Are chlorine solutions effective for disinfection of gloves?

3. Does the use of chlorine solutions for hand hygiene cause health workers’ skin irritation or lesions, respiratory side effects or any other adverse reactions?

http://www.who.int/mediacentre/news/releases/2014/ebola-ppe-guidelines/en/









Pandemic & Epidemic Diseases department 6 |

IPC Essential Precautions in Healthcare Facilities

• Standard precautions for all patients at all times

• Isolation of suspected and confirmed cases in separated rooms/areas with restricted access

• Exclusively dedicated staff and equipment for isolation rooms/areas

• Hand hygiene with alcohol-based handrub or water and soap

• Use of PPE

• Rigorous environmental cleaning and surfaces/objects decontamination

• Safe injection practices and sharps handling

• Post-exposure evaluation and care following professional accidents

WHO Interim IPC Guidance - 2014 Update

http://www.who.int/csr/resources/who-ipc-guidance-ebolafinal-09082014.pdf












Routine precautions to

be applied in ALL

situations for ALL

patients

– whether or not they

appear infectious or

symptomatic

– especially important for

EVD because the initial

manifestations are non-

specific

Standard Precautions


Reduce the risk of transmission of

microorganisms from both recognized and non-

recognized sources of infection

Apply to blood, all body fluids, secretions and

excretions (except sweat) whether or not they

contain visible blood; non-intact skin; and

mucous membranes

Standard Precautions


Standard Precautions: key elements

hand hygiene

gloves BASED ON RISK ASSESSMENT

gown BASED ON RISK ASSESSMENT

facial protection BASED ON RISK ASSESSMENT (eyes, nose, mouth)

respiratory hygiene and cough etiquette

environmental cleaning and disinfection

cleaning and disinfection of patient care equipment

waste disposal

injection safety and prevention of sharps injuries


Personal protective

equipment


It is most important to have PPE which protects the

mucosae – mouth, nose and eyes – from contaminated

droplets and fluids.

Hands are known to transmit pathogens to other parts of the

body or face and to other individuals. Therefore, hand

hygiene and gloves are essential, both to protect the health

worker and to prevent transmission to others.

Face cover, protective foot wear, gowns or coveralls, and

head cover are also considered essential to prevent

transmission to health workers.

Balance between the best possible protection against

filovirus infection while allowing HCWs to provide the best

possible care to patients with maximum ease, dexterity,

comfort and minimal heat-associated stress.

Fundamental principles guiding PPE selection


Strong recommendations to wear:

• Either a face shield or goggles that closely fits with the contours of

the face and does not allow fluids to see through.

• Fluid-resistant medical/surgical mask with a structured design (e.g.

duckbill, cup shape) that does not collapse against the mouth.

• Double gloves while providing clinical care (nitrile gloves preferred

over latex gloves; outer glove should have a long cuff)

• Disposable, waterproof apron (if not available, heavy duty, reusable

waterproof apron)

WHO Guidelines on

Personal Protective Equipment (PPE)


• WHO strongly recommends: a protective body wear in

addition to regular on-duty clothing (i.e. surgical scrubs).

• The protective body wear could either be a disposable gown

and apron, OR a disposable coverall and apron

• The gown and the coverall should be made of fabric that is

tested for resistance to penetration by blood or body fluids OR

to blood-borne pathogens

Gown: EN 13795 high performance level, or AAMI level 3

performance, or equivalent; AAMI PB70 level 4 performance,

or equivalent

Coverall: meets or exceeds ISO 16603 class 3 exposure

pressure, or equivalent; OR meets or exceeds ISO 16604

class 2 exposure pressure, or equivalent.

PPE to cover the body (1)


Coveralls and gowns are equally acceptable (lack of

comparative evidence to show whether one is more effective

than the other)

Gowns:

considerably easier to put on and, in particular, to take off (safer

when removing PPE)

generally more familiar to HCWs and hence more likely to be used

and removed correctly. These factors also facilitate training in their

correct use

heat stress is significantly less for gowns and they are

more likely to be available in areas commonly affected by filovirus

disease

in some cultures, gowns may be more acceptable than coveralls

when used by women

PPE to cover the body (2)

Strong recommendations to wear:

• Either a face shield or goggles that closely fits with the contours of the

face and does not allow fluids to see through.

• Fluid-resistant medical/surgical mask with a structured design (e.g.

duckbill, cup shape) that does not collapse against the mouth.

• Double gloves while providing clinical care (nitrile gloves preferred over

latex gloves; outer glove should have a long cuff)

• Disposable, waterproof apron (if not available, heavy duty, reusable

waterproof apron)

• Disposable either coverall or gown, tested for resistance to penetration

by blood or body fluids OR to blood-borne pathogens

• Waterproof boots (e.g. rubber/ gum boots) (if not available, closed shoes

- slip-ons without shoelaces and fully covering the dorsum of the foot

and ankles)

Conditional recommendation: head cover that covers the head

and neck (suggested to be separate from the gown or coverall)

WHO Guidelines on

Personal Protective Equipment (PPE)


Protection depends on:

adequate and regular supplies

adequate staff training

proper hand hygiene

appropriate human behavior

close supervision and support

Essential: for putting on and removing PPE, supervision by

a trained member of the team

Avoid touching or adjusting PPE

Perform hand hygiene before donning new gloves

Avoid touching your eyes, mouth, or face with gloved or

ungloved hands

Leave the red zone and remove PPE if you have to urinate

or touch your PPE or eyes, mouth, or face

For removal:

Remove the most contaminated PPE items first and PPE

protecting eye, nose and mouth mucosae at last

Be careful to avoid any contact between the soiled items (e.g.

gloves, gowns) and any area of the face (i.e. eyes, nose or mouth)

or non-intact skin

Discard disposable items in a waste container

HOW YOU USE PPE is crucial:

REVISED INSTRUCTIONS FOR WEARINGPPE R E V I S E D J A N U A RY 2 0 1 5

http://who.int/csr/resources/publications/ebola/ppe-steps/en/





Put on head cover or pull hood of suit over the top band of the face

shield. The hair and forehead must be completely covered

With GOOGLES

With FACE SHIELD

STEPS TO PUT ON PPE


Your hands must stay below this point and not go near

your face. You cannot adjust your face shield, face mask

or glasses

HANDS

SHOULD

NEVER

GO ABOVE

NIPPLE

LINE

STEPS TO PUT ON PPE


Spraying

Spraying chlorine solutions should not be routinely encouraged because it is not an evidence-based practice, and it can cause virus spread through aerosolization, it gives a false sense of safety (insufficient contact time), and if extensively used, can lead to adverse events among staff and patients

If spraying chlorine solutions is utilized, staff should still maintain maximum attention while manipulating organic material, touching contaminated surfaces, and removing PPE because these may still be contaminated by the Ebola virus


Clean boots by stepping

into the first pan/bowl of

water (if heavily soiled

with mud and/or organic

materials, remove dirt ….)

STEPS TO REMOVE PPE


Perform hand

hygiene on outer

gloved hands

STEPS TO REMOVE PPE


REMOVE APRON

Taking care to avoid

contaminating your

hands

First carefully untie

the apron behind the

waist and then untie

the neck

STEPS TO REMOVE PPE


If the apron neck is one

piece and cannot be

untied, then carefully break

the plastic behind the neck

Remove apron taking care to avoid

contaminating your hands by

peeling it off

Drop the apron into a waste

container

STEPS TO REMOVE PPE


Perform hand

hygiene on outer

gloved hands

STEPS TO REMOVE PPE


Remove

face shield

from

behind the

head and

dispose of

safely

CV

KEEP EYES CLOSED

STEPS TO REMOVE PPE


Remove face mask

from behind the head,

the bottom string first

and the top string next,

and dispose of safely

KEEP EYES CLOSED

STEPS TO REMOVE PPE


Disinfect boots by

stepping into the

second pan/bowl

of 0.5% bleach

solution for at

least 1 minute

and then wipe

them with 0.5%

bleach solution

Remove rubber

boots in the green

zone without

touching them

STEPS TO REMOVE PPE


At least once a day boots should be

disinfected by soaking in a 0.5%

chlorine solution for 30 min

STEPS TO REMOVE PPE

Perform hand

hygiene preferably

with liquid soap and

water and dry with

single-use towel

STEPS TO REMOVE PPE

New WHO Guidelines on Hand Hygiene

In Health Care in the Context of Filovirus

Disease Outbreak Response Guideline development process


questions




framework

Expert consultation


Committee

Issued in December 2014 http://www.who.int/mediacentre/news/

releases/2014/ebola-ppe-guidelines/en/

1. Are chlorine solutions effective for hand hygiene in health care?

2. Are chlorine solutions effective for disinfection of gloves?

3. Does the use of chlorine solutions for hand hygiene cause health workers’ skin irritation or lesions, respiratory side effects or any other adverse reactions?

4. Does glove disinfection with chlorine solutions cause damage to permeability or increased perforations?











The 5 Moments apply to any setting where health care

involving direct contact with patients takes place

Hand hygiene


Hand hygiene indications

before donning gloves and wearing PPE on entry to the

isolation room/area,

before any clean/aseptic procedures being performed on

a patient,

after any exposure risk or actual exposure with the

patient’s blood and body fluids,

after touching (even potentially) contaminated

surfaces/items/equipment in the patient’s surroundings,

and after removal of PPE, upon leaving the care area.

Adaptation for EVD patient care


Hand hygiene should be performed within the isolation

rooms/areas every time it is needed according to these

indications during care to a patient, along with change

of outer gloves

When caring for patients in the same room, it is

essential to organize the complete care to each patient

before moving to the next and to perform hand hygiene

between touching the patients

Neglecting to perform hand hygiene after removing

PPE will reduce or nullify any benefits of the protective

equipment.

Hand hygiene


If heavily soiled with blood or any body fluids while

providing care to the same patient

When moving from one patient to another while caring for

patients in the same room.

Perform careful hand hygiene immediately after removal

2-step procedure to facilitate changing gloves safely:

1) disinfect the outer gloves before removing them safely

2) keep the inner gloves on and disinfect them before

putting on a fresh outer pair. Alcohol-based hand rubs

are preferred when disinfecting hands and gloved hands.

Change gloves during patient care


1.Are chlorine solutions effective for hand hygiene

in health care?

2.Are chlorine solutions effective for disinfection of

gloves?

3.Does the use of chlorine solutions for hand

hygiene cause health workers’ skin irritation or

lesions, respiratory side effects or any other

adverse reactions?

4.Does glove disinfection with chlorine solutions

cause damage to permeability

or increased perforations?

Systematic Reviews on Use of Chlorine Solutions

for Hand Hygiene and Glove Disinfection

Systematic reviews

Conclusions (1)

1. Very limited evidence (not for filovirus or other enveloped

viruses) to evaluate the efficacy of sodium hypochlorite

(bleach/chlorine solutions) compared with other agents when

used for hand hygiene or glove disinfection

2. Available data indicates that for hand hygiene efficacy there

is a relation between bleach/chlorine concentration and

contact time.

3. No study on efficacy of chlorine solutions compared with

alcohol-based hand rub or other antisepsis products,

including water and soap, for glove disinfection. Only one

study assessed the permeability of surgical gloves to sodium

hypochlorite 13% and showed no permeation or glove

damage. 43

4.Limited evidence (only one case report, at much higher

concentration than is currently used for hand hygiene)

showing that sodium hypochlorite used for hand hygiene

purposes can cause skin irritation or lesions

5.No evidence that low concentrations of sodium

hypochlorite used for hand hygiene cause respiratory

irritation, other respiratory symptoms or asthma

6.Risk for irritative conjunctivitis is noted

7.Final expert evaluation of the evidence: the use of

bleach/chlorine solutions (500 ppm sodium hypochlorite

or a 0.05% chlorine solution) is likely to be efficacious

and can be acceptable from the tolerability point of view

for hand hygiene, if other products are unavailable.

44

Systematic reviews

Conclusions (2)

45

• We recommend performing hand hygiene, by using either an

alcohol-based hand rub or soap and running water applying

the correct technique recommended by WHO.

• Alcohol-based hand rubs should be made available at every

point of care (at the entrance and within the isolation

rooms/areas) and are the standard of care.

• If alcohol-based hand rubs are unavailable, hand hygiene

should be performed with soap and running water whenever

necessary. When hands are visibly soiled, hand hygiene

should always be performed with soap and running water.

Strong recommendation, high-quality evidence for the

effectiveness of alcohol-based handrub or soap and water.

Recommendation 1

46

• In settings where bleach/chlorine solutions are

currently used for hand hygiene, we recommend

implementing a strategy to change to alcohol-based

hand rub or soap and water.

Strong recommendation, very strong evidence for

the in-vivo effectiveness of alcohol-based hand rubs

or soap and water.

Recommendation 2

http://apps.who.int/iris/bitstream/10665/144578/1/WHO_HIS_SDS_2014.15_eng.pdf?ua=1

47

• Bleach/chlorine solutions currently in use for hand hygiene

and glove disinfection can be used in the interim period in

emergency situations until alcohol-based hand rubs or

soap and water become available.

Conditional recommendation, very low-quality evidence for

the comparative efficacy of bleach /chlorine solutions

compared with alcohol-based handrub or soap and water,

and very low-quality evidence about tolerance to bleach or

chlorine solutions for hand hygiene and glove disinfection.

Recommendation 3

http://apps.who.int/iris/bitstream/10665/144578/1/WHO_HIS_SDS_2014.15_eng.pdf?ua=1


Hand hygiene

Procedure Time

Handrubbing with alcohol 20-30 seconds

Handrubbing with 0.05

chlorine

40-60 seconds

Handwashing (soap and

water)

40-60 seconds

CONTACT TIME IS CRUCIAL FOR EFFICACY!

PERFORMING HAND HYGIENE FOR A FEW SECONDS

ONLY

WILL NOT PROTECT YOU!


Hand hygiene - WARNING

• Do not wash or decontaminate your hands or gloves just by

soaking them into a bucket of chlorine

• The reason is that organic material contaminates and

inactivates chlorine; therefore, the solution will become

rapidly inactive

• In addition, for effective cleaning and decontamination

hands need to be vigorously rubbed

• Therefore, use freshly prepared running chlorine solution or

water and soap

Guide for the local production of the WHO alcohol-based handrub formulations

From sugar can,

at low cost

(0.30 $US) = 0.006%

of the total annual

hospital budget

Mali, Africa, 2007

System change made possible WHO alcohol-based formulation local production Global Survey 2012

39 sites in 28 countries

Joanna Bauer-Savage et al. Bulletin of the World Health Organization 2013, available online


Other key elements for IPC

Patient isolation

Environmental cleaning and disinfection

Cleaning and disinfection of patient care equipment

Waste disposal

Injection safety and prevention of sharps injuries

Laboratory safety

Safe post-mortem examination

Safe management of dead bodies

Management of exposure risk and accidents


Cleaning and decontamination process

WARNING: chlorine is inactivated when it gets in

contact with organic material; therefore, directly

pouring chlorine over spills or liquid waste containing

blood or body fluids will NOT lead to appropriate

decontamination of this waste and of the soiled

surfaces

Key principles for environmental cleaning and

decontamination:

1. Remove the soiled

2. Clean with soap/detergent

3. Disinfect with chlorine


Do not reuse disposable articles

Thoroughly clean and decontaminate reusable materials

Clean items with detergent and water while wearing appropriate PPE to remove organic matter, then let soak in 0.5% chlorine at least 10 minutes

When you cannot use chlorine, decontaminate with alcohol

Decontamination of reusable material


IPC training

and reinforcement after training

Importance of standard precautions in all outpatient and

inpatient care

– Many HCW infections from failure to apply standard

precautions, rather than PPE in treatment centre

PPE - putting on and taking off is a skill

– not just knowledge that can be conveyed by demonstration

– needs practice

– needs ongoing supervision by dedicated supervisor

Importance of safe work set-up and consistent practices

57

INFECTION PREVENTION AND CONTROL

ASSESSMENT AND QUALITY IMPROVEMENT

IN EBOLA FACILITIES

PROJECT

Funded by USAID & OFDA

58

Project objectives and plans

• To assess key indicators of IPC and quality of care in

Ebola facilities by using unified tools

• To implement immediate improvement actions

based upon the results of assessments

• To develop and strengthen IPC knowledge and

expertise at district and facility level

• To support IPC activities at district level during the

transition/scaling down phase of the Ebola response

• Phase 1: Immediate emergency action plan

• Phase 2: Nation-wide quality improvement system for

medium-/long-term support

59

Roles and responsibilities

• MOHS: leadership and coordination

• WHO: mentorship, training and support to

coordination

• Partners: contribution to assessments and

support to improvement… and more (acc.

to interests and availability)

• Sub-committee of the case management

pillar created to support this project

60

Type of proposed tools

• External quality improvement tool

• Facility IPC Daily Self-Assessment Checklist

• Facility IPC Weekly Quality Improvement Self-

assessment Survey

• Health-care Workers (HCWs) and Ebola Virus

Disease (EVD) Exposure Risk

62

Phase 1: Immediate emergency action plan

• Need for assessing and providing immediate support to Ebola

facilities in areas of high transmission and which require

immediate attention using a unified approach and tool

• Identified target areas: Western Area, Bombali and Kambia,

Kono, Port Loko

• Approach:

– Linkage to the district medical officer (DMO) and to the facility

coordinator to agree on the visit

– Visit to the facilities and completion of the unified tool and

development of a priority list for action

– Discussion of the main findings and suggested actions with the

DMO, especially when important and urgent actions are required

– Submission of an official report and proposed action plan to the

DMO, partners and the facility coordinator

65

National coordination team

Responsible district authority

IPC and QI support team

Phase 2: Quality Improvement System

Roll Out

Ebola facility IPC lead or coordination entity

MOHS

WHO

PARTNERS

MOHS

WHO

PARTNERS

66

IT SYSTEM SUPPORT • The tool can be accessed online and offline through a web-

and mobile-based system by using the links you will be

provided with

• After complete data input the web form should submitted

through the WHO Data Coordination Platform shared with

MOH

• The user can receive the data in Excell format

69

Official Report

SCORES DASHBOARD

Total Score/ Sections' Score

Elements/Indicators

Facility Facility Facility Facility Facility Facility Facility Facility

1 1 2 3 4 5 6

28/11/14 11/12/14 09/12/14 09/12/14 10/12/14 10/12/14 12/12/14 Date

Total Score 46.5 87 94.1 84.9 75.1 85.9 81.9

IPC guidance and training 4.2 67 91.6 75 33.3 55.8 56.3

Infrastructure 37.5 94 87.5 81.2 85.7 92.8 92.8

PPE use and hand hygiene 87.5 100 100 75 87.5 87.5 90 Environmental cleaning, disinfection and waste

management 71.4 93 100 100 85.7 100 85.7

Equipment and Supplies 71.4 82 96.4 89.2 89.3 92.8 92.8

Staff health 25 100 100 100 90 100 100

Clinical management / 83 100 100 75 100 66.7

Observations 0 85 77.5 59 54.5 59 71.4

Key indicators: 2. IPC guidance and training 3. Infrastructure 4. PPE use and hand hygiene 5. Environmental cleaning, disinfection and waste

management

6. Equipment and Supplies

7. Staff health

8. Clinical management

9. Observations

Facility Facility Facility Facility Facility Facility Facility

1 1 2 3 4 5 6

Date Date Date Date Date Date Date

28/11/2014 11/12/2014 09/12/2014 09/12/2014 10/12/2014 10/12/2014 12/12/2014

2.1 Standard IPC guidelines/protocol

2.2 Designated IPC supervisor

2.3 Standard triage algorithm or protocol

2.5 Continuous staff training on IPC practices

3.1 Safe waste disposal systems

3.2 Clean running water

3.3 Generator

3.4 Patients triaged in a dedicated area upon arrival

3.5 Suspected/probable & confirmed cases separated in dedicated isolation areas

3.7 Unidirectional flow

4.1 Full PPE used

4.4 Appropriately located HH stations

4.5 Chlorine solution freshly prepared daily

5.2 Sharps punture resistant containers

5.4 All surfaces cleaned/decont daily & on discharge

5.7 Body fluid waste disposed of in toilets

6.1 Gowns/coverall available

6.2 Plastic/heavy duty apron

6.3 Face masks/respirator

6.4 Eye protection

6.5 Heavy duty gloves

6.6 Examination gloves

6.8 Boots

6.9 Liquid soap

6.10 ABHR

6.11 Chlorine

6.13 Waste bags

7.1 SOP staff exposure

7.3 Daily staff screening

7.4 Staff EVD reporting system

8.1 ORS prepared safely

9.1 Triage tools & equipment

9.5 PPE correctly used

9.7 PPE put on correctly performed

9.9 PPE removal correctly performed

9.10 Gloves decontaminated & changed between pts

9.11 HH correctly performed

9.14 Spills cleaned/decontaminated correctly

9.15 Blood samples correctly packaged

KE

Y I

ND

ICA

TO

RS

DA

SH

BO

AR

D

Repeated measurements and improvement

75

SCORES

Facility Facility Facility Facility Facility Facility Facility

A A B B C C D D

1 2 1 2 1 2 1 2

28/11/14 11/12/14 09/12/14 22/01/15 10/12/1424/10/20

14Date 15/01/15

46.5 87 84.9 88.09 85.9 95.21 59.6 90.19

4.2 67 75 66.7 55.8 100 94.4 100

37.5 94 81.2 100 92.8 92.8 50 93

87.5 100 75 90 87.5 90 80 100

71.4 93 100 78.57 100 92.8 42.8 85.7

71.4 82 89.2 96.42 92.8 96.1 89.2 89.28

25 100 100 100 100 100 100 100

/ 83 100 100 100 100 50 75

0 85 59 73.07 59 90 30 78.57

Total Score/ Sections' Score

Observational

Elements/Indicators

Total Score

IPC guidance and training

Infrastructure

PPE use and hand

hygiene

Environmental cleaning,

disinfection and waste

management

Equipment and Supplies

Staff health

Clinical management

76

Main issues identified

• Infrastructure deficiencies:

– Inadequate buildings to assure separation of suspected,

confirmed and negative cases

– Inadequately located and equipped doffing and donning areas,

decontamination areas, and triage areas

– Lack of water supplies

– Lack of appropriate hand hygiene facilities

– Limited space for staff resting

• Inappropriate hand hygiene and environmental cleaning and

decontamination practices

• Inappropriate PPE donning and donning procedures

• Gaps in staff training and no continuous training

Transitioning the FMTs expertise

in a new phase

• Important opportunity to take advantage from the tremendous

amount of experience, knowledge and wisdom accumulated

during the response

• Role to be played in the context of activities linked to scaling

down, essential services recovery and health systems

recovery

IPC supervision for Ebola facilities decommissioning

Supervision of IPC protocols implementation for schools reopening

Organizing appropriate triage, isolation measures and standard

precautions implementation in non Ebola healthcare settings

Mentorship and training

• Collaboration with WHO to support MOH to develop new IPC

policies

• Warning: IPC expertise required!

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