mers-cov%2c infection control measures 17 april (1)

8/11/2019 MERS-CoV%2c Infection Control Measures 17 April (1)

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Prepared by: Iman Nahle RaadHead, Infection Control Department

Infection Control Measures

to Prevent HospitalTransmission MERS CoV

Infection Control Department 2014 1

ICD-RCMC April 17, 2014

Coronaviridae


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Epidemiology & ClinicalManagement

BackgroundChronologyEpidemiologyCase DefinitionsClinical PictureClinical Management

Case study (Al Hasa-KSA ) published byDr Memish & Dr.Asiri



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Background

In September 2012, the World HealthOrganization announced the discovery of anovel coronavirus .

This virus has been named the Middle EastRespiratory Syndrome Coronavirus (MERS-CoV)



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The first indication that MERS-CoV could betransmitted in health care setting was observedin Jordan in April 2012 .

On 15 May 2013,the Ministry of Health in SaudiArabia announced that 2 patients are health careworkers who were exposed to patients withconfirmed MERS-CoV.


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Approximately 132 laboratory Confirmedcases including 58 deaths . Until September2013. A significant number of cases have

been in health care workersAs of March 2014, MERS-CoV has beenidentified in several countries in the MiddleEast (Saudi Arabia, Qatar, the United Arab

Emirates, Jordan, Oman, and Kuwait),Europe (the United Kingdom, France, andItaly), and Tunisia.



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14 April 2014 - WHO has been informed of an

additional 16 laboratory-confirmed cases ofinfection with Middle East respiratory syndromecoronavirus (MERS-CoV) from Saudi Arabia andthe United Arab Emirates (UAE).

15 laboratory-confirmed cases, including twodeaths announced on the Ministry of Health ofSaudi Arabia website and provided to WHObetween 6 and 11 April


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The World Health Organization (WHO) iscoordinating the international responsesto provide epidemiological, clinical andlogistical support as required



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Epidemiology


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Cause : New Corona VirusRecent evidence of new corona virus identifiedwith etiological co-factors ? involved

Highly infectious Means of transmission

Evidence of person to person transmission

Close contact with body fluids (especiallyrespiratory droplets )Contaminated hands, clothes, equipment; theenvironment may also be important



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Incubation period

2 10 days and up to 13 days in exceptionalcases Onset and duration of infectivity unknown

Organism survival in environment Duration unknown Other corona virus are known to survive for up

to 4 hours



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KSA and the WHO announced that, there are 3

main epidemiological patterns. The first pattern is the occurrence of sporadiccases in communities. The source or how these

people became infected is not known at the present

time.The second pattern is intra-familial infection. Thisis likely related to person to-person transmissionlimited to close contacts with a sick familymember.The third pattern contains clusters of healthcaretransmission .


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A person presenting after 1 February 2003 with a historyof:

High fever >38 0 C AND

One or more respiratory symptoms includingcough, shortness of breath or breathing difficulty

AND one or more of the following: Close contact, within 10 days prior to onset of

symptoms with a person diagnosed with MERS

COV; History of travel, within 10 days prior to onset ofsymptoms to an affected area (see archive ofAffected Areas athttp//www.who.int./csr/mers/en/ ).


Suspect Case

Case Definitions


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Close contact : having cared for, lived with, orhad direct contact with the respiratorysecretions or body fluids of a suspect orprobable case of MERS CoV.

Affected area : an area in which local chain(s) oftransmission of MERS CoV is/are occurring asreported by the national public healthauthorities .


Explanations:


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Probable Case


A suspect case with chest X-Ray findingsconsistent with pneumonia or respiratorydistress syndrome (RDS)

OR

A suspect case with an unexplained illnessresulting in death, with autopsy

examination demonstrating thepathology of RDS without an identifiablecause.


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Sudden onset of high fever withmyalgia, chills, rigors and a non-productive cough

Most cases have bilateral pneumonia

~ 90% begin to recover from day 6 or 7

Clinical Picture Onset / Presentation


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Patients Who Should be Evaluated for MERS-CoV Infection A person with fever ( 38C , 100.4F)and pneumonia or acute respiratory

distress syndrome (based on clinical orradiological evidence);AND

History of travel from countries in or near

the Arabian Peninsula within 14 days beforesymptom onset;OR



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Close contact with a symptomatictraveler who developed fever and acute

respiratory illness (not necessarilypneumonia) within 14 days after travelingfrom countries in or near the ArabianPeninsula;

OR

Is a member of a cluster of patients with

severe acute respiratory illness (e.g.,fever and pneumonia requiringhospitalization) of unknown etiology inwhich MERS-CoV is being valuated.


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Collection of LaboratorySpecimens

Determine if patient meets PUI criteriaCollect:An upper respiratory specimen:

Nasopharyngeal AND oropharyngeal swab

A lower respiratory specimen:Broncheoalveolar lavage, ORTracheal aspirate, ORPleural fluid, ORSputum


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The best specimen for testing is a lowerrespiratory tract specimen as nasopharyngealswabs .

It is strongly advised that lower respiratory

specimens such as sputum, endotracheal aspirate, or bronchoalveolar lavage should be used when possible

Serum for eventual antibody testing (tigertop tube)

Should be collected during acute phaseduring first week after onset, and againduring convalescence 3 weeks later


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SUPPORTIVE TREATMENT Antibiotic Therapy : to cover causative

organisms

Prophylactic Antibiotic Therapy : toprevent secondary bacterial infection

Maintain oxygenation :

intubate and ventilate as necessary

Clinical Picture Management


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SUPPORTIVE TREATMENT

Avoid interventions which may causeaerosolisation ofrespiratory secretions:

BronchoscopyNebulised bronchodilatorsChest physiotherapy

GastroscopyAny procedure / intervention that mayrelease respiratory secretions


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MERS CoV Therapy

CDC suggestionThe suggested Ribavirin oral

dosage is 2000 mg loading dose then1200mg q8h for 4 days, then 600mg poq8h for 4-6 days with pegelated

interferon 1.5mcg/kg once per week.



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So far there is no treatment &no Vaccine


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TO PREVENT

TRANSMISSION TO

HCWs AND OTHERS

Infection ControlPrecautions MUST BE

PRACTICED AT ALLTIMES


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MERS CoV : Infection Control Goals

In addition to providing the best possible clinical care:

Detect early any suspect casesImplement appropriate isolation measures

Protect healthcare personnelProtect other patientsProtect family and community members



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Triage for MERS CoV Admissions Where possible have a specific area for triaging

patients who may have MERS CoV :Establish separate reception area for patienttriage.Staff must wear full personal protectiveequipment (PPE).Patients must be given a surgical maskScreen patients by closely questioning themabout symptoms, close contacts and travel.Admit if they meet the case definition.



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If possible, there should be separatewards/areas for each of the followingcategories :

Patients with colds, sniffles and runny nosesshould be isolated in a single room / area

Suspect cases Place in a single room

Probable cases If cohort nursing : keep probable and suspect cases

apart May share room with other probable cases : wherepossible use a single room for all patients



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Components of MERS CoV Isolation

FacilityAdministrative ControlsClinical Surveillance of Staff

Organization of Isolation AreaProtective EquipmentStandard Precautions



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Administrative Controls Limit, and control points, of entry to MERS

CoV ward(s) One entrance Guard to control entrance Log of permitted visitors (staff & visitors) Visitors must be restricted or preferably forbidden

with NO EXCEPTIONS Limit patient travel/transport outside unit Minimize the number of staff exposure to cases



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Clinical Surveillance of Staff

Maintain list of all staff who worked with MERS CoVpatients or on the MERS CoV ward Systematically monitor for fever Twice daily temperature for staff working in the

area (baseline Chest X-Ray may be needed )Screen for symptoms of MERS CoV -like illnessamong staff reporting for dutyList contact information for:

Persons visiting or caring for MERS-CoV patients Contacts of HCWs in close contact with MERS CoV

patients



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Organization of Isolation AreaSigns: MERS CoV Isolation AreaDesignated area for clean protectiveequipment Instructions for using protective equipment Accessible to personnel Sufficient inventory to meet daily needs

Separation of clean and dirty suppliesincluding an area for containment of wasteand soiled linen Color-coded bags and containers for

contaminated waste and laundry

Containers for laundry and all waste should havefoot-operated lids



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Personal Protective Equipment(PPE)

N-95 Respirator Mask must be worn

Goggles (protective glasses)

Disposable Gowns

Disposable Gloves

Cap


I f i C l P i


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Infection Control Practices

Standard Precautions (Respiratory

Precautions) Exposure Risks

Hand Washing

PPE

Patient transport

Patient and familyeducation

Laboratories /Specimens

Mortuary Care

Waste and LinenHandling

Cleaning &Disinfection



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A,C Precautions

Designed to reduce the risk foroccupational exposure to

MERS CoV infection from bothrecognized andunrecognized sources ofinfection



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Exposure RisksPatient: Respiratory

secretions Blood Body fluids

including excreta Skin lesions

Staff Visitors

Health Care Staff: Respiratory

secretions Blood

Body fluidsincluding excreta Mucous membranes Skin lesions

Sharps Visitors



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Principles of Hand WashingHand Washing :

Is the single most important and effectivecomponent for preventing the transmission ofinfection.

Is designed to remove transientmicroorganisms that may have been picked upfrom the environment.

Prevents the transfer of these microorganisms

to other patients, staff and equipment. Is best performed using soap (preferably

liquid) and warm running water


H d hi Wh ?


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After removing gloves Before and after patient

contact After contact with blood

or body fluids from anypatient

After taking bloodpressure or vital signsfrom any patient

Other times: After using bathroom

After blowing or wipingnose

Before eating Before preparing food


Handwashing When ?


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Drying Your HandsIt is important to dry your hands thoroughly afterwashing them because :

Damp hands collect microorganisms Damp hands spread potentially infectious

microorganisms Damp hands may become colonised with

potentially infectious microorganisms

Therefore it is important to pat dry your handsthoroughly.

Pat drying also helps to prevent damage to skin .Infection Control Department 2014 44


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Handwashing Tips


Remember:

Wash hands for a minimum of 15 to 20seconds.

Ensure you have washed all areas

properly.

Dry hands thoroughly.

MERS C V


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MERS CoV



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Personal Protective Equipment (PPE)

CapGown

N-95 RespiratorMaskGloves

Goggles



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Principles for Using PPEPPE reduces but does not completelyeliminate the possibility of infection

PPE is only effective if used correctly

The use of PPE does not replace basichygiene measures such as hand washing hand washing is still essential to prevent

transmission of infection.



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N-95 Respirator Masks

N-95Respirator

Mask


P i i l f U i g th


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Principles for Using theN-95 Respirator Mask

The N-95 respirator mask is used to protecthealth care workers, other patients, staffor visitors by preventing potentially

infectious microorganisms such asrespiratory secretions from :

Contaminating their face including thenose and mouth.

Being inhaled or ingested.



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N-95 Respirator MaskFor respiratoryprotection wearan N-95respirator maskduring allpatient contact



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Proper use of N-95 Respirator Mask DO NOT touch the front of the mask

Wear only one N-95 mask no need for

additional respiratory protection

REMOVE the N-95 respirator mask beforeleaving the isolation unit / area



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WHY an N-95 Respirator Mask?

N-95 respirator masks offer

a higher level of filtrationfor respiratory secretionsthan a surgical mask



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HOW to use an N-95Respirator Mask

Use for single shift unless excess moisturenecessitates replacement during each shift Label with the wearer s name

Dispose of with medical waste

NB: You must fit the mask securelyover both your nose and mouth


HOW to use an N-95 Respirator


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HOW to use an N 95 RespiratorMask

Always use the correct sized mask. The incorrect size will not fit properly and

will fail the fit test.

NB: You must fit the mask securely over bothyour nose and mouth so size is important.


N 95 R i t M k


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N-95 Respirator Masks- Fitting Instructions



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N-95 Respirator Masks- Fitting Instructions


Inhale deeply. If there isno leakage, the negativepressure will make themask cling to your face.

A poor seal will result in

prompt loss of negativepressure in the mask due toair entering through gaps inthe seal.

Negative Fit Test


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Principles for Using Goggles,Gowns, Gloves and Caps

Goggles, gowns, gloves, caps andovershoes are used to protect health careworkers, by preventing potentiallyinfectious microorganisms from :

Contaminating their eyes, clothing, handsand hair

Being transmitted to other patients andstaff.



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Goggles


Assign one pair to each worker at the beginning ofa shift

Wear goggles in room with MERS CoV patients

Leave in the container in the anteroom at the endof the shift to be cleaned and disinfected

Go ns


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GownsLong sleeved gowns must be

worn when in direct contactwith the patientWear gown at all times in thepatients room

Gowns must be removedbefore leaving the patientsroom or dedicated anteroomRemove used gowns as soonas possible particularly whengrossly contaminated



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Gloves

Before all patientcontact

Before allcleaning

Before handlingsoiled linen &waste



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Gloves Remove after contact

with patients or labspecimens

Do not wear gloves

outside of thepatient s room /anteroom

Do not re-use gloves

Wash hands afterremoving your gloves



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Caps


Caps are worn to protectthe hair from aerosolsthat may otherwise lodgeon the hair and betransferred to otherparts of the health careworker such as the face

or clothing by the handsor onto inanimateobjects .


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Patient TransportIt is essential to avoid all unnecessarytransport of isolated patients to control

and prevent the potential spread ofinfection.


P ti t T t


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Patient TransportIf the patient needs to be out of their room for an

essential procedure, e.g. X-Ray Transport route must avoid populated areas.

Patient must and an isolation gown.

Accompanying staff must wear :N-95 respirator maskGlovesGownGoggles


Patient Transport


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Patient Transport

Transport Ambulance No dedicated ambulance needed Mask patient (N-95 respirator mask) Transporters wear personal protective equipment

N-95 respirator mask, disposable gown, goggles, gloves

Disinfect ambulance after transport Standard cleaning and disinfecting or

1:100 dilution of bleach; after 10 minute contact time,clean and disinfect using standard procedures.

DO NOT use spray cleaners



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Patient, Family & CommunityEducation

Education for the patient, their family andthe community is essential in the controland prevention of the MERS Cov.

It is particularly essential for thosepersons requiring hospital or homeisolation to understand the necessaryrestrictions.



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Patient, Family & CommunityEducation

Explain: What MERS Cov. is (to date)

Why isolation is required.

Precautions required including PPE

Hand washing procedures



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Patient and Family Education

Teach the patient and family members : about the MERS Cov. illness and the reason for the precautions being used

Teach the patient and visiting family members : how to perform hand hygiene how to wear an N-95 respirator mask, gown,

gloves and goggles (if available)



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Patient and Family Education

Explain to the patient and family whydisposable equipment is being used such as:

Eating utensilsMedical equipmentPatient gowns



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LaboratoriesLaboratory staff must ensure that theirpractices are meticulous.

Advance planning in each designatedlaboratory is essential to ensure thatspecimen handling, transportation andstorage is managed according to the

guidelines.



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Storage of Specimens

Respiratory samples and frozen tissues : store at 70 oC

Serum : store at 4 - 8 oC for 24-48 hours or at -20 oC for longer periods


P ti t S i


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Patient Specimens

Treat allpatientspecimensas highlyinfectious

Use leakproofcontainersfor collection

Do notcontaminateoutside ofcontainer

Transportspecimens inleak-proofoutercontainerse.g. a sealedplastic bag



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WasteWear full PPE when handling waste.Clinical waste: all items from treatmentareas Soiled surgical dressings

Swabs Masks Gowns Other contaminated waste



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Cleaning & Disinfecting the HospitalEnvironment and Equipment

Cleaning is usually sufficient for preventionand control of infection, but for MERS Covinfection the use of a disinfectant followingcleaning is essential.It is essential to clean thoroughly beforedisinfecting the environment or equipment.Cleaning and disinfection must be carried outat least daily and particularly when gross

contamination occurs.In some instances it may be necessary todisinfect to render the item safe to handle.



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Cleaning and disinfecting patient

rooms and equipment is the best wayto reduce transmission of infection

Wear full PPE when cleaning anddisinfecting



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Cleaning & Disinfecting the Hospital


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The immediate area around patientsmust be considered heavilycontaminated.

Bedside table, bed stand, and accessible

areas of bed and floors must be cleanedwith detergent and twice a day.

In addition, disinfect all surfaces aftercleaning.

Use disinfectant first if surfaces aregrossly contaminated before cleaning toreduce the viral load. Infection Control Department 2014 81



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Contain and dispose of infectious materialsin waste containers : Put waste containers near entrance / exit to

patient room.

Provide dedicated patient equipment whenpossible.

Clean and disinfect patient care equipmentimmediately after use depending on thetype of equipment.



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When areas and inanimate objects are grosslycontaminated use : 1:100 sodium hypochlorite (bleach) solution

to disinfect (before cleaning) it will reduce the viral load and the potential

for infection to spread.

Then use the standard cleaning anddisinfecting procedures mentioned previously.




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All reusable patient items should be:

Cleaned and disinfected before being usedon another patient

Taken to the dirty utility room for cleaningSend to CSSD for sterilization

Staff should wear full PPE when handlingcontaminated equipment.


Hospital Environment and


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pEquipment

DO NOT spray clean the room / area.

Why?

Because it : Spreads droplets

Spreads aerosols Is not effective as a surface disinfectant



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Case Study

In April to May 2013, there were 27 casesand the majority of those cases were

linked to different healthcare facilities inAl-Hasa, the eastern province of theKingdom of Saudi Arabia (KSA).Themajority of these cases occurred inpatients with underlying comorbidities



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Symptoms n (%)Fever 46 (98 0)


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Fever 46 (98.0)Fever with chills/rigors 41 (87.0)

Respiratory symptomsCough 39 (83.0)Dry 22 (56.0)Productive (sputum) 17 (44.0)Hemoptysis 8 (17.0)Shortness of breath 34 (72.0)Chest pain 7 (15.0)Sore throat 10 (21.0)Runny nose 2 (4.0)

Gastro-intestinal symptomsAbdominal pain 8 (17.0)

Nausea 10 (21.0)

Vomiting 10 (21.0)Diarrhea 12 (26.0)

Other symptomsMyalgia 15 (32.0)Headache 6 (13.0)


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The current case-fatality rate is 58%.The median age of affected individuals is 56

years (range:2-94 years),with a male-to-female ratio of 2.6-1


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Dr. Al-Assiri: Coronavirus Doesnot Spread Easily amongHumans, and Needs DirectContact


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MERS i


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MERS Resources

MERS overview:http://www.cdc.gov/coronavirus/mers/ind

ex.html Case definitions and guidance:

http://www.cdc.gov/coronavirus/mers/case-def.html

Additional MERS resources:http://www.cdc.gov/coronavirus/mers/related-materials.html

Infection Control Measures to
http://www.cdc.gov/coronavirus/mers/index.htmlhttp://www.cdc.gov/coronavirus/mers/index.htmlhttp://www.cdc.gov/coronavirus/mers/case-def.htmlhttp://www.cdc.gov/coronavirus/mers/case-def.htmlhttp://www.cdc.gov/coronavirus/mers/related-materials.htmlhttp://www.cdc.gov/coronavirus/mers/related-materials.htmlhttp://www.cdc.gov/coronavirus/mers/related-materials.htmlhttp://www.cdc.gov/coronavirus/mers/related-materials.htmlhttp://www.cdc.gov/coronavirus/mers/case-def.htmlhttp://www.cdc.gov/coronavirus/mers/case-def.htmlhttp://www.cdc.gov/coronavirus/mers/index.htmlhttp://www.cdc.gov/coronavirus/mers/index.html


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Prevent Hospital Transmission

We hope YOU have learntsomething about MERS CoV and YOUR role in :

preventing transmission and

infection control

mers-cov%2c infection control measures 17 april (1)

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