Severe Acute Respiratory Syndrome SARS

1
Severe Acute Respiratory Syndrome (SARS)

• Infection Control Measures to Prevent Hospital
  Transmission

WHO Western Pacific Regional Office 14 October
2
Overview

• Epidemiology and Clinical Management
• Infection Control Precautions
• Laboratory Safety
• Mortuary Safety
• Linen, Laundry, Waste Management
• Environmental Cleaning

3
Background

• Approximately 8098 cases in 29 countries as
  of 31 July 2003
• At least 774 deaths
• 1707 Cases (21) have been health care workers

4
Chronology

• SARS, an atypical pneumonia of unknown etiology,
  was recognized at the end of February 2003
• The World Health Organization (WHO) co-ordinated
  the international responses to provide
  epidemiological, clinical and logistical support
  as required

5
Chronology

• 11 February
• Chinese health officials reported atypical
  pneumonia in Guangdong Province, China 305
  cases/5 deaths (Nov 02Feb 03)
• 19 February
• Hong Kong confirms human infection of Influenza
  H5N1

6
Chronology

• 5 March
• Outbreak in Hanoi recognized
• 11 March
• Hong Kong reports SARS outbreak
• 13 March
• Singapore reports 3 SARS cases
• 15 March
• The disease spread to outside Asia (Canada,
  Germany)

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Chronology

• WHO initiates
• Global Alert (12 March)
• Travel Advisory (15 March 2, 23 29 April)
• Enhanced global surveillance
• Global Outbreak Alert and Response Network
• Specific Global Networks (Lab, Case Management,
  Epidemiology)

8
Chronology

• Forward planning of Activities since then
• Infection Control Guidelines bi-regional
  guidelines will now cover all issues for
  Infection Control practice in a Health Care
  Facility due out soon
• Infection Control Programme will support member
  states in how to set up an IC programme
• IC Audit tool for self evaluation of HCF

9
Epidemiology

• Cause SARS CoV
• Highly infectious
• Mainly affects adults
• Superspreading events important in transmission
  process
• No reports of transmission occurring before onset
  of symptoms

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Epidemiology

• Means of transmission
• Evidence of person to person transmission
• Close contact with body fluids (especially
  respiratory droplets )
• Contaminated hands, clothes, equipment
  environment may also be important

11
Epidemiology

• Risk factors for transmission
• High risk medical procedures
• Intubation
• Bronchoscopy
• Cough-inducing procedures (sputum induction,
  administration of nebulised medications,
  suctioning)

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Epidemiology

• Incubation period
• 2 10 days and up to 13 days in exceptional cases
• Onset and duration of infectivity unknown
• Organism survival in environment
• Duration unknown
• Data has shown SARS CoV may survive for 2-3 days

13
Case Definitions

• Developed for public health purposes in the
  inter-outbreak period
• A person with a history of
• Fever (gt 38oC)
• AND one or more of the symptoms of lower
  respiratory tract illness (cough, difficulty
  breathing, shortness of breath)
• AND Radiographic evidence of lung infiltrates
  consistent with pneumonia or RDS or autopsy
  finding consistent with the pathology of
  pneumonia or RDS without an identifiable cause
• AND No alternative diagnosis can fully explain
  the illness

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Case Definitions

• Laboratory case definition of SARS
• A person with symptoms and signs that are
  clinically suggestive of SARS AND with positive
  laboratory findings for SARS-CoV based on one or
  more of the following diagnostic criteria
• a) PCR for SARS-CoV using a validated method
  from
• At least 2 different clinical specimens (eg
  nasopharyngeal or stool) OR
• The same clinical specimen collected on 2 or more
  occasions during the course of the illness
• Two different assays or repeat PCR using a new
  RNA extract from the original clinical sample on
  each occasion of testing

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Case Definitions

• b) Seroconversion by ELISA or IFA
• Negative antibody test on acute serum followed
  by positive antibody test on convalescent phase
  serum tested in parallel OR
• Fourfold or greater rise in antibody titre
  between acute and convalescent phase sera tested
  in parallel
• c) Virus Isolation
• Isolation in cell culture of SARS-CoV from any
  specimen AND PCR confirmation using a validated
  method
• Testing should only be undertaken in a national
  or regional reference laboratory as per WHO
  guidelines.

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Contacts

• Definition
• Close contact having cared for, lived with, or
  had
• direct contact with the respiratory secretions or
  body fluids of a suspect or probable case of
  SARS.
• Contacts of persons under investigation for SARS
  should be traced and quarantined until SARS has
  been ruled out as the cause of the illness

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Clinical Picture Onset / Presentation

• Sudden onset of high fever with myalgia, chills,
  rigors and a non-productive cough
• Most cases have bilateral pneumonia
• 90 begin to recover from
• day 6 or 7

19

Clinical Picture Onset / Presentation

• Rapid deterioration in 10 (/-) of cases
• Acute RDS
• Require ICU admission
• mechanical ventilation
• Case fatality rate 6
• No specific treatment available

20

Clinical Picture Management

• SUPPORTIVE TREATMENT
• Antibiotic Therapy
• to cover causative organisms
• Prophylactic Antibiotic Therapy
• to prevent secondary bacterial infection
• Maintain oxygenation
• intubate and ventilate as necessary

21

Clinical Picture Management

• SUPPORTIVE TREATMENT
• Avoid interventions which may cause
• aerosolisation of respiratory secretions
• Bronchoscopy
• Nebulised bronchodilators
• Chest physiotherapy
• Gastroscopy
• Any procedure / intervention that may
• release respiratory secretions

22

Clinical Picture Management
SUPPORTIVE TREATMENT In severe cases
corticosteroids and ribavirin have been used,
however there is no evidence to support
their general or routine use at this stage.

23

Summary SARS

• Multi - Country Outbreak
• New Pathogen
• CoronaVirus family SARS CoV
• Clinical Picture
• Fever and respiratory symptoms
• case fatality rate currently 4
• Transmission
• Close contact with symptomatic case(s)
• Contaminated hands and objects

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Summary SARS

• Prevention Control
• Identification
• Isolation of suspect and probable cases
• Tracing quarantine of close contacts
• Infection control precautions for all suspect and
  probable cases
• Public Education
• Health care workers are currently at greatest
  risk therefore
• Infection control precautions are essential

25
Infection Control Precautions

• Infection Control precautions (previously known
  as Barrier nursing techniques) are designed to
  prevent infection from the patient to the
  staff/visitor or the staff/visitors to other
  patients.
• Strict precautions must be used
• for all
• SARS patients.

26
Patient Management

• SARS Infection Control Goals
• SARS Admissions - Triage
• Components of SARS Isolation
• SARS Infection Control Practices

27
SARS Infection Control Goals

• In addition to providing the best possible
  clinical care
• Detect early any suspect cases.
• Implement appropriate isolation measures.
• Protect health care personnel.
• Protect other patients.
• Protect family and community members.

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Triage for SARS Admissions

• If possible, there should be separate wards/areas
  
• for each of the following categories
• Patients with colds, sniffles and runny noses
  should 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 where
  possible use a single room for all patients

29
Components of SARS Isolation

• Facility
• Administrative Controls
• Clinical Surveillance of Staff
• Organization of Isolation Area
• Protective Equipment
• Standard Precautions

30
Facility

• Isolated from other patient / staff movement
• Good ventilation
• Air movement corridor to room to outdoors
• Turn off central air-conditioning systems unless
  the room can be isolated from the system.
• Sinks and running water
• Adequate bathroom facilities
• Capacity to handle waste and laundry
• Sufficient rooms for expected number of patients
• Contingency plans for converting other areas to
  isolation facilities

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Facility

• Isolation Area Full IC Precautions required
• Colour codes
• Green
• (GO) General reduced staff movement
• Yellow
• (CAUTION) Limited staff movement
• Red
• (RESTRICTED) Assigned staff only

34
Administrative Controls

• Limit and control points of entry to SARS 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

35
Administrative Controls

• Assignment of responsibility
• Determining patient placement
• Overseeing implementation and enforcement of
  infection control measures
• Enforcing access restrictions
• Supply acquisition and distribution
• Surveillance of Health Care Workers (HCWs)

36
Clinical Surveillance of Staff

• Maintain list of all staff who worked with SARS
  patients or on the SARS ward
• Systematically monitor for fever and
• Twice daily temperature for staff working in the
  area (baseline Chest X-Ray may be needed )
• Screen for symptoms of SARS-like illness among
  staff reporting for duty.
• List contact information for
• Persons visiting or caring for SARS patients
  and
• Contacts of HCWs in close contact with SARS
  patients.

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Organization of SARS Isolation Area

• Put Up Signs eg. SARS Isolation Area
• Designated area for clean protective equipment
• Instructions for using protective equipment
• Accessible to personnel
• Sufficient inventory to meet daily needs
• Separation of clean and dirty supplies including
  an area for containment of waste and soiled linen
  
• Color-coded bags and containers for contaminated
  waste and laundry
• Containers for laundry and all waste should have
  foot-operated lids

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Infection Control

• You can minimize YOUR risk of catching
• SARS
• by following
• Infection Control Precautions.

40
Infection Control Precautions for SARS Standard
PrecautionsRespiratory PrecautionsContact
Precaution
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Exposure Risks

• Patient
• Respiratory secretions
• Blood
• Body fluids including excreta
• Skin lesions
• Staff
• Visitors

• Health Care Staff
• Respiratory secretions
• Blood
• Body fluids including excreta
• Mucous membranes
• Skin lesions
• Sharps
• Visitors

42
An essential Infection Control precaution to
prevent the transmission of SARS

• Hand Washing

43
Principles of Hand Washing

• Hand Washing
• Is the single most important and effective
  component for preventing the transmission of
  infection.
• Is designed to remove transient microorganisms
  that may have been picked up from 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.

44
Handwashing When?

• After removing gloves
• Before and after patient contact
• After contact with blood or body fluids from any
  patient
• After taking blood pressure or vital signs from
  any patient
• Other times
• After using bathroom
• After blowing or wiping nose
• Before eating
• Before preparing food

45
Handwashing How?

• Handwashing procedure
• Running water
• Soap (preferably liquid)
• Friction
• Or use Alcohol-based hand rub

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Handwashing Steps

Step 1
Wet hands and wrists. Apply soap
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Handwashing Steps

Step 2
Right palm over left. Left over right.
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Handwashing Steps

Step 3
Palm to palm with fingers interlaced.
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Handwashing Steps

Step 4
Back of the fingers to the opposing fingers
and interlocked.
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Handwashing Steps
Step 5
Rotational rubbing of the right thumb
by clasping it in the left palm. And vice
versa.
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Handwashing Steps

Step 6
Rotational rubbing backwards and forwards with
tops of fingers and thumb of right hand in
left. And vice versa.
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Drying Your Hands

• It is important to dry your hands thoroughly
  after
• washing them because
• Damp hands collect microorganisms
• Damp hands spread potentially infectious
  microorgansims
• Damp hands may become colonised with potentially
  infectious microorganisms
• Therefore it is important to pat dry your hands
  thoroughly.
• Pat drying also helps to prevent damage to
  skin.

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Handwashing Tips

• Remember
• Wash hands for a minimum of 15 to 20 seconds.
• Ensure you have washed all areas properly.
• Dry hands thoroughly.

54
Handwashing Tips

• Alcohol based hand gels/ lotions
• Use on clean (unsoiled) hands
• Use enough of the product to cover hands
• Vigorously rub hands using the same steps as
• Step 1 6 (do not wet hands prior to applying
  the solution/gel)

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Handwashing in Difficult Situations

• If running water is not immediately available,
  what should you do?
• Use a basin of clean water and wash hands.
• Use a clean basin each time.
• Use fresh water each time.
• DO NOT contaminate sources of fresh / clean water
  by handling ladles or dippers.

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Handwashing in Difficult Situations

• If water is not immediately available, what
  should you do?
• Use an 70 alcohol based hand rub solution.
• Use sufficient amount to completely cover your
  hands.
• Wash your hands using running water
• and soap as soon as they become soiled
• NB Alcohol is very effective when hands are
  clean
• (i.e.. not soiled with blood, body fluids etc)

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Infection Control Precautions

• Precautions
• Standard Precautions
• Respiratory Precautions
• Contact Precautions
• Hand Washing
• PPE
• Exposure Risks
• Patient transport

• Other Infection Control Factors
• Patient and family
• education
• Laboratories / Specimens
• Mortuary Care
• Waste and Linen Handling
• Cleaning Disinfection

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Personal Protective Equipment (PPE)

• N-95 Respirator Mask must be worn
• Goggles (protective glasses)
• Disposable or Reusable Gowns
• Disposable Gloves
• Cap and shoe covers are optional

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Personal Protective Equipment for SARS
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Personal Protective Equipment (PPE)

• N-95 Respirator Mask
• Gloves
• Gown
• Goggles
• Optional
• Cap
• Shoe covers

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Principles for Using PPE

• Personal Protective Equipment (PPE) is used
• to protect health care workers by preventing
• potentially infectious microorganisms from
• Contaminating their hands, eyes and clothing
• and
• Being transmitted to other patients and staff.

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Principles for Using PPE

• PPE reduces but does not completely eliminate the
  possibility of infection.
• PPE is only effective if used correctly.
• The use of PPE does not replace basic hygiene
  measures such as hand washing hand washing is
  still essential to prevent transmission of
  infection.

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N-95 Respirator Masks
Different types of N-95 Respirator Masks
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Principles for Using the N-95 Respirator Mask

• The N-95 respirator mask is used to protect
  health
• care workers, other patients, staff or visitors
  by
• preventing potentially infectious microorganisms
• such as respiratory secretions from
• Contaminating their face including the nose and
  mouth.
• Being inhaled or ingested.

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N-95 Respirator Mask

• For respiratory
• protection wear
• an N-95
• respirator mask
• during all
• patient contact

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Proper use of N-95 Respirator Mask

• DO NOT touch the front of the mask once the mask
  has been fitted
• Wear only one N-95 mask no need for additional
  respiratory protection
• REMOVE the N-95 respirator mask before leaving
  the isolation unit / area

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WHY an N-95 Respirator Mask?

• N-95 respirator masks offer a higher level of
  filtration for respiratory secretions than a
  surgical mask

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HOW to use an N-95 Respirator Mask

• Use for single shift unless excess moisture
  necessitates replacement during each shift or it
  has become contaminated by touching or soiling
• Label with the wearers name
• Dispose of with medical waste
• NB You must fit the mask securely over both
  your nose and mouth

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HOW to use an N-95 Respirator Mask

• 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 both your
  nose and mouth so size is important.

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N-95 Respirator Mask

• This is only one example (brand) of an N95
  respirator mask.
• Other types of N95 masks must be fitted according
  to the manufacturers instructions

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N-95 Respirator Masks- Fitting Instructions
Step 1
Cup the respirator in your hand with the
nosepiece at your fingertips allowing the
headbands to hang freely below your hand.
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N-95 Respirator Masks- Fitting Instructions

Step 2
Position the respirator under your chin with the
nosepiece up.
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N-95 Respirator Masks- Fitting Instructions
Step 3
Pull the top strap over your head resting it high
at the top back of your head. Pull the bottom
strap over your head and position it around the
neck below the ears.
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N-95 Respirator Masks- Fitting Instructions

Step 4
Place the fingertips of both hands at the top of
the metal nosepiece. Mould the nosepiece to the
shape of your nose by pushing inward while moving
your fingertips down both sides of
the nosepiece. Pinching the nosepiece using one
hand may result in less effective respirator
performance.
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N-95 Respirator Masks- Fitting Instructions

Step 5.1
The seal of the respirator on the face should be
fit- checked prior to wearing in the work area.
Cover the front of the respirator with both
hands, being careful not to disturb the
position of respirator.
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N-95 Respirator Masks- Fitting Instructions

Step 5.2 Positive Fit Test
Exhale sharply. A positive pressure should be
felt inside the respirator. If any leakage is
detected, adjust the position of the respirator
and/or tension of straps. Retest the
seal. Repeat the steps until the respirator is
sealed properly.
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N-95 Respirator Masks- Fitting Instructions

Step 5.3 Negative Fit Test
Inhale deeply. If there is no leakage, the
negative pressure will make the mask cling to
your face. A poor seal will result in prompt loss
of negative pressure in the mask due to air
entering through gaps in the seal.
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When to change your N-95 Respirator Mask?

• If you touch the front of the mask
• If it is grossly contaminated
• If it becomes wet

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Principles for Using Goggles, Gowns, Gloves, Caps
and Overshoes

• Goggles, gowns, gloves, caps and overshoes are
• used to protect health care workers, by
  preventing
• potentially infectious microorganisms from
• Contaminating their eyes, clothing, hands, hair
  and shoes and
• Being transmitted to other patients and staff.

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Goggles

• Assign one pair to each worker at the beginning
  of a shift
• Wear goggles in room with SARS patients
• Leave in the container in the anteroom at the
  end of the shift to be cleaned and disinfected

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Goggles
You should use goggles to cover all of the eye
area.
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Gowns

• Long sleeved gowns must be worn when in direct
  contact with the patient
• Wear gown at all times in the patients room
• Gowns must be removed before leaving the
  patients room or dedicated anteroom
• Remove used gowns as soon as possible
  particularly when grossly contaminated

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Gowns
A new Gown should be worn for every patient
contact

• Disposable Gowns
• Use a new gown for
• each patient contact.
• Discard immediately if
• visibly contaminated.

• Reusable Gowns
• If necessary, gowns may be
• reused during one shift for
• the same patient, e.g. when
• short of supplies.
• Discard immediately if
• Visibly contaminated.
• Hang gown with outside
• facing in when not in use.
• Discard at the end of the
• shift.

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Gloves

• Before all patient contact
• Before all cleaning
• Before handling soiled linen waste

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Gloves

• Remove after contact with patients or lab
  specimens
• Do not wear gloves outside of the patients room
  / anteroom
• Do not re-use gloves
• Wash hands after removing your gloves

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Plastic Disposable Aprons

• Plastic disposable aprons must be worn whenever
  there is a likelihood of other PPE such as gowns
  becoming wet.
• They are worn to reduce the risk of breakthrough
  and contamination of clothing worn underneath the
  PPE.
• They must be disposed of after use.

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Plastic Disposable Aprons

• Aprons must be worn when
• Performing patient care activities where soiling
  or increased moisture is likely
• Cleaning and disinfecting the patient
  environment.
• Cleaning and disinfecting medical other patient
  care equipment.
• Laundering used linen.
• Cleaning and disinfecting the cleaning equipment.

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Caps
Caps are optional and worn to protect the hair
from aerosols that may occur from high risk
procedures such as intubation or bronchoscopy
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Overshoes
Overshoes are optional and worn to protect the
health care workers shoes and feet from being
splashed by spills such as blood or other body
fluids or aerosols
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Key Points

• Wear N-95 respirator mask, goggles, disposable
  gowns, gloves (and hats, overshoes optional in
  high risk situations) for all patient contact
  aprons when necessary
• Wash hands using soap (preferably liquid) and
  water when leaving the anteroom
• Use an 70 alcohol-based hand rub solution after
  hand washing
• Wash hands when leaving the unit

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Personal Protective Equipment for SARS
92
Patient Transport

• It is essential to avoid all unnecessary
  transport of isolated SARS patients to control
  and prevent the potential spread of SARS
  infection.

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Patient Transport

• If 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 wear an N-95 respirator mask
  (standard surgical masks can be used by patients
  if N-95 respirator masks are not tolerated or are
  in insufficient supply) and an isolation gown.
• Accompanying staff must wear
• N-95 respirator mask
• Gloves
• Gown
• Goggles

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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
• Clean and disinfect ambulance after transport
• Standard cleaning and disinfecting
• or
• 1100 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 Community Education

• Education for the patient, their family and the
  community is essential in the control and
  prevention of the SARS Virus.
• It is particularly essential for those persons
  requiring hospital or home isolation to
  understand the necessary restrictions.

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Patient, Family Community Education

• Explain
• What SARS 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 SARS 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 why
• disposable equipment is being used
• such as
• Eating utensils
• Medical equipment
• Patient gowns

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Laboratories

• Laboratory staff must ensure that their practices
  are meticulous.

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Laboratories

• Advance planning in each designated laboratory is
  essential to ensure that specimen handling,
  transportation and storage is managed according
  to the guidelines.

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Bio Safety for SARS in Laboratories

• The following activities may be performed in
  biosafety level 2 (BSL-2) facilities with
  appropriate work practices
• Routine diagnostic tests
• Manipulations involving known inactivated viru
  and/or incomplete, non-infectious portions of the
  viral genome
• Routine examination of mycotic and bacterial
  cultures
• Final packing of specimens for transport

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Bio Safety for SARS in Laboratories

• Precautions for BSL-2 labs
• biological safety cabinet for any procedure that
  may generate aerosols
• PPE to be worn
• disposable gloves
• solid-front or wrap-around gowns with cuffed
  sleeves
• eye protection
• surgical mask, or full-face shield, according to
  the risk of aerosols and exposure
• When working at a biological safety cabinet, a
  full face shield is not necessary.

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Bio Safety for SARS in Laboratories

• Precautions for BSL-2 labs
• Use sealed centrifuge cups unload in a safety
  cabinet
• Decontaminate work surfaces and equipment
• Biological waste should be treated as outlined in
  the WHO Laboratory Biosafety Manual 2nd Edition
  (Revised), 2003

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Bio Safety for SARS in Laboratories

• BSL-3 facilities BSL-3 work practices are
  required for
• Viral cell culture of the etiologic agent
• Manipulations involving growth or concentration
  of the etiologic agent.
• When a procedure or process cannot be conducted
  within a biological safety cabinet, then
  appropriate combinations of personal protective
  equipment (e.g., respirators, face shields) and
  physical containment devices (e.g., centrifuge
  safety cups or sealed rotors) must be used.

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Specimen Collection

• Wear full PPE
• Write clinical details on the request form
• Samples should be collected by clinical staff
• Label the clinical samples clearly
• Change PPE between patients
• Discard all disposable materials in a biohazard
  bag

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Storage of Specimens

• Respiratory samples and frozen tissues
• store at 70oC
• Serum
• store at 4 - 8oC for 24-48 hours
• or
• at -20oC for longer periods

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Patient Specimens

• Treat all patient specimens as highly infectious
• Use leak proof containers for collection

• Do not contaminate outside of container
• Transport specimens in leak-proof outer
  containers e.g. a sealed plastic bag

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Mortuary Precautions

• Health care workers must wear full PPE
• (N-95 respirator mask, Goggles, Gown, Gloves)

• Health Care Workers must
• Prepare the body
• Place in a body-bag or leak-resistant bag
• or
• Place in plastic sheeting, wrap the body and
  tape/seal with waterproof adhesive tape

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Mortuary Precautions

• The body must be placed in cold storage (3C
• /- 2C ) as soon as possible after the body is
• prepared and wrapped in a bag or plastic
  sheeting.
• The need for a post mortem must be discussed
• with the designated national laboratory as there
• are potential infection risks for personnel
  during a
• post mortem.
• Post mortems must be performed wearing full PPE

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Mortuary Care

• Although all due deference must be given to local
  
• cultural and religious customs associated with
  the
• death of a member of the community, the following
• must be considered to minimize the potential risk
  of
• spread of the SARS Virus.
• The body must not be embalmed, to reduce exposure
  risk.
• The need for cremation with minimal delay.
• The delaying of a wake to celebrate the life of
  the individual until all close contacts and
  possible secondary contacts are cleared.

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Linen LaundryWaste Management

• Health care and laundry workers must understand
  the importance of handling linen correctly to
  prevent the spread of potentially infectious
  microorganisms
• Linen can be washed using routine laundry
  practices.
• The health care facility should follow routine
  waste management practices but all waste must be
  incinerated.

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Linen

• All contaminated or
• soiled linen is potentially
• infectious therefore
• Wear full PPE when handling linen.
• Separate grossly contaminated linen from non-
  contaminated linen in the patients room for ease
  of handling in the laundry.

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Laundry

• Place in color-coded bags and double bag for
  transport.
• Do not sort linen in the laundry to avoid the
  creation of aerosols.
• Staff handling linen should wear full PPE as per
  standard procedures for SARS.
• Use routine detergents.
• Bleach may be added if desired, and compatible
  with the detergent being used.

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Waste

• Wear full PPE when handling waste.
• Clinical waste all items from treatment areas
• Soiled surgical dressings
• Swabs
• Masks
• Gowns
• Other contaminated waste

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Waste

• Sharps Containers.
• Collect waste in designated color-coded plastic
  bags for incineration.
• Double bag for transport.
• Contact the local authorities for assistance if
  the health care facility does not have
  incineration facilities.

116
Sharps Disposal
Disposal containers should be puncture-resistant
and leak- proof.

• Do not overfill container
• Do not reach into container
• Dispose of used sharps into the sharps container

117
Cleaning Disinfecting the Hospital Environment
and Equipment

• Cleaning is usually sufficient for prevention and
  control of infection, but for SARS infection the
  use of a disinfectant following cleaning is
  recommended
• It is essential to clean thoroughly before
  disinfecting the environment or equipment.
• Cleaning and disinfection must be carried out at
  least daily and particularly when gross
  contamination occurs.
• In some instances it may be necessary to
  disinfect to render the item safe to handle.

118
Cleaning Disinfecting the Hospital Environment
and Equipment

• Cleaning and disinfecting patient
• rooms and equipment is one of the best ways
• to reduce transmission of infection
• Wear full PPE when cleaning and
• disinfecting

119
Cleaning Disinfecting the Hospital Environment
and Equipment

• To communicate infection risk, use signs.
• eg. SARS Isolation
• Protect patients staff by
• - Cleaning and disinfecting equipment.
• - Cleaning and disinfecting the room and
  anteroom.

120
Cleaning Disinfecting the Hospital Environment
and Equipment

• The immediate area around patients must be
  considered heavily contaminated.
• Bedside table, bed stand, and accessible areas of
  bed and floors must be cleaned with detergent and
  warm water at least daily (preferably twice a
  day).
• In addition, disinfect all surfaces after
  cleaning.

121
Cleaning Disinfecting the Hospital Environment
and Equipment

• Contain and dispose of infectious materials in
  waste containers
• Put waste containers near entrance / exit to
  patient room.
• Provide dedicated patient equipment when
  possible.
• Clean and disinfect patient care equipment
  immediately after use depending on the type of
  equipment.

122
Cleaning Disinfecting the Hospital Environment
and Equipment

• Use standard procedures and agents for cleaning
• And disinfecting environmental surfaces and
• patient care equipment.
• Use detergent and warm water, rinse in hot water
  and dry.
• Use disinfectant afterwards.

123
Cleaning Disinfecting the Hospital Environment
and Equipment

• When areas and inanimate objects are grossly
  contaminated use
• 1100 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 and disinfecting
  procedures mentioned previously.

124
Cleaning Disinfecting the Hospital Environment
and Equipment

• All reusable patient items such as basins and
• bedpans should be
• Cleaned and disinfected before being used on
  another patient
• Taken to the dirty utility room for cleaning
• Staff should wear full PPE when handling
• contaminated equipment.

125
Cleaning Disinfecting the Hospital Environment
and Equipment

• DO NOT spray clean the room / area.
• Why?
• Because it
• Spreads droplets
• Spreads aerosols
• Is not effective as a surface disinfectant