Avian Influenza

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Avian Influenza

• Infection control and Isolation
• M Hajiabdolbaghi.
• Tehran university .Medical Sciences

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In an era of emerging and re-emerging
communicable diseases, basic infection control
precautions are the cornerstone of the approach
to prevent transmission of communicable diseases
in health-care facilities.
Facilitating compliance with these basic
precautions should be emphasized in all
health-care facilities at all times.
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transmission of human influenza viruses occurs
through multiple routes including large droplets,
direct and indirect contact, and droplet
nuclei. observational studies suggest that
droplet transmission is the major mode of
transmission in that setting
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Standard and droplet precautions should
be the minimum level of precautions to be used
in all health-care facilities when providing care
for patients with acute febrile respiratory
illness, regardless of whether AI infection is
suspected.
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The most critical elements of these
precautions include facial protection (nose,
mouth, and eyes if sprays/splashes of secretions
are anticipated) and hand hygiene and these
precautions should be prioritized .
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HA Infection Control Plan for Avian Influenza

• Respiratory hygiene and cough etiquette
• Standard precautions
• Contact precautions
• Droplet precautions
• 5. Eye protection
• 6. Airborne precautions

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Recommendation for all individuals with
respiratory symptoms
Respiratory hygiene and cough etiquette

• Cover the nose/mouth when coughing or sneezing

• Perform hand hygiene if contact respiratory
  secretions and contaminated objects
• Put on a surgical mask

• Use tissue paper to contain respiratory
  secretions and dispose in the waste receptacle

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Universal Respiratory Hygiene/Cough Etiquette
Strategy

• Encourage patients to alert staff
• Give patients surgical masks
• Provide hand hygiene product
• designate areas in waiting room for symptomatic
  patients
• Encourage triage personnel to wear surgical mask
  during respiratory season
• Use droplet precautions for all patients with
  suspected pneumonia until diagnosis is defined

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• Respiratory hygiene/cough etiquette for all
  health-care facilities
• a) Persons with respiratory infection should be
  educated to
• Cover their mouth and nose with a tissue when
  coughing and dispose of used tissue in
• waste containers
• Use a mask if coughing, when a mask is available
  and can be tolerated
• Perform hand hygiene (use an alcohol-based hand
  rub or wash hands with soap and
• water) after contact with respiratory secretions
  and
• Stand or sit at least 1 metre (3 feet) from
  other persons, if possible.

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Isolation precautions for suspected or confirmed
AI-infected patients
Hand hygiene
Patient placement
PPE
Isolation Precautions
Patient Transport
Decontamination
Linen laundry
Waste Management
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Hand hygiene

• Perform hand hygiene
• Before and after patient contact
• After removing gloves or any other PPE item
• After touching blood, body fluids, secretions,
  excretions, and contaminated items, whether or
  not gloves are worn
• Perform hand hygiene after touching surgical
  mask/ N 95 respirator or before touching the face

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Hand hygiene, which includes hand washing
with soap and water and the use of alcohol-based
hand rubs is critical to prevent possible
self-inoculation of the nose, mouth, and
conjunctiva and the transfer of microorganisms to
the environment or to other patients by
contaminated hands.
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Hands should be washed with soap, either
plain or antimicrobial, and water when visibly
soiled or contaminated with proteinaceous
material. The use of an alcohol-based
hand rub for routine hand antisepsis is
recommended in the health-care setting for all
other clinical situations.
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Ethyl alcohol has greater activity against
viruses than isopropyl alcohol, and therefore
ethyl alcohol-based hand disinfection products
may be preferred over isopropyl alcohol products
in settings where transmission of AI is likely.
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PPE - Gloves

• Change gloves when heavily contaminated

1. When expose to blood, body fluids, secretions,
   excretions, mucous membranes and non-intact skin,
   and contaminated items

• Perform hand hygiene immediately after glove
  removal

• Disposable glove should not be reused

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PPE - Gown

• 2. contact with patient, environmental surfaces
  or patient items

• 1. When splashes or sprays of blood and body
  fluids, secretions and excretions to skin and
  working clothes are likely

3. Select an appropriate gown for the procedure
Long-sleeved gown, fluid-resistant or a
waterproof apron should be worn over the gown
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PPE Respiratory eye protection

• Surgical masks and eye protection
• -When splashes or sprays of blood and
  body fluid, secretions and excretions are likely
  and
• for all aerosol-generating procedures
• - Droplet precautions
• N95 Respirator
• Airborne isolation precautions
• Change PPE promptly if heavily
• contaminated during the procedure

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Types of protective masks

• Surgical masks
• Easily available and commonly used for routine
  surgical and examination procedures
• High-filtration respiratory mask
• Special microstructure filter disc to flush out
  particles bigger than 0.3 micron. These masks are
  further classified oil proof oil resistant
  not resistant to oil
• The more a mask is resistant to oil, the better
  it is
• The masks have numbers beside them that indicate
  their filtration efficiency. For example, a N95
  mask has 95 efficiency in filtering out
  particles greater than 0.3 micron under normal
  rate of respiration.
• The next generation of masks are called
  Nanomasks. These boast of latest technologies
  like 2H filtration and nanotechnology, which are
  capable of blocking particles as small as 0.027
  micron.

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Air Purifying Respirators N95 (filter)
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Powered Air Purifying Respirators (PAPR)
Hooded (versus face-piece)
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• Surgical and procedure masks
• Wear masks once and then discard
• Change masks when they become moist
• Do not leave masks dangling around the neck
• After touching or discarding a used mask,
  perform hand hygiene

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Strategy of Patient Placement

• Isolate suspected or confirmed cases in a
  negative pressure isolation room (12 air changes
  per hour
• When single rooms are fully occupied
• Cohort patients with same confirmed diagnosis in
  same cubicles, maintaining a minimum of 1 metre
  distance from each other
• Confirmed and suspected cases should be nursed in
  separate cubicle

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• Preparation of the isolation room/area
• Appropriate infection control precautions signage
  on the door.
• Place a recording sheet at the entrance.
• All HCWs and visitors entering the isolation
  room/area should print their names (contact
  information) on the recording sheet
• Remove all nonessential furniture.
• furniture should be easy to clean.

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• Doors must be kept closed
• To facilitate cleaning, and to reduce virus
  aerosolization via vacuuming, in uncarpeted
  rooms/areas,.
• When possible, isolation rooms should have
  their own hand washing sink, toilet, and bath
  facilities.
• The number of persons entering the isolation
  room should be limited to the minimum number
  necessary for patient care and support.

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Preparation of the isolation room/area

• Stock the sink area with suitable supplies for
  hand washing, as well as with alcohol based hand
  rub near point of care and room door
• Place appropriate waste bags in a bin. If
  possible use a touch-free bin
• Place a puncture-proof container for sharps
  inside the isolation room.

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Preparation of the isolation room/area

• Keep the patients personal belongings to a
  minimum. and all items necessary for attending to
  personal hygiene within the patients reach.
• Non-critical patient-care equipment (e.g.
  stethoscope, thermometer, blood pressure cuff,
  sphygmomanometer) should be dedicated to the
  patient,
• If it is not possible should be thoroughly
  cleaned and disinfected prior to use.
• Set up a trolley outside the door to hold PPE.
• A checklist may be useful to ensure that
• all equipment is available

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• A telephone or other method of communication
  should be set up in the isolation room to enable
  patient or family members/visitors to communicate
  with HCWs to minimize the necessity for HCWs to
  enter the room.

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Transport of Suspected or confirmed patient

1. Limit patient transport unless clinically
   indicated
2. Encourage patients to wear surgical mask if no
   contraindication

1. Inform the receiving service/department of
   concern beforehand
2. Clean / disinfect transport vehicles after use

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Decontamination - Patient Care Items

• Dedicated non-critical patient care items for
  suspected and confirmed cases
• Clean and disinfect reusable equipment before
  used on other patients.
• Use 1,000 ppm of hypochlorite solution (i.e. add
  1 part of 5.25 hypochlorite in 99 parts of
  water) to disinfect non-critical items
• Use 70 alcohol on metallic surfaces
• Reusable respiratory equipment should undergo
  high level disinfection before reused on other
  patients

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Decontamination - Environmental Control

• Disinfect isolation and procedure rooms
  after use by a high risk patient
• Clean and disinfect the environment regularly
• Contaminated area(and If blood spills occur
  )should be disinfected by one part of
  hypochlorite solution add in 99 parts of water
  for non-metallic and 70 alcohol for metallic
  items.
• the blood should be removed by disposable
  material soaked with one part of hypochlorite
  solution add in 4 parts of water before further
  cleaning and disinfection

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Survival of influenza in the inanimate
environment and on skin

•  
• -         24 48 hr. or hard, non porous
  surfaces
• -         8 12 hr. on cloth, paper, tissue
• -         5 min. or hand
• -         in water 22ºc ? 4 days, 0ºc ? 30 days
• -         at 60ºc for 30 mintues
• -         inactivated by 70 alcohol and by
  Chlorine
• WHO. Interim Infection Control Guidelines for
  Healthcare Facilities for HPAI
  http//www.WPRO.WHO.int/avian/docs/IC_Guidelines_f
  or_HPAI.pdf

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Survival of Influenza Virus on Surfaces

• (WHO) recommends that environmental surfaces be
  cleaned by
• disinfectants such as Sodium hypochloride 1
  in-use dilution, 5 solution to be diluted 15 in
  clean water for materials contaminated with blood
  and body fluids
• bleaching powder 7 gram/liter with 70 available
  chlorine for toilets and bathrooms and
• 70 alcohol for smooth surfaces, tabletops and
  other surfaces where bleach cannot be used.
• Environmental cleaning must be done on a daily
  basis.

Source World Health Organization. Highly
pathogenic avian influenza (HPAI) Interim
infection control guidelines for health care
facilities.
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Environmental cleaning and disinfection

• Cleaning MUST precede disinfection.
• AI virus is inactivated by a range of
  disinfectants, including
• phenolic disinfectants
• quaternary ammonia compounds
• peroxygen compounds
• sodium hypochlorite (household bleach) o alcohol
• other germicides with a tuberculocidal claim on
  the label

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Alcohol

• effective. (e.g. rubber stoppers of multiple-dose
  medication vials, and thermometers) and
  occasionally external surfaces of equipment (e.g.
  stethoscopes and ventilators).
• flammable, its use as a surface disinfectant
  should be limited
• . Alcohol may also cause discoloration, swelling,
  hardening, and cracking of rubber and certain
  plastics after prolonged and repeated use.
• also result in health-care worker injury.

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Sodium hypochlorite (bleach)

• Strong and effective
• Readily inactivated in the presence of organic
  material heat and light.
• From 1060 min
• Available at a low cost,
• Irritates mucous membranes, the skin and the
  airway,, and
• Reacts readily with other chemicals

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Linen and laundry management

• Proper handling of soiled linen
• Avoid sorting
• Minimum agitation and shaking
• Well pack soiled linen to prevent leakage
• Wear appropriate PPE when handling soiled linen
• Clean linen should be transported and stored
  separately to prevent recontamination

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Waste Management

1. All waste generated from room/ area housing
   suspected or confirmed avian influenza patients
   should be treated as clinical waste
2. Biohazard labeling
3. Wear appropriate PPE when handling clinical waste

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Principles of precautions for high-risk procedures

• In high risk patients
• Limit indications of use
• Limit extent of procedure
• Limit number of persons involved
• Use recommended PPE

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Control measures for high-risk procedures (cont)

• Specific CDC recommendations
• Limit aerosol-generating procedures to those
  medically necessary perform them in negative
  pressure isolation room
• Most experienced staff
• Minimal of staff in room
• N95 or higher level respirator (such as PAPR)

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Examples of aerosol-generating procedures include

• Endotracheal intubation
• Bronchoscopy
• Airway suctioning
• Tracheostomy care
• Chest physiotherapy
• Nasopharyngeal aspiration
• Positive pressure ventilation via face mask (e.g.
  BiPAP, CPAP)
• High-frequency oscillatory ventilation
• Resuscitation manoeuvres
• Postmortem excision of lung tissue.

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In countries with AI infections in animals or
humans
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Infection control measures in AE and clinic

• Follow Respiratory Hygiene and Cough Etiquette
  precautions
• Triage Fever, Travel history, Occupational
  exposure, Contact history and Cluster of persons
  with fever and pneumonia symptoms.
• Designated areas for suspected patients while
  waiting for referral and arrange speedy
  consultation and management
• Wear appropriate PPE
• Environment and equipment cleaning and
  disinfection

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Patient discharge

• If the patient is discharged while possibly still
  infectious, family members should be educated in
  personal hygiene and infection control measures
  (e.g. hand hygiene
• and the use of a surgical or procedure mask by a
  patient who is still coughing).
• Family members should be educated to avoid
  poultry and other animals that have been ill,
• and to self-monitor their health status
  Terminal cleaning of the patient room should be
  performed after patient discharge

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Infection Control for Outreach staff

• Cardiac Life Support
• Avoid direct mucosal exposure, e.g. mouth to
  mouth resuscitation
• Use alternative ventilation device e.g.
  resuscitation bags, pocket masks
• Wear appropriate PPE

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Handling of dead bodywith known Avian Influenza

1. Implement standard precautions when caring for
   the deceased patients
2. Wear appropriate PPE when handling dead body
3. Ensure proper covering and packing to prevent
   leaking
4. Attach warning tag indicating risk category 2
   (Yellow label) on outside of the body bag
5. Cremation is not mandatory

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Visiting policy

• In general
• Children under 12 are generally not permitted
• Pregnant women are strongly discouraged  
• Volunteer activities will be arranged differently
  according to corresponding response levels.
• 2. High-risk areas
• No visiting except on compassionate grounds
• Register on visitors record
• Adopt infection control precautions
• Non face to face visiting Mobile phone, video
  conferencing
• 3. Other patient areas
• Keep number of visitors to minimum (2 in each
  times),2 hours /day
• Keep track on the number of visitors
• Wear surgical mask and encourage hand hygiene
• Arrange PPE and hand hygiene facilities
• Supply health information on proper infection

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• arents/legal guardians of paediatric patients
  should be strongly supported to accompany the
  patient throughout the hospitalization.
• Parents/relatives/legal guardians may assist in
  providing care to AI-infected patients in special
  situations (e.g. lack of resources, paediatric
  patients, etc.) if adequate training and
  supervision of PPE use and hand hygiene is
  ensured.
• Because family members may have been exposed to
  AI via the patient or similar environmental
  exposures, all family members and visitors should
  be screened for symptoms of respiratory illness
  at entry to the facility.

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• using PPE and when taking PPE off. Example
• put on fluid-resistant gown
• put on disposable particulate respirator
• perform user seal check of particulate respirator
• put on hair cover (if used, e.g. during an
  aerosol-generating procedure)
• put on face shield or goggles
• put on gloves (make sure gloves cover cuff of
  gown sleeves).
• Enter the room and shut the door.

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• Leaving the isolation room/area
• leave the isolation room/area
• Remove PPE either in the anteroom or if there is
  no anteroom make sure that neither the
  environment outside nor other persons can get
  contaminated
• Remove gloves and discard in rubbish bin (gloves
  may be peeled from hands when gown is removed)
• Perform hand hygiene with an alcohol-based hand
  rub (preferably) or soap and water
• Remove protective eyewear and discard in rubbish
  bin. If reusable, place face shield in container
  for decontamination

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• oRemove medical mask or particulate respirator by
  grasping elastic bands,
• Do not touch front of particulate respirator
  (front of masks may be
• contaminated) and discard in rubbish bin.
• Perform hand hygiene with an alcohol-based hand
  rub (preferably) or soap and water.

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• Antiviral prophylaxis for potentially exposed
  HCWs
• When used, the HCW should take 75 mg
  oseltamivir phosphate each day for at least 7
  days beginning immediately, or as soon as
  possible, after unprotected exposure (lt 48 hours)
  to an AI A (H5N1) infected patient.
• prophylaxis should continueuntil 1 week after
  the last unprotected exposure.

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• Please check your temperature twice a day
  (morning, AM evening, PM) for 10 days after
  providing care for an
• AI-infected patient (including 10 days after your
  last exposure), and also monitor yourself for any
  of the
• following influenza-like illness symptoms
  including
• fever gt 38 C
• cough
• acute onset of respiratory illness
• sore throat
• arthralgia
• myalgia or prostration
• gastrointestinal symptoms (e.g., diarrhea,
  vomiting, abdominal pain)
• If any symptoms of influenza-like illness (ILI)
  occur, immediately limit your interactions with
  others, exclude
• yourself from public areas, and notify
  _____________________________at
  __________________________

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