Global Health Prep Course 2008

Global Health Prep Course 2008

W. Charles Huskins, MD, MSc

Mayo Clinic, Rochester, MN

November 8, 2008

Infection Prevention in Settings with Limited Resources

Disclosures: None

Healthcare-associated infections in settings with limited resources are…

A. B. C. D.

21%

10%

67%

2%

A. Caused by agents typically associated with infections in tropical settings

B. Infrequent because most care is not associated significant risk

C. Similar to those in settings with adequate resources

D. Unfortunate but mostly unavoidable

Protect your patients!

Protect yourself!

Protect Your Patients and Yourself From “community infections” spread in healthcare settings

Respiratory & GI infections

Infection

Person-to-person, via direct, indirect or droplet spread

Contaminated infant formula, enteral feedings

Improperly prepared/stored foodContaminated waterContaminated surfaces

RSV, influenza, etcRotavirus, etcGiardia, Cryptosporidium

SalmonellaShigellaVibrio cholera

Source/causeOrganisms

Airborne spread from infected persons

Measles, varicella, rubella, mumps

Systemic viral infections

Airborne spread from unidentified and/or inadequately treated persons

M. tuberculosisTB

Overcrowding

Inadequate Sinks and Suppliesfor Hand Hygiene

Protect Your Patients and Yourself From “community infections” spread in healthcare settings

• Hand hygiene– Use an alcohol-based hand rub in most situations– Wash hands with soap & water if visible contamination

• Barrier precautions– Wear gloves for contact with blood, body fluids, secretions,

excretions, mucous membranes, & non-intact skinIf limited in supply, use new gloves for contacts with blood &

body fluids and reused gloves for other types of contactsIf limited in supply, dip gloved hands in diluted household bleach

(0.05% chlorine concentration) for 1 minute between contacts; remove soiling by washing with soap and water first.

– Wear goggles & mask if splashing/aerosolization possible– Wear gowns if soiling of clothing is possible

Simple Solutions to Improve Hand Hygiene

Alcohol-based hand rub &container with clean gloves on cart

Cistern with clean water, soap & clean, single use cloth towels on cart

WHO Clean Care is Safer CareThe First Global Patient Safety Challenge

http://www.who.int/gpsc/en/

http://www.cdc.gov/ncidod/dvrd/spb/mnpages/vhfmanual.htm

Infection Control for Viral Hemorrhagic Fevers in the African Healthcare Setting

• Detailed descriptions of IC procedures for VHF

• Practical descriptions of general IC procedures– Standard Precautions– Isolation Precautions– Disinfection of reusable

supplies & equipment– Disinfection water for

drinking, cooking & cleaning– Disposal of waste– Safe burial practices

Protect Your Patients and Yourself From “community infections” spread in healthcare settings

• Additional measures for infections spread by airborne or droplet contact– Cohort patients with same disease– Avoid cough-inducing procedures– Ensure adequate ventilation– Close doors and use out-facing window or wall fan to

direct air out of building– Ultraviolet germicidal irradiation may be appropriate in

some situations

http://www.who.int/tb/publications/who_tb_99_269/en/index.html

WHO Guidelines for Preventing Spread of TB in Healthcare Settings

Initial Management of a Patient with Suspected TB

• Provide face mask or tissues

• Instruct in cough hygiene – cover nose and mouth when coughing or sneezing

• Dispose of tissues, cloths or masks in no-touch waste receptacles after use

• Direct to a separate waiting area

• Deliver services quickly (ahead of the queue)

• Refer to a TB diagnostic & treatment facility

Protect Your Patients and YourselfFrom bloodborne infections

Blood productsUnsafe injection practicesContaminated fluids/meds & sharps

Hepatitis B & C viruses

HIV

Hepatitis, AIDS

Source/causeOrganismsInfection

Blood productsUnsafe injection practicesContaminated fluids/meds

Plasmodium sp.Trypanosoma cruzi

MalariaChagas Disease

Direct contact with blood, body fluids, or mucous membranes

Unsafe injection practicesContaminated sharps

Ebola, Lassa Fever, Marburg, etc

Hemorrhagic fever

Protect Your Patients and YourselfFrom bloodborne infections

• Blood products– Eliminate unnecessary transfusions– Screen products appropriately– Administer products appropriately

• Injections– Use sterile needles & syringes– Prevent contamination of injection equipment and

fluids or medications

• Sharps injuries– Avoid handling sharps– Dispose sharps properly

http://www.who.int/injection_safety/toolbox/en/LeafletBestPracticesPrinter.pdf

http://www.who.int/injection_safety/toolbox/en/LeafletBestPracticesPrinter.pdf

Syringes for Injection Safety Reuse Prevention Feature Reuse & Needlestick

Prevention Features

Internal mechanism blocks plunger once it is fully pressed.

Internal mechanism cracks plunger completely once it is fully pressed

Additional shield to cover needle creating a protective cap

Needle is pulled back inside the syringebarrel upon retraction of the plunger

Protect Your Patients From infections associated with invasive

devices and procedures

IV cathetersContaminated fluids and medications

Gram negative rodsStaph. aureusCandida

Bloodstreaminfections

Source/causeOrganismsInfection

Urinary catheters & open collection systems

Gram negative rodsCandida

Urinary tractinfection

Poor techniqueContaminated instrumentsNo/late/inadequate prophylaxis

Staph. aureus Gram negative rods

Surgical site infection

Intrapartum examsContaminated instrumentsNo/late/inadequate prophylaxis

Gram negative rodsAnaerobes

Postpartum endometritis

Etiology of Invasive Bacterial Infections in Newborns 0-3 day in Hospitals, 1990-2004

E. coli GBS S. aureus OthersKlebsiella, Pseudomonas, Acinetobacter & other gram negative rods

0

10

20

30

40

50

60

70

Africa (n=110) Middle East (n=27) South Asia (n=239) South East Asia (n=91) LatinAmerica/ Caribbean

(n=41)

All developing regions(n=508)

%

Zaidi AKM, Huskins WC, Thaver D, et al. Lancet 2005; 365:1175-88

Inappropriate Use of Invasive Devices

Lack of Acceptable Quality Supplies & Equipment

Contaminated IV Fluidsand Medications

Inadequate Sterilization/Disinfection Procedures

Protect Your Patients From infections associated with invasive

devices and procedures

• Invasive devices– Eliminate unnecessary use– Remove as soon as possible– Use sterile devices and supplies– Use aseptic technique during insertion and care– Maintain closed systems

• Invasive procedures– Eliminate unnecessary use– Use sterile instruments and supplies– Use aseptic/sterile technique– Use peri-procedure antimicrobial prophylaxis as indicated

(clean-contaminated, contaminated, dirty procedures)

Infection Control Assessment ToolA Standardized Approach for Improving

Hospital Infection Control Practices

• Modules for assessment and problem-solving regarding– Infection control programs

– Practices: hand hygiene, isolation & standard precautions, injections, IV catheters, fluids & meds, urinary catheters, sterilization/disinfection

– Areas: general wards, labor & delivery, surgery, ICUs

– Ancillary services: microbiology, pharmacy, employee health, waste management

• Developed and supported by – Rational Pharmaceutical Management Plus Infection Control

Project team

– USAID Rational Pharmaceutical Management Plus Project, Management Sciences for Health, Washington DC