National Infection Prevention And Control Guidelines

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National InfectionPrevention andControl GuidelinesMINISTRY OF HEALTHRepublic of Liberia

National InfectionPrevention andControl GuidelinesMINISTRY OF HEALTHRepublic of Liberia

Table of ContentsForeword. IIAcknowledgments. IIIAbbreviations and Acronyms. IVGlossary of Select Terms. VBackground. 1IPC Core Components. 31. IPC programme. 32. IPC guideline development,dissemination and implementation . 53. IPC education and training . 64. Surveillance of healthcare-associated infections . 65. Multimodal strategies forimplementing IPC activities. 86. Monitoring, evaluation,and feedback. 87. Workload, staffing andbed occupancy . 88. Promotion of WASH infrastructure,equipment and services. 8Technical guidelines. 8Basic principles . 10The chain of transmissionof microorganisms . 10Modes of transmission. 11Standard precautions . 11Additional (transmission-based)precautions. 34Contact precautions. 74Droplet precautions. 76Airborne precautions. 78Isolation in health facilities. 82IPC considerations forinvasive devices and surgicalprocedures. 42IPC considerations in facilitydesign. 47Laboratory safety. 46Introduction. 48Classification of biological agents. 48Biosafety guidelines . 50Biological spills . 50General first aid . 51Occupational health and safety. 51Medical screening. 54Post exposure prophylaxis. 54IOccupational hazards. 54Coping with stress. 55Annex 1: County QualityManagement Team TOR. 56Annex 2: County IPCFocal Person TOR. 58Annex 3: District QualityManagement Team TOR. 59Annex 4: Facility QualityManagement Team TOR. 61Annex 5: Facility IPC FocalPerson TOR. 63Annex 6: The WHO multimodalimprovement strategy. 64Annex 7: Joint IntegratedSupportive Supervision (JISS)IPC indicators. 65Annex 8: How to perform handhygiene with alcohol basedhand rub. 66Annex 9: How to perform handhygiene with soap and water. 67Annex 10: Surgical handpreparation using alcohol basedhand rub. 68Annex 11: WHO Five Momentsfor Hand Hygiene. 70Annex 12: Hand HygieneSelf-Assessment Framework(HHSAF). 71Annex 13: Hand hygieneobservation form. 71Annex 14: Pyramid of indicationsfor type of gloves. 81Annex 15: How to put onand take off non-sterile gloves. 82Annex 16: How to put onand take off sterile gloves. 83Annex 17: How to put onpersonal protective equipment(PPE). 85Annex 18: How to remove personalprotective equipment (PPE). 86Annex 19: How to manuallyclean instruments. 87Annex 20: Indications for theuse of PPE in the sterilizationdepartment. 88Annex 21: Standard operatingprocedure for autoclaves (pressurecooker). 89Annex 22: Steps in dry heatsterilization. 94Annex 23: Procedure for sortingsoiled linen. 95Annex 24: Procedure for washingsoiled linen. 96Annex 25: Cleaning small splashesand sprays and large bodyfluid spills. 97Annex 26: How to prepare chlorinesolution for environmentalcleaning. 98Annex 27: Specific cleaningprocedures for the operatingroom. 99Annex 28: Specific cleaningprocedures for the labourand delivery room.101Annex 29: Standard designfor triage and isolation structure.102Annex 30: Non-outbreak screeningform and flow chart.103Annex 31: Referral pathway forpatients with priority infectiousdiseases.105Annex 32: Triage and IsolationUnit SOP.106Annex 33: 5 moments for handhygiene for a patient with a PVC.106Annex 34: Standard operatingprocedure for the prevention ofbloodstream infections associatedwith use of a PVC.107Annex 35: 5 moments for handhygiene for a patient with a urinarycatheter.110Annex 36: Standard operatingprocedure for the prevention ofcatheter-associated urinary tractinfections (CAUTI).111Annex 37: Priority recommendationsfor the prevention of surgical siteinfections.113Annex 38: WHO surgical safetychecklist.114Annex 39: 5 Moments for handhygiene for a patient with a postoperative wound.115Annex 40: Restrictions for health careworkers exposed to or infected withinfectious diseases.116Annex 41: Recommendationsfor health care workerimmunizations.119References.120

ForewordLiberia suffered immense setbacks due to the debilitating effects of the Ebola VirusDisease (EVD) outbreak of 2014 and 2015. This outbreak was characterized by rapidtransmission of the virus from affected persons to healthy people by touching withoutappropriate handwashing. Our health care workers lacked the basic infection preventionand control (IPC) knowledge and skills, leading to the unfortunate death of thousands ofLiberians including several hundred health care workers. Health care facilities becameunsafe and a source of transmission.Despite lack of effective treatment and vaccines, the Ministry of Health (MOH) incollaboration with its partners introduced evidence-based public health measures tomanage the epidemic. IPC was a key response pillar; activities undertaken helped incurtailing and eventually stopping transmission in communities and health facilities.Consequential to lessons learnt from the outbreak, MOH established an IPC divisionwithin the Quality Management Unit. Amongst its mandate is to develop evidence basednational IPC guidelines for the purpose of reducing health care-associated infections(HAIs) and antimicrobial resistance (AMR).These guidelines, which were developed jointly by the Ministry of Health and its strategicpartners, will serve as a resource and reference document for all health care facilities,health care workers, regulatory bodies and training institutions where it relates totraining, implementation and monitoring of IPC practices.The Ministry of Health is hopeful that this document, when rolled out to our healthcare workers across the length and breadth of this country, will lead to establishinga sustainable IPC culture in our country and that the catastrophic effects of the EVDoutbreak will not repeat itself.Dr. Wilhemina S. JallahMinister of HealthRepublic of LiberiaII

AcknowledgmentsThe National IPC Guidelines for Liberia is the result of tremendous and collaborativeefforts from many individuals, institutions, organizations and development partners,who were involved in both the conceptualization and development. Cognizant of thefact that any attempt to mention all those who have contributed carries the risk ofunknowingly omitting important names, the Ministry of Health wishes to take thisopportunity to express special appreciation to the following divisions, institutions andorganizations for their tireless effort and involvement throughout the development ofthe guidelines: National Public Health Institute of Liberia (NPHIL), the United StatesCenters for Disease Control and Prevention (CDC), University of MassachusettsMedical School-Academic Consortium Combating Ebola in Liberia Project (UMMSACCEL), Partners in Health (PIH), UNICEF, and Expertise France. A special gratitudegoes to the World Health Organization (WHO) for providing technical, logistical andfinancial support throughout this process.The Ministry wishes to specifically acknowledge the Quality Management Unit(QMU) for the commitment and tireless efforts in ensuring that the first National IPCGuidelines were developed in a highly participatory manner and the IPC technicalworking group that comprised members from the QMU, UMMS-ACCEL, CDC, ExpertiseFrance and WHO. This team jointly participated in the coordination and provision ofguidance to the whole process through various consultative forums and documentreviews.III

Abbreviations and AcronymsABHR Alcohol based hand rubAMRAntimicrobial resistanceCAUTI Catheter-associatedurinary tract infectionCDCCenters for DiseaseControl and PreventionCHOCounty Health OfficerCHTCounty Health TeamCQMT County QualityManagement TeamDHTIVIntravenousJISSJoint IntegratedSupportive SupervisionLMDC Liberia Medical andDental CouncilM&EMonitoring andevaluationMoHMinistry of sureprophylaxisPPEPersonal protective equipmentQMUQuality ManagementUnitSOPStandard operating procedureSSISurgical site infectionTORTerms of referenceTBTuberculosisVHFViral haemorrhagic feverEbola virus diseaseFQMT Health Care Facility QualityManagement TeamHAIInfection preventionand controlDistrict Health TeamDQMT District QualityManagement TeamEVDIPCHealth care-associatedinfectionHBVHepatitis B virusHCFHealth care facilityHCVHepatitis C virusHCWHealth care workerHIVHuman immunodeficiencyvirusHLDHigh level disinfectionICUIntensive care unitWASH Water, sanitation,and hygieneWHOWorld HealthOrganizationIV7

Glossary of Select TermsAlcohol-based hand rub: A liquid, gel or foamformulation of alcohol (e.g. ethanol, isopropanol), which isused to reduce the number of microorganisms on handswhen the hands are not visibly soiled. They may containemollients to reduce skin irritation and are less timeconsuming to use compared with hand washingAntimicrobial resistance (AMR): Develops whenmicroorganisms (bacteria, viruses, fungi and parasites)no longer respond to a drug to which it was originallysensitive to. When the microorganisms become resistantto antimicrobials they are often referred to as “superbugs”Antiseptics: Antimicrobial substances applied to livingtissue or skin to prevent infection. They differ fromantibiotics, which destroy bacteria within the body,and from disinfectants, which are used on nonlivingobjects. Some antiseptics are true germicides, capable ofdestroying microbes whereas others are bacteriostatic andonly prevent or inhibit their growthAseptic technique: The manner of conductingprocedures to prevent microbial contamination. An aseptictechnique alters the method of hand hygiene, PPE worn,the location and physicial characteristics wherea procedure is conducted, the use of skin antisepsis anddisinfectants in the environment, the manner of opening ofpackages and the use of sterile suppliesBiohazard (biological hazard): A risk to the health ofhumans caused by exposure to harmful bacteria, virusesor other dangerous biological agents, or by a materialproduced by such an organismBloodborne pathogens: Pathogenic microorganismsin human blood that are transmitted through exposureto blood or blood products, and cause disease inhumans. Common pathogens of occupational concerninclude hepatitis B virus, hepatitis C virus and humanimmunodeficiency virusCleaning: The step required to physically removecontamination by foreign material (e.g. dust, soil) toprepare a medical device for disinfection or sterilization.Pre-cleaning occurs prior to clean if medical devices aregrossly contaminatedColour coding: Designation of different colours for thestorage of different categories of health-care wastesViContamination: The soiling of inanimate objects or livingmaterial with harmful, potential infectious or unwantedmatterCross-contamination: The act of spreading microbes(bacteria and viruses) from one surface to another. Sincebloodborne viruses can live on objects and surfacesfor up to a week, and other pathogens for months ormore, microbes could be spread when surfaces are notdisinfected correctly or equipment is not cleaned andsterilized between patientsDecontamination: Removes soil and pathogenicmicroorganisms from objects so they are safe to handle,subject to further processing, use or discardDetergent: compounds that possess a cleaning actione.g. soapDisinfectant: A chemical agent that is capable ofkilling most pathogenic microorganisms under definedconditions, but not necessarily bacterial spores. It isa substance that is recommended for application toinanimate surfaces to kill a range of microorganisms. Theequivalent agent, which kills microorganisms present onskin and mucous membrane, is called an antisepticDisinfection: A process by which most pathogenicmicroorganisms are killed, except bacterial spores, prionsand some virusDisposal: Intentional burial, deposit, discharge, dumping,placing or release of any waste material into or on any air,land or water. In the context of this document, disposalrefers to the storage and subsequent destruction of allmedical wasteFit Test: A “fit test” tests the seal between the respirator’sface piece and your face. It takes about fifteen to twentyminutes to complete and is performed at least annually.After passing a fit test with a respirator, you must use theexact same make, model, style, and size respirator on thejobHealth care-associated infection (also referred to as“nosocomial or “hospital acquired infection”):An infection occurring in a patient during the process ofcare in a hospital or other health care facility, which wasnot present or incubating at the time of admission. Healthcare-associated infections can also appear after discharge

Glossary of Select TermsHand hygiene: Any type of hand cleansingHandwashing: Washing hands with soap and water, anddrying thoroughly afterwards with single-use towelsHigh touch surfaces: High-touch surfaces are thosethat have frequent contact with hands. Examples includedoorknobs, bedrails, light switches, wall areas around thetoilet and edges of privacy curtainsImproved water source: Defined by WHO/UNICEF JointMonitoring Programme as a water source that by itsnature of construction adequately protects the sourcefrom outside contamination, particularly feacal matterIndicator: Measurable variable used as a representationof an associated (but non-measured or non-measurable)factor or quantityInfection control: Infection prevention and control (IPC)is a practical, evidence-based approach which preventspatients and health care workers from being harmed byavoidable infectionsInjection: Percutaneous introduction of a medicinalsubstance, fluid or nutrient into the body. This may beaccomplished most commonly by a needle and syringe,but also by jet injectors, transdermal patches, microneedles and other newer devices. The injections arecommonly classifed by the target tissue (e. g. intradermal,subcutaneous, intramuscular, intravenous, intraosseous,intra- arterial, peritoneal)Low touch surfaces: Surfaces that have minimal contactwith hands (e.g. walls, ceilings, mirrors and windowsills)Mode of transmission: How an infectious agent spreadsor travelMedical device: Any instrument, apparatus, appliance,material or other article, where used alone or incombination, intended by the manufacturer to be usedin humans for the purpose of the diagnosis, prevention,monitoring, treatment or alleviation of – or compensationfor – an injury or handicapMultimodal strategy: A multimodal strategy comprisesseveral elements or components (three or more; usuallyfive) implemented in an integrated way with the aim ofimproving an outcome and changing behaviour. It includestools, such as bundles and checklists, developed bymultidisciplinary teams that consider local conditions.The five most common components include: (i) systemchange; (ii) education and training of health care workersand key players; (iii) monitoring infrastructures, practices,processes, outcomes and providing data feedback;(iv) reminders in the workplace/communications; and(v) culture change within the establishment or thestrengthening of a safety climateNeedle-stick injury: Penetrating stab wound caused by aneedleOccupational exposure: Exposure to materials thatresults from the performance of an employee’s dutiesPathogen: A microorganism which can cause infectionPersonal protective equipment (PPE): Specializedequipment worn by an employee to protect against ahazard. PPE includes gloves, lab coats, gowns, aprons,shoe covers, goggles, glasses with side shields, masksand coveralls. The purpose of PPE is to prevent bloodand body fluids from reaching the workers’ skin, mucousmembranes, or personal clothing. It must create aneffective barrier between the exposed worker and anyblood or other body fluidsPoint of care: The place where three elements cometogether: the patient, the HCW, and care or treatmentinvolving contact with the patient or his/her surroundings.Point-of-care products should be accessible withouthaving to leave the patient surroundingsPortal of entry: The point where the infectious agententers a new hostPortal of exit: The point where the infectious agent leavesthe reservoirPost-exposure prophylaxis (PEP): Medical treatmentgiven to prevent the transmission of bloodbornepathogens after potential exposure. It is available for HIVand hepatitis B.Pre-cleaning: this is cleaning at the point of use; rinsinggross organic material (e.g. blood clot, vomitus, stool) offand placing in a container.Recapping: The act of replacing a protective sheath ona needle. Recapping needles using two-handed methodsincreases the risk of needle-stick injuries and is notrecommendedReprocessing: All steps that are necessary to makea contaminated reusable medical device ready for itsintended use. These steps may include cleaning, functionaltesting, packaging, labelling, disinfection and sterilizationReservoir: a place where microorganisms can multiply orat least survive for a period of time (e.g. in or on humansand animals or on objects such as sinks)V ii

Glossary of Select TermsSafe injection: An injection that does no harm to therecipient, does not expose the health care worker to anyrisk and does not result in waste that puts the communityat riskSafety needle: A “safe needle” device incorporatesengineering controls to prevent needlestick injuries before,during or after use through built-in safety featuresSharp: Any object that can penetrate the skin; sharpsinclude needles, scalpels, broken glass, broken capillarytubes and exposed ends of dental wiresSharps container: A puncture-resistant, rigid, leakresistant container designed to hold used sharps safelyduring collection, disposal and destruction (sometimesreferred to as a “sharps box” or “safety box”)Sharps inj

the guidelines: National Public Health Institute of Liberia (NPHIL), the United States Centers for Disease Control and Prevention (CDC), University of Massachusetts Medical School-Academic Consortium Combating Ebola in Liberia Project (UMMS-ACCEL), Partners in Health

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