Reference Manual for Health Care Facilities with Limited Resources

Editors Melanie S. Curless, MPH, RN, CICChandrakant S. Ruparelia, MD, MPHElizabeth Thompson, MHSPolly A. Trexler, MS, CIC

Infection Prevention and Control.

 The authors have made every effort to check the accuracy of all information, the dosages of any drugs, and instructions for use of any devices or equipment. Because the science of infection prevention and control is rapidly advancing and the knowledge base continues to expand, readers are advised to check current product information provided by the manufacturer of:  

Each drug, to verify the recommended dose, method of administration, and precautions for use 

Each device, instrument, or piece of equipment to verify recommendations for use and/or operating instructions 

 In addition, all forms, instructions, checklists, guidelines, and examples are intended as resources to be used and adapted to meet national and local health care settings’ needs and requirements. Finally, neither the authors, editors, nor the Jhpiego Corporation assume liability for any injury and/or damage to persons or property arising from this publication.  

  Jhpiego is a nonprofit global leader in the creation and delivery of transformative health care solutions that save lives.  In partnership with national governments, health experts, and local communities, we build health providers’ skills, and we develop systems that save lives now and guarantee healthier futures for women and their families. Our aim is revolutionizing health care for the planet’s most disadvantaged people.  Jhpiego is a Johns Hopkins University affiliate.  Jhpiego Corporation Brown’s Wharf 1615 Thames Street Baltimore, MD 21231‐3492, USA www.jhpiego.org  © 2018 by Jhpiego Corporation. All rights reserved.   Editors:  Melanie S. Curless, MPH, RN, CIC   Chandrakant S. Ruparelia, MD, MPH   Elizabeth Thompson, MHS   Polly A. Trexler, MS, CIC   Editorial assistance:  Karen Kirk  Design and layout:  AJ Furay   Dana Lewison  Young Kim   Joan Taylor  Bekah Walsh  Jhpiego Leadership:  Kelly Curran 

Ronald Magarick Jeffrey Smith 

 Jhpiego technical reviewers–Initial Draft:  Oniyire Adetolye, Nigeria 

Rashmi Asif, India Zaib Dahar, Pakistan (Late) Eneud Gumbo, Malawi  Rosemary Kamunya, Kenya Youdit Kidanemariam, Ethiopia Albert Komba, Tanzania Valentina Msechu, Tanzania Benilde Soares, Mozambique   

Infection Prevention and Control: Reference Manual for Health Care Facilities with Limited Resources 1

Infection Prevention and Control: Reference Manual for Health Care Facilities with Limited Resources Preface........................................................................................................................................ 2

Foreword .................................................................................................................................... 3

List of modules and chapters ...................................................................................................... 5

2 Infection Prevention and Control: Reference Manual for Health Care Facilities with Limited Resources

Preface This is a reference manual for infection prevention and control (IPC) practices for health care facilities where resources are limited. It is an updated and expanded version of the 2003 Infection Prevention: Guidelines for Healthcare Facilities with Limited Resources, which was based on Infection Prevention for Family Planning Service Programs, published in 1992. As with previous versions, the authors have tried to keep the writing straightforward and practical while including essential information of a wide variety of topics for a wide variety of services provided at hospitals and much smaller health care facilities. The manual has been designed to provide information and recommendations in a simple, easily understandable format so that users can find what they want, when they want it. The intent is to offer users a quick reference to essential IPC practices. The IPC principles and scientific information on which this manual is based are universally applicable. In selecting the material, the emphasis has been on choosing practices and procedures that are doable even in the most basic settings; those designed to minimize cost and the need for expensive technology or fragile equipment but assure a high degree of safety.

How to use the manual This manual can be made available at points of care for health care workers to use as a source for specific information on tasks they are carrying out. In addition, the authors hope the manual will be used by hospital administrators, clinic managers, and health care professionals working in limited resource settings to develop their own IPC policies, guidelines, education and training materials, or surveillance tools. The content also may be used as a text for preservice education, group-based training, or on-the-job learning programs or as content for developing teaching, job, or behavior change aids For each of these uses, the content may be produced and distributed on paper or digitally. To facilitate the manual’s adaptation and use, each chapter is fully referenced and each module is page numbered so that it can be printed as a stand-alone document. Not all health care workers will need all of the modules. Selection will depend upon the job functions, expected IPC competencies of various cadre of staff members, and the immediate priority needs of the health care facility. The Infection Prevention and Control: Reference Manual for Health Care Facilities with Limited Resources is a result of a collaboration between Jhpiego, an international nonprofit affiliate of Johns Hopkins University, and the Johns Hopkins Medicine Healthcare Epidemiology and Infection Control. It has also been reviewed by staff from Jhpiego’s field offices around the world for accuracy and ease of use. The authors hope that this manual will help reduce the risk of health care-associated infections for patients and health care workers at all levels—including clinicians, nurses and midwives, and cleaning and housekeeping staff—and save precious lives and resource.

Infection Prevention and Control: Reference Manual for Health Care Facilities with Limited Resources 3

Foreword Worldwide, health care-associated infections (HAIs) are a major threat to patient safety. These are infections that occur during the care a patient receives at a health care facility. Based upon data from many countries, the World Health Organization estimates that HAIs harm hundreds of millions of patients each year, leading to increased morbidity, disability, and even death.1 They also result in longer hospital stays and higher health care costs for countries, health systems, health care facilities, patients and their families. The burden of HAIs is estimated to be substantially higher in low- and middle-income countries than in high-income countries.1 In spite of this daunting worldwide problem and the challenges of preventing harm from HAIs, there is one significant piece of news that offers hope—infection prevention and control (IPC) practices. By this, we mean that very basic IPC measures, when implemented and practiced correctly and consistently, can prevent the vast majority of HAIs and thereby save lives. This manual is designed to provide IPC guidance to hospitals (e.g., tertiary care teaching, regional and district hospitals), clinics, and other health care facilities (e.g., in the private sector), including in resource-limited settings. IPC interventions do not need to be elaborate or expensive to be effective. Preparation, knowledge, attention to details, and rigorous, systematic processes are critical elements of an IPC program and are far more important than expensive technologies or devices. Using the latest available evidence-based recommendations and guidelines, Jhpiego collaborated with colleagues from the Johns Hopkins Medicine Healthcare Epidemiology and Infection Prevention team to update and expand the 2003 Infection Prevention: Guidelines for Healthcare Facilities with Limited Resources. The authors, editors, and Jhpiego field staff reviewers worked together to create this new version, titled Infection Prevention and Control: Reference Manual for Health Care Facilities with Limited Resources. The first three modules of the manual give an overview of IPC principles, including Standard Precautions and Transmission-Based Precautions, basic microbiology, hand hygiene, and the importance of personal protective equipment. Each chapter provides information and suggestions for how to implement these basic IPC practices even in resource-limited circumstances. Module 4 addresses safety of both patients and health care personnel with the important topics of injection and sharps safety and occupational health. It is clear that the environment plays an enormous role in the transmission of infectious diseases and, therefore, in IPC. Chapters in Module 5 outline how a facility’s design and workflow patterns affect IPC. This module also contains useful information on a variety of topics, including environmental cleaning, management of food and water services, reprocessing textiles, and waste management practices. Module 6 covers the related and extremely important topic of cleaning, disinfection, and sterilization of surgical instruments and medical devices. Modules 7 and 8 address the rational use of antibiotics and antiseptics in health care as well as laboratory, blood bank, and transfusion safety from the IPC standpoint. Modules 9 and 10 contain chapters that detail methods of surveillance for, and management of, an HAI outbreak and evidence-based prevention and control measures for common types of HAIs. While surveillance takes time, effort, and resources, some type of surveillance is an essential element of effective IPC programs. Surveillance data provides information about the current state of IPC in a facility and allows staff to evaluate the effectiveness of interventions and follow trends over time. The data

1 The World Health Organization. Clean Care is Safer Care. www.who.int/gpsc/country_work/burden_hcai/en/

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itself becomes a powerful intervention to drive change and improve IPC practices when it is shared with leaders and facility staff. Finally, Module 11 discusses the recommended structure and management of IPC programs, including principles of preparing for a public health emergency and outbreak. Sound management of an IPC program will ensure that the measures outlined in this manual can be successfully implemented so that good IPC outcomes can be achieved and sustained over time. Infection prevention and control is everyone’s job and responsibility. It is vital for the safety and protection of patients and their families, visitors, health care personnel, and the community. It is our hope that this updated and enhanced IPC manual will provide health care facilities, particularly those with limited resources, with the knowledge, information, guidelines, and implementation guidance they need to achieve excellent IPC results and save lives. Lisa L. Maragakis, MD, MPH Associate Professor of Medicine, Division of Infectious Diseases Johns Hopkins University School of Medicine Senior Director of Healthcare Epidemiology and Infection Prevention The Johns Hopkins Health System

Infection Prevention and Control: Reference Manual for Health Care Facilities with Limited Resources 5

List of modules and chapters

Module/Chapter Author(s) Jhpiego Technical Reviewer(s)s

Module 1: Introduction to Infection Prevention and Control

Chapter 1: Introduction to Health Care-Associated Infections

LaToya A. Forrester, MPH, CIC Neeta Bhatnagar, India Saswati Das, India Silvia Kelbert, USA Chapter 2: Standards Precautions and

Transmission-Based Precautions LaToya A. Forrester, MPH, CIC

Chapter 3: Basic Microbiology for Infection Prevention and Control

Melanie S. Curless, MPH, RN, CIC; and Polly A. Trexler, MS, CIC

Module 2: Hand Hygiene

Chapter 1: Hand Hygiene Bria S. Graham-Glover, MPH, CIC; and Meredith A. Gerland, MPH, CIC

Chan Aung, Myanmar Patricia Gomez, USA Silvia Kelbert, USA

Module 3: Personal Protective Equipment

Chapter 1: Personal Protective Equipment

Bria S. Graham-Glover, MPH, CIC Oniyire Adetiloye, Nigeria Silvia Kelbert, USA Marion Subah, Liberia Chapter 2: Use of Personal Protective

Equipment during Outbreaks of Viral Hemorrhagic Fever

Melanie S. Curless, MPH, RN, CIC

Module 4: Patient and Health Care Worker Safety

Chapter 1: Injection Safety Patricia Lawson, MS, MPH, RN, CIC Martha Appiagyei, Ghana May Htin Aung, Myanmar Yodit Kidanemariam, Ethiopia Farid Midhet, Pakistan

Chapter 2: Infection Prevention and Control Aspects of Occupational Health in Health Care Settings

Melanie S. Curless, MPH, RN, CIC; and Clare Rock, MD, MS

Chapter 3: Sharps Injuries and Management of Exposure to Bloodborne Pathogens

Patricia Lawson, MS, MPH, RN, CIC

Module 5: Facility Management

Chapter 1: Facility Design, Traffic Flow, and Work Practices in Health Care Facilities

Polly A. Trexler, MS, CIC Vinita Dayal, India Sunita Dhamija, India Abha Dhuriya, India Rhoda Njeru, Kenya Dinesh Singh, India

Chapter 2: Environmental Cleaning Malorie Givan, MPH, CIC

Chapter 3: Managing Food and Water Services for the Prevention of Health Care-Associated Infections

Melanie S. Curless, MPH, RN, CIC

Chapter 4: Processing Reusable Health Care Textiles

Malorie Givan, MPH, CIC

Chapter 5: Waste Management in Health Care Facilities

Malorie Givan, MPH, CIC

6 Infection Prevention and Control: Reference Manual for Health Care Facilities with Limited Resources

Module/Chapter Author(s) Jhpiego Technical Reviewer(s)s

Module 6: Processing Surgical Instruments and Medical Devices

Chapter 1: Overview of Processing Surgical Instruments and Medical Devices

Chandrakant S. Ruparelia, MD, MPH

Kofi Asare, Ghana Rashmi Asif, India Silvia Kelbert, USA Ronald Wandira, Botswana

Chapter 2: Cleaning and Preparing Surgical Instruments and Medical Devices for Disinfection or Sterilization

Chandrakant S. Ruparelia, MD, MPH

Chapter 3: High-Level Disinfection of Surgical Instruments and Medical Devices

Chandrakant S. Ruparelia, MD, MPH

Chapter 4: Sterilization of Reusable Surgical Instruments and Medical Devices

Chandrakant S. Ruparelia, MD, MPH

Chapter 5: Reprocessing Single-Use Devices

Anne Caston-Gaa, MSN, MPH, RN, CIC

Module 7: Antibiotics and Antiseptics

Chapter 1: Rational Use of Antibiotics Kathryn Dzintars, PharmD, BCPS-AQID; Kathryn DeMallie; Ifeoma N. Ibe, PharmD

Willy Shasha USA Stacy Stender, South Africa

Chapter 2: Use of Antiseptics in Health Care Facilities

Melanie A. Gavin, MPH, M(ASCP)CM, CIC

Module 8: Laboratories and Blood Banks

Chapter 1: Clinical Laboratory Biosafety Melanie A. Gavin, MPH, M(ASCP)CM, CIC; and Melanie S. Curless, MPH, RN, CIC

Regina Mbayaki, Kenya Emmanuel Otolorin, Nigeria Minati Rath

Chapter 2: Infection Prevention and Control in Blood Bank and Transfusion Services

LaToya A. Forrester, MPH, CIC; and Melanie S. Curless, MPH, RN, CIC

Module 9: Surveillance of Health Care-Associated Infections

Chapter 1: Basic Epidemiology and Statistics for Infection Prevention and Control

Meredith A. Gerland, MPH, CIC

Chapter 2: Introduction to Surveillance of Health Care-Associated Infections

Polly A. Trexler, MS, CIC; and Melanie S. Curless, MPH, RN, CIC; and Elizabeth Thompson, MHS

Chapter 3: Investigation of Outbreaks of Health Care-Associated

Polly A. Trexler, MS, CIC; and Melanie S. Curless, MPH, RN, CIC

Module 10: Prevention of Health Care-Associated Infections

Chapter 1: Preventing Surgical Site Infections

Melanie A. Gavin, MPH, M(ASCP)CM, CIC; and Melanie S. Curless, MPH, RN, CIC

Blami Dao, USA Rosemary Kamunya, Kenya Ricky Lu, USA Win Kaythi Lwin, Myanmar Willy Shasha, USA

Chapter 2: Preventing Catheter-Associated Urinary Tract Infections

Patricia Lawson, MS, MPH, RN, CIC; and Melanie S. Curless, MPH, RN, CIC

Infection Prevention and Control: Reference Manual for Health Care Facilities with Limited Resources 7

Module/Chapter Author(s) Jhpiego Technical Reviewer(s)s

Chapter 3: Preventing Intravascular Catheter-Associated Bloodstream Infections

Julia Gardner, BSN, CIC; and Melanie S. Curless, MPH, RN, CIC

Chapter 4: Preventing Hospital-Acquired Pneumonia

Anne Caston-Gaa, MSN, MPH, RNCIC; and Melanie S. Curless, MPH, RN ,CIC

Chapter 5: Preventing Maternal and Newborn Infections in Health Care Settings

Julia Gardner, BSN, CIC; and Melanie S. Curless, MPH, RN, CIC

Chapter 6: Preventing Health Care-Associated Infectious Diarrhea

Melanie S. Curless, MPH, RN, CIC

Module 11: Infection Prevention and Control Program Management

Chapter 1: Structure and Oversight of Infection Prevention and Control Programs

Lisa L. Maragakis, MD, MPH; and Melanie S. Curless, MPH, RN, CIC

Kofi Asare, Ghana

Chapter 2: Principles of Public Health Emergency Preparedness and Outbreak Management for Health Care Facilities

Meredith A. Gerland, MPH, CIC

Review of Initial Draft: Oniyire Adetolye, Nigeria; Rashmi Asif, India; Zaib Dahar, Pakistan; Eneud Gumbo, Malawi; Rosemary Kamunya, Kenya; Youdit Kidanemariam, Ethiopia; Albert Komba, Tanzania; Valentina Msechu, Tanzania; Benilde Soares, Mozambique

8 Infection Prevention and Control: Reference Manual for Health Care Facilities with Limited Resources