INFECTION CONTROL

Head of Phthisiopulmonary department

Professor Maryandyshev Andrey
TB expert of Euro WHO
10 January 2020
Level of infectious disease -
One of the components characterizing
“A health index” of the nations.
Among infectious disease nosocomial
infections is one of the major places.
Indicators of level of the nosocomial infection in
the world

Russia 1

USA 50

Chehia 163

Spane 100

Swedish 117

0 20 40 60 80 100 120 140 160 180

в показателях на 1000 пациентов

Семина Н.А., Ковалева Е.П. (1999)

 Social and economic damage from NCI in
other countries

USA
• NCI more then 2 mln patients every year;
• Dead from NCI 88.000 patients;
• Annual economic damage - 4-10 billion dollars
• Great Britain
• Hospitalization of patients increases by 3,6
million days;
• Annual economic damage - 1 billion pounds
sterling
 Nosocomial infection in Russia

Annually according to official figures -

About 30 thousand cases
Really - 2-2,5 million cases
(About 1-1,5 % of the population of the country)

Annual economic damage -

More than 5 billion roubles
Nosocomial infections level in the Russian Federation
1.9
2.0
1.7 1.7 1.7 1.7
1.6 1.6
1.5
1.5
1.2 1.2 1.2
1.0 1.0
On 1000 hospitalised patients

1.0 0.9
0.8 0.8 0.8
0.70.7
Disease indicator

0.5

0.0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2013 2014 2015

годы
 Since 2006 Russia has begun
cooperation with the World Alliance
for Safety of the Patients, working
under the umbrella of the World
Health Organization
 The factors growth NСI

• Hospital complex with • Constant of a

specifically ecology sources of
• The powerful artificial infections (patients,
mechanism air transfer the employees who
• Activation of airborne are ill)
and household • Wide, uncontrolled
transmission of application of
infection, in the antibiotics
conditions of close • Produce
contact intrahospital strains
 The factors promoting growth NCI in
modern conditions
• Wide use of a difficult technique for
• diagnostics
Increasing ofand
risktreatment,
contingents - the
• Epidemics virus hepatitis,
patients survival due HIV-infection,
to achievements of
tuberculosis
modern medicine
• Immunosuppressive
among patients
 Categories of patients making up the
concept of “nosocomial infection”

Categories

Patients
Patients Patients
Patients
of the
of the hospital
hospital of the
of the hospital
hospital Medical staff
Medical staff of
of
inpatient
inpatient outpatient
outpatient hospital
hospital
departments
departments departments
departments
 Structural diseases of nosocomial infections
in Russia

19.8% After operation infection

26.6% infection after giving birth

0.2%
0.7% infection of the women after
birth of child
1.2%
post injection infection
1.5%
acute intestinal infection
7.5%
Urinary tract infections

Salmonellosis

Hepatitis B
13.8% 17.0%
Hepatitis C

11.7% Other infection diseases

Г.С.Коршунова, 2006
Structure professional diseases medical staff of hospital

7.0% 4,0%
3.0% Tuberculosis

6.0%
Hepatits B

Hepatitis C
12.0%
Hepatitis A

Broncthitis astma

68.0%
Other diseases
Category of the medical personal with professional
diseases

2,0% 5.5%
Medical nurses
2.0%
Laboratory assistants
24.5%
Assitants of medical nurses

Doctors

Obstetricians

Staff of patology department

10.0% 53.0%
3.0% Others
Rate of professional diseases among different type of hospitals

2.5%2,5%
Tuberculosis dispensary
12.0% 38.0%
In-patient department of
General hospital

10.0% Out patinets department of

the General hospital

Tuberculosis in-patients
department

Infection dideases in-patients

department

35.0% Pathological departments

 Character of NCI

• Multi Drug resistance;

• Resistance for Environment influence:
- UV light;
- Traditional disinfection .
Mechanisms of transfer infection

Air-drop (aspiration)
Contact - hand by hand
Faces - oral
Artificial
 Nosocomial infection

Bacteria
•Staphylococci Virus Protosoa
•Streptococcus • Viruses • Pneumocysts Fungi
•Pseudomonas aeruginosa • hepatitis B, C, D • • Candida
•Enterobacteria • Virus Toxoplasma
• Aspergillus
• Cryptospori diy
•Esherichia immunodeficiency • Cytoplasm
•Salmonella • Flu viruses
•Shigella • other ARVI
•Yersinia • Measles
•Listeria • virus Rubella
•Campylobacter • Virus epidemic
•Legionella • mumps
•Clostridia
•Non-spore forming • Rotavirus
•Anaerobic bacteria • Enteroviruses
•Mycoplasmas • Norwolf viruses
•Chlamydia • Herpes virus
•Mycobacteria Bordetella • Cytomegalovirus
 How to manage risk of
tuberculosis in health care
 RISK of TB in health care compared to
other population ?

• Difficult to see by number of cases

• Incidence in different empolyee groups
has to be analysed
 helps in evaluation of need of
corrective measures
 Calculate by employee group
 ANALYSIS of cases/100.000/year
in subgroups in health care
Health care workers
TB workers
TB dispensary workers
TB physicians, TB nurses, laboratory
staff
 Risk in TB dispensary

Examples from real life:

7 new cases among 400 in 1 year 
> 1500 / 100.000/year
8 new cases among 40 in 5 years 
~ 4000 /100.000/ year
All in TB laboratory had TB in life-time
 To decrease the TB risk

• Can something be done ?

• What needs to be done ??

 Factors influencing TB risk
• Concentration of live bacilli in air
• Length of exposure

• Immunological status of the exposed

• Virulence of the M. tuberculosis strain
 Infectious aerosols: Droplet size
• >150 μm land on surface  stick to it
 touch to mouth (ROTA, RSV)

• <150 μm evaporate in 2-3 sec

•  droplet nucleus 5 μm
• settle 1 cm/ min  float hours
if inhaled  alveoli
• if reach floor stick to it
 Survival of M. tuberculosis in droplet
nuclei

• A doplet nucleus may carry 2-3 bacilli

• 90% of TB bacilli remain alive for hours in

droplet nuclei
• Compare: 90% of Escherichia coli die
quickly
 TB BACILLI IN ENVIRONMENT
• Don’t multiply outside cellular material or at < 30o
• Killed by sun light
• Killed easily in water environment by heat:
pasteurisation or laundry at 60o
• In dried sputum, stay infectious in the dark at <<20o
for months
• Survive months in sputum at +4o; yrs at -20o
 TB risks other than aerosols
• Direct transfer through epithelia in medical
procedures (bronchosopy..) YES

• Via gastrointerstinal tract minimal

– 1/10.000 compared with inhalation exposure
• Infection via skin, theoretical
• Books etc no importance
• Bed clothing little
importance
• Cups, spoons no importance
 Actions to decrease TB risk health care ?

I. Prevention of development and spread of

aerosols

II. Clearance of aerosols in room air

III. Protection against inhalation of aerosols

 Actions to decrease TB risk health care

• Patient associated actions

• Environmental actions

• Employee associated actions

 Infectious patient: risk factor No. 1
1. Early diagnosis and rapid initiation of treatment
2. Cohort patients according to infectivity
3. Isolate in infectious phase
4. Train patients in cough hygiene
– never unprotected cough
– use a paper napkin – dispose it into plastic bag
– specimen collection in a ventilated room
– outside of own room, wear a mask
 Diagnostic and therapeutic procedures of
TB patients
Sputum collection
*in specially designed cabinets
*good ventilation between patients
Measurement of lung function and operative
procedures: Only in life-threatening situations
Sputum collection cabinet
Cabinet ventilated out  lower pressure in
the cabinet than in the room.
Outside: Hand washing basin and table for
specimens and other material

Inside: A chair, a shelf, material to

clean and disinfect spills
Sputum collection in prison
Glass walls with bars; ventilation out 
lower pressure in the cabinet than in the
room.
Outside: Hand washing basin and table for
specimens and other material
 Infectious patients the source of infective
aerosols
Isolation and cohorting protect others in the ward
Use of technical measures in isolation rooms if
possible:

Inhibit spread of TB bacilli containing air to other

parts of department
Minimize concentration of bacilli in air in isolation
room.
 Environmental actions
• Ventilation out – not to corridoor
– mechanical ventilation or natural via windows
• Air pressure in patient & laboratory rooms
must be lower than in corridoors
• Keep doors closed
• Ventilate sputum collection cabinet and
procedure room between patients
 Mechanical ventilation
• How many times room air is changed / h

• No. air changes/h Time to 99.9% efficacy

• ---------------------------------------------------------------------
• 6 70 min
• 12 ~30 min
• 18 ~20-25 min
 UV- irradiation – a controversial matter
Kills and inactivates TB bacilli;
Yet, not generally recommended in patient rooms.
In laboratories, only in biosafety cabinets.

Efficacy of UV-lamps influenced by many technical

factors:
distance (10 cm OK but >1 m ? placebo blue)
dose, age of lamp, relative humidity, dust on lamps
and air
Exposure to UV-light  skin and conjunctival irritation
 Personal protection- Masks
Rational use of surgical masks:
• To protect patient from aerosols produced by
the surgical team
• If worn by patient diminishes some of the
aerosols produced by him/her
• No value in protection of staff against
infectious air
 Personal HEPA filter respirators
• Tightly fitting masks with HEPA filter for
aerosols in inhaled air with or without a vent
for expiration
• Disposable or re-usable  powered air-
purifying respirators
• European standard grading for TB work
• P2 filters 92% of 1-5 μm particles
• P3 filters 98% of 1-5 μm particles
FFP4 class respirator
Protection during medical procedures
• Bronchoscopy:

FFP3 class respirator, disposable gloves and gown for

the whole team
• When taking specimens for laboratory
examinations:
*Pus, pleural fluid, other secretions: FFP2 class
respirator (if MDR-TB FFP3 class), disposable gloves.
Possibly gown depending on risk of producing
aerosols.
*Blood samples: FFP2 respirator (FFP3 if MDR-TB)
 Bronchoscopy in TB work
• • Not recommended for suspected TB cases in adults.
• In suspected TB cases if poor sputum production, 3
specimens found negative in microscopy and a
suspicion of other illness.
• Done as the last bronchoscopy of the day
• For smear + patients with vital indication only.
• Afterwards, all surfaces cleaned with chlorine
containing disinfectant (5000 ppm)
Protection during medical procedures
• Therapeutic procedures:
• FFP2 class respirator (FFP3 if MDR-TB),
disposable gloves and gown in close-to-
patient procedures and handling excretions
containg TB – bacilli (sputum, bronchial
secretions, abscess or fistular pus).
• Hand wash and disinfection after every visit to
isolation room.
 Safety in laboratories handling infectious
material

• Organization of laboratories according to risk

of infection

• Four BioSafety Levels (BSL) depending which is

the risk for employees or environment
 BSL 2
Work with moderate risk microbes present in
the community.
• Risk of infection associated with accidental
inoculation of skin or mucous membranes, or
ingestion
– Staphylococcus aureus
• Smear microscopy is included in this group in
some countries
 BSL 3
• Work involves microbes known to cause
aerosol mediated infections; the disease may
have serious consequences

• Example microbes:
• Mycobacterium tuberculosis,
• Brucella spp, Fracisella tularensis, Yersinia
pestis
 BSL 3
• Work is done in biological safety cabinets
– class I safety cabinet
• airflow through work opening, across work surface and
out with help of exhaust fan with or without HEPA
filtration

– class II safety cabinet

• HEPA-filtered laminal airflow, partially re-circulated
 BSL 3
• Work that produces aerosols, such as mixing
or centrifuging must be done using devices
which protect against spread of aerosols from
leaking tubes.
• For instance, aerosol proof centifuges
– which allow high enough g-force
– no leak of aerosols from buckets containing the
tubes
 Protection in laboratory
• KNOWLEDGE of risks
• Use of safe working practices
• Design of work flow
• Engineering controls
• Administrative controls
 Generating aerosols in lab
• Pouring, dropping or transfering into liquid or
on hard surface, breaking tubes …
• Transferring with syringe and needle, mixing,
pipetting, centrifugation…
• Decontaminating specimens, making cultures
or susceptibility tests…
• NO danger with closed culture tubes or
stained sputum slides.
 Bronchoscopy in TB work
• Not recommended for suspected TB cases in adults.
• In suspected TB cases if poor sputum production, 3
specimens found negative in microscopy and a
suspicion of other illness.
• Done as the last bronchoscopy of the day
• For smear + patients with vital indication only.
• Afterwards, all surfaces cleaned with chlorine
containing disinfectant (5000 ppm)
 Therapeutic procedures
• If possible, in isolation room only.

• Infectious secretions (sputum, tracheal

aspirate, fistule and wound secretes) must be
handled so that aerosols are not generated.
 Cleaning and waste
• Surfaces contaminated with secretes wiped
with chlorine containing disinfection solution
(5000 ppm) before general cleaning.
• Other surfaces according to general rules
• Change of bed linen as usual
• Waste form isolation room disposed in closed
plastic bags as usual
 Mechanical ventilation demands know-
how and money
• Recommended in isolation rooms for infectious TB
patients (particularly MDR) & TB labs.
• Ventilation ducts (in and out) separate from general
ventilation
• Room air never ducted to general ventilation system.
• Incoming air flow never connected before out-flow
generated.
• Change of air 6-12 times / hour.
 Negative pressure must be followed

Pressure must be followed daily:

A meter outside of the room
Safety box needs indicators outside; also air flow
must be daily checked
Air low in rooms must be measured 1-2 a year
by external consultants
 Other special needs
• Bronchoscopy and other procedure rooms
equipped with HEPA-filters in out-flow ducts
• In mortuary rooms, ventilation 6-12 times /
hour ducted directly outdoors, or HEPA
filtered
• Bacterial filters for 1-5 μm particle size in
anesthesia and respirator equipment and
equipment for measuring lung function
 Summary
• Risk of infection highest when treating undiagnosed TB
patient.
• Classify grade of infectioness with smear microscopy from 3
sputum samples
• Train patients to diminish aerosol production with cough
hygiene.
• Start isolation and efficient therapy quickly.
• Use personal respirator (class P2 in susceptible TB and P3 in
MDRTB) in work with suspected or known infectious case.
• Avoid generation of aerosols by own working methods
Technical measures in isolation rooms
• Inhibit spread of TB bacilli containing air to other
parts of department and minimize concentration of
bacilli in air in isolation room.
• Proper use of respirators prevents inhalation of bacilli
in air.
• Success of prevention depends on how well risk of
infection is identified and protective measures are
used in each case of infectious TB patient.
 Individual protection

• Respirators FFP4 in high risk zone

 Video education – YouTube

• https://www.youtube.com/watch?v=tsnGi-eLI
Qc
• Thank you for attention