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Occupational Health and Safety Act, 1993 (Act No. 85 of 1993)

Regulations

Hazardous Biological Agents Regulations

Annexure C : Precautions for Workplaces

 

 

[Regulations 10(1)(b), 15(a) and 16(a), (b) and (c)]

 

Five Main Routes Of Transmission :

 

1) Contact

 

The most important route of transmission in a workplace is by –

a) direct contact with an infected or contaminated body surface or fluid; and
b) indirect contact via contact with an object previously contaminated with organisms from an infected person or animal.

 

2) Droplet Transmission

 

Droplets are generated during coughing, sneezing, talking and during procedures such as suctioning.

 

Droplets may carry organisms that can infect a new host if they are deposited on conjunctivae, nasal mucosa or the mouth.

 

Droplets do not remain suspended in the air.

 

Droplets do not travel more than one metre.

 

3) Airborne Transmission

 

Small particles (droplet nuclei) that remain suspended in air for long periods of time have a far greater potential for spreading disease than large droplets.

 

Few organisms are carried by this route, the most important being Mycobacterium tuberculosis and the viruses causing measles and chickenpox.

 

Prevention of spread requires an enclosed area with at least six air changes per hour, or an open window that provides adequate ventilation.

 

4) Common Vehicle Transmission

 

Transmission by items such as food, water, devices and equipment.

 

Normal hygienic practices and proper sterilization or disinfections of equipment should make this type of spread a rare event in certain workplaces, e.g. hospitals.

 

5) Vector-Borne Transmission

 

Vectors such as mosquitoes, flies, fleas, etc. are hopefully not frequently encountered in workplaces as a cause of outbreaks.

 

In areas where there is a problem the appropriate measures, e.g. screens on windows and the use of insecticides must be instituted

 

Two levels of precautions are recommended :

-           Standard Precautions

These are applied at all times to all patients irrespective of their diagnosis. All body fluids (except sweat) are regarded as potentially infectious.

-           Transmission-Based Precautions

These are applied when a specific infectious disease is diagnosed or suspected.

The route by which the disease is transmitted will determine the category of precautions that must be applied.

 

 

Precautions

 

A) Administrative Controls

 

1) Education and Training
2) Adherence to precautions

 

B) Precautionary measures

 

1) Standard Precautions
2) Airborne Precautions
3) Droplet Precautions
4) Contact Precautions
5) Formidable Epidemic Disease (e.g. viral haemorrhagic fevers) Precautions

 

 

Administrative Controls

 

1) Education And Training

 

A system must be developed to ensure that hospital patients, employees, contractors and visitors are educated about :

-           the use of precautions.

-           the responsibility for adhering to the precautions.

 

2) Adherence To Precautions

 

Periodic evaluation of adherence to precautions must be carried out. The findings are to be used to implement improvements.

 

Precautionary Measures

 

1) Standard Precautions

 

Standard precautions are used for the protection of all people exposed to HBA.

 

1.1 Hand Washing

 

-          Wash hands after touching blood, body fluid, secretions, excretions and contaminated items, whether or not gloves are worn.

-          Wash hands (when working with patients) :

immediately after gloves are removed.
between patient contact.
where indicated to prevent cross-contamination of different body sites.

-          Use plain (non-antimicrobial) soap for routine hand washing.

-          Use an antimicrobial agent or an alcohol hand disinfectant for specific circumstances (e.g. control of outbreaks or hyperendemic infections) as defined by the infection control program. (See contact precautions.)

 

1.2 Gloves

 

-           Wear gloves (clean, intact non-sterile gloves are adequate) when touching blood, body fluid, secretions, excretions and contaminated items.

-           Put on clean intact gloves just before touching mucous membranes and non-intact skin.

-          Change and dispose of gloves between tasks and procedures -

on the same person.
after contact with material that may contain high concentration of micro-organisms.

-          Remove gloves promptly after use –

before touching non-contaminated items and environmental surfaces.
before attending to another person.

-          Wash hands immediately to avoid transfer of micro-organisms to other persons and environments.

 

1.3 Mask, eye protection, face shield

 

-          Wear a mask and eye protection or a face shield -

to protect mucous membranes of the eyes, nose and mouth.
during procedures and activities that are likely to generate splashes or sprays of blood or body fluid, secretions and excretions.

 

1.4 Protective Clothing

 

-           Wear appropriate protective clothing to protect skin and to prevent soiling of clothing during procedures and activities that are likely to generate splashes or sprays of blood, body fluid, secretions and excretions.

-           Select protective clothing that is appropriate for the activity and amount of fluid likely to be encountered.

-           Remove soiled protective clothing as promptly as possible and consider it contaminated.

-           Wash hands immediately after removal of protective clothing to avoid transfer of micro-organisms to other people or environments.

 

1.5 Patient-care equipment

 

-          Handle patient-care equipment soiled with blood, body fluids, secretions and excretions in a manner that prevents –

skin and mucous membrane exposures.
contamination of clothing.
transfer of micro-organisms to other environments.

-          Ensure that reusable equipment is not used for the care of another patient until -

it has been cleaned.
it has been reprocessed appropriately.

-          Ensure that-

sufficient disposable syringes and needles are at all times available for 3 provision is made for their safe disposal.

 

1.6 Environmental Control

 

-            Ensure that adequate procedures are in place for routine care, cleaning and disinfection of environmental surfaces, and other frequently used or potentially contaminated surfaces

-            Disinfection of environmental surfaces is not routinely required. Simple cleaning is adequate unless there has been significant soiling by potentially infectious body fluids.

 

1.7 Linen

 

-          Process, handle and transport used linen contaminated with blood, body fluid, secretion and excretions in colour coded, impervious containers and all possible measures should be observed to prevent -

skin and mucous membrane exposure.
contamination of clothing.
transfer of micro-organisms to other persons and environments.

 

1.8 Occupational Health

 

1.8.1 Injuries

-           Take care to prevent injuries when –

using needles, scalpels and other sharp instruments or devices.
handling sharp instruments after a procedure.
cleaning instruments.
disposing of used needles.

 

Never

-           Re-cap needles or manipulate them using both hands, if it is absolutely necessary to reheat a needle. A variety of mechanical devices that are commercially available must be used.

-           Use any other technique that involves directing the point of a needle toward any part of the body.

 

Do not

 

-           Remove used needles from disposable syringes by hand.

-           Bend or break or otherwise manipulate needles by hand.

 

Do

-           Place used disposable syringes and needles, scalpel blades and other sharp objects in appropriate puncture-proof containers that are as close as possible to the area in which the procedure is carried out.

-           Transport them safely to the disposal area.

 

1.8.2 Resuscitation

 

Use mouthpieces, resuscitation bags or other ventilation devices as an alternative method to mouth-to-mouth resuscitation in areas where the need for resuscitation is predictable.

 

1.9 Patient Placement

 

-           Place in an isolation area (single or private room) patients who -

contaminate the environment.
do not or cannot be expected to assist in maintaining appropriate personal hygiene or environmental control.

-           If an isolation area is not available, consult infection control professionals regarding patient placement or other alternatives.

 

2) Airborne Precautions

 

In addition to Standard Precautions, use Airborne Precautions for -

-           patients known or suspected of being infected with micro-organisms transmitted by airborne droplet nuclei, i.e. small particle residue of evaporated droplets containing micro-organisms that -

remain suspended in the air;
can be widely dispersed by air currents within a room or over a long distance.

 

2.1 Patient Placement

 

Ideally place patients in a private room that has -

-           monitored negative air pressure in relation to the surrounding areas.

-           6 -12 air changes per hour.

-           Appropriate discharge of air outdoors or monitored high-efficiency filtration of room air before the air is circulated to other areas of the hospital.

 

Where this is not possible

-           Use -

a room with a simple extraction fan providing at least six air changes per hour.
a room with an open window, and adequate ventilation.

-           When an isolation area is not available, place the patient in a room with another patient who has active infection with the same micro-organism, and no other infection, unless otherwise recommended.

-           When a private room is not available and cohorting is not desirable, consultation with infection control professionals is advised before patient placement.

-           Keep the patient in the room and keep the door closed.

 

2.2 Respiratory Protection

 

Tuberculosis:

 

-            Respiratory protection may be worn when entering the room of a patient known or suspected to have infectious pulmonary tuberculosis.

-            Measles (rubeola) and chickenpox (varicella).

-            Susceptible person should not enter the room of patients known or suspected of having measles or vermicelli if other immune caregivers are available.

-            if susceptible persons must enter the room they must wear respiratory protection.

-            Persons immune to measles or vermicelli need not wear respiratory protection,

 

2.3 Patient Transport

 

Movement and transport of the patient should be kept to a minimum.

-           If transport or movement is necessary, the patient must wear a surgical mask to minimise dispersal of droplet nuclei.

 

2.4 Additional precautions for preventing transmission of tuberculosis

 

-          Respirators –

must be worn by all who enter the room.
must be able to filter particles 1 micron or less in size with a filter efficiency of 95%.

-          Effective treatment of the patient

-           Isolation –

there is significant clinical improvement in the patient’s condition.

ideally, two negative acids fast bacilli smears must be obtained.

ideally a smear positive patient will require isolation for a minimum of two weeks.

 

3) Droplet Precautions

 

In addition to Standard Precautions, use Droplet Precautions for patients known or suspected to be infected with micro-organisms transmitted by droplets (large particle droplets that can be generated during coughing, sneezing, talking or respiratory therapy).

 

3.1 Patient Placement

 

Place the patient in an isolation area, e.g. private or single room

 

-          When a private room is not available and cohorting is not achievable, maintain spatial separation of at least one metre between the infected patient and other patients and visitors.

-           Additional ventilation measures are not necessary and the door may remain open.

 

3.2 Masks

 

Wear a mask when working within one metre of the patient. However, logistically some hospitals may want to implement the wearing of a mask to enter the room.

 

3.3 Patient Transport

 

Movement and transport of the patient from the room should be kept to a minimum. If transport or movement is necessary, minimise dispersal of droplets by masking the patient.

 

4) Contact Precautions

 

In addition to Standard Precautions use Contact Precautions for specified patients known or suspected to be infected or colonised with epidemiologically important micro-organisms that can be transmitted by direct contact with the patient (hand to skin contact occurs when performing patient care activities that required touching the patient’s dry skin) - or indirect contact (touching) environmental surfaces or patient care items in the patient’s environment.

 

4.1 Patient Placement

 

Place the patient in an isolation area, e.g. private or single room

-          When a private room is not available, place the patient in a room with patients who have active disease with the same microorganism but no other infection (cohorting).

-          When either a private room nor cohorting is achievable, consider the epidemiology of the microorganism and the patient population when determining patient placement.

 

Consultation with infection control professionals is advisable before patient placement.

 

4.2 Gloves And Hand Washing

 

In addition to wearing gloves and washing hands as outlined in Standard Precautions -

 

-          Wear clean gloves when entering the room.

-          Change gloves after having contact with infective material,

-          Remove gloves before leaving the patient’s environment.

-          Wash hands immediately after glove removal with an antimicrobial or an alcohol hand rub.

-          Ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient’s room to avoid transfer of micro-organisms to other patients or the environment.

 

4.3 Protective Clothing

 

In addition to wearing a gown or plastic apron as outlined in Standard Precautions -

 

-         Wear a clean, non-sterile gown and/or plastic apron as appropriate -

when entering a room where soiling of clothing is anticipated.
following substantial contact with the patient.
following contact with environmental surfaces or items in the patient’s room.
if the patient is incontinent or has diarrhea, an ileostomy or a colostomy.
where wound drainage is not contained by a dressing.

-          Remove the gown or plastic apron before leaving the patient’s environment.

-          After gown or plastic apron removal, ensure that clothing does not make contact with potentially contaminated environmental surfaces to avoid transfer of micro-organisms to other patients or environments.

 

4.4 Patient Transport

 

-          Movement and transport of the patient from the room should be minimised.

-          Ensure that precautions are maintained to minimize the risk of transmission of micro-organisms to other patients and contamination of environmental surfaces or equipment.

 

4.5 Patient-Care Equipment

 

Where possible dedicate the use of non-critical patient-care equipment to a single patient (or cohort of patients infected or colonised with the pathogen requiring precautions).

 

Avoid sharing equipment between patients

 

-           If the use of common equipment or items is unavoidable, then these must be cleaned and disinfected before use for another patient.

 

4.6 Additional Precautions For Preventing The Spread Of Multi-Drug-Resistant Micro-Organisms

 

-          Limit antibiotic use and prevent misuse.

-          Educate staff.

-          Detect multi-drug-resistant micro-organisms early by laboratory and infection control surveillance.

-          Consult an Infection Control Practitioner regarding further management.

 

5) Formidable Epidemic Disease (Fed) Isolation

 

-           Standard and contact precautions plus additional items such as respirators, visors, water repellent gowns and boots, caps, double gloves are required.

-           Standard precautions are adequate during the non-hemorrhagic phase in cases of hemorrhagic fevers, such as Ebola and Congo-Crimean hemorrhagic fever.

 

5.1 Isolation Area

 

-       This may be a dedicated viral hemorrhagic fever (VHF) unit or a dedicated sideward or private room, preferably with an anteroom.

 

-        The door must be kept closed, and strict access control must be implemented.

 

5.2 Gowns

 

-        Impervious disposable gowns must be worn over a theatre scrub suit.

 

5.3 Gloves

 

-         Two pairs are worn, the one pair on top of the other.

-         Sterile latex gloves are used because of the thicker quality and longer nori-roll cuff.

 

5.4 Boots

 

-         Impervious boots or overshoes are worn in the isolation room.

 

They must be -

high enough to cover the area of skin below the trouser legs.
strong enough to withstand wear and tear.

 

5.5 Theatre Capsi goggles or Visors

 

-         Worn inside the isolation room.

-          Theatre caps.

A theatre cap worn with a visor providing full protection of the head and neck s preferred.

 

5.6 Masks and Respirators

 

-         Masks - good quality, high-filtration respirators are necessary.

 

5.7 Formidable Epidemic Disease Pack (FED Pack)

 

A FED pack contains all the isolation gear necessary, must be safely stored in an area not accessible to unauthorised persons. The FED pack must be immediately replenished after every usage.

 

This pack is available immediately, is portable and is used until the patient is diagnosed or transferred to an isolation unit or an infectious diseases hospital. The pack is kept in a box or in a trolley. The box (or trolley) is distinctive and kept in an easily accessible place. The pack contents are replenished as required by the infection control staff.

 

Instruction posters provide instructions for untrained personnel until infection control professionals arrive to provide guidance and instruction in VHF procedures.

 

Contents -

 

-         Sterile latex gloves of varying sizes.

-         Disposable impermeable gowns.

-         Goggles or visors.

-         Masks.

-         Shoe covers (half-leggings).

-         Theatre caps.

-          Blood tubes, labels, bio-hazard plastic specimen bags, a rigid, walled container for transportation of specimens and bio-hazard stickers.

-          Masking tape used for -

sealing boxes of refuse.
fixing instruction posters to the wall.
securing tops of plastic shoe covers,

-         Plastic refuse bags for contaminated refuse.

-         Autoclavable bags for non-disposable items.

-         Clear plastic bags.

-          Sodium-hypochlorite sachets of powder (NaOCI) and liquid 1 % hypochlorite.

-          Plastic-covered instruction posters containing detailed instructions on how to -

put on isolation gear.
undress safely.
collect and handle specimens safely.
mix disinfectants.
disinfect and handle contaminated equipment.
dispose of linen and refuse.
deal with a blood spill.

 

5.8 The infection control professionals must ensure that staff follows correct procedures and that equipment is available for disposal of refuse.

 

-         All refuse bags are colour coded, double bagged and are placed into cardboard boxes.

 

-          Refuse bags are sealed and labelled with bio-hazard stickers and tape.

 

-          Containers are escorted to the incinerator.

 

-          Their immediate incineration is ensured.

 

5.9 Transporting VHF specimens

 

-          These specimens require a special container and packaging :

The specimen is placed in a bio-hazard bag.
The patient’s label is placed in the outer pouch.
The specimen is then wrapped in absorbent material and placed in an unbreakable screw-top container.
The container is labelled with a bio-hazard sticker and the destination (name of the receiving laboratory).
It is preferably delivered by hand.
If the specimen has to be posted or sent by courier a second unbreakable container is used and labelled accordingly.

 

5.10 Management of soiled linen, refuse and equipment

 

Bedding

 

-         All bedding used is either disposable or condemned linen that is subsequently incinerated.

-          Mattresses must be covered with durable plastic covers

The covers are disposable.

If the mattress becomes soiled with blood or body substance it must be destroyed.

 

Linen and Refuse

 

-          All linen (disposable and condemned) is placed into plastic refuse bags

The person inside the cubicle or room takes the sealed bag and places it in a second bag held by another person outside the room.
This bag is then sealed and sent for incineration.

 

Terminal disinfection of equipment

 

-          All equipment is washed down well with a hypochlorite-detergent.

-          It is then dried, using a paper towel.

-          If the equipment is not autoclavable, it must .be wrapped in clear plastic bags, then -

double bagged into a clean bag held by a second person outside the cubicle.
clearly labelled with the contents and a biohazard sticker attached.
sent to Central Sterilizing Service Department (CSSD) for ethylene oxide gas sterilization.

-         Autoclavable items must be placed in Asepto type bags -

labelled as above.
sealed in clean plastic bags for transport to CSSD.
autoclavable plastic bags may be used if available.

 

Furniture or environment

 

-        All furniture, walls and floors are washed down well with hypochlorite-detergent.

 

TABLE I

 

Infection / Condition

Precautions Type*

Duration

Abscess

Draining. major

Draining, minor or limited

AIDS

Actinomycosis

Adenovirus infection, in infants and young children

Amebiasis

Anthrax

Cutaneous

Pulmonary

Antibiotic-associated colitis (see C dificile)

Arthropodborne viral encephalitides (eastern. western, Venezuelan equine encephalomyelitis: St Louis,

California encephalitis)

Arthropodborne viral fevers (dengue, yellow fever, Colorado tick fever)

Ascariasis

Aspergillosis

Babesiosis

Blastomycosis, North American, cutaneous or pulmonary

Botulism

'NO dressing or dressing does not adequately contain damage

'Dressing covers and adequately contains drainage.

Bronchiolitis (see respiratory infections in infants and young children)

Brucellosis (undulant, Malta, Mediterranean fever)

Camp!lobacfer gastroenteritis (see gastroenteritis)

Candldiasis, all forms including mucocutaneous

Cat-scratch fever (benign inoculation lymphoreticulosis)

Cellulitis, uncontrolled drainage

Chancroid (soft chancre)

Chickenpox (varicella) (see F" for varicella exposure)

Chlamydia trachomatis

Conjuctivitis

Genital

Respiratory

Cholera (see gastroenteritis)

Closed-cavify infection

Draining, limited or minor

Not draining

Clostridium spp

C. botulium

C. difficile

C. perfringens

food poisoning

Gas gangrene

Coccidiodomycosis (valley fever)

Draining lesions

Pneumonia

Colorado tick fever

Congenital rubella

Conjunctivitis

Acute bacterial

Chlamydia

Conococcal

Acute viral (acute hermorhagic)

Coxsackle virus (see enteroviral nfection)

Creutzfeldt-Jakob disease

Croup (see respiratory in infants and young children)

Cryptosporidiosis (see gastroenteritis)

Cysticercosis

Cytomegalovirus infection neonatal or immunosuppressed

Decubitus ucler. infected

Crypiococcosis

Major

Minor or Iimited

Dengue

Diarrhea acute-infective etlology suspected (see gastroenteritis)

Diptheria

Cutaneous

Pharyngeal

Ebola viral hemorrhagic fever

Echnococcosis (hydatidosis)

Echovirus (see enteroviral enfection)

Encephalitis (see enteroviral infection)

Encephalitis or encephalomyelitis (see specific etiologic agents)

Endometritis

Enterobiasis (pinworm disease, oxyuriasis)

Enterococcus species (see multidrug-resistant organisms if epdidemiologically

significantorvancomycin resis-

Enteroco/itis. C. difficile

Enteroviral infctions

Adults

Infants and young children

Epiglottitis caused by H. influenzea

Epstein-Barr virus infection, including infectious mononucleosis

Erythema infectiosum (also see Parvovirus B 19)

Escherichia coli gastroenteritis (see gastroenteritis)

Food poisoning

Botulism

Clostridium perfringens or welchii

Staphylococcal

Furunculosis-staphylococcal

Infants and young children

Gangrene (gas gangrene)

Gastroenteritis

Campylobacter sp

Cholera

C. difficile

Cryptosporidium species

E. coli

Enternhemorrhagic 0157.H7

Diapered or incontinent

Other species

Giardia lamplia

Rota virus

Diapered or incontinent

Salmonelia species (including S. fyphil

Shigella species

Diapered or incontinent

Vibrio paraharnolyticus

Viral (if not covered elsewhere)

Yersinia enterocolitica

German measles (rubella)

Giardiasis (see gastroenteritis)

Gonococcal ophthalmia neonatorum (gonorrheal ophtalmia acute conjunctivitis of newborn)

Gonorrhea

Granuloma inguinale (donovanosis, granuloma venereum)

Guillain-Barre syndrome

Hand, foot and mouth disease (see enterviral infection)

Hantavirus pulmonary syndrome

Helicobacter pylori

Hemorrhagic fevers (for example Lassa and €bola)

Hepatitis, viral

Type A

Diapered or incontinent patients

Type B-HBsAg positive

Type C and other unspecified, non-A, non-8

Type E

Herpangina (see enteroviral infection)

Herpes simplex (Herpesvirus horninis)

Encephalitis

Neonatal' (see F' for neonatal exposure)

Mucocutaneous disseminated or primary severe

Mucocutaneous, recurrent (skin, oral, genital)

Herpes zoster (varicella zoster)

Localised in immunocompromised patient or disseminated

Localized in normal patient

Histoplasmosis

HIV (see human immunodeficiency virus)

Hookworm disease (ancyclostomiasis, uncinariasis)

Human immunodeficiency virus (HlV) infectioe

Impetigo

Infectious mononucleosis

Influenza

Kawasaki syndrome

Lassa fever

Legionnaires disease

Leprosy

Leptospirosis

Lice (pediculosis)

Listeriosis

Lyme disease

Lymphocytic choriomeninggitis

Lymphogranuloma venereum

Malaria

Marburg virus disease

Measles (rubeola) all presentations

Meliodiosis all forms

Meningitis

Aseptic (non bacterial or viral meningitis) (also see enteroviral infections)

Bacterial, gram-negative enteric in neonates

Fungal

H. influenzea, known or suspected

Listeria monocytogenes

Neisseria meningitidis (meningococcal) known or suspected

Pneumococcal

Tuberculosis

Other diagnosed bacterial

Meningococcal pneumonia

Meningococcal (meningococcal sepsis)

Molluscum contagiosum

Mucormycosis

Multidrug resistant organisms, infection or colonizatior

Gastrointestinal

Respiratory

Pneumococcal

Skin, wound or burn

Mumps (infections parotitis)

Mycobacteria non tuberculosis (atypical)

Pulmonary

Wound

Mycopiasma pneumonia

Necrotizing enterocolitis

Nocardiosis draining lesions or ther presentations

Norwalk agent gastroenteritis (see viral gastroenteritis)

Orf

Parainfluenza virus infection, respiratory in infants and young children

Parvovlrus B 19

Pediculosis (lice)

Pertussis (whooping cough) '

Pinworm infection

Plague

Bubonic

Pneumonic

Pleurodynia (see enterovival infection)

Pneumonia

Adenovirus

Bacterial not listed elsewhere (including gram -negative bacterial)

Burkholderia cepacia in patience with CF including respiratory tract colonization

C[arrydia

Fungal

H. irfluerzzae

Adults

Infants and children (any age)

Legionella

Meningococcal

Multidrug - resistant bacterial (see multidrug- resistant organisms)

Mycoplasma (primary atypical pneumonia)

Pneumococcal

Multidrug- resistant (see multidrug -resistant organisms)

Pneumocystis carinii

Pseudomonas cepacia (see Burkholderia cepacia)

Staphylococcus aureus

Streptococcus, Group A

Adults

Infants and children

Viral

Adults

Infants and young children (see respiratory infectious disease, acute)

Poliomyelitis

Psittacosis (ornithosis)

Q fever

Rabies

Rat-bite fever (Streptopacillus moniliformis disease. Spirillum minus disease)

Relapsing fever

Resistant bacterial infection or colonization (see multidrug resistant organisms)

Respiratory infectious disease acute (if not covered elsewhere)

Adults

Infants and young children

Respiratory Syncitial Virus infection in infants and young children and immunocompromisedadults

 

APPENDIX A

Reye's syndrome

Rheumatic fever

Rickettsiai fever, tickborne (Rocky Mountain spotted fever, tickborne typhus fever)

Rickettsiaipm (vesicular rikeftsiosis)

Ringworm (dermatophytosis, dermatomycosis, tinea)

Ritter's disease (staphylococcal scalded skin syndrome)

Rocky Mountain spotted fever

Roseola infantum (exanthum subitum)

Rotavirus infection (see gastroenteritis)

Rubella German measles) (also see congenital rubella)

Salmonellosis (see gastroenteritis)

Scabies

Scalded skin syndrome, staphylococcai (Ritter's disease)

Schistosomiasis (bilharzias)

Shigellosis (seegastroenterihi)

Sporom'ckosis

Spirillium minus disease (rat-bite fever)

Staplylococcal disease (S aureus)

Skin wound or burn

Major

Minor or limited

Enterocolitis

Endometritis (puerperal sepsis)

Pharyngitis in infant and young children

Pneumonia in infant and young children

Scarlet fever in infant and young children

Streptococcal disease (group B Streptococcus) neonatal

Streptococcal disease (not group A or B) unless covered elsewhere

Multidrug-resistant bacterial (see multidrug-resistant organisms)

Strongyloidiasis

Syphilis

Skin and mucous membrane including congenital primary secondary

Latent (tertiary) and seropositivity without lesions

Tapeworm disease

Hymenolepis nana

Taenia soluun (pork)

Other

Tetanus

Tinea (fungus infection dermatophytosis dermatomycosis ringworm)

Toxoplasmosis

Toxic shock syndrome (staphylococcal disease)

Trachoma acute

Trench mouth (Vincent angina)

Trichinosis

Trichomoniasis

Trichuriasis (whipworm disease)

Tuberculosis

Extrapulmonary draining lesion (including scrofula)

Extrapulmonary mengitis

Pulmonary confirmed or suspected or laryngeal disease

Skin-test positive with no evidence of cument pulmonary disease

Tularemia

Draining lesion

Pulmonary

Typhoid (Solnronello 4pl11] fever (see gastroenteritis)

Typhus endemic and epidemic

Urinary tract infection (including pyelonephritis) with or without urinary catheter

Varicella (chickenpox)

Vibrio parahaemolyticus (see gastroenteritis)

Vincent's angina (trench mouth)

Viral deceases

Respiratory (if not covered elsewhere)

Adults

Infants and young children (see respiratory infectious disease acute)

Whooping cough (pertussis)

Wound infections

Major

Minor or limited

Yersinia ettrercolitica gastroenteritis (see gastroenteritis)

Zoster (varicella-zoster)

Localised in immunocompromised patient, disseminated

Localised in normal patient

Zygomycosis (phycomycosis mucormycosis)



 

Abbreviations used

 

Type of precautions:

 

Standard precautions (S) are applied at all times in addition to either :

 

A       Airborne

C       Contact

D        Droplet

VHF   Viral haemorrhagic fever

 

Duration of precautions :

 

CN  until antibiotics are discontinued and culture-negative

DH  duration of hospitalisation

Dl    duration of illness (with wound lesions, Dl means until they stop draining)

U     until time specified in hours (hrs) after initiation of effective therapy.

F      footnote number under type

 

Meaning of superscript number (i.e. FE Standard precaution is applied at all times)

 

a) No dressing, or dressing does not contain drainage adequately.

 

b) Dressing covers and contains drainage adequately.

 

c) Also see syndromes or conditions listed in Table 2.

 

d) lnstall screens in windows and doors in endemic areas.

 

e) Maintain precautions until all lesions are crusted. The average incubation period for varicella is 10 to 16 days, with a range of 10 to 21 days. After exposure, use varicella-zoster immune globulin (VZIG) when appropriate and discharge susceptible patients if possible. Place exposed susceptible patients on Airborne Precautions beginning 10 days after exposure and continuing until 21 days after last exposure (up to 28 days if VZIG has been given). Susceptible persons should not enter the room of the isolated patient on precautions if other immune caregivers are available.

 

f) Isolate all infants on precautions during any admission until one year of age, unless -nasopharyngeal and urine cultures are negative for virus after age three months of age.

 

g) Additional special precautions are necessary for handling and decontamination of blood, body fluids and tissues, and contaminated items from patients with confirmed or suspected disease.

 

h) until two cultures are taken at least 24 hours apart are negative,

 

i) Consult the National Institute of Virology for guidelines issued by provincial health departments. Use Contact Precautions for diapered or incontinent children less than six years of age for duration of illness. Maintain precautions in infants and children under three years of age for duration of hospitalisation; in children three to fourteen years of age, until two weeks after onset of symptoms; and others, until one week after onset of symptoms. For infants delivered vaginally or by Caesarean section and if mother has active infection and membranes have been ruptured for more than four to six hours.

 

m) Persons susceptible to varicella are also at risk for developing varicella when exposed to patients with zoster lesions: therefore, susceptibles should not enter the room if other immune caregivers are available.

 

n) Many hospitals encounter logistic difficulties and suspected or diagnosed limitations when admitting multiple patients with suspected influenza during community outbreaks. If sufficient private rooms are unavailable, consider cohorting patients or, at the very least, avoid room sharing with high-risk patients.

 

o) Patients should be examlned for evidence of current (active) pulmonary tuberculosis, If evidence exists, additional precautions are necsssary (see tuberculosis 3).

 

p) Resistant bacteria judged by the infection control program, based on current state, regional or national recommendations, to be of special clinical and epidemiologic significance. For nine days after onset of swelling. Maintain precautions for duration of hospitalisation when chronic disease occurs in an immunodeficient patient. For patients with a transient plastic crisis or red cell crisis, maintain precautions for seven days. Maintain precautions for five days after patient is placed on effective therapy. Avoid cohorting or placement in the same room with a cystic fibrosis (CF) patient who is not infected or colonised with B. cepacia. Persons with CF who visit or provide care and are not infected or colonised with B. cepacia may elect to wear a mask when within one metre of a colonised or infected patient. Avoid pjacement in the same room with an immunocompromised patient. Until seven days after onset of rash. Discontinue precautions _only when TB patient is improving clinically and has three consecutive negative sputum smears collected on different days or TB is ruled out. Maintain all precautions until the patient stops bleeding.

 

TABLE II

 

Clinical Syndromes or Conditions Warranting Additional Empiric Precautions to Prevent Transmission or Epidemiologically Important Pathogens Pending Confirmation of Diagnosis*

 

 

Clinical Syndrome or Condition**

Potential Pathogens

Empiric Precautions

Diarrhoea

Acute diarrhoea-like infections:

Contact cause in an incontinent or diapered patient

Enteric pathogens***

Contact

Diarrhoea in an adult with a history of recent antibiotic use Rash or exanthems, generally, etiology unknown

Clostridium

Droplet

Petechial or ecchymotic with fever

Neisseria meningitidis

Droplet

Vesicular

Varicella

Airborne and contact

Maculopapular with coryza and fever

Measles

Airborne

 

Respiratory infections

Coughlfeverlupper lobe pulmonary infiltrate in an HIV-negative patient or a patient at low risk for HIV infection

 

 

Mycobacterium tuberculosis

 

 

Airborne

Cough/fever/pulmonary infiltrate in any lung location in an HIV-infected patient or a patient at high risk of HIV infection

Mycobacterium tuberculosis

Airborne

Paroxysmal or severe persistent cough during periods of pertussis activity

Bordella pertussis

Droplet

Particularly bronchiolitis and croup in infants and young children

 

Respiratory syncytial virus or parainfluenza virus

 

Contact

Risk of multidrug-resistant micro-organisms

History of infection or colonisation with multidrug- resistant organisms

Resistant bacteria

Contact

Skin and wound if urinary tract infection in a patient with a recent hospital or nursing home stay in a facility where multidrug-resistant organisms are prevalent.

Resistant bacteria

 

Contact

Skin and wound infection

Abscess or draining wound that can not be covered

 

Staphylococcus aureus, Group A streptococcus

 

Contact

 

 

*          Infection control professionals are encouraged to modify or adapt this table according to local conditions. To ensure that appropriate empiric precautions are always implemented, hospitals must have systems in place to evaluate patients routinely according to these criteria as part of their pre-admission care.

 

**        Patients with the syndromes or conditions listed below may present atypical signs or symptoms (e.g. pertussis in neonates and adults may not have paroxysmal or severe cough). The clinician’s index of suspicion should be guided by the prevalence of specific conditions in the community, as well as clinical judgement.

 

***     The organisms listed under "Potential Pathogens’’ are not intended to represent the complete, or even the most likely, diagnosis, but rather possible etiologic agents that require additional precautions beyond Standard Precautions until they can be ruled out.

 

Synoposis of types of precautions and patients requiring the precautions

 

Abbreviations used in list of precautions.

 

α  See Table I for a complete list of infections requiring precautions, including appropriate footnotes.

 

β  Certain infections require more than one type of precaution.

 

γ   See "Guidelines for Preventing the Transmission of Tuberculosis in Health-Care Facilities" available from the Department of Health.

 

1) Standard Precautions

 

Use Standard Precautions for the care of all patients.

 

2) Airborne Precautions

 

In addition to Standard Precautions, use Airborne Precautions for patients known or suspected to have serious illnesses transmitted by the airborne droplet nuclei. Examples of such illnesses include -

 

Measles
Varicella (including disseminated zoster)*
Tuberculosis‘

 

3) Droplet Precautions

 

In addition to Standard Precautions, use Droplet Precautions for patients known or uspected to have illnesses transmitted by large-particle droplet.

 

Examples of such illnesses include

 

Invasive Haemophilus influenzae Type B disease, including meningitis, pneumonia,
epiglottitis and sepsis.
Invasive Neisseria rneningifidis disease, including meningitis, pneumonia and sepsis.

 

Other serious bacterial respiratory infections spread by droplet transmission, including

 

Diphtheria (pharyngeal)
Mycoplasma pneumonia
Pertussis
Pneumonic plague
Streptococcal pharyngitis, pneumonia or scarlet fever in infants and young children

 

Serious viral infections spread by droplet transmission, including

 

Adenovirus'
Influenza
Mumps
Pawovirus 812
Rubella

 

4) Contact Precautions

 

In addition to Standard Precautions, use Contact Precautions for patients known or suspected to have serious illnesses easily transmitted by direct contact or by contact with terms in the patient's environment. Examples of such illnesses include-

 

-          Gastrointestinal, respiratory, skin or wound infections or colonisation with multidrug-resistant bacteria judged by the infection control program, based on current state, regional, or national recommendations, to be of special clinical and epidemiologic significance.

-          Enteric infections with a low infectious dose or prolonged environmental survival, including :

Clostridium difficile

-         For diapered or incontinent patients: enterohaemorrhagic Escherichia coli 0157 :H7, Shigella, Hepatitis A or Rotavirus

-         Respiratory syncytial virus, parainfluenza virus or enteroviral infections in infants and young children.

 

Skin infections that are highly contagious or that may occur on dry skin, including :

 

Diphtheria (cutaneous)
Herpes simplex virus (neonatal or mucocutaneous)
Impetigo
Major (non-contained) abcesses, cellulitis or decubitus ulcers
Pediculosis (lice)
Scabies
Staphylococcal furunculosis in infants and young children.
Zoster (disseminated or in the immunocompromised host)
Virallhaemorrhagic conjunctivitis
Viral haemorrhagic infections (Ebola, Lassa, Marburg, Congo-Crimean) (during early non-haemorrhagic stages)

 

5) Formidable Epidemic Disease (FED) Precautions

 

In addition to Standard Precautions and Contact Precautions, use FED precautions for persons proven or suspected of having a viral haemorrhagic fever. Examples of such diseases are :

 

-           Ebola Viral Haemorrhagic Fever

-           Marburg Haemorrhagic Fever

-           Congo-Crimean Haemorrhagic Fever

-           Lassa Fever