CHAPTER 15

Causes and spread of infection

Y
ou have a duty of care to
protect the service users
you work with, and other
workers, from harm, including harm
from infectious disease. To do this
you need to understand the causes
of infection and how infection is
spread from one person to another.
Once you have a clear understanding
of where infections come from and
how they are spread, you can take
the necessary actions to reduce
the likelihood of service users you
support becoming infected.

Links to other units

Along with other health and safety
issues, the information in this chapter
should inform daily practice, so it links
to many of the units that make up the
Diploma.
 THE DIFFERENCES BETWEEN BACTERIA, VIRUSES, FUNGI AND PARASITES

In order to understand the causes and spread of infection you need to

understand:

■ what is meant by the term ‘infection’

■ how infection is spread from person to person
■ the means (routes) by which the body becomes infected
■ how the body can be affected by bacteria, viruses, pathogenic
fungi and infectious parasites
■ the chain of infection.

Key terms THE CAUSES OF INFECTION

Microscopic means so small as to be
visible only with a microscope.
Infection is harm caused by micro-organisms, which are often referred
Pathogen is a bacterium, virus, or other to as ‘germs’. Micro-organisms (microbes) are living organisms so
micro-organism that can cause disease.
small that they cannot be seen without the use of a very powerful
Not all bacteria, viruses or other micro-
organisms are pathogenic; they will not all
microscope – they are microscopic. Micro-organisms that cause
cause disease in humans. infection are known as pathogens. Bacteria, viruses, pathogenic
fungi and parasites are all examples of micro-organisms that can
Bacteria are microscopic organisms, some
types of which are pathogenic. Bacteria are
cause infection.
made up of just one cell and are capable of
reproducing themselves.

Virus is a pathogenic microscopic

THE DIFFERENCES BETWEEN BACTERIA,
organism. Viruses cannot multiply on their VIRUSES, FUNGI AND PARASITES
own, so they have to invade a ‘host’ cell.

Pathogenic fungi are yeasts and moulds

The different kinds of micro-organisms have different characteristics.
which can infect humans.

Parasites are organisms that live on other

organisms.
BACTERIA
Bacteria are classified into different groups and can be pathogenic
(capable of causing illness) or non-pathogenic (not likely to cause
illness). Different types of bacteria are identified by their varying
shapes.
Bacteria are simple organisms, made up of just one cell, and are
capable of reproducing by themselves. They do this through a process
of growing to twice their original size and splitting into two; those two
cells then split into two more, and so on. This may appear to be a very
simple process; however, conditions have to be right for it to happen
and for the bacteria to be viable. Under the right conditions they can
divide and multiply rapidly. The term used for this process is binary
fission.
Bacteria exist everywhere, including inside and on our bodies. Most of
them are completely harmless and some of them are very useful. For
example, most strains of Escherichia coli (E. coli) are required as part of

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 CAUSES AND SPREAD OF INFECTION CHAPTER 15

the normal gut flora, as it has beneficial functions such as helping Key term
with the production of vitamin K2. Bacteria in the large intestine Flora are microorganisms that normally
help with the final stages of digestion. inhabit the body without causing harm.

However, some bacteria are pathogenic and can cause diseases,

either because they end up in the wrong place in the body, or simply
because they are ‘designed’ to invade us. Some bacterial infections
can make people very ill, while others have a fairly mild effect. Different
streptococcal infections which are caused by strains (or varieties) of
the bacterium Streptococcus can range from being mild, such as a
sore throat, to life-threatening, as in necrotising fasciitis (in the latter
they are often called ‘flesh-eating’ bacteria). Group A Streptococcus
is commonly found on the skin and inside the throat, and in many
people does not cause any symptoms at all. It is important to note
that bacteria may have non-pathogenic and pathogenic strains. As
mentioned above, most strains of E. coli do not cause us harm, but the
strain known as E. coli O157:H7 can cause food poisoning if ingested.
Key terms
Bacteria tend to be vulnerable to an antibiotic, which is why people Antibiotic is a substance from a micro-
who have a bacterial infection are often prescribed antibiotics. It organism that is used to destroy other
is important to understand that bacteria can become resistant to micro-organisms or prevent their growth.

antibiotics as a result of several factors: Resistance is the ability of a micro-

organism to withstand an antimicrobial
■ Bacteria can mutate and eventually become resistant to specific agent.
antibiotics.
■ If a person is treated with an antibiotic it is possible for that
antibiotic to destroy harmless bacteria that live in and on the
person, and this allows harmful bacteria to multiply and take
their place.
■ It is believed that the over-use of antibiotics in recent years
has played a large part in antibiotic resistance, and the rise of
what are often called ‘superbugs’, such as methicillin-resistant
Staphylococcus aureus (MRSA).

Nowadays, doctors and GPs have to think carefully before prescribing

antibiotics. Officials at Public Health England (PHE) remind GPs that
many patients do not benefit from antibiotics even if the patients
themselves think that they do. Health officials have acknowledged the
pressure on GPs to prescribe, but have warned them that it adds to the
cycle of antibiotic resistance.
PHE and the Royal College of General Practitioners have issued
guidance to help GPs explain to patients when antibiotics are not
needed. The TARGET antibiotics toolkit can be seen at http://www.
rcgp.org.uk/TARGETantibiotics/.

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 THE DIFFERENCES BETWEEN BACTERIA, VIRUSES, FUNGI AND PARASITES

VIRUSES
Viruses are much smaller than bacteria, and more complex. They
can survive out of the body for a time. Viruses are not affected by
antibiotics, which is why antibiotics are not prescribed for viral
infections. There are, however, antiviral drugs available to treat some
infections. Viruses cannot multiply on their own, so they have to
invade a ‘host’ cell and take over its machinery in order to be able to
make more virus particles. They do this by latching on to human cells
and getting inside them. Viruses consist of genetic materials (DNA or
RNA) surrounded by a protective coat of protein.
The cells of the mucous membranes, such as those lining the
Key terms
respiratory passages we breathe through, are particularly open to
DNA (Deoxyribonucleic acid) is sometimes virus attacks because they are not covered by protective skin. As well
called ‘the blueprint of life’ because it as all cold and flu infections and most coughs and sore throats, viruses
contains the code for building organisms. are also the cause of many serious infectious diseases. In order to get
RNA (Ribonucleic acid) acts as a rid of a virus, the cell which has been invaded by the virus must be
messenger of the above mentioned code killed, which results in damage to the cells themselves. For this reason
when new cells are formed. doctors can only control the symptoms of a viral infection, but to date
medical research has found no cures.
When a virus invades the body, the immune system releases white
blood cells. These cells produce antibodies, which cover the virus’s
protein coat and prevent it from attaching itself to the cell. White
blood cells also destroy infected cells and thus kill the virus before it
can reproduce. Unfortunately, some viruses such as measles, influenza
and mononucleosis (glandular fever) weaken the immune system for a
period of time.

PATHOGENIC FUNGI
Pathogenic fungi can be either yeast or moulds, including yeasts
(single-celled), and mushrooms and moulds (multi-celled). A fungus is a
simple plant-like organism. Unlike plants, fungi do not make their own
food. Some species of fungi get their nutrition by breaking down the
remains of dead plants or animals. Others are parasites. Examples of
fungal infections include athlete’s foot, thrush and ringworm. Fungal
infections are not often the cause of healthcare-acquired infections;
however, it is possible for an individual to acquire an infection such as
ringworm in a healthcare environment.

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PARASITES
Some parasites are very complex; many are pathogenic and cause
infection and can be spread from person to person. Parasites
usually enter the body through the mouth or the skin. For example,
threadworms, sometimes known as pinworms, are small, white,
thread-like worms a few millimetres long that live in the human gut.
The female worm lays eggs around the anus, which often leads to
itching and scratching. Eggs can then become stuck to fingertips or
under the fingernails and can be transferred to other people, food,
children’s toys, kitchen utensils or even toothbrushes. Other people
then come into contact with the eggs, and if they touch their mouths
and swallow the eggs they become infected with the threadworm.
Scabies is a contagious disease caused by tiny mites (Sarcoptes
scabiei). The main symptom of scabies is itching caused by the mite
burrowing under the skin. Scabies is spread by skin-to-skin contact
with an infected person; this is the most common method. It can also
be spread by sharing clothes, infected linen, towels and so on with an
infected person.

COMMON ILLNESSES AND INFECTIONS

CAUSED BY BACTERIA, VIRUSES, FUNGI AND
PARASITES

The following table is not an exhaustive list, but is provided to further

illustrate the types of illnesses that are caused by micro-organisms.

Condition Type of Outlines of transmission

micro-
organism

Acquired Virus AIDS is the final stages of HIV (Human

Immune Immunodeficiency Virus). Most
Key term
Deficiency common modes of transmission are Transmission means passing an infectious
Syndrome unprotected sex, sharing infected disease from one person to another.
(AIDS) needles, HIV-positive mother to
baby during pregnancy, birth or
breastfeeding.

Bronchiolitis Virus Mostly common in babies and young

children. Mode of infection is usually
droplet infection from infected people
sneezing and coughing.

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 COMMON ILLNESSES AND INFECTIONS CAUSED BY BACTERIA, VIRUSES, FUNGI AND PARASITES

Condition Type of Outlines of transmission

micro-
organism

Chickenpox Virus Common childhood illness. Mode

of transmission is that it spreads
through the air in tiny droplets –
fifteen minutes in the same room as
an infected person is likely to lead to
infection; also spread through skin
contact with the blisters.

Chlamydia Bacteria Mode of transmission is unprotected

sex or from an infected mother to a
baby during birth.

Cold and flu Virus Can be spread by droplet infection,

or the unwashed hands of an infected
person touching surfaces.

Cold sores Virus Modes of transmission include skin-

to-skin, eg kissing, and sharing items
such as cups, towels or any other item
that has made contact with the cold
sore.

Diphtheria Bacteria The most common mode of

transmission is droplet infection;
since the vaccination programme
started in 1940 this once-common
cause of death in the UK is now rare.
Since 1896 there have been 15 cases
reported in England and Wales. It is,
however, still common in some other
areas of the world.

Dysentery Bacteria or There are two main types of

parasite dysentery; the most common type
in the UK is caused by the Shigella
bacteria. Amoebic dysentery is caused
by an amoeba (single-celled parasite)
called Entamoeba histolytica, which
is mainly found in tropical areas. Both
types of dysentery are commonly
passed on through poor hygiene,
and people often become infected by
eating contaminated food.

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Condition Type of Outlines of transmission

micro-
organism

Glandular Virus Mostly infects young adults. Common

fever modes of transmission are kissing,
droplet infection from infected people
coughing and sneezing, and sharing
eating and drinking utensils such as
cups, glasses and unwashed forks and
spoons.

Hepatitis Virus Hepatitis A is caused by faecal

A/B/C contamination. Hepatitis B can be
passed on through sexual contact,
infected needles and from mother to
baby. Hepatitis C is blood-borne so
can be passed on by infected blood,
contaminated needles, needle-stick
injuries and from mother to unborn
child.

Impetigo Bacteria This is an infection of the top layers

of skin caused by bacteria getting
into the skin when it is damaged, for
example, by insect bites, tiny cuts
and grazes. The mode of transmission
is by contact with blister fluid either
from direct skin contact or by cross-
contamination from objects that have
touched the blister fluid such as face
cloths, towels, clothing or toys.

Measles Virus Modes of transmission are droplet

infection, either by breathing in the
droplets when an infected person has
coughed or sneezed or by touching
contaminated surfaces where
droplets have fallen and then touching
the mouth or nose area.

Mumps Virus Same as measles, above.

Norovirus Virus Caused by a group of viruses called

(winter noroviruses, this is the most common
vomiting bug) cause of stomach bugs in England
and Wales. Modes of transmission
are person-to-person, consuming
contaminated food or water, and
touching contaminated surfaces or
objects.

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 COMMON ILLNESSES AND INFECTIONS CAUSED BY BACTERIA, VIRUSES, FUNGI AND PARASITES

Condition Type of Outlines of transmission

micro-
organism

Poliomyelitis Virus Poliomyelitis (polio) is a highly

(polio) infectious vaccine-preventable
disease. It invades the nervous
system, and can cause total paralysis
in a matter of hours. It can strike at
any age, but mainly affects children
under three.

Pneumonia Virus or Pneumonia means inflammation of the

bacteria or lungs usually caused by an infection.
fungus

Ringworm Fungus Can affect skin, nails and hair. The

mode of transmission is by touching
an infected person, animal or infected
object or surface, eg shared towels or
farm gates.

Rubella Virus Direct contact and droplet infection

(German breathed in when an infected person
measles) coughs or sneezes are the common
modes of transmission.

Scabies Parasite Contagious, very itchy skin disorder

(scabies leading to a rash caused by the
mite) microscopic mite burrowing under
the skin to lay eggs. The mode of
transmission is skin-to-skin contact, eg
prolonged hand-holding.

Scarlet fever Bacteria Caused by the same Streptococcus

bacteria that causes impetigo. These
bacteria are commonly found on
the skin and in the throat, where
they do not cause any problems.
Unfortunately under certain
circumstances they cause disease.
Scarlet fever is highly contagious and
is transmitted via airborne droplets
from coughing and sneezing, and by
direct contact with mucus or saliva
from an infected person or items
contaminated by droplets or saliva/
mucus such as drinking vessels or
eating utensils.

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Condition Type of Outlines of transmission

micro-
organism

Tetanus Bacteria Tetanus occurs when a flesh wound

becomes contaminated. The bacteria
live in soil, house dust and animal and
human waste.

Tinea pedis Fungus Spreads easily from person to person

(athlete’s foot) on towels, clothing and foot contact
surfaces. The fungi survive and
multiply in warm humid areas such as
swimming pools, changing rooms and
showers.

Tuberculosis Bacteria Spread by inhaling droplets from the

coughs and sneezes of an infected
person. Most commonly affects the
lungs, but can affect any part of the
body.

Warts and Virus Very contagious; modes of

verrucas transmission are skin to skin and
contact with infected objects or
surfaces such as the areas around
swimming pools.

Whooping Bacteria Spread by inhaling droplets from the

cough coughs and sneezes of an infected
person.

TYPES OF INFECTION
The following are terms commonly used to describe how and where
microbes are affecting a person’s body:

■ Systemic infection. This is when the infection caused by a pathogen

has spread through the body to several organs in different systems
of the body, for example, the digestive, respiratory or circulatory
systems.
■ Localised infection. This is an infection that is confined or restricted
to a specific location of the body, for example, an infected wound.

Colonisation versus infection

Infection means that the organism is present and is causing illness.
Colonisation means that the organism is present in or on the body but
is not causing illness. When someone is exposed to a micro-organism

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 THE TRANSMISSION OF INFECTION

such as MRSA or Clostridium difficile, they can become colonised.

This means that the organism takes up residence harmlessly (for
example, on the skin, in the nose or in the bowel) but does not cause
an infection. This colonisation may:

■ continue harmlessly indefinitely

■ clear spontaneously
■ develop into an infection.

Sometimes it is possible and indeed necessary to use medical

treatments to help the colonisation clear faster, for example, before
an operation can take place. For this reason screening for MRSA often
takes place prior to elective surgery, for example, in day cases having
routine surgery.

THE TRANSMISSION OF INFECTION

Micro-organisms that cause infection may originate from:

Key terms ■ ourselves (endogenous) micro-organisms which transfer from

Endogenous means originating from one site on the body to another site where they invade and cause
within. infection
Exogenous means originating from an
external source.
■ other people (exogenous) via hands, equipment, etc
■ the environment, including contaminated food, contaminated
equipment, contaminated surfaces, contaminated laundry, clinical
waste and dust.

The difference between infectious and non-infectious disease is that

infectious disease can be spread from person to person. Infection can
pass from person to person by cross-contamination (cross-infection,
indirect contamination) or by direct contact (direct contamination).
Cross-contamination is where the pathogenic organisms are moved
from their source to another location and then to a person. Sharing
contaminated objects such as a bedpan or hairbrush can lead to cross-
contamination, as can misusing cleaning equipment, for example, by
using cleaning cloths in more than one location. Remember, hands are
the most common vehicles of cross-infection.
It is very important to remember that some people are more
susceptible to infection than others. For instance older people,
babies and children are more susceptible, as are people with lowered
immunity due to illness or existing health conditions.
One of the reasons that the organisms that cause infections spread
so easily is because they cannot be seen by the naked eye. For that
reason we need to be aware of how to minimise the conditions for

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their growth and how they get into our bodies. With this information
we can start to minimise the chances of transmission of infections.
Bacteria live on or in just about every material and environment on
this planet: from soil, to water, to air; from inside home environments,
to arctic ice. Every living creature, including humans, is covered with
bacteria. Some microbes live on the skin and offer protection from
harmful agents. The drier areas of the body, such as the back and
forearm, have few microbes; moist areas, such as the armpit, have
many more. Each square centimetre of skin averages about 100,000
bacteria. The forearms, which tend to be dry, average approximately
1,000 bacteria per square centimetre, while the armpits may have
many millions per square centimetre.

CONDITIONS NEEDED FOR THE GROWTH OF

MICRO-ORGANISMS
To multiply and reproduce, pathogenic micro-organisms require the
following:

■ moisture
■ nutrients
■ temperature
■ time.

Moisture
Like most living things, bacteria must have moisture to stay alive.
Bacteria will not multiply in dry areas, but as soon as liquid is added,
for instance to dried food like powdered milk and dried eggs, the
products will provide ideal conditions for bacteria to multiply.
However, if enough salt or sugar have been added to foods such
as bacon, savoury biscuits, jam and confectionery, this will absorb
the available moisture in the food so the bacteria cannot multiply as
easily. It is not only moist foods that provide the right environment for
bacteria, though. Moist skin or damp areas of an environment will also
provide the right atmosphere for bacterial growth.
Nutrients
Bacteria, like all living things, need nutrients to survive. Different types
of food-poisoning bacteria can live on a range of foods, but most
prefer food that is moist and high in protein such as meat, poultry,
eggs, shellfish, milk and dairy products, cooked rice, pasta, or any
product made from these foods.
All these foods are subject to bacterial growth even after they have
been cooked and served cold later. This is why such ready-to-eat items
are classified as high-risk foods.

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KEY POINT Bacteria will live on and in people, plants and soil, and they take
Photosynthesis is the process by nutrition from everything from sugar and starch to sunlight, sulphur
which some organisms use sunlight to and iron. Some bacteria are photosynthetic – they can make their
synthesize nutrients from carbon dioxide own food from sunlight, just like plants. Also like plants, they give off
and water. oxygen. Other bacteria absorb food from the material they live on or
in. Some of these bacteria can live off unusual substances such as the
elements iron or sulphur. The microbes that live in your gut absorb
nutrients from the food you’ve digested.
Temperature
Most food-poisoning bacteria multiply at temperatures between 5°C
and 63°C, which is why this range of temperatures is often called
the ‘danger zone’. Ambient temperatures (room temperatures)
are generally within the danger zone. The ideal temperature for
bacteria to multiply is around 37°C, which is the average human body
temperature. When food is kept at temperatures colder than 5°C and
hotter than 63°C bacterial growth slows down or stops, but most
bacteria can survive cold temperatures and resume multiplication
when conditions are more suitable. Freezing will make most bacteria
dormant, but it does not kill them, so when frozen food is thawed it is
just as susceptible to risks as fresh food.
Time
When bacteria are left in warm conditions on the right type of nutrient
with adequate moisture, they will reproduce quickly. For example,
most types of food-poisoning bacteria take around 10 to 20 minutes to
multiply.

VIRUSES
In order for a virus to multiply it needs to latch on and invade an
appropriate host cell of an animal or plant. Once it is within the ‘host’
cell it takes over its machinery and makes more virus particles. The
cells of the mucous membranes, such as those lining the respiratory
passages that we breathe through, are particularly open to virus
attacks because they are not covered by protective skin.

MAIN ROUTES OF INFECTION

There are four main routes of infection, or ways in which infections
enter our bodies:

■ The respiratory tract (nose, windpipe, lungs). Airborne pathogens

such as those causing coughs and colds can be inhaled.
■ Broken skin. One of the functions of the skin is to provide
protection against infection. This includes the mucous membrane
of the nose and mouth. If skin is broken by bites, scratches,

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puncture wounds or dry chapped skin that breaks down, this

provides a route for infection to enter the body.
■ The digestive tract. Infected products such as food and drink can
be swallowed, often affecting the bowels or stomach.
■ The urinary tract and reproductive system. Infections may remain
localised or enter the bloodstream. One of the problems with
catheterisation is the possibility of bacteria being carried into the
urinary tract during the catheterisation procedure.

COMMON CAUSES OF THE SPREAD OF

INFECTION
The most common causes of spread of infections in a health and social
care environment are:

■ lack of or poor hand hygiene

■ lack of or poor cleaning procedures
■ lack of, or incorrect use of, personal protective equipment (PPE)
such as gloves and aprons
■ contaminated bed linen or clothing
■ infected food handlers – remember, this includes not only those
who prepare food but also those who serve food or support people
to eat and drink
■ airborne infection (such as colds and flu).

Some of these are described in more detail below.

Lack of or poor hand hygiene
People carry millions of microbes on their hands. Most are harmless,
but some can cause illnesses such as colds, flu, diarrhoea, hepatitis
and E. coli infection when we forget to wash our hands, or don’t wash
them properly. We can spread these germs to other people, or give
them to ourselves by touching our eyes, mouths, noses or cuts on
our bodies. Microbes can also be picked up from objects such as
doorknobs, taps, and wheelchair handles touched by other people
who have not washed their hands. Think about all the things you touch
each day and how many people may have touched them before you.
The Hand Hygiene Campaign – Give Soap a Chance states that some
bacteria and viruses can stay alive on our hands for up to three
hours. They can be spread to all the things touched during that time,
including food and other people, so good hand hygiene is of the
utmost importance. On its website, NHS Choices, the National Health
Service gives a wealth of information about how long micro-organisms
can live outside of the body. For instance, cold viruses can survive on

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indoor surfaces for more than seven days; however, their ability to
cause an infection starts to decrease after 24 hours. Also, 40% of cold-
causing viruses remain infectious on hands after one hour. Washing
hands reduces the number of micro-organisms on our hands and helps
prevent the spread of infection.
The following are examples of the types of microbes that can be
spread on the hands of health and social care workers:

■ Staphylococcus aureus (including MRSA)

■ Streptococcus pyogenes (Group A Streptococci)
■ Pseudomonas – a bacterium found in soil and water, likely to infect
people with underlying health problems staying in hospital
■ Clostridium difficile – a bacterial infection that affects the digestive
system, most commonly affecting people staying in hospital
■ Candida – fungi which live on all surfaces of our bodies; under
certain conditions, they can cause infections such as vaginal
thrush, oral thrush, skin and nappy rash
■ rotavirus – a common cause of diarrhoea and sickness
■ adenovirus – a common cause of respiratory tract infections and
gastroenteritis, especially in young children; adenoviruses can also
cause conjunctivitis and cystitis
■ hepatitis A virus
■ norovirus.

DID YOU KNOW?

■ Around 20% of women and 40% of men don’t wash their hands after using a public toilet.
■ According to research carried out in the United States of America and presented to the International
Association for Food Protection conference in San Diego in July 2002, 90% of germs on hands are
found under the nails.
■ A right-handed person tends to wash their left hand more thoroughly than their right hand, and
vice versa.
■ The number of bacteria can double in 20 minutes, and after one day without hand washing a single
bacterium can multiply 2 billion, trillion times.
■ There are between 2 million and 10 million bacteria between the fingertip and the elbow.
■ The number of microbes on your fingertips doubles after you use the toilet.
■ Pathogens can stay alive on hands for up to three hours.
■ Millions of germs hide under watches and bracelets, and there could be as many germs under a ring
as there are people in Europe.
(Foodink, Food and Drink Federation)

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Hand hygiene is of utmost importance. It is important that you are fully

aware of your employer’s laid-down policies and procedures relating
to hand hygiene, including which resources should be used for the
various activities carried out during the course of your daily duties.
Generally, washing hands with liquid soap and water is sufficient as
you go about your daily activities. Nowadays, hand rub containing
alcohol is available at the entrance to hospital wards and residential
support services. It is important that staff and visitors use it on
entering and exiting such facilities. If you are supporting a service user
from a social care environment into a clinical setting such as a hospital
you must remember that your duty of care still applies, and that you
have a responsibility to ensure that correct hand hygiene is adhered to
by you, the person you are supporting and anyone else involved in the
service user’s support and health care.
The Code of Practice on prevention and control of infections published
by the Department of Health within The Health and Social Care Act
states that service providers must ensure that there is adequate
provision of hand-washing facilities, and anti-microbial hand rubs
where appropriate. This clearly indicates the importance of hand
washing with soap and water. However, according to the National
Institute for Health and Care Excellence (NICE) in its Clinical Guidelines,
hand rubs containing 60% isopropyl alcohol and conforming to the
current British Standard are the recommended products for ensuring
effective hand hygiene, except when:

■ hands are visibly soiled

■ the patient is experiencing vomiting and/or diarrhoea
■ there is direct hand contact with any body fluids, ie if gloves have
not been worn
■ there is an outbreak of norovirus, Clostridium difficile or other
diarrhoeal illnesses.

In these instances hands should always be cleaned with liquid soap

and warm running water.
Hand washing with soap and water
It takes at least 15 seconds to wash your hands thoroughly (about
the same amount of time as it takes to sing ‘Happy Birthday’ through
twice). The correct method for hand washing is covered in more detail
in Chapter 14.

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Damp hands spread 1,000 times more germs than dry hands. Clean
towels should be available at all times – dirty towels mean exposing
the skin to more dirt and the risk of infection. Ideally, ‘single-use’
disposable towels should be used, as the use of ‘communal’ towels
can lead to contamination.
When using hand gel, apply gel to dry hands and follow steps 3–9 as
shown above, ensuring that enough gel is applied. Refer to Chapter 14
for more information on how to wash your hands correctly.

REFLECT
What tasks do health and social care workers in your work
environment carry out that require hand washing prior to starting
the task and after completion of the task?

Lack of or poor cleaning procedures

If there is a lack of cleaning procedures in place, or they are poor, you
and the service users you support can become infected. Pathogenic
organisms can be moved from their source and into the environment,
and cross-contamination can happen by people passing microbes from
one area to another either by their hands or by cleaning equipment
such as mops and cloths. For example, taps and door handles can
harbour a multitude of micro-organisms, as can wheelchair handles
and telephone receivers. In fact, any hand contact surface can be a
breeding ground for pathogens.
If the correct methods are not used for cleaning the environment,
be that in a hospital ward/department or residential/day services
setting, micro-organisms may be transmitted from one site to another.
For this reason it is important to follow laid-down processes and
procedures using colour-coded cleaning equipment, which after use is
decontaminated or disposed of in the correct manner.

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REFLECT
■ What surfaces are there in your work environment that could
harbour harmful microbes? What measures are there in place to
ensure that such risks are kept to a minimum?
■ What antibacterial/viral cleaning materials do you have in your
work environment, and what measures are there in place to
ensure that everyone knows how to use them effectively?
■ What measures are there in place where you work to ensure
that no cross-contamination occurs due to inappropriate use of
cleaning equipment?
■ If you needed to clean up a spillage of urine from the floor of a
toilet, what equipment (including PPE) would you use?
■ Do you have a spillage kit at work to use in the case of blood
spillage? If so, where is it kept – and could you explain to a new
member of staff how and when to use it?

CASE STUDY
Silas is a home care worker. He recognises that
al
service users have the right to live in a non-clinical
environment, and he also knows about infection
control. As he does not want to take away service
users’ dignity by refusing to use their soap and
terry cotton towels, he always carries with him
the bacterial hand gel provided by his employing
agency. He uses the hand gel very discreetly
before entering and after exiting people’s
homes in addition to using their own facilities.

■ Name two infections that can be spread by sharing towels.

■ What is the recommended percentage of isopropyl alcohol for
hand gel to contain?

Contamination of food
Bacteria can cause food-borne illness. When food is kept warm,
between the temperatures of 5°C and 63°C, these bacteria can grow
rapidly and reach dangerous levels within hours.
The incubation period (the time that elapses between eating the food
and feeling unwell) varies with each type of organism, and in some KEY POINT
cases can be as much as 10 to 15 days. It is important to realise, Incubation is the time from the moment of
therefore, that the last meal eaten may not be the cause of the exposure to an infectious agent until signs
and symptoms of the disease appear.
symptoms. The government publishes a wealth of information about

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types of food-borne illnesses, symptoms and incubation times in their

PHE guidance sheets, which can be found at www.hpa.org.uk.
The Food Standards Agency (FSA) identifies the following as the main
causes of food poisoning and food-borne illness:

■ not cooking food thoroughly (particularly poultry, pork, burgers,

sausages and kebabs)
■ not correctly storing food that needs to be chilled at below 5°C
■ leaving cooked food for too long at warm temperatures
■ someone who is ill or who has dirty hands touching food
■ eating food that has passed its use-by date
■ cross-contamination (the spread of bacteria, such as E. coli, from
contaminated foods), for example, bacteria-harbouring juices
of raw meat dripping on to foodstuffs that will be eaten without
cooking or processing.

Anyone can become ill as a result of food poisoning or food-borne

illness, but babies, young children and older people can quickly
become very ill when infected. Pregnant women, people with a
pre-existing illness and anyone whose immune system is weakened
can also be especially vulnerable and seriously affected by food-borne
illness.

CASE STUDY
Mary is supported in her own home by Georgie.
Every Monday, food that Mary has ordered online is
delivered by a local supermarket. Mary takes
great pride in putting away her purchases
herself. Georgie has coached Mary in the
importance of ensuring that raw meat is
stored at the bottom of the refrigerator,
ensuring that no bacteria-laden juices can
drop on to and contaminate food to be eaten
raw, such as cheese.

■ Why is cheese likely to be a high-risk food?

■ Other than ensuring that the meat is stored at the bottom of the
refrigerator, what other steps should be taken to ensure that no
bacteria passes from raw meat to other foodstuffs?

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Contaminated linen and clothing

Workers may become infected or cause cross-contamination if they
do not use PPE such as gloves and aprons, for example, when dealing
with soiled linen and clothing. Special care needs to be taken if there
is any risk of splashing, spraying or splattering of faeces or vomit.
Even when there is no visible sign of soiling of linen and clothing,
microbiological pathogens may still be present. Putting soiled linen on
chairs or floors instead of into laundry bags is especially bad practice
and can lead to cross-infection.

CASE STUDY
Miriam is a new support worker at a residential
establishment for older people. During her second d
week in her new job, Miriam is stripping a bed to
change the linen when her supervisor comes
looking for her to discuss her induction. The
supervisor asks Miriam why, as a new member
of staff, she is working alone and why she is
stripping the bed without wearing gloves.
The supervisor points out that the person
whose bed is being stripped has urinary incontinence,
and that by not wearing gloves Miriam is putting herself and others
at risk of infection. Miriam explains that her colleague, who she
was making the beds with, was called away to deal with something
else, so she had agreed to strip the beds in readiness for the two
of them to make them again later. The supervisor reminds Miriam
of the care plans and risk assessments for all service users that she
has been shown; she also makes a note to herself that new workers
should have closer supervision until they are fully conversant with
the care plans and risk assessments.

■ In addition to wearing gloves, what steps should be taken when

dealing with soiled linen?
■ Would it be acceptable to wear the same pair of gloves to strip
several beds of their linen? Why?

Infected food handlers

People suffering from certain infections (mainly from bacteria and
viruses) can contaminate the food they handle or the surfaces food
may come into contact with. This can spread infection to other people
through the food. Food-borne infections from infected food handlers
result primarily in gastrointestinal infections.

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The FSA is an independent government department responsible for

food safety and hygiene across the UK. It works with businesses to
help them produce safe food, and with Local Authorities to enforce
food safety regulations. The FSA states that Campylobacter is the
most common cause of food poisoning in the UK. It is considered to
be responsible for around 460,000 cases of food poisoning, 22,000
hospitalisations and 110 deaths each year, and most of these cases
come from poultry. The FSA also tells us that norovirus, commonly
known as the winter vomiting bug, is the most common cause of
infectious intestinal disease resulting in diarrhoea and vomiting
in the UK. The Second Study of Infectious Intestinal Disease in the
Community (the IID2 Study) published in September 2011 suggested
that there were approximately 3 million UK cases of norovirus
annually. Norovirus poses additional problems in the management of
outbreaks of infection, as even very low numbers of particles can lead
to infection.
Although most cases are caused by contact with an infected person,
a proportion of cases are due to contaminated food and drink.
There are, of course, other infections with which food handlers can
contaminate food and surfaces such as salmonella – and E. coli.
Salmonella bacteria are often found in raw meat and poultry. They can
also be passed to dairy products such as eggs and unpasteurised milk.
E. coli are bacteria found in the digestive systems of many animals,
including humans. Most strains are harmless but some strains can
cause serious illness.
In most cases, food handlers with diarrhoea or vomiting should refrain
from work for 48 hours after symptoms subside. However, in some
cases different action is required. Guidance is available from the Health
Protection Agency.
Infected health and social care staff
Health and social care staff, in common with any other group of
workers, can become infected themselves and, along with the
rest of the population, carry bacteria within and on themselves.
Because of the vulnerability of service users, workers must be
extra-vigilant with their own health and consider how to best
protect the people they support from infection by pathogens
they might be carrying.

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CASE STUDY
Carlos is a senior day services officer. One lunchtime he observes Raymond
supporting a service user to eat his meal. Afterwards he gives Raymond
some feedback. He tells Raymond how impressed he was with the way in
which Raymond had treated the service user with dignity and respect,
offered choices, supported them at their own pace and communicated well
with them throughout the meal, using appropriate language to meet their
needs. At one point during the meal Raymond had to cough, and Carlos had
noted that Raymond had turned away from the service user and their food to
cough, held his hand over his mouth while coughing and immediately apologised d
f t t l
to the service user – all of this was, as Carlos said, very appropriate behaviour. Unfortunately,
Raymond had not washed his hands immediately following the cough; instead he picked up a
glass of water and handed it to the service user. It is almost certain that his hand was covered
with bacteria, if not virus particles, from his respiratory tract.
On receiving the feedback Raymond understood his error and made a mental note never to repeat it.

■ Name at least three infections that Raymond could pass to the service user by touching their
glass with an unwashed hand after coughing into it.
■ Name at least six daily situations at work in which you need to wash your hands.

HOW INFECTIONS ARE SPREAD FROM PERSON

TO PERSON
The chain of infection shows how infection is spread from person to
person.
The chain of infection

Infectious agent

Susceptible host Reservoir

Portal of entry Portal of exit

Mode of transmission

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As stated previously, micro-organisms (eg bacteria and viruses) live

in or on some parts of the body such as the skin, mouth and intestinal
tract. This mixture of organisms normally found on or in the body that
do not usually cause harm is referred to as the normal flora.
Some of these organisms may cause illness if they find their way into
areas of the body where they don’t belong. For example, if micro-
organisms normally found in the bowel enter the bladder they may
have the potential to cause infection. For this reason people are
instructed to ‘wipe towards the back’ after using the toilet.
Normal skin flora which are there all the time are essential for
good health and rarely causes infection. However, there are some
procedures that can make people vulnerable to infection, because
the micro-organisms can be carried from the surface of the skin –
where they belong – into the flesh or blood vessels, where they do
not belong. This may happen during surgery, insertion of catheters,
or peripheral intravenous (IV) cannulation. Normal flora live naturally
on the skin and are difficult to remove by routine hand hygiene
techniques, although the numbers of micro-organisms will be reduced
by this process.
Many other micro-organisms are acquired or deposited on the skin
from other people or from the environment. These micro-organisms do
not live permanently on the skin and are readily removed or destroyed
by correct and frequent hand hygiene procedures.
The reservoirs of infection
The Health Protection Agency (HPA) describes a reservoir of infection
as being where a micro-organism normally lives and reproduces,
for example, in animals, water or food. The human body is the most
common reservoir for micro-organisms. A person with an infectious
disease such as salmonella, tuberculosis, polio, hepatitis A or hepatitis
B may act as a source of infection to others because the micro-
organisms are present in some of the body fluids and can be passed on
to others.
There are two types of human reservoirs: clinical cases and carriers.
Clinical cases are people who are infected with the disease agent
and become ill. Because they are ill, their contacts and activities may
be limited. They are also more likely to be diagnosed and treated
than carriers. Carriers, on the other hand, are people who harbour
infectious agents but are not ill. Carriers may present more risk for
disease transmission than clinical cases, because their contacts are
unaware of their infection, and their activities are not restricted by
illness.
Depending on the disease, there may be different types of carriers:

■ incubatory carriers
■ inapparent infections

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■ convalescent carriers
■ chronic carriers.

Incubatory carriers
These are people who are going to become ill, but begin transmitting
their infection before their symptoms start. For example, in the case of
measles, a person infected with measles can pass the virus to others
via nasal and throat secretions a day or two before any symptoms are
noticeable.
Inapparent carriers
Inapparent infections are where the individual is asymptomatic (has no
symptoms of infection) but is carrying the infectious agent.
Convalescent carriers
These are people who continue to be infectious during and even
after their recovery from illness. This happens with many diseases.
For example, with salmonella, individuals may excrete the bacteria in
faeces for several weeks and (rarely) even for a year or more. This is
most common in infants and young children.
Chronic carriers
These are people who continue to harbour infections for a year or
longer after their recovery. For example, the chronic carrier state is
not uncommon following hepatitis B infection, whether or not the
person became ill, and may be lifelong.
Contaminated food may also act as a reservoir of infection. A common
example of this is the presence of salmonella. If food contaminated
with salmonella is not thoroughly cooked, individuals who consume it
can become infected.
The environment can also be reservoir of infection if it becomes
contaminated by micro-organisms shed by people with an infection.
This can then spread to others. Regular cleaning minimises this risk.
Poorly maintained or incorrectly decontaminated cleaning or medical
equipment can also act as a reservoir of micro-organisms. For
example, inadequately maintained and shared commodes can be
contaminated with micro-organisms that cause diarrhoea.
Portal of exit
This refers to the way in which the pathogen escapes from the
reservoir, such as via faeces, urine, wound discharge, mucus, blood,
vomit, droplet transmission by sneezing, coughing or talking.
Mode of transmission
The mode of transmission is the method by which the pathogen gets
from the reservoir to the new host. This can happen by one of the
following means:

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■ Direct contact (actual contact with an infected person).

■ Indirect contact (contact with contaminated surfaces touched by
the infected person, or where droplets of body fluid have landed;
spread on unwashed hands). Hands play a big part in spreading
infection. Micro-organisms may be present in body excretions
and secretions. If hands come into contact with these, the micro-
organisms may be carried from one person to another unless the
hands are properly decontaminated.
■ Airborne – via ‘aerosols’, or tiny infected particles from an infected
person released when they cough or sneeze, which can be breathed
in. The viruses responsible for colds and influenza are found in nasal
Key terms secretion, saliva and sputum. Coughing or sneezing near another
Sputum is mucus that is sometimes person may pass on these viruses in the droplets or aerosol produced.
coughed up from the lower airways.
■ Consumption of contaminated food/water or swallowing of micro-
Vector is an organism, typically a biting organisms carried on the hands.
insect or parasite, that transmits a disease.
■ Exposure to blood.
■ Vector-borne (parasite bites).
■ Sexual contact.

Portal of entry
Every micro-organism needs to have an entry point into the human
body. Different micro-organisms have different ways of achieving this.

Portal of entry Example infection

Ingestion – eating contaminated Salmonella, a group of bacteria

food. that can cause food poisoning.

Inhalation – micro-organisms Influenza

suspended in particles of liquid
are exhaled by the infected
person and inhaled (breathed in)
through the nose or mouth by
another person.

Blood – this can occur through Hepatitis B

punctures to the skin by
contaminated sharps.

Urinary tract – organisms causing Escherichia coli

urinary tract infections may enter
during poor catheter care or poor
personal care.

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Portal of entry Example infection

Skin – via breaks in the skin, which Enterobacteriaceae, a group of

is normally a protective barrier, bacteria including many of the
for example, during surgery or more often heard-of pathogens
through punctures made by such as salmonella, E. coli,
cannulation cuts, scratches or helicobacter.
abrasions caused by injury.
Staphylococcus, a common type
of bacterium often carried on
the skin and inside the nostrils
and throat, which can cause mild
infections of the skin such as boils
and impetigo. If Staphylococcus
bacteria get into a break in
the skin, they can cause life-
threatening infections, such as
blood poisoning or endocarditis
(an infection of the inner lining of
the heart).
Staphylococcus epidermidis

Mucous membranes (in the Streptococcus, a bacterium that

mouth, eyes and nose) – having is commonly found on the skin or
no protective skin, these can in the nose and throat.
be very vulnerable to micro-
organisms, for example, those
that cause Streptococcal throat
infections.

FACTORS THAT WILL MAKE IT MORE LIKELY

THAT INFECTION WILL OCCUR
Susceptibility to infection varies from person to person. Risk factors for
infection include:

■ age (the very young and very old are more vulnerable to infections)
■ physical wellbeing
■ psychological wellbeing
■ hygiene
■ underlying or chronic diseases or medical conditions (eg diabetes,
chronic chest and heart problems, or cancer)
■ other existing infections
■ medical interventions (eg an indwelling medical device)
■ medical therapies (eg cancer chemotherapy or steroids)
■ immune status.

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It is important that key factors that will make infection more likely are
identified. These factors vary from one work setting to another, and
according to the duties being carried out. Some activities – or lack
of activities – put the worker at risk of becoming infected, others put
the service user at risk, and some activities or the lack of them put
both the worker and the service user at risk. The following are some
examples of risk factors:

■ dealing with personal care tasks

■ a lack of personal hygiene
■ wounds requiring treatment
■ contact with body fluids
■ long-term use of antibiotics
■ close proximity to others, whether infected or uninfected
■ age – very young or very elderly
■ dirty and/or contaminated areas of the environment
■ dirty and/or contaminated equipment
■ dirty and/or contaminated laundry
■ people who are ill
Key term ■ people who are immunocompromised, ie where their immune
Immunocompromised is where a person
system does not function properly.
has impaired immunity due to disease (eg
cancer) or treatment (eg corticosteroids or
radiotherapy).
REFLECT
■ Think about your work setting. What key factors can you identify
that might make it more likely that infection will occur, and how
are those factors managed?
■ Can you identify any further steps that could be taken to reduce
the risks?

Before going to the next chapter, take some time to consider:

■ what policies and procedures you have in your work setting
relating to the causes and spread of infection
■ what your responsibilities are regarding stopping the spread of
infection
■ how you can help colleagues and others to understand the
causes and spread of infection
■ what you would do if you observed poor practice that might lead
to the spread of infection
■ if there is anything you can do to improve your own practice
connected with stopping the potential spread of infection.

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