MODULE 25:

Hospital Hygiene, Infection Control

and Healthcare Waste Management
 Module Overview
• Explain the importance of hospital hygiene
• Describe nosocomial infections, their sources,
and routes of transmission
• Present standard and transmission-based
precautions for infection control
• Describe cleaning, disinfection, sterilization, and
hand hygiene
• Present measures to improve infection control
• Describe components of an infection control
program
 Learning Objectives

• Understand the problem of nosocomial

infections and how to prevent them
• Understand basic concepts of cleaning,
disinfection, and sterilization
• Describe hand hygiene procedures
• Understand the link between infection control
and healthcare waste management
 Guiding Principles

• Healthcare Waste Management

is an integral part of hospital
hygiene and infection control.
 Why Hospital Hygiene?
• Examples of surfaces where pathogens have
been found
– Door handles
– Soap dispensers
– Sink taps
– Sites where dust has accumulated
– Stethoscopes
– Lifting equipment
– Ultrasound probes
 Nosocomial Infections

• Also called hospital-acquired infections (HAI) or hospital-

associated infections
• Infections not present in the patient at the time of
admission but developed during the course of the
patient’s stay in the hospital
• Infections are caused by microorganisms that may come
from the patient’s own body, the environment,
contaminated hospital equipment, health workers, or
other patients.
• The risk of HAI is heightened for patients with altered or
weakened immunity.
 Common Sites of
Nosocomial Infections
 Examples of Sources of Nosocomial
Infections

• Hospital environment
o Salmonella, Shigella spp., or Escherichia coli O157:H7 in food
o Waterborne infections from the water distribution system
o Legionella pneumophilia in water cooling of air conditioning
• Healthcare workers
o Methicillin-resistant Staphylococcus aureus (MRSA) carried in
the nasal passages of healthcare personnel
• Other patients
o Chicken pox spread through the air or contact with freshly soiled
contaminated items
 Examples of Nosocomial Agents From
Environmental Sources
SOURCE BACTERIA VIRUSES FUNGI
Air Gram-positive cocci from skin Influenza Aspergillus
Tuberculosis Varicella zoster
Water Acinetobacter calcoaceticus Human papillomavirus Aspergillus
Aeromonas hydrophilia Molluscum Exophiala jeanselmei
(tap water
Burkholderia cepacia contagiosum
& bath Legionella pneumophila Noroviruses
water) Mycobacterium Xenopi
Mycobacterium chelonae
Pseudomonas aeruginosa
Food Campylobacter jejuni Caliciviruses
Clostridium botulinum Rotavirus
Clostridium perfringens
Escherichia coli
Listeria monocytogenes
Salmonella
Staphylococcus aureus
Streptococcus species
Vibrio cholerae
Yersinia enterocolitica
Examples of Nosocomial Agents
By Type of Infection
TYPE OF INFECTION MICROORGANISM
Urinary Catheter Escherichia coli
Klebsiella spp.
Pseudomonas aeruginosa
Serratia marcescens
Streptococcus faecalis
Pneumonia Enterobacter spp.
Escherichia coli
Klebsiella pneumonia
Legionella penumophilia
Pseudomonas aeruginosa
Staphylococcus aureus
Surgical Site Enterococcus species
Escherichia coli
Staphylococcus aureus
Staphylococcus epidermidis
Streptococcus faecalis
Intravenous Catheter Candida spp.
Staphylococcus aureus
Staphylococcus epidermidis
Streptococcus faecalis
 Antibiotic Resistant Microorganisms
• An increasing problem due to overuse and
misuse of antibiotics
• Often spread through hands of health workers
• Examples:
– methicillin-resistant Staphylococcus aureus (MRSA),
vancomycin-resistant enterococci (VRE), clindamycin-
resistant Clostridium difficile, multidrug resistant
Acinetobacter baumannii
 Reduce the general use of antibiotics to
encourage better immune response in patients
and reduce the cultivation of resistant bacteria
Routes of Transmission of Nosocomial
Infections
• Contact transmission
o Direct contact (e.g., surgeon with infected wound in the finger
performing a wound dressing)
o Indirect contact (e.g., secretion from one patient transferred to
another through hands in contact with contaminated waste)
o Fecal-oral transmission via food
• Bloodborne transmission
o E.g., needle-stick injury – hepatitis B and C, HIV/AIDS
• Vector transmission
o E.g., insects or other pests in contact with excreta or secretions
from infected patients and transmitted to other patients
Routes of Transmission of Nosocomial
Infections
• Droplet transmission (droplets from sneezing, coughing
or vomiting are expelled to surfaces or to the air and fall
typically within 2 meters of the source)
o Direct droplet transmission (droplets reach mucous membranes
or are inhaled by others)
o Indirect droplet-to-contact transmission (droplets contaminate
surfaces/hands and are transmitted to mucous membranes or
other sites) – cold virus, respiratory syncytial virus
• Airborne transmission (small contaminated particles as
aerosols carried by air currents >2 meters from source)
o E.g., Varicella zoster suspended in air and spread by inhalation,
Staphylococcus aureus depositing in wounds
SOURCES
Spread of Nosocomial Infections
Persons Environment
Waste Food
Personnel
Patients
Air Water
Symptomless
carriers Pharmaceuticals etc.

Contamination Contaminated
TRANSMISSION

Contaminated Rats, Contaminated

Contamination of objects by water for
air by mosquitos, Air circulation food,
of the hands of blood, excreta, drinking and
sneezing or flies, in contact in hospital pharmaceuti-
personnel other body personnel
coughing with excreta cals in hospital
fluids hygiene

EXAMPLES
influenza, Excreta: measles, malaria, Legionnaires brucellosis, giardiasis,
salmonellosis, typhoid, meningococcal leishmaniasis, disease, tuberculosis cryptosporidiosis
staphylococcal salmonellosis, meningitis, typhus Q fever
infections, hepatitis A pertussis,
helminthiasis Blood: tuberculosis
viral hepatitis B, C

Contact of the patient with contaminated hands, objects, air, water, food, etc.

Nosocomial Infection
 Guiding Principles

• Knowing the chain of infection helps

identify effective points to prevent
disease transmission.
 Chain of infection

Susceptible Infectious
Host Agent

Portal of
Chain of Infection
Reservoir
Entry

Mode of
Portal of Exit
Transmission
 Standard Precautions
• Basic level of infection control to be used in the care
of all patients
• Key components
– Hand hygiene
– Use of PPE (gloves, face protection, gown)
– Safe injection practices
– Respiratory hygiene and cough etiquette
– Safe handling of contaminated equipment and surfaces in the
patient environment
– Environmental cleaning
– Handling and processing of used linens
– Proper waste management
 Transmission-Based Precautions
• Additional precautions used when routes of transmission are not completely
interrupted by Standard Precautions
• Three categories of transmission-based precautions
1. Contact Precautions – e.g. for E. coli O157:H7, Shigella spp. Hepatitis A
virus, C. difficile, abscess draining, head lice
2. Droplet Precautions – e.g., for Neisseria meningitidis, seasonal flu,
pertussis, mumps, Yersinia pestis pneumonic plague, rubella
3. Airborne Precautions – e.g., for M. tuberculosis, rubeola virus
• Combined precautions, e.g.
– Airborne and contact precautions for varicella zoster, methicillin-resistant
S. aureus (MRSA), severe acute respiratory syndrome virus (SARS-CoV),
avian influenza
– Contact and droplet precautions for respiratory syncytial virus
 Some Standards of Hospital Hygiene
• The hospital environment must be visibly clean, free from dust
and soilage, and acceptable to patients, visitors and staff.
• Increased levels of cleaning, including the use of hypochlorite
and detergent, should be considered in outbreaks where the
pathogen survives in the environment and environmental
contamination may contribute to spread.
• Shared equipment in the clinical environment must be
decontaminated appropriately after each use.
• All healthcare workers need to be aware of their individual
responsibilities for maintaining a safe environment for patients
and staff.
• Regular cleaning will not guarantee complete elimination of
microorganisms, so hand decontamination is required.
 Cleaning

• The most basic measure for maintaining hygiene

in a healthcare facility
• Cleaning is the physical removal of visible
contaminants such as dirt without necessarily
destroying microorganisms
• Thorough cleaning with soaps and detergents
can remove more than 90% of microorganisms
 Sterilization and Disinfection

• Sterilization – rendering an object free from

microorganisms; shown by a 99.9999% reduction of
microorganisms
• High-level disinfection – destruction of all
microorganisms except for large numbers of bacterial
spores
• Intermediate disinfection – inactivation of Mycobacterium
tuberculosis, vegetative bacteria, most viruses and fungi,
but not bacterial spores
• Low-level disinfection – destruction of most bacteria,
some viruses and fungi, but no resistant microorganisms
such as tubercle bacilli or bacterial spores
Methods for Sterilization and Disinfection
• Autoclaving – use of steam under pressure
(moist heat)
• Dry heat – relatively slow and requiring higher
temperature compared to moist heat
• Use of chemical sterilants and disinfectants
• Others: low-temperature plasma with hydrogen
peroxide gas, radiation sterilization, germicidal
ultraviolet irradiation
 Main Chemical Disinfectants
Agent Spectrum Uses Advantages Disadvantages
Alcohols Low to • Used for some semi critical • Fast acting • Volatile, flammable, and
intermediate-level and noncritical items (e.g. oral irritant to mucous
(60–90%) including • No residue
disinfectant and rectal thermometers and membranes
ethanol or isopropanol
stethoscopes) • No staining
• Inactivated by organic
• Used to disinfect small • Low cost matter
surfaces such as rubber • Readily • May harden rubber,
stoppers of multi-dose vials available in all cause glue to deteriorate,
• Alcohols with detergent are countries or crack acrylate plastic
safe and effective for spot
disinfection of countertops,
floors and other surfaces
Chlorine and chlorine Low to high-level • Used for disinfecting • Low cost, fast • Corrosive to metals in
compounds: the most disinfectant tonometers and for spot acting high concentrations
widely used is an disinfection of countertops and (>500 ppm)
• Readily
aqueous solution of floors
available in • Inactivated by organic
sodium hypochlorite
• Can be used for most settings material
5.25–6.15% (house
decontaminating blood spills
bleach) at a • Available as • Causes discoloration or
concentration of 100– • Concentrated hypochlorite or liquid, tablets bleaching of fabrics
5000 ppm free chlorine chlorine gas is used to or powders
• Releases toxic chlorine
disinfect large and small
gas when mixed with
water-distribution systems
ammonia
such as dental appliances,
hydrotherapy tanks, and • Irritant to skin and
water-distribution systems in mucous membranes
haemodialysis centres • Unstable if left uncovered,
exposed to light or
diluted; store in an
opaque container
 Main Chemical Disinfectants
Agent Spectrum Uses Advantages Disadvantages
Aldehydes High-level • Most widely used as high-level • Good material • Allergenic and its fumes are irritating to
disinfectant/ disinfectant for heat-sensitive compatibility skin and respiratory tract
glutaraldehyde: ≥2%
sterilant semi critical items such as
aqueous solutions • Causes severe injury to skin and
endoscopes (for 20 minutes at
buffered to pH 7.5–8.5 mucous membranes on direct contact
20 °C)
with sodium bicarbonate
• Relatively slow activity against some
There are novel mycobacterial species
glutaraldehyde
• Must be monitored for continuing
formulations
efficacy levels

Peracetic acid 0.2–0.35% High-level • Used in automated endoscope Rapid sterilization cycle time • Corrosive to some metals
and other stabilized disinfectant/ reprocessors at low temperature (30–45
• Unstable when activated
organic sterilant min. at 50–55 °C)
• Can be used for cold
• May be irritating to skin, conjunctive
sterilization of heat-sensitive Active in presence of organic
and mucous membranes
critical items (e.g. matter
haemodialysers)
Environment friendly by-
• Also suitable for manual products (oxygen, water,
instrument processing acetic acid)
(depending on the formulation)
Orthophthalaldehyde High-level • High-level disinfectant for Excellent stability over wide • Expensive
disinfectant/ sterilant endoscopes pH range, no need for
(OPA) 0.55% • Stains skin and mucous membranes
activation
• May stain items that are not cleaned
Superior mycobactericidal
thoroughly
activity compared to
glutaraldehyde • Eye irritation with contact

Does not require activation May cause hypersensitivity reactions in

bladder cancer patients following repeated
exposure to manually processed urological
instruments

• Slow sporicidal activity

• Must be monitored for continuing

efficacy levels
 Main Chemical Disinfectants
Agent Spectrum Uses Advantages Disadvantages
Hydrogen peroxide 7.5% High-level • Can be used for cold sterilization of heat- No odour • Material compatibility
disinfectant/ sensitive critical items concerns with brass,
Environment friendly by-
sterilant copper, zinc, nickel/silver
• Requires 30 min at 20 °C products (oxygen, water)
plating

Hydrogen peroxide 7.5% and High-level • For disinfecting haemodialysers Fast-acting (high-level • Material compatibility
peracetic acid 0.23% disinfectant/ disinfection in 15 min) concerns with brass,
sterilant copper, zinc and lead
No activation required
• Potential for eye and skin
No odour
damage

Glucoprotamin High-level disinfectant • Manual reprocessing of endoscopes Highly effective against • Lack of effectiveness
mycobacteria against some enteroviruses
• Requires 15 min at 20 °C
and spores
High cleansing
performance

No odour
Phenolics Low to intermediate- • Have been used for decontaminating Not inactived by organic • Leaves residual film on
level disinfectant environmental surfaces and non-critical matter surfaces
surfaces
• Harmful to the environment
• Should be avoided
• No activity against viruses

• Use in nurseries should be

avoided due to reports of
hyberbilirubinemia in
infants

Iodophores (30–50 ppm free Low-level disinfectant • Have been used for disinfecting some Relatively free of toxicity • Inactivated by organic
iodine) non-critical items (e.g. hydrotherapy or irritancy matter
tanks); however, it is used mainly as an
• Adversely affects silicone
antiseptic (2–3 ppm free iodine)
tubing
• Phenolics
• May stain some fabrics
 Hand Hygiene
• Wash Hands
– Immediately after arriving for work
– Always after handling healthcare waste
– After removing gloves and/or coveralls
– After using the toilet or before eating
– After cleaning up a spill
– Before leaving work
 Hand Hygiene

• Steps in hand washing

– Wet hands and apply soap
– Work up lather on palms,
back of hands, sides of
fingers, and under
fingernails
– Scrub vigorously with soap
for at least 20 seconds
– Rinse well
– Dry with a clean towel or
allow to air dry
Hand Hygiene Technique with Soap and Water
Recommended Duration: 40-60 seconds
Hand Hygiene Technique with Alcohol-Based Formulation
Recommended Duration: 20-30 seconds
Measures for Improving Infection Control
Wasteful practices that should be eliminated:
• routine swabbing of health care environment to monitor
standard of cleanliness
• routine fumigation of isolation rooms with formaldehyde
• routine use of disinfectants for environment cleaning,
e.g. floors and walls
• inappropriate use of PPE in intensive care units,
neonatal units and operating theatres
Measures for Improving Infection Control
Wasteful practices that should be eliminated (contd.,):
• use of overshoes, dust attracting mats in the operating
theatres, intensive care and neonatal unit
• unnecessary intramuscular and intravenous (IV)
injections
• unnecessary insertion of invasive devices (e.g. IV lines,
urinary catheters, nasogastric tubes)
• inappropriate use of antibiotics for prophylaxis and
treatment
• improper segregation and disposal of clinical waste.
Measures for Improving Infection Control
No-cost measures: using good infection-control practices:
• use aseptic technique for all sterile procedures
• remove invasive devices when no longer needed
• isolate patients with communicable diseases or a multidrug-resistant
organism on admission
• avoid unnecessary vaginal examination of women in labour
• minimize the number of people in operating theatres
• place mechanically ventilated patients in a semi-recumbent position.
Measures for Improving Infection Control
Low-cost measures: cost-effective practices:
• provide education and practical training in standard infection control
(e.g. hand hygiene, aseptic technique, appropriate use of PPE, use
and disposal of sharps)
• provide hand-washing material throughout a health-care facility (e.g.
soap and alcoholic hand disinfectants)
• use single-use disposable sterile needles and syringes
• use sterile items for invasive procedures
Measures for Improving Infection Control
Low-cost measures: cost-effective practices (Contd.,):
• avoid sharing multi-dose vials and containers between
patients
• ensure equipment is thoroughly decontaminated
between patients
• provide hepatitis B immunization for health-care workers
• develop a post-exposure management plan for health-
care workers
• dispose of sharps in robust containers.
 Infection Control Program

• Infection Control Committee

• Should be multidisciplinary with representation
from management, doctors, nurses, other health
workers, clinical microbiology, pharmacy, central
supply, maintenance, housekeeping and waste
management coordinator
 Infection Control Program
• Role of the Infection Control Committee
– Annual work program of activities for surveillance and prevention
– Periodic review of epidemiological surveillance data and
identification of areas for intervention
– Review of risks of new technologies, devices, and products
– Assessment of cleaning, disinfection, and sterilization
– Review of antibiotic use and antibiotic resistance
– Promotion of improved practices
– Provision of staff training in infection control and prevention
– Integration of healthcare waste management
– Response to outbreaks
 Discussion
• What are the potential routes of disease transmission
and how can they be eliminated?
• What are the main components of the infection control
program of your facility?
• Discuss any available surveillance data related to
nosocomial infections in your facility?
• What are your specific responsibilities regarding hospital
hygiene and infection control?
• What areas of patient safety would you like to focus on in
your facility? What are the barriers to patient safety?
• How can proper health care waste management
minimize disease transmission?