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Table of Contents

CHAPTER 1: INTRODUCTION TO INFECTION PREVENTION AND CONTROL (IPC) .......................... 1

1.1. The Role of IPC in Delivery of Safe and Quality Healthcare Service ............................................. 2
1.2. WHO Core Components of Infection prevention and control (IPC) ............................................ 3
1.3. Basic Concepts of Microbiology ................................................................................................ 5
1.4. The Infection Transmission Cycle and Measures to break the cycle .......................................... 6
1.5. Health Care Associated Infections .......................................................................................... 10
1.6. Summary ............................................................................................................................... 11
CHAPTER 2: STANDARD AND TRANSMISSION BASED PRECAUTIONS ......................................... 12
2.1. Definition of Standard and Transmission Based Precutions .................................................... 12
2.2. Key Principles and Components of Standard Precaution ........................................................ 14
2.3. Tranmission-Based Precaution: Components and Precaution Required for Each Component . 17
2.4. Summary ............................................................................................................................... 21
CHAPTER 3: HAND HYGIENE ............................................................................................................ 22
3.1. Importance of Hand Hygiene .................................................................................................. 23
3.2. When to Perform Hand Hygiene (Hand Hygiene Opportunities) .............................................. 23
3.3. Hand Hygiene Methods .......................................................................................................... 24
3.4. Improving Hand Hygiene practice in health facilities................................................................ 27
3.5. Summary ............................................................................................................................... 28
CHAPTER 4: PERSONAL PROTECTIVE EQUIPMENT ....................................................................... 29
4.1. Benefit of PPE........................................................................................................................ 30
4.2. Do not wait for stocks to run out before ordering moreEffectiveness and limitations of PPE..... 32
4.3. Donning and Doffing of PPE ................................................................................................... 52
4.4. PPE management during Outbreak ........................................................................................ 55
4.5. Summary ............................................................................................................................... 56
CHAPTER 5: SHARPS AND INJECTION SAFETY .............................................................................. 57
5.1. Risks and impact of Unsafe Injection and Conditions Causing the Risks ................................. 58
5.2. The Role of Prescribers and Providers in Injection Safety ....................................................... 60
5.3. Principles of Safe Injection Practice ........................................................................................ 61
5.4. Practical Guidance on Handling Parenteral Medication ........................................................... 65
5.5. Safe Handling of Sharps ......................................................................................................... 67
5.6. Summary ............................................................................................................................... 69
CHAPTER 6: Reprocessing of Instruments and Reusable Items........................................................... 70
6.1. OVERVIEW OF INSTRUMENT REPROCESSING ................................................................. 71
6.2. Level of disinfection or sterialization required.......................................................................... 71

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 6.3. Commonly used disinfectants and their properties .................................................................. 72
6.4. STEPS OF MEDICAL INSTRUMENTS AND OTHER ITEMS REPROCESSING ..................... 75
6.5. Monitoring, Safe Storage of Sterile/ HLD Instrument ............................................................... 85
6.6. Shelf Life ................................................................................................................................ 88
6.7. Summary ............................................................................................................................... 88
CHAPTER 7: LINEN MANAGEMENT................................................................................................... 90
7.1. Standard Laundry Service ...................................................................................................... 91
7.2. Key Steps in Processing Used Linen ...................................................................................... 93
7.3. summary ................................................................................................................................ 97
CHAPTER 8: ENVIRONMENTAL CLEANING ...................................................................................... 98
8.1. Importance of Environmental Cleaning in Healthcare Facilities ............................................... 99
8.2. General Principles of Cleaning and disinfection .................................................................... 100
8.3. Preparation of cleaning and disinfectant solution .................................................................. 101
8.3.1 Preparation of disinfectant and cleaning solution ..................................................................... 102
8.4. CLEANING Methods ............................................................................................................ 103
8.5. Risk Based area categorization and cleaning Schedule ........................................................ 107
8.7 Summary ............................................................................................................................. 110
CHAPTER 9: HEALTH CARE WASTE MANAGEMENT ..................................................................... 111
9.1. Sources and types of healthcare Waste................................................................................ 112
9.2. Risk associated with healthcare waste .................................................................................. 113
9.3. Management of Healthcare Waste........................................................................................ 114
9.4. Summary ............................................................................................................................. 124
CHAPTER 10: FOOD AND WATER SAFETY ...................................................................................... 125
10.1. Principles and Standards of Food Safety at HealthCare Facilities ......................................... 126
10.2. Main Causes of Food Contamination .................................................................................... 128
10.3. Actions for Prevention of Food Poisoning ............................................................................. 130
10.4. Drinking Water Quality and Safety ........................................................................................ 132
10.5. Summary ............................................................................................................................. 134
CHAPTER 11: TRAFFIC FLOW AND FACILITY DESIGN .................................................................... 135
11.1. Significance of Traffic Flow and Activity Pattern .................................................................... 136
11.2. Traffic Flow and Activity Patten Design ................................................................................. 137
11.3. Traffic Flow Requirments in Differnet Areas .......................................................................... 140
11.4. Summary ............................................................................................................................. 145
CHAPTER 12: OCCUPATIONAL HEALTH AND SAFETY IN HEALTH CARE SETTINGS .................... 146
12.1. Introduction of Occupational Health Safety in HealthCare Setting ......................................... 147
12.2. Hazard Identification, Risk Assessment and Risk Control ..................................................... 148

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 12.3. Occupational Health Activities for Preventing Infections among Health Care Workers ........... 150
12.4. Occupational Health and Safety for Specific Groups of HealthCare Workers ......................... 151
12.5. Post Exposure Prophylaxis ................................................................................................... 152
12.6. Monitoring Prevention of Occupational Exposures and Injuries ............................................. 160
12.7. Summary ............................................................................................................................. 160
CHAPTER 13: CLIENT EDUCATION ON INFECTION PREVENTION AND CONTROL (IPC) .............. 161
13.1. Significance of Clinet Education on IPC ................................................................................ 162
13.2. Components of Effective Client Education Program .............................................................. 162
13.3. Steps in client’s education on IPC......................................................................................... 163
13.4. Models of Client Education ................................................................................................... 164
13.5. Summary ............................................................................................................................. 166
CHAPTER 14: ANTIMICROBIAL RESISTANCE (AMR) AND RATIONAL USE OF ANTIBIOTICS ........ 167
14.2. Overview of Antimicrobial Resistance and Rational Use of Antibiotics ................................... 169
14.3. Consequences and Magnitude of Antibiotic Resistance ........................................................ 171
14.4. Causes of Antibiotic Resistance ........................................................................................... 173
14.5. Rational Use of Antibiotics .................................................................................................... 176
14.6. Promoting Rational Use of Antibiotics ................................................................................... 177
14.7. Summary ............................................................................................................................. 180
CHAPTER 15: PREVENTING HEALTH CARE ACQUIRED INFECTIONS AT SPECIAL SERVICE AREAS
IN PRIMARY HEALTH-CARE SETTING .............................................................................................. 182
15.1. tHE Epidemiology of HAIS in special health care settings Primary Healthcare Setting ........... 183
15.2. Risk Factors for Mother and New-Born Infection ................................................................... 186
15.3. Prevention of infection during pregnancy, labor and post-natal period ................................... 186
15.4. Safe work practices and IPC practices in laboratory at primary health care setting ................ 192
15.5. Summary ............................................................................................................................. 193
CHAPTER 16: IPC PROGRAM GOVERNANCE AND MANAGEMENT ................................................ 194
16.1. Overview to the National IPC Policy and Strategic Plan Pertaining to Primary Healthcare
Facilities .......................................................................................................................................... 195
16.2. IPC program governance and Management.......................................................................... 196
16.3. The Attributes of Effective Infection Prevention and Control (IPC) Programs ......................... 198
16.4. Major Infection Prevention and Control (IPC) Program Activities ........................................... 199
16.5. Using Quality Improvement models AND MULTIMODAL staregy to Improve IPC Practices... 200
16.6. Summary ............................................................................................................................. 207

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FORWARD
Healthcare associated infections (HAI) are posing a formidable threat to healthcare
providers, patients and community at large. It is affecting millions of patients worldwide
and the problem even more is greater in low- and middle-income countries. In
healthcare settings where the practice of infection prevention and control is inadequate,
healthcare providers and patients would be at an increased risk of acquiring serious
infections like HIV, HBV, HCV, Ebola and other emerging and re-emerging bacterial or
viral infections. It also poses a great risk of spreading multidrug resistant microbial
infections. However, most health care associated infections in healthcare facilities can
be prevented with readily available, relatively inexpensive and simple infection
prevention and control interventions and strategies.
Ministry of health has given particular attention to its national Infection Prevention and
Control program and it is scaling-up health facility infection prevention and control
activities. Infection Prevention and Control (IPC) in healthcare settings is a broad and
cross-cutting component of healthcare which involves every aspect of patient care, food
hygiene, housekeeping, laundry service, healthcare waste management and many
more. For the IPC program to be implemented effectively, preparation of standard
manuals and training of healthcare work force would be of a great importance.
This IPC manual is intended to serve as a training manual for healthcare providers and
managers in primary health care facilities. It is mainly adapted from the national IPC
reference manual and customized to provide guidance in the implementation of
standard Infection Prevention and Control activities in primary health care facilities.
Evidence based international standards and recommendations that known to be
effective in prevention and control of health care associated infection in resource limited
settings are also incorporated.
This training manual embodies particular topics that are pertinent to prevention and
control of health care associated infections in primary healthcare facilities. It is
anticipated that health bureaus, primary health care facilities, CPD training centers and
other stakeholders would use the manual to train health care workers in primary health
care facilities. We also hope that health care workers working at primary health care
setting would improve their IPC practice by regularly consulting the manual. Finally, I
would like to extend my heartfelt gratitude to all individuals and institutions that have
contributed to the realization of this training manual.

Abas Hassen (PhD)

Director, Clinical Services Directorate, MoH- Ethiopia

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 APPROVAL STATEMENT OF THE MINISTRY

The Federal Ministry of health of Ethiopia has been working towards standardization
and institutionalization of In-Service Trainings (IST) at national level. As part of this
initiative the ministry developed a national in-service training directive and
implementation guide for the health sector. The directive requires all in-service training
materials fulfill the standards set in the implementation Guide to ensure the quality of in-
service training materials. Accordingly, the ministry reviews and approves existing
training materials based on the IST standardization checklist annexed on the IST
implementation guide.

As part of the national IST quality control process, this infection prevention and control
for PHCU training package has been reviewed based on the standardization checklist
and approved by the ministry in June , 2022.

Assegid Samual CheruHuman

Resource Development Directorate
Director
Ministry of Health, Ethiopia

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 ACKNOWLEDGEMENT
Ministry of Health-Ethiopia acknowledges the commitment and technical support of the
National Infection Prevention and Control (IPC) Technical Working Group (TWG)
members and key contributors along with their organizations who made the revision of
this training material a reality. The Ministry of Health would like to specially thank, CDC,
RTSL, MSH/MTaPS, EPHI, WHO and ICAP for their technical and financial support in
the preparation of this manual.

The MOH would also like to thank the following individuals and their organization
for the contribution they made on this training material:
Dr Abas Hassen MOH, Clinical Service Directorate
Mr. Biniyam Kemal MOH, Clinical Service Directorate
Mr. Kasu Tola MOH, Clinical Service Directorate
Sr. Gezashign Denekew MOH, Clinical Service Directorate
Dr. Fekadu Assefa MOH, Clinical Service Directorate
Mr. Hailegebriel Abomsa MOH, Clinical Service Directorate
Mr Biruk Kefelegn MOH, Clinical Service Directorate
Mr. Molla Godif MOH/RTSL
Dr. Atkure Defar EPHI
Dr. Birhanu Tekle ICAP- Ethiopia
Mr. Arone Mebrhatu RTSL
Dr. Fahmi Ahmed WHO
Mr. Abebe Shume WHO
Mrs. Selamawit Gebreegziabiher CDC- Ethiopia
Mr.Tewodros Fantahun MSH/MTaPS
Mr Sem Daniel MOH, Clinical Service Directorate
Mr. Abiy Dawit MOH, Clinical Service Directorate
Mr Deneke Ayele MOH, Clinical Service Directorate
Dr Zelalem Tadesse MoH, Health Extension Primary Health Care Directorate
Mr.Kiflemariam Tsegaye MoH, Health Extension Primary Health Care Directorate
Mr. Tegene Arega, MoH, Human Resource Development Directorate
Mr. Leta Tagessu MoH, Human Resource Development Directorate
Mr Salahdin Seid MoH, Human Resource Development Directorate
Mr.Addisalem Bogale St.Paul‘s hospital Millennium Medical college
Danica Gomes,CDC Atlanta
Janelle Kibler,CDC Atlanta

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ACRONYMS

ABHR Alcohol-Based Hand Rub

AMR Antimicrobial resistance
ARV Anti-retroviral
AZT Azidothymidine
CDC US Centers for Disease Control and Prevention
CPD Continuous professional development
CSSD Central Sterile Supply Department
EFDA Ethiopian Food and Drug Authority
HAIs Healthcare associated infections
HBeAg hepatitis B e antigen
HBV Hepatitis B Virus
HCF Healthcare Facilities
HCV Hepatitis C Virus
HCWM Healthcare Waste Management
HCWs Health Care Workers
HIV Human Immunodefiencey Virus
HLD High Level Disinfection
IPC Infection Prevention and Control
MDRO Multidrug Resistant Microorganism
MRSA Methicillin-Resistant Staphylococcus aureus
OPA Orthophthalaldehyde
OT Operating Theater
PEP Post Exposure Prophylaxis
PHCU/S Primary Health Care Unit/ Settings
PPE Personal Protective Equipment
RSV Respiratory Syncytial Virus
SARS CoV-2 Severe Acute Respiratory Syndrome Coronavirus 2
SHEA The Society of Healthcare Epidemiology of America
SIGN Safe Injection Global Network
SOP Standard Operating Procedure
SP Standard Precaution
TWG Technical Working Group
VHF Viral Hemorrhagic Fever
VRE vancomycin resistant Enterococci
WASH Water Sanitation and Hygiene
WHO World Health Organization

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INTRODUCTION TO THE MANUAL
Effective Infection prevention and control (IPC) measures plays critical role in
prevention and control of the spread of infections in healthcare facilities and the
community. For the effective implementation of IPC program and interventions all
healthcare workers require at least a basic understanding of IPC principles and practice.
With this in mind MoH, has tailored this training manual specifically for the purpose
training of health care workers and managers in primary Health care facilities.

The training manual is prepared considering the current training material requirements
that fulfills the minimum in-service training package. This manual incorporates a
participant manual, facilitator guide as well as power point slides for respective
chapters. It will also include tools for facilitation of learning during the training. The
training manual consists of 16 chapters that are thought to be relevant for the functions
of the primary health care facilities. Efforts has been made to make the training more
practical and participatory.

This training manual is prepared as a tool to guide the training of health care providers
and managers in primary health care settings in line with the required in-service training
standards of Ministry of Health. This will enable trainees implement the IPC program
and interventions with clear understanding of the implications

This training package has the following core competency:

 Describe how infections are transmitted in healthcare facilities and the

associated risks
 Distinguish the basic concept of antimicrobial resistance and rational use of
antibiotics
 Apply proper Personal Protective Equipment utilization
 Apply proper reprocessing instruments and linen management
 Practice appropriate healthcare facility wastes management.
 Design traffic flow and activity pattern of healthcare facilities
 Conduct effective client education program within their healthcare facility

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COURSE SYLLABUS
Course Description: The Four-day course is designed to provide participants with the
basic knowledge,skill and attituide required to provide infection prevention with
recommended IPC principles and practices in primary health care and hospital settings
with limited resources.
Corse Goal: The goal of this course is to enable participants to make healthcare
facilities a safer places.
Learning Objectives: After completing this course, Participants will be able to;
 Describe how infections are transmitted in healthcare facilities and the
associated risks to healthcare workers, patients/clients and community at
large.
 Demonstrate proper Personal Protective Equipment utilization.
 Demonstrate reprocessing instruments and other items (before reuse)
 Analyze the proper linen management in our healthcare facility.
 Analyze the proper linen management in our healthcare facility.
 Demonstrate appropriate segregation, collection, transportation, storage,
treatment, and final disposal of healthcare facility wastes.
 Explain principles of food and water safety and measures
 Design traffic flow and activity pattern of healthcare workers, patients,
visitors/attendants, and equipment’s.
 Discuss assessment and identification of health workers occupational health
risks and their mitigation strategies.
 Design effective client education program within their healthcare facility using
recommended delivery techniques.
 Explain the basic concept of antimicrobial resistance and rational use of
antibiotics
 Discuss how infections are transmitted and prevented in special services
areas

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  Discuss IPC Program Management
Training Methods:
 Interactive lecture
 Group work and Individual Activities
 Demonstration exercises
Training Materials:
 Training packages Participant’s Manual and Facilitator’s Guide
 Laptop, LCD, Flip chart
Participants Selection Criteria: Health professionals working at the health Centers.
Trainer selection criteria:
 Member of Developers of the training manual
 Certified TOT Training on Infection Prevention and Control
Continuing Education Unit: 15 CEU’s
Methods of Evaluation
Participants Evaluation
 Formative: Individual and Group exercise
 Summative: Post test
Course Evaluation:
 Daily Evaluation form
 Daily Trainers feedback meeting
 End of course evaluation
Course venue: The training will be provided at an Accredited CPD Center

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 COURSE SCHEDULE

Infection prevention and control training for PHCU

Day-1 Day-2 Day-3 Day-4
Welcome and Registration Warm-up and recap Warm-up and recap Warm-up and recap
Introduction and Opening Chapter 4: Personal Chapter 9: Health care waste Chapter 14: Antimicrobial
Remark Protective Equipment’s management Resistance (AMR) and
Pre test Chapter 10: Food and water Rational Use of Antibiotics
safety

TEA BREAK
Chapter 1: Introduction to Chapter 5: Sharps and
Infection Prevention and Control Injection safety Chapter 15: Preventing heath
(IPC) care acquired infections at
Chapter 11: Traffic flow and special service areas in
Facility design primary health- care settings
LUNCH
Chapter 2: Standard and Chapter 6: Processing of Chapter 12: Occupational Chapter 16: IPC Program
Transmission based Precautions Instruments and Reusable Health and Safety in Health Governance and
items care settings Management
Chapter 7: Linen
Management
TEA BREAK
Chapter 3: Hand Hygiene Chapter 8: Environmental Chapter 13: Client Education Post test
Cleaning on Infection Prevention and Evaluation and Feedback
Control Closing remark

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CHAPTER 1: INTRODUCTION TO INFECTION PREVENTION AND
CONTROL (IPC)

Duration: 1:45 hrs.

Chapter description: This chapter comprises the definition and goals of infection
prevention and Control (IPC) and an overview of basic microbiology. It also
summarizes the WHO Core components of IPC. The disease transmission cycle and
measures to halt the spread of disease in healthcare delivery settings and the
common healthcare associated infections (HAIs) are also introduced. The ultimate
objective of this chapter is to enable participants to understand IPC practices in
healthcare settings.

Chapter Objective: By the end of this chapter the participants will be able to explain
infection in healthcare facilities.

Enabling Objectives

By the end of this chapter, participants will be able to:

 Describe the role of Infection Prevention and Control (IPC)
 List the WHO core components for Infection prevention and control
 Describe the basic concepts of microbiology
 Illustrate the disease transmission cycle and measures to halt the spread of
disease in health care delivery settings
 Identify the common HAIs in healthcare associated settings

Chapter Outline:

1.1. The role of IPC in delivery of safe and quality health service
1.2. WHO Core Components of Infection Prevention and Control
1.3. Basic concepts of microbiology
1.4. Infection Transmission Cycle and Measures to Break the Chain of Infection.
1.5. Common Healthcare Associated Infections (HAIs)
1.6. Summary

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 1.1. THE ROLE OF IPC IN DELIVERY OF SAFE AND QUALITY
HEALTHCARE SERVICE

Activity 1.1: Individual Reflection

Instruction:

Think about the following questions by yourself and share

your thought with the whole group.
Brainstorming Questions:

1. How do you define infection prevention and Control

(IPC)
2. What is the role of IPC in patient safety and quality of
healthcare?
3. How would you describe the burden of HAIs in your
facility/Region/Country?

Time Allowed: 5 Minutes

What are Infection Prevention and Control (IPC)?

Infection Prevention and Control (IPC) - refers to scientifically sound practices aimed
at preventing harm caused by infection to patients, health workers and the
community, grounded in principles of infectious disease, epidemiology, social
science, and health system strengthening, and rooted in patient safety and health
service quality. It is a systematic effort or process of placing barriers between a
susceptible host (person lacking effective natural or acquired protection) and
infectious agents. Infection Prevention and Control (IPC) is essential for delivery of
safe and quality healthcare services. Healthcare workers have a critical role to play
in the prevention and control of infections at all levels of care and the nature of their
work increases their chances of acquiring or transmitting infectious agents
Healthcare-associated infection (HAI) is a preventable infection that a patient can
encounter in a healthcare facility while receiving medical care. It occurs after 48 h of
hospital admission, up to 3 days after discharge, or up to 30 days after the operation
when someone was admitted for reasons other than infection. Health care-
associated infections are the most frequent adverse events in health care delivery
systems worldwide. On average at any given time 7% of patients in developed and
10% in developing countries will acquire at least one HAI. Death from HAI occurs in
about 10% of affected patients. These infections are a major cause of preventable

2
diseases, deaths, and higher healthcare costs. The application of evidence-based
IPC practices at all healthcare settings is the key in preventing health care
associated infections.

The goal of IPC is to make healthcare facilities safer for patients, staff, and the
community.

1.2. WHO CORE COMPONENTS OF INFECTION PREVENTION AND

CONTROL (IPC)

Activity 1.2: Group Discussion

Instruction:

Form four groups and discuss the following questions in

your group and report the work in the plenary (share
group response with the larger groups using flipchart)
Questions:

1. What are the gaps/challenges in infection

prevention and Control (IPC)? Group 1& 3
2. What shall be done to improve the gaps in
Infection Prevention and Control Practice?
Group 2&4
Time Allowed: 15 Minutes

To improve the desired outcome of the implementation of infection prevention and

control and ultimately to protect healthcare workers and patients, prevent the spread
of infectious pathogens in healthcare settings, and improve quality of care, WHO
recommends the following core components:

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Table 1.1: WHO’s Eight Core Components for Infection Prevention and Control
(IPC)
S. N Component Recommendation
1 IPC program An appropriate IPC program with a dedicated, trained
team should be in place in each acute health care
facility for the purpose of preventing HAI and
combating AMR through good IPC practices.
2 IPC guidelines Evidence-based guidelines should be implemented for
the purpose of reducing HAI and AMR.
3 IPC Education and IPC Training should be in place for all health care
training workers by utilizing team and task-based strategies that
are participatory and include bedside and simulation
training to reduce the risk of HAI and AMR.
4 Health care- HAI Surveillance, as per the burden of HAI in the
associated infection facility, can be done to guide IPC interventions and
(HAI) surveillance detect outbreaks, including AMR surveillance, with
timely feedback of results to health care workers and
stakeholders and through national networks.
5 Multimodal strategies IPC activities should be implemented using multimodal
strategies to improve practices and reduce HAI and
AMR.
The WHO multimodal improvement strategy addresses
the areas of system change, training and education,
monitoring and feedback, reminders and
communications, as well as cultural change supporting
IPC in a patient safety perspective.
6 Monitoring and audit Regular monitoring/audit and timely feedback of health
of IPC practices and care practices should be undertaken according to IPC
feedback standards to prevent and control HAIs and AMR at the
health care facility level.
Feed-back should be provided to all audited persons
and relevant staff.
7 Workload, staffing In order to reduce the risk of HAI and the spread of
and bed occupancy AMR, the following should be addressed:
(for facility level) (1) Bed occupancy should not exceed the standard
capacity of the facility.
(2) Health care worker staffing levels should be
adequately assigned according to patient workload.
8 Built environment, Patient care activities should be undertaken in a clean
materials and and/or hygienic environment that facilitates practices
equipment for IPC related to the prevention and control of HAI, as well as
(for facility level) AMR, including all elements around the WASH
infrastructure and services and the availability of
appropriate IPC materials and equipment.
Materials and equipment to perform appropriate hand
hygiene should be readily available at the point of care.

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 1.3. BASIC CONCEPTS OF MICROBIOLOGY

Activity 1.3: Think-Pair-share

Instruction:

Respond to the questions individually and discuss with next

seat and share with large audience
Question:

1. Identify
one Common infection, describe its
causative agent, mode of transmission and identify
one key prevention measure
Time Allowed: 10 Minutes
Microorganisms that HCWs and IPC staff may encounter in health care settings
include bacteria, fungi, parasites, and viruses.
BACTERIA
Bacteria are the most common causes of HAIs (WHO 2002) and thus it is helpful for
HCWs as well as the IPC team to know the key characteristics of bacteria commonly
seen in health care facilities.
VIRUSES.
Many viruses can be transmitted in the health care environment and often cause
HAIs and outbreaks. Blood borne viruses, such as HIV and hepatitis B and C, can
spread from patient to patient during transfusions, dialysis, injections, and
endoscopy. Viruses such as SARS CoV-2 influenza and respiratory syncytial virus
(RSV) can spread from patient to patient by respiratory fluid droplets during crowding
or sharing of respiratory equipment, or on contaminated hands. These viruses can
also be spread from healthcare workers to patients and from patients to healthcare
workers if good IPC standards and practices are not adhered to during healthcare
delivery.
The presence or absence of a virus envelope has significance for cleaning and
disinfection. Enveloped viruses (e.g., herpes, HIV, Ebola, COVID-19 etc) are easier
to kill with disinfectants than non-enveloped viruses (e.g., norovirus, rotavirus,
adenovirus, and poliovirus).
FUNGI
While fungi can cause infection in humans (e.g., Candida albicans), most are
opportunistic pathogens that cause infections (which can be severe) in those who are
on extended antibiotic treatment or are immunosuppressed (C. albicans, Aspergillus
5
spp., Cryptococcus neoformans, Cryptosporidium). A species of yeast, Candida
auris, with a propensity to spread in hospitals and resistant to multiple antifungals, is
emerging globally.
PARASITES
Health care-associated parasitic infestations include scabies, lice, and myiasis
(maggots). Water- or foodborne parasite infestations—such as amoebiasis (caused
by Entamoeba histolytica) or cryptosporidiosis (caused by Cryptosporidium
parvum)—mainly occur in community settings but can also spread within hospitals.

1.4. THE INFECTION TRANSMISSION CYCLE AND MEASURES TO

BREAK THE CYCLE

Activity 1.4: Group Discussion

Instruction:

Form four groups and discuss the following questions in your

group and report the work in the plenary (share group
response with the larger groups using flipchart)
Questions:
Group 1: Describe the Transmission cycle of COVID-19 and
list the possible prevention measures based on the cycle
Group 2: Describe the Transmission cycle of TB and list the
possible prevention measures based on the cycle
Group 3: Describe the Transmission cycle of Cholera and list
the possible prevention measures based on the cycle
Group 4: Describe the Transmission cycle of Hepatitis B and
list the possible prevention measures based on the cycle
Time Allowed: 25 Minutes

All humans are susceptible to infections due to bacteria, viral agents and other
infectious agents. These disease-causing microorganisms are also called
pathogens.
The number (dose) of microorganisms necessary to produce infection in a
susceptible host varies with the body site.
All of us touch surfaces, which contain microorganisms, every day but do not suffer
from an infection because microorganisms coming into contact with intact skin are
6
unlikely to cause a risk of illness. Infections typically occur when microorganisms get
inside the body, which can occur through a puncture, cut, or wound in the skin or
mucosa, through ingestion or even through inhalation.
Infection risk increases greatly when organisms come into contact with normally
sterile body sites. In such cases, the introduction of even just a few microorganisms
may produce disease.
For infectious agents to successfully survive and spread, certain factors or conditions
must be present; these are illustrated as the components or elements of the ‘Chain
of Infection’.
If any of the links or components of the chain are absent or removed, an infection
cannot occur. This interruption of the chain is commonly referred to as breaking the
chain of infection.

These concepts are illustrated below.

Figure 1.1: The Infection Chain

Key Elements of the Chain of Infection

The following elements are required in sequential order, for an infection to occur and
spread as shown by the Chain of Infection illustration:

1. Infectious Agent- These are disease-causing organisms including

7
 bacteria, virus, fungus, parasites etc.

2. Reservoir: Reservoir of an agent is the habitat in which an infectious agent

normally lives, grows, and multiplies. Reservoirs include humans, animals,
and the environment. The reservoir may or may not be the source from
which an agent is transferred to a host. For example, the reservoir of
Clostridium botulinum is soil, but the source of most botulism infections are
from improperly canned food containing C. botulinum spores. Many of the
common infectious diseases have human reservoirs. Diseases which are
transmitted from person to person without intermediaries include the
sexually transmitted diseases, measles, mumps, streptococcal infection,
most respiratory pathogens, and many others. Smallpox was eradicated
after the last human case was identified and isolated because humans were
the only reservoir for the smallpox virus.

3. Portal of Exit - This is a gateway through which the agent leaves the host
or reservoir. However, the agent must have the right environment for its
survival until it gets an entry to infect another person/animal.
4. Mode of Transmission - An agent which exits and develops in its natural
reservoir can be transmitted in numerous ways to a susceptible host and
get portal of entry. These modes of transmission are classified based their
routes as:
 Contact
 Droplet
 Airborne

4. Portal of Entry - Is the gateway through which an infectious agent enters in

to the susceptible host. These portals of entry could be mouth, nose, skin
etc.

5. Susceptible Host - Is an organism (human, animal, Insects or any living

organism) which is liable to take up infectious agents/pathogens and harbor
them. People are exposed to disease-causing agents every day but do not
always get sick.

8
Breaking the Chain of Infection

Understanding the Chain of Infection, or the Transmission Cycle, of specific

infectious diseases is important if healthcare workers are to:

Prevent transmission of microorganisms from patient to patient and from patient to

provider, including themselves, or vice versa during medical and surgical
procedures.
Teach others about the factors required for transmission to occur and how to break
the disease transmission cycle.

Preventing the spread of infectious agents and practicing proper infection prevention
and control requires breaking the chain of infection by removing one or more of the
conditions necessary for transmission of the diseases through practices which:

Reduce the number of microorganisms present (e.g., environmental cleaning, hand

washing, cleaning of instruments)
Kill, inhibit or inactivate microorganisms (e.g., hand washing with a waterless alcohol
preparation, decontamination of patient care items);
Create barriers to prevent infectious agents from spreading (e.g., wearing gloves or
personal protective equipment that are changed or cleaned between patients);
Reduce or eliminate risky practices (e.g., by using hands-free technique in the
operation room and using disposable syringes or safety-engineered syringes, etc.);
and encourage and support vaccination efforts, especially among healthcare workers

Note: Failure to apply infection prevention and control measures in healthcare

settings can increase the risk for Healthcare Associated Infections.

9
 1.5. HEALTH CARE ASSOCIATED INFECTIONS

Activity 1.5: Individual Reflection

Instruction:
Think about the following questions by yourself and share
your thought with the whole group.
Discussion question:
How do you define HAIs?
How would you identify HAIs?
Time Allowed: 5 Minutes
Healthcare Associated Infections (HAIs) were previously known as Hospital Acquired
Infections or Nosocomial Infections. An infection is called healthcare-associated if it is
acquired during the course of healthcare intervention for other conditions, regardless
of where the interventions are provided. OR
Infections acquired while a patient is under hospital (or any other health facility) care
which are not present or incubating at time of admission. It is a time related criterion
which refers to Infections occurring more than 48 hours after admission.
This situation, therefore, is inclusive of infections acquired in the hospital but
appeared after discharge and occupational infections among the staff of the facility
as well.

HAIs may also occur:

up to 48 hours after the episode of care

up to 3 days after discharge
up to 30 days after an operation
up to 1 year after an operation with an implant
Note: That both patients and healthcare workers are at risk of acquiring HAIs.

HAIs may be endogenous (from self) where the infectious agents are from the
patient. And example would be an infection caused by the body’s normal flora which
may cause disease as a result of gaining access into another part of the body where
it is not normally found.
HAIs may also be exogenous (from others or cross-infection). This involves acquiring
infection from an external source, for example a patient or health worker, through
contaminated hands, or contaminated patient care items or the environment.

10
 1.6. SUMMARY

The goal of infection prevention and control is to make health care facilities a safe
place for all, including patients, healthcare workers, and visitors.
Understanding each step of the infection chain or cycle is an important step in
preventing and controlling HAI’s.
The basics of Infection prevention and Control are Standard Precautions and
Transmission-Based Precautions.
Generally, effective implementation of the Core components of Infection Prevention
and Control as defined by WHO will help ensure safe healthcare delivery and reduce
the incidence of HAI.

11
CHAPTER 2: STANDARD AND TRANSMISSION BASED
PRECAUTIONS

Duration: 1:30 hrs.

Chapter Description: In this chapter, the two major precautions that help to prevent
the transmission of micro-organisms are elaborated and discussed. These are
standard and Transmission-based precautions.
Chapter Objective: By the end of this chapter the participants will be able to apply
the basic principles and components of standard precautions and transmission-
based precautions in preventing infection.
Enabling Objectives:
By the end of this chapter, participants will be able to:
 Define standard and transmission-based precautions
 Apply the principles of standard precaution
 Outline components of standard precaution
 Identify the three major routes that require transmission-based precaution

Chapter Outline

2.1. Definition of standard and transmission-based precaution

2.2. Key Principles and components of Standard Precaution
2.3. Transmission-based precaution: components and precaution required for
each
2.4. Summary

2.1. DEFINITION OF STANDARD AND TRANSMISSION BASED

PRECUTIONS

Activity 2.1: Individual Reflection

Instruction:
Think about the following questions by yourself and share
your thought with the whole group.
Brainstorming question:
1. What do we mean by standard and transmission-
based Precaution?
2. Can you define and give practical example for each?
Time Allowed: 2 min for reading and 3 min for discussion

12
Standard Precautions – are the minimum infection prevention practices that
apply to all patient care, regardless of suspected or confirmed infection status of
the patient, in any setting where health care is delivered. These are a set of
guidelines designed to create physical, chemical, and mechanical protective
barriers between the microorganisms and person to prevent the spread of
infection (please note that these barriers serve to break the diseases
transmission cycle). Can you identify examples of each barrier?

Example of barriers:
 Physical-PPE

 Mechanical barrier –High Level disinfection (HLD) and Sterilization

 Chemical- Antiseptic and disinfectant

Transmission-Based Precautions: are the second tier of basic infection control

and are to be used in addition to Standard Precautions for patients who may be
infected or colonized with certain infectious agents for which additional precautions
are needed to prevent infection transmission. These are designed to reduce the risk
of transmitting infections that are spread wholly or partly by airborne, droplet, or
contact routes between hospitalized patients and health providers.

Use the below list to give examples of organisms transmitted by airborne, droplet, or
contact routes?

Table 2.1: Important note on Standard Precaution (SP)

1.Cholera, 2. Varicella-zoster 3. Herpes simplex virus 4. Chicken pox, 5. Measles,

6. M. tuberculosis, 7. Pneumonia, 8. Flu, 9. Mumps, 10. H. influenza, 11. N.
Meningitides, 12. SARS Cov
Airborne
droplet
Contact

13
 Important note on Standard Precaution (SP)
 Standard Precaution is first and most important level of
precautions.
 The aim of SP is to reduce the risk of transmitting
microorganisms from a known or unknown source infection
within health care settings.
 Applying SP while providing patient care is based on the
anticipated interaction a HCW will have with blood, body fluid or
any potential pathogen exposure from patients.
 Standard Precautions apply to all clients and patients attending
healthcare facilities whereas Transmission-Based Precautions
which apply primarily to hospitalized or isolated patients.

2.2. KEY PRINCIPLES AND COMPONENTS OF STANDARD

PRECAUTION

Activity 2.1: Individual Reflection

Discussion Question:
1. What are the key principles of SP?
Time Allowed: 2 min for brainstorming and 2 min for reply

The following are the key principles of Standard Precaution:

1. Consider every client or patient as potentially infectious or susceptible to
infection.
2. SP Applies to all patients and clients attending health care facility
3. SP Applies to all blood, body fluid, secretion, execration (except sweat),
mucous membrane, intact and non-intact skin.

Activity 2.2: Group discussion on components of standard Precaution

Instruction:
Form a group of 4-5 participants
Discuss the following questions in your group and report the
work in the plenary (share group response with the larger
groups using flipchart)
Discussion Question:
 What are the key components of Standard Precaution?
 Please elaborate on each of the components based on
your experience and referring documents
Time Allowed: 30 min for reading and discussion

14
The Key Components of Standard Precautions

1. Hand Hygiene –
Hand hygiene involves HCWs cleaning their hands before, after, and at specific
moments during patient care and when performing health care tasks (five moments
for hand-hygiene).
Hand hygiene is the most important intervention for preventing transmission of
infections (help to prevent 50-60% of HAI)
It must be performed consistently at the recommended moments during patient care
using soap and water or alcohol-based hand rub (ABHR) and with a precise
technique and steps that effectively remove microorganisms from hands.

2. Use of Personal Protective Equipment (PPE) –

PPE relies on a HCW’s assessment of the likely risk of contact with potentially
infectious materials during each task.
The appropriate PPE should be chosen by the HCW according to the assessed risk.
Facilities may have guidance for the appropriate PPE based on healthcare activity.
Please note that the risk is not based on the appearance, characteristics, or
diagnosis of the patient, but rather the potential for the HCW to be exposed to blood,
body fluids, none-intact skin, mucous membranes, or items that have been in contact
with these.
The risk may be re-assessed during the task (e.g., if the patient starts vomiting) and
PPE is added as needed.
3. Safe injection practices –
 These are injection practices that prevent harm to the patient, prevent HCW
exposure to any risks, and are performed by skilled person, using
appropriate injection equipment and safe waste management practices.

4. Environmental Cleaning –

 It is cleaning of noncritical care equipment, instruments, devices, and

environmental surfaces. We must clean patient care equipment after and
before (i.e., between) each use on patients to prevent cross-contamination
between patients.

15
5. Instrument Processing –
Re-processing instruments and other items following the correct steps must be done
before reuse for any clinical procedures.

6. Processing textile and Laundry – in a manner that:

Removes pathogens from the textiles and protects cleaned textiles from
reintroduction of pathogens.
Reduces risk for transfer of pathogens to HCWs, other patients, and the
environment. [For detailed information see CHAPTER 7: LINEN MANAGEMENT].

7. Healthcare waste management –

Is a key issue to control and reduce HAIs in healthcare facilities (HCF) and to ensure
that the environment is well protected? Healthcare Waste Management (HCWM)
should be part of the overall management system of a HCF and reflect the quality of
the services provided by the facilities.

Key Components of SP

 Hand Hygiene
 Use of PPE
 Respiratory hygiene and cough etiquette
 Safe injection practice and Sharps Safety
 Environmental cleaning and disinfection
 Medical instrument reprocessing
 Processing of linen
 Health-care waste management

16
2.3. TRANMISSION-BASED PRECAUTION: COMPONENTS AND
PRECAUTION REQUIRED FOR EACH COMPONENT

Activity 2.4: Group discussion on Transmission-based Precaution: Key

components
Instruction:

Form three groups and discuss the following questions in your group
and report the work in the plenary (share group response with the
larger groups using flipchart)
Discussion Question:

Group 1: Please elaborate on Airborne Precaution and list down

standard and other precautions required for each (patient-placement,
respiratory hygiene, transport, cleaning, etc.…)
Group 2: Please elaborate on droplet Precaution and list down
standard and other precautions required for each (patient-placement,
respiratory hygiene, transport, cleaning, etc.…)
Group 3: Please elaborate on Contact Precaution and list down
standard and other precautions required for each (patient-placement,
respiratory hygiene, transport, cleaning, etc.…)

Time Allowed: 5 min for discussion and 10 min for presentation

Box 2.2: Important note on Transmission-based Precaution (TP)
Important note on Transmission-based Precaution (TP)
Airborne Precautions:
It prevents transmission of infectious agents that remain infectious
over long distances (applies for particles which are 5μm or less in
size and can remain in the air for several hours and be widely
dispersed).
Airborne transmission can occur either through airborne droplet
nuclei or dust particles containing the infectious microorganisms,
which can be produced by coughing, sneezing, talking, or by
procedures like bronchoscopy or suctioning).
Special air handling and ventilation methods are needed to ensure
prevention of airborne transmission of infectious agents.
Airborne particles do not land on and contaminate surfaces.
These precautions are effective in preventing infections like
Mycobacterium tuberculosis, Chicken pox and measles.
Airborne Precautions are recommended for patients with either
known or suspected infections that could be transmitted by
airborne route
Droplet Precaution
These precautions reduce the risks of transmission of pathogens
spread wholly or partly by droplets larger than 5μm in size such
17
 as: H. influenza & N. Meningitides, M. pneumonia, flu, mumps,
SARS Cov., rubella, diphtheria, Pertussis, Pneumonic Plague and
S. pharyngitis.
Such organisms remain in the air briefly and can travel about 1
meter.
Droplet transmission requires close contact between the source
and the susceptible host. Droplets may also land on surfaces and
then be transferred to other person object by contact
transmission.
Contact Precautions

 Contact is a common way that germs spread in health care

facilities.
 Spread can occur through both direct contact (person to person
transmission without a contaminated intermediate object of
person) as well as indirect contact (transmission through a
contaminated intermediate object or person (e.g., patient-care
devices, inadequately cleaned medical instruments,
environmental surface))
 Organisms that require Contact Precautions include cholera,
varicella-zoster (shingles); neonatal or mucocutaneous herpes
simplex virus; enterovirus meningitis.
 Furthermore, patients infected or colonized with enteric pathogens
like: hemorrhagic fever viruses, multidrug-resistant organisms
such as and carbapenem-resistant Enterobacteriaceae (CRE);
and C. difficile also transmit pathogens through contact.

Table 2.1. Interventions required for the three components of Transmission –

based precaution.

Intervention Types of precaution

area
Airborne Droplet Contact
Patient Private room: door
SINGLE Airborne Isolate patients in a
placement may be left open.
Infection isolation single room, if
If no private room:
room (AIIR). possible.
apply cohorting by
Air in the room should The door may be left
placing patient in a
be exhausted to the open in this case.
room with other
outside using a fan or If private room is not
patients who have
open window available, place the
active infection with
Keeping the door closed patient in a room with
the same
at all the time. other patients who
microorganism, not
If private room not have active infection
with other infections
available, place with the same
18
 patients in a room If neither option is microorganism, not
with patient having available, maintain with other infections
active infection with at least 1 meter (3 In multi-patient rooms,
the same disease, but feet) spatial more than one meter
with no other infection separation between (3 feet) spatial
(cohorting). patient beds. Use separation between
Visitors should NOT of a physical patient beds is
enter rooms of barrier, such as a important to prevent
patients on Airborne curtain or divider, is inadvertent sharing of
precautions. especially important items between the
Exceptions include: to prevent infected/colonized
clearance from transmission by patient and other
staff/healthcare droplets. patients as well as
provider based on infection transmission
NOTE: Patients
assessment of risks, between patients.
should wear a
use of appropriate
surgical mask in
PPE, etc.”
waiting rooms and
Limit movements in and
when outside of the
out of the room to
patient room (e.g.,
HCWs caring for the
during transport to
patient.
other locations in
facility).
Hand
Perform hand hygiene: with soap & water or alcohol hand-rub
hygiene
Before and immediately after patient care
After contact with respiratory secretions or other bodily fluids
After touching patient environment and/or objects contaminated with
patient bodily fluids
Use antimicrobial soap for contact precaution
Airborne Droplet Contact
Respiratory 1. Cover the mouth and 1. Same as airborne None
hygiene nose when coughing 2. Same as airborne
and sneezing and
dispose of used
tissues in the nearest
waste container.
1. Maintain an
appropriate distance
from and between
symptomatic
patients, 1-2 meter
Patient Identify persons with symptoms suggestive of
education acute respiratory illness and teach them to use
a surgical mask and practice cough etiquette

19
Use of PPE Wear eye protection
Wear a particulate Use gown and gloves for
and a face mask or
respirator such as a all interactions that
face shield, to cover
fit-tested N95, may involve contact
eyes, nose, and
In case of chickenpox with patient or patient
mouth completely,
or measles, no mask environment
is needed for
immune persons,
Gown, gloves, and eye
protection are
needed for
microorganism
transmitted by
multiple routes (e.g.,
varicella virus,
SARS-Cov).
Patient 3. Limit transport of patient to critical service 1. Limit transport of
Transport /procedures that cannot be performed in the patient to critical
patient’s room. service/20rocedur
4. If the patient needs to leave the room for a e that cannot be
test or procedure: performed in the
patient’s room.
Alert the department or facility to which the
2. When
patient is being transported so they can prepare
transporting
to receive a patient on Transmission-Based
patient: cover
Precautions.
patient with clean
HCWs who transport the patient need to Use
linen, never use a
PPE appropriately.
linen that was
Ensure that patients on Droplet or Airborne
used on patients’
Precautions wear a surgical mask while outside
bed.
of the patient room.
Cover wounds with appropriate dressings
Clean and disinfect the wheelchair or coach
after transportation.
Remove PPE and perform hand hygiene once
the patient has been transported.
Cleaning

1. All surfaces should be cleaned PRIOR to disinfection

2. Disinfected (at least daily and prior to use by another patient). Focus
cleaning on surfaces, frequently touched items or surfaces touched with
hands, and equipment in the immediate patient area
3. Ensure that rooms of patients on Droplet Precautions are frequently
cleaned and
4. Use gloves, gown and face/eye protection when cleaning patient care
equipment and the environment of a patient who has been on Contact

20
 Precautions.
Empiric/ Syndromic Use of Transmission Based Precaution

Every effort should be made to diagnose the microorganism responsible for infection;
however, laboratory diagnosis is not immediately available and not always available.
In these circumstances, precautions must be based on empiric/syndromic findings. If
there is any question about whether a patient without a known diagnosis has specific
infection, implement Transmission-Based Precautions based on the patient’s signs
and symptoms until a definitive diagnosis (i.e., laboratory test results) can be made.

2.4. SUMMARY

Please Note that: to protect HCWs, patients, and visitors from acquiring infections
during health care facility visits, ensure compliance with:

1. Standard Precautions for all patients

2. Transmission-Based Precautions for all patients with potential or confirmed
infections that are transmitted via contact, droplet, and airborne routes.

Standard Precautions, including hand hygiene, are the cornerstone of IPC. They
provide the first line of defense in the prevention of transmission of pathogens in
health care facilities.

Transmission-Based Precautions, including their empiric use, are designed to

provide additional protection and reduce the risk of transmissions via airborne,
droplet, and contact routes among hospitalized patients and HCWs.

21
CHAPTER 3: HAND HYGIENE

Duration: 1:15 hrs.

Chapter Description: This chapter provides an overview of the hand hygiene

techniques. Mainly, the chapter presents importance of hand hygiene, World Health
Organization’s (WHO’s) 5 Moments for Hand Hygiene and proper technique for
washing hands with soap and water. Proper techniques for use of alcohol-based
hand rub and its production are also discussed in this chapter.

Chapter Objective

By the end of this chapter the participants will be able to practice proper hand
hygiene techniques and improve hand hygiene compliance.

Enabling Objectives

By the end of this module, participants will be able to:

 Explain the importance of hand hygiene

 Distinguish moments of hand hygiene
 Demonstrate proper hand hygiene technique

Chapter outline

3.1. Importance of hand hygiene

3.2. When to perform hand hygiene
3.3. Hand hygiene methods
3.4. Improving Hand Hygiene practice in health facilities
3.5. Summary

22
 3.1. IMPORTANCE OF HAND HYGIENE

Activity 3.1: Think-Pair-Share

Instruction:
 Respond to the questions individually and discuss with next
seat and share with the large audience
Reflection question:
1. What is the importance of hand hygiene in the clinical
setting?
2. When do you usually wash your hands (your actual
practice)?
Time Allowed: 5 Min

Hand hygiene is the single most important measure to prevent transmission of

infection and is the cornerstone of infection prevention and control (IPC). Proper
hand hygiene can prevent transmission of microorganisms and decrease the
frequency of HAIs.
The goal of hand hygiene is to remove soil, dirt, and debris and reduce both transient
and resident flora. Hand hygiene can be performed using ABHR or by washing
hands with water and plain or antimicrobial soap (bar or liquid) that contains an
antiseptic agent such as chlorhexidine, iodophors, or triclosan.
Failure to perform appropriate hand hygiene is considered to be the leading
cause of
 Healthcare associated infections (HAIs)
 Spread of multidrug resistant microorganisms
 Significant contributor to outbreaks
3.2. WHEN TO PERFORM HAND HYGIENE (HAND HYGIENE
OPPORTUNITIES)

Before making contact with a patient

Before performing a clean/aseptic task,
including touching invasive devices
After performing a task involving the risk
of exposure to a body fluid, including
touching invasive devices
After patient contact
After touching equipment in the patient’s
surrounding areas

23
Other opportunities for hand hygiene

 Immediately on arrival and before departure from work (the health facility).
 Immediately after touching contaminated instruments or articles.
 Before putting on gloves and after removing them
 Whenever the hands become visibly soiled
 After nasal blowing or following a covered sneeze
 Before touching the face (eyes, nose or mouth)
 Before and after cleaning the environment
 Before and after preparing food
 Before eating and drinking or serving food
 After visiting the toilet.

3.3. HAND HYGIENE METHODS

1. Hand washing with Soap and Water

Activity 3.2: Demonstration

Instruction:

Select two volunteers from the trainees to demonstrate the steps in

hand washing.
And ask the participants to comment on the demonstrations
comparing the two.

Time Allowed: 10 Min

The purpose of routine hand washing in health care is to remove dirt and organic
material, as well as microbial contaminants, from the hands. Clean water must be
used to prevent microorganisms in the water from contaminating the hands.
However, water alone is not effective at removing substances containing fats and
oils, which are often present on soiled hands. Proper hand washing also requires
soap, which is rubbed on all hand surfaces, followed by thorough rinsing and drying.

The cleansing activity of hand washing is achieved by both friction and the detergent
properties of the soap. Plain soap has minimal antimicrobial properties, but assists
with the mechanical removal of debris and loosely adherent microbes, while the
mechanical action removes some bacteria from hands. Time is also an important

24
factor—hand washing for 30 seconds has been shown to remove 10 times the
number of bacteria as hand washing for 15 seconds. The entire hand washing
procedure, if completed properly, as described step by step in Figure 1-2, should
take 40–60 seconds. (CDC 2002; WHO 2009a)

Figure 3.1: The Steps for Routine Hand washing (How to Properly Wash Your
Hands)
Hand washing with soap and water is recommended (rather than using ABHR) in the
following situations:
1. If hands are visibly soiled or contaminated with blood or body fluids
2. After using the toilet
3. Before eating
4. To remove the buildup of emollients (e.g., glycerol) on hands after repeated
use of ABHR
5. In outbreaks of C. difficile, but not in health care settings with only a few
cases of C. difficile.
2. Alcohol-Based Hand Rub (ABHR)

The antimicrobial activity of alcohol results from its ability to denature proteins (i.e.,
the ability to dissolve some microbe components) and kill microbes. Alcohol
solutions containing 60–80% alcohol are most effective, with higher concentrations
25
being less effective. This paradox results from the fact that proteins are not
denatured easily in the absence of water; as a result, microorganisms are not killed
as easily with higher alcohol-based solutions (> 80% alcohol).

The use of an ABHR is more effective in killing transient and resident flora than hand
washing with antimicrobial agents or plain soap and water. It also has persistent
(long-lasting) activity. ABHR is quick and convenient to use and can easily be made
available at the point of care. ABHR usually contains a small amount of an emollient
(e.g., glycerol, propylene glycol, or sorbitol) that protects and softens skin. ABHR
should be used at any of the 5 Moments described earlier in this chapter, unless
hands are visibly soiled.

To be effective, approximately 3–5 mL (i.e., 1 teaspoon) of ABHR should be used.

ABHR should be used, following the steps shown in Figure 1-3, for approximately
20–30 seconds or until the solution has fully dried. To reduce the buildup of
emollients on hands after repeated use of ABHR, washing hands with soap and

water after every 5–10 applications of ABHR is recommended.

26
Figure 3.2: WHO Recommendation on How to Perform Hand Hygiene with
ABHR

Activity 3.3: Video demo

Please check the link below that shows the correct procedure
for hand hygiene with ABHR. (Source: WHO)
https://player.vimeo.com/video/406383268

3. Antiseptic Soaps

Antiseptic soaps may be used in place of plain soap during the ―My 5 Moments for
Hand Hygiene described above but are not recommended for most settings. Hand
washing with antiseptic soap is more irritating to the skin and more expensive than
using ABHR. Therefore, if available, ABHR should be used under normal
circumstances. Use of antiseptic soaps is recommended for surgical hand scrub and
before entry into special areas of health care facilities (e.g., neonatal intensive care
units).

3.4. IMPROVING HAND HYGIENE PRACTICE IN HEALTH FACILITIES

Activity 3.4: Think-Pair-Share

Instruction:
 Respond to the questions individually and
discuss with next seat and share with the
large audience
Reflection question:
1. What are the common reasons that health care
workers do not wash their hands in your health
facilities?
Time Allowed: 5 Min
 Give each staff member a small bottle of ABHR.
 Create a schedule for staff to refill ABHR bottles.
 Work with management to ensure a steady supply of ABHR.
 Observe staff during their work and provide feedback on hand hygiene.
 Reward staff who consistently performs proper hand hygiene.
 Put up signs in the health center to remind staff of best practices in hand
hygiene.

27
 3.5. SUMMARY

The goal of hand hygiene is to remove soil, dirt, and debris and reduce both transient
and resident flora.
Five moments of hand hygiene are: before making contact with a patient, before
performing a clean/aseptic task, after performing a task involving the risk of exposure
to a body fluid, after patient contact, and after touching/contact with patient
environment.
ABHR is more effective in killing transient and resident flora than hand washing with
antimicrobial agents or plain soap and water.

28
CHAPTER 4: PERSONAL PROTECTIVE EQUIPMENT

Duration: 2:00 hrs.

Chapter Description: This chapter highlights the role of Personal Protective

Equipment (PPE) in preventing infection among health service providers as well as
patients and visitors.

Chapter Objective:

By the end of this chapter participants will be able to properly utilize the appropriate
PPE.

Enabling Objectives:

By the end of this Chapter, participants will be able to:

 Describe the benefit of PPE

 List the types, uses, effectiveness and limitation of PPE
 Demonstrate the correct way of donning and doffing of PPE
 Select the proper PPE in outbreak management

Chapter outline

4.1. Benefit of PPE

4.2. Types and Effectiveness and limitations of PPE
4.3. Donning and doffing of PPE
4.4. PPE management in outbreak
4.5. Summary

29
 4.1. BENEFIT OF PPE

Activity 4.1: Individual Reflection

Instruction:
 Think about the following questions by yourself and
share your thought with the whole group
Discussion question
 What are the benefits of PPE for healthcare providers,
patients and community?
Time Allowed: 5 min for discussion

Healthcare workers are confronted each day with the difficult question of how to work
safely within the potentially hazardous environment of health care facilities. Today,
the most common occupational risk that healthcare personnel face is due to contact
with blood and bodily fluids during routine work like cleaning, instrument processing
and patient care. This exposure to pathogens increases the risk of getting
Healthcare Associated Infections and possible death. Use of risk appropriate
personal protective equipment (PPE) is one of the components of Standard
Precautions, which refers to wearing of protective barriers or clothing. Hospital
administrators, supervisors and healthcare workers need to be aware not only of the
benefits and limitations of specific PPE, but also of the actual role PPE plays in
preventing infection so that they can use them effectively and efficiently.

The basic principle behind wearing personal protective equipment is to create a

physical barrier/protection from pathogenic microorganisms. PPE includes gloves,
masks/respirators, eyewear (face shields, goggles or glasses), caps, gowns, aprons,
boots and other items. The most effective barriers are made of treated fabrics or
synthetic materials that do not allow water or other liquids (blood or body fluids) to
penetrate them.

30
Table 4.1: How Personal Protective Equipment Blocks the Spread of Microorganisms

WHERE MICROORGANISMS HOW MICROORGANISMS BARRIERS TO STOP THE MUST BE WHO THE BARRERS
ARE FOUND (RISK ARE SPREAD SPREAD OF USED FOR PROTECT
ASSESMENT) MICROORGANISMS (Examples of indications)
Healthcare Staff
Hair and scalp Shedding skin or hair Cap Invasive procedures where tissue beneath the Service Provider
Nose and mouth Coughing, talking, Mask (water resistant), skin is exposed and Patients
sneezing Situation where splashing or exposure
Face (eyes nose or mouth) Splashing, coughing and Masks, face shields, of blood, body fluids, secretions or excretions is
taking goggles likely
Body, Arm and skin Shedding skin or hair Scrub suit, cover gowns
Nose and mouth Coughing, talking Masks Situation which calls for droplet transmission
Special Masks (N95%) When airborne transmission is anticipated.
Hands Touching Gloves with hand washing When there is a reasonable chance of hand Patient
or alcohol hand rubbing coming in contact with blood and other body
fluids
Closed boots or closed-
Splashes, Spills and Situation where splashing or blood, body
Feet and lower legs toe shoes (open sandals Service provider
Sharp Material fluids, secretions or excretions is likely
are not acceptable)
Patient
Mucous membrane and non- Situation where there is direct contact with Service provider
Touching Gloves
intact skin mucous membrane and non-intact skin and Patient
Gloves, eyewear, mask,
Splashing or spraying
drapes, and apron
Touching (contact) Instrument processing Invasive procedures where tissue beneath the
Protective footwear, skin is exposed Service provider
Blood and body fluids
Accidental exposure with decontamination and Situation where splashing or exposure of blood, and Patient
contaminated needles disposal; use of a Safe or body fluids, secretions or excretions is likely
and scalpel blades Neutral Zone during
surgery
Utility gloves, plastic bags
Contaminated Items or waste Infectious waste Collection, transportation, and disposal of waste Staff
and proper disposal
Skin preparation, drapes, Invasive procedures where tissue beneath the
Unprepared skin Touching Patient
gloves skin is exposed
Clinic or hospital Gloves, hand washing, Staff and their
Touching Environmental cleaning and disinfection
environment Appropriate dressing families

31
As a rule, PPE selection should be based on risk assessment. If there is risk of exposure of
patients or health workers, then the PPE or combination of PPEs appropriate for the
identified risk should be used. Effectiveness in protection is also dependent on the practice of
correct procedures and adherence to rules for wearing (donning) and removing (doffing) of
PPE.

PPE should be:

 Made available close to the point of use for easy accessibility.

 Stored neatly in a clean / dry area to prevent contamination until required for use.
 Preferably single use; if reusable there must be a clear policy and SOP for placement
in bins after use and removal for laundering and recycling.
 Have an SOP for stock ordering and rotation to ensure there is always an adequate
supply based on usage and that older items are always used first.
 Do not wait for stocks to run out before ordering

4.2. DO NOT WAIT FOR STOCKS TO RUN OUT BEFORE ORDERING

MOREEFFECTIVENESS AND LIMITATIONS OF PPE

Activity 4.2: Group discussion

Instruction:
Form a group of 4-5 participants
Discussion questions
 Discuss the effectiveness and limitations of PPE in your group
and report the summary of discussion in the plenary (share
group response to the larger groups using flipchart and
demonstration)

Time Allowed: 5 min for discussion and 10 min for presentation

Table 4.2: List of PPE and area of Protection

Types of PPE Provides protection for
Head Covering/Caps Hair and Scalp
Goggles Eyes
Face Masks Nose, Mouth and Lower Jaw
Face Shield Face
Gloves Hands
Gowns Upper body, skin and cloth
Apron Front of the body
Boots Lower legs and feet

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 Shoe cover Shoes

Head Covering/Caps

Head covers are most commonly used as part of surgical attire in surgical and
procedure areas. When used, head covers or caps should be large enough to cover
the entire scalp and hair (see Figure 4-1A–C: Surgical Head Coverings A, B, and C).
Facial hair is also required to be covered for surgical procedures in sterile areas (e.g.,
in the operating theater) using a facial hair covering. They can be disposable or made
of reusable cloth that can be laundered. In the surgical and procedure areas, a new
clean head covering should be worn each day and changed sooner when soiled with
blood or bodily fluids. The same standard and regularity of cleaning expected for
surgical scrubs should be applied when cleaning head/facial coverings (e.g.,
laundered at the health center and changed at least daily).

A. Head covering B. Surgical Cap

Adapted from: Blue Sky Scrubs 2015. Adapted from: Halyard Health, Inc. 2018.

C. Surgical Hood

Source: Jhpiego 2015.

Figure 4.1 A–C: Surgical Head Coverings Protective

33
Eye Wear
There are four different types of eye protection that are effective in preventing infection
in health care facilities (see Figure 4-2: Different types of Eye Protection Equipment’s):

 Goggles
 Safety Glass
 Masks attached shield
 Face shield
Eye protection should be comfortable, allow for sufficient peripheral vision (i.e., the
area that is visible outside the central area of focus), and must be adjustable to
ensure secure fit. Compared to older styles of goggles, newer styles may provide
better indirect airflow properties to reduce fogging, provide better peripheral vision,
and offer more size options for fitting goggles to different HCWs.

Eye wear protects the staff during accidental splash of blood or other bodily fluids
by covering the eyes. Masks and eyewear should be worn when performing any
task where an accidental splash into the face could occur (e.g., performing
cesarean section, vaginal delivery, or cleaning instruments) when giving care to
patients with droplet precautions. If face shields are not available, goggles or
glasses and mask can be used together. If reusable eye/face protection is used, it
should be decontaminated in accordance with the manufacturer’s guidelines.
Hands should always be decontaminated after removing the equipment.

Note: Personal eyeglasses and contact lenses are NOT considered adequate
eye protection.

Suitable protective eye/face equipment should be worn:

As part of Standard Precautions

As part of Droplet Precautions to protect from respiratory secretions
During procedures and surgery when splashing is likely to happen
During specimen collection or aerosol-generating procedures on patients with
specific respiratory tract pathogens (e.g., TB or novel respiratory viruses) (WHO
2008 tract pathogens (e.g., TB or novel respiratory viruses) (WHO 2008).

34
Cover the entire face area (e.g., face shield) if protection of the mouth and nose
area is also required
Be changed if visibly soiled
Be removed using the earpieces / headband to avoid touching potentially
contaminated surfaces
Be disposed of after use if single-use or placed into a receptacle for reprocessing
Fit over personal glasses and anti-fog properties should be considered

Figure 4.2: Different types of Eye Protection Equipment and how to wear the
protective eyewear

Put on eye protection after putting on the isolation gown and mask (if used) but
before putting on gloves (see Figure 4.3: Putting on Eye Protection).

Figure 4.3: Putting on Eye Protection

Source: Siegel et al. 2007.

Removal of face shield, goggles, and mask can be performed safely after gloves
have been removed (see Figure 4.4: Taking off Eye Protection). The ties, ear pieces,

35
and/or head band used to secure the equipment to the head are considered clean
and safe to touch with bare hands. If the ties, ear pieces, and/or head band are
found to be contaminated, they should be removed using gloved hands and the
skin/face should be rinsed using ample running water and soap. The front of a
mask, goggles, and face shield is considered contaminated.

Figure 4.4: Taking off Eye Protection

Source: Siegel et al. 2007.

Masks

There are many different types of masks used to cover the mouth and nose. Masks
made from cotton or paper are comfortable but are not fluid-resistant (do not
protect from splashes) and are not an effective filter to prevent inhalation of
microorganisms transmitted via droplet nuclei (≤ 5 µm). Masks made from
synthetic materials provide protection from large droplets (> 5 µm) spread by
coughs or sneezes. They may be more difficult to breathe through than cotton or
paper masks. The use of masks during patient care is part of Standard Precautions
when there is a potential for splashes or droplet transmission and is part of Droplet
Precautions. (Siegel et al. 2007).

There are two types of masks:

Surgical masks: Regulating bodies (such as The United States Food and Drug
Administration [FDA], the European Union, and WHO) require surgical masks to
have fluid-resistant properties.

Procedure/isolation masks: These are not regulated, and they do not have any
specifications for their manufacture.

36
 1. Surgical Masks

Masks should be large enough to cover the nose, the lower part of the face, the
jaw and all of the facial hair. They are worn in an attempt to retain/confine moist
droplets expelled as health Workers or surgical staff speaks, cough or sneeze.
Equally important, is its protective function against accidental splashes of blood or
other contaminated body fluids on the health workers’ nose or mouth. This
preventive function, however, would not be effective unless the masks are made of
fluid-resistant materials.

When removing, one should handle the masks by the strings, do it with great care
as the center of the mask is the most contaminated site of all other parts
(Rothrock, McEwen & Smith, 2003).

2. Respirators
This are special types of masks called particulate respirators worn by healthcare
personnel for protection against inhalation exposure to airborne infectious agents
that are < 5μm. These include infectious droplet nuclei from patients with
Mycobacterium tuberculosis, Variola virus (smallpox), SARS-CoV, and dust
particles containing infectious particles such as spores of environmental fungi (e.g.,
Aspergillus sp.). Respirators should be worn when filtering inhaled air is deemed
important. These articles contain multiple layers of filter material and fit into the
face tightly allowing no air leaks around the mask when breathing. The N95
disposable

particulate and air purifying respirator are the type used most commonly by
healthcare personnel. Other respirators used include N-99 and N-100 particulate
respirators; powered air-purifying respirators with high efficiency filters; and non-
powered full-face piece electrometric negative pressure respirators (Siegel JD. et

37
al.; HICPAC, 2007).

Figure 4.5: Types of Masks frequently used by health care workers

Gowns

Types of gowns and their purposes Gowns should fully cover the torso of the
HCW, fit comfortably over the body, and have long sleeves that fit snuggly at the
wrists.

There are three types of protective gowns used in health care facilities:

Isolation gowns,
Surgical gowns, and
Coverall suits (Siegel et al., 2007)

Isolation gowns should be long-sleeved, fluid-resistant, single- use, and preferably

disposable. Isolation gowns are designed to prevent contamination of HCWs’
arms, exposed areas of the body, and clothing from blood and other bodily fluids
as well as other potentially infectious materials.

Note: Isolation gowns should be worn in combination with gloves and other
PPE, as recommended.

Surgical gowns are sterile and preferably fluid-resistant, with sleeves that either
taper gently toward the wrists or end with elastic or ties around the wrists. Large,
droopy sleeves are not recommended because they can cause accidental
contamination. Surgical gowns are used during surgery or procedures to protect
patients and the sterile field from microorganisms from blood and other body fluids
(e.g., amniotic fluid) present on the HCW’s clothing, the front of the HCW’s body,
and the HCW’s arms.

When the surgical gowns are put on, the cuffs of sterile surgical gloves should
completely cover the end of the sleeves of the gowns.

Lightweight cloth or paper gowns are not recommended because they offer little
protection against moisture, which can easily pass through, allowing the passage

38
of microorganisms. If a cloth or paper gown is used, always wear a plastic apron
under/over it.

If a protective covering fails (e.g., during a large spill) and skin/clothing becomes
contaminated with blood or body fluids, clothing should be removed and laundered
immediately. The HCW should bathe as soon as possible after completing the
operation or procedure. Coveralls are full-body suits made from materials that are
lightweight, breathable, and impermeable to liquids (see Figure 2-1). These are to
be worn by all HCWs who work in isolation areas for treating highly infectious

diseases (e.g., VHF). They are designed to go over a scrub suit and create a
barrier to eliminate or reduce contact exposure to blood, body fluids, and highly
infectious microorganisms (CDC 2015). Coveralls without attached hood and with
thumbholes are recommended.

Figure 4.6: Coverall Suit When to wear gowns

The type of gown to use is based on the type of patient interaction, including the
anticipated degree of contact with infectious material and the potential for blood
and body fluid penetration of the barrier and the type of task to be carried out by
the HCW:

 During Standard Precautions, an isolation gown (with gloves) is worn if

blood or body fluid contact, spills, or splashes onto clothing is anticipated.
 During Contact and Droplet Precautions, an isolation gown (with gloves) is
used to prevent transmission of an infectious agent that cannot be prevented
by Standard Precautions alone.

39
  During surgical procedures, deliveries, or other aseptic procedures, a sterile
surgical gown is worn to protect the sterile field and the clothes of the scrub
team or those performing the procedure.

How to wear and remove gowns

Full coverage of the arms and body front, from the neck to the mid-thigh or below,
will ensure that clothing and exposed areas of the upper body are protected.

Isolation gowns are usually the first piece of PPE to be put on (see Figure 4-7 A
and B: Putting on and removing an Isolation Gown). HCWs should remove
isolation gowns before leaving the patient care area to prevent possible
contamination of the environment outside of the patient care area (see Figure 4-7
A and B: Putting on and Removing an Isolation Gown). (Siegel et al. 2007)

Figure 4.7 A and B: Putting on and Removing an Isolation Gown

Adapted from: Siegel et al. 2007.

40
Plastic Apron

It is used to protect clothing or surfaces from contamination. Reusable aprons

which are made of rubber or plastic provide a waterproof barrier along the front of
the personnel’s body. Thus, it should also be worn during cleaning and procedures
with likelihood of splashes or spillage of blood, body fluids, secretions or excretions
(e.g., when conducting deliveries). Disposable water- proof aprons are also
available for clinical use.

Aprons keep contaminated fluids off the healthcare worker’s clothing’s and skin.
For example, during invasive procedures, wearing a water-resistant apron
(disposable or reusable) will not only help to guard the healthcare providers
against exposure to blood or body fluids (e.g., amniotic fluid), but also prevents the
healthcare workers’ abdominal skin from being a source of contamination to the
patient.

Gloves

Healthcare Workers Wear Gloves for the Following Three Reasons:

1. To reduce the risk of acquiring infections to the staff from patients

2. To reduce the risk of transmitting microorganisms including skin flora from
provider to clients/patients
3. To reduce contamination of the hands of the staff by microorganisms which
are transmissible from one patient to another (cross-contamination).

Types of Gloves

Surgical Glove - should be used when performing invasive medical or surgical

procedures.

Clean Examination Gloves - provide protection to healthcare workers when

performing many of their routine duties. These gloves can be used whenever
contact with mucous membrane and non-intact skin is anticipated (e.g., during
medical examinations and procedures such as pelvic examination).

Utility or Heavy-Duty Gloves - should be worn when processing instruments,

equipment and other items, for handling and disposing contaminated waste, and

41
 when cleaning contaminated surfaces. Double gloving of either new examination
gloves or reprocessed surgical gloves provide some protection in case utility
gloves are not available.

Note:
Clear understanding of the parameters to opt for sterile or high- level disinfected
gloves is important. Judicious use of these options can reduce costs and at times
maintain safety both for the patients and the staff.
The use of high-level disinfected surgical gloves when performing surgical or
invasive procedures is the only acceptable alternative on the condition that sterile
surgical gloves are not available.
Non-sterile Gloves can be made form:

1. Latex
2. Vinyl
3. Nitrile

Table 4.3: Advantages and Disadvantages of Different Types of Non-Sterile

Gloves
Material Advantage Disadvantage
Long contact with fatty
Latex Offer best fit, natural feel, and dexterity
substances (e.g., fatty tissue
Approved by regulatory authorities
and vegetable oils) will
Provide protection against most chemicals, including
disintegrate latex gloves
acids and bases, chlorine, iodine, and formaldehyde
Not recommended for HCWs
Offer better puncture resistance than other gloves
with known allergies to latex
(e.g., vinyl gloves)
Loose-fitting (i.e., baggy), have
Vinyl First synthetic material gloves available on the
limited elasticity, and tear easily
market
Have higher failure rates than
Least expensive of the three types and generally
latex or nitrile gloves because
available in low- and middle- income countries
they tear more easily and they
Recommended if they are the only type of non-
are loose- fitting around the
sterile glove available and the risk of exposure to
wrist, which can allow fluids to
blood and body fluids is high
contaminate an HCW’s hand
Acceptable for short procedures/tasks (e.g.,
suctioning endotracheal secretions, removing IV
lines) that involve minimum risk of glove tears,
have low risk of exposure to contaminants, and
involve minimal stress on the gloves

42
 Not recommended for HCWs
Nitrile Allergy-free
with known allergies to nitrile
Preferred choice for HCWs with latex allergies
compounds
Made from synthetic materials and are very elastic
Can be used with petroleum-based substances,
including hand moisturizers
3–5 times more puncture-resistant than latex
gloves
Fit well on hands like latex gloves
More elastic than vinyl gloves
Available in various thicknesses and colors

Note:

When using latex rubber gloves, avoid use of hand cream or lotions that contain
mineral oil, petroleum jelly (Vaseline) or lanolin to protect your hands, because
they may cause the gloves to break down within minutes.

When to Wear Gloves

Depending on the situation, surgical gloves, clean examination or utility gloves

should be worn by all staff where:

There is a chance of hands coming in contact with blood or other body fluids,
mucous membranes or non-intact skin.
They perform invasive medical procedures (e.g., inserting vascular devices
such as peripheral venous lines); or
They handle contaminated waste items or touch contaminated surfaces.

The Glove Pyramid – to aid decision making on when to wear (and not wear)
gloves
Gloves must be worn according to standard and contact precautions. The pyramid
details some clinical examples in which gloves are not indicated, and others in
which clean or sterile gloves are indicated. Hand hygiene should be performed
when appropriate regardless of indications for glove use (see Figure 4.8: The
Decision Pyramid – when to and not to wear gloves)

When to Use Double Gloves

Even the best quality, new latex rubber surgical gloves may leak up to 4% of the
time. Moreover, it was found that latex gloves gradually become weaker and lose
their intactness especially when exposed to fat on surfaces of wounds.

43
Note:

The acceptable ―leak rate for new surgical and examination gloves
designated by regulatory agencies is up to 4% (Davis 2001).
Although double gloving is of little benefit in preventing exposure to blood in case
of needle sticks or other similar injuries, it may decrease the risk of blood-hand
contact. A recent study, for instance, showed that surgeons wearing single gloves
had a blood-hand contact rate of 14% while those wearing double gloves had only
a rate of 5% (Tokars et al., 1995; Tokars et al., 1992).

Figure 4.8: The Decision Pyramid – when to and not to wear gloves
Image from WHO (2009); Hand Hygiene Why, How and When

Health care providers should Double Glove when:

The procedure involves coming in contact with large amounts of blood or other
body fluids (e.g., vaginal deliveries and cesarean sections).
Performing orthopedic procedures in which sharp bone fragments, wire sutures
and other sharp-edged materials are likely to be encountered.

44
Performing surgical procedures lasting more than 30 minutes. (Most surgeons,
these days use double glove routinely).

When double gloving, the first glove should be a half size larger than normally
worn gloves. The second pair, however, should be the correct size as this will help
prevent the hand from cramping. In general, for short time surgical procedures (30
minutes or less) and those involving minimal exposure to blood or mucous
secretions (e.g., laparoscopy or mini-laparotomy), double gloving is probably not
necessary.

When to Use Elbow Length Gloves

Elbow length gloves should be used during vaginal deliveries and caesarean
sections where the chance of coming in contact with blood is 25% and 35%
respectively. Elbow length gloves are also recommended to be used during
performing procedures like manual removal of placenta and any other procedure
where contact with a large volume of blood or body fluids is likely. This kind of
glove is generally meant to give protection to the hands including the forearms.

How to make Elbow Length Gloves

When readymade elbow length gloves are not available, an effective alternative
material (as described below) can easily be made from new or previously used
surgical latex gloves that have been re-processed (decontaminated, cleaned and
dried, through the two methods of either sterilization or high-level disinfection).

Cut one or more fingers depending on the size of your hands completely off each
glove just below where all the fingers join to allow all of the fingers slip into the
gloves. (Figure 4.9).

How to Use

Perform surgical hand scrub.

Put on the intact sterile to completely cover up the distal end of the fingerless
gloves. (See Figure 5-9: Technique how to make elbow length gloves).
Put the fingerless sterile or HLD gloves and pull them up to the forearms.
Put on the intact sterile (I.e., double glove)

45
Figure 4.9: Technique how to make elbow length gloves

How to Use Gloves

Although the effectiveness of gloves in preventing contamination of the healthcare

workers’ hands has been repeatedly confirmed (Tenorio et al., 2001), wearing
gloves does not replace the need for hand washing. The truth is that even the best
quality latex surgical gloves may have small and unnoticeable defects; they may
be torn during use; and the hands can become contaminated during removal
(Bagg et al., 1990; Davis, 2001).

Note:
Practice of hand hygiene, coupled with the use of protective gloves, is a key
component in minimizing the spread of disease.

46
Figure 4.10: How to don and remove examination gloves

47
 Figure 4.11: How to wear (don) sterile gloves

The purpose of donning and removing sterile gloves as indicated in Figure 4.11:
How to wear (don) sterile gloves is to ensure maximum asepsis for patients and
protect the healthcare workers from the patient’s body fluid. In the correct usage of
gloves-an instrument to achieve this double goal, the skin of the healthcare worker
remains exclusively in contact with the inner surface of the glove and has no contact
with the outer surface. Any error in the performance of this technique leads to a lack
of asepsis requiring a change of glove.

Procedure for wearing Sterile Gloves

1. Perform hand hygiene before an ―aseptic procedure’’ by surgical hand scrub.

2. Check the package for intactness. Open the first non-sterile packaging by
peeling it completely off the heat seal (cover) to expose the second sterile
wrapper, but without touching it.
3. Place the second sterile package on a clean and dry surface without touching
the surface. Open the package and fold it towards the bottom so as to unfold the

48
paper and keep it open.
4. Using the thumb and index finger of one hand, carefully grasp the folded cuff
edge of the glove.
5. Slip the other hand into the glove in a single movement, keeping the folded
cuff at the wrist level.
6. Pick up the second glove by sliding the fingers of the gloved hand underneath
the cuff of the glove (Includes Step7).
7. In a single movement, slip the second glove on to the ungloved hand while
avoiding any contact/resting of the gloved hand on surface other than the glove
to be donned (contact/resting constitutes a lack of asepsis and requires a change
of glove) (also includes step 9 and 10).
8. If necessary, after donning both gloves, adjust the fingers and inter-digital
spaces until the gloves fit comfortably.
9. Unfold the cuff of the first gloved hand by gently slipping the fingers of the
other hand inside the fold, making sure that any contact with the outer surface of
the glove is avoided (lack of asepsis requiring a change of gloves) (Includes
Step13).
10. The hands are gloved and must touch exclusively sterile devices or the
previously- disinfected patient’s body area.
11. Remove the first glove by peeling it back with the fingers of the opposite
hand. Remove the glove by rolling it inside out to the second finger joint (do not
remove completely) (Includes step 16 and 17).
12. Remove the other glove by turning its outer edge on the fingers of the partially
un-gloved hand.
13. Remove the glove by turning it inside out entirely (ball forming) to ensure that
the skin of the health-care worker is always and exclusively in contact with the
inner surface of the glove.
14. Discard gloves.
15. Perform hand hygiene after glove removal according to the recommended
indication.
Donning surgical sterile gloves at the time of a surgical intervention follows the
same sequences except that:
 It is preceded by a surgical hand preparation.
 Donning of the gloves is performed after putting on the sterile surgical

49
 gown.
 The opening of the first packaging (non-sterile) is done by an assistant.
 The second packaging (sterile) is placed on a sterile surface and then
used for the intervention.
 Gloves should cover the wrists of the sterile gown.

Figure 4.12: How to remove (doff) sterile gloves

Some DOS and DON’TS about Gloves

 Do wear the correct size gloves, A poorly fitting glove can limit your ability to
perform the task and may get damaged easily
 Do change surgical gloves periodically (every 45 minutes) during long cases
as the protective effect of latex gloves decreases with time and in apparent
tears may occur.
 Do keep fingernails trimmed moderately short (less than 3mm beyond the
finger tip) to reduce the risk of tears.
 Do pull gloves up over cuffs of gown (if worn) to protect the wrists.
 Do use water-soluble hand lotions and moisturizers often to prevent hands
from drying, and cracking due to frequent hand washing and gloving.

50
  Re-process utility gloves by immersing them in a 0.5% Chlorine solution
briefly, remove gloves by inverting them and then soak them in the 0.5%
Chlorine solution for 10 minutes before washing and drying them for reuse.
 Don’t use oil-based hand lotions or creams, because they will damage latex
surgical and examination gloves.
 Don’t use latex gloves if you or the patients have an allergy to latex.
 Don’t store gloves in areas where there are extremes of temperature (e.g.,
direct sunlight, near the heater, air conditioner, ultraviolet light, and X-ray
machine). These conditions may damage the gloves (cause breakdown of
the material they are made of), thus reducing their effectiveness as a
barrier.
 Don’t reprocess gloves that are cracked or have detectable holes/tears.
 Don’t reprocess examination gloves for reuse.
Note:
A separate pair of gloves must be used for each client to avoid cross-contamination
or when moving from one site to another site on the same patient (i.e., from
respiratory care to a dressing change). It is preferable to use new and single use
(disposable) gloves only.

Footwear
Footwear is worn to protect the feet from injury by sharp or heavy items or fluids that
may accidentally spill over, drip, or even pour out upon them. All footwear should
have closed toes, low heels, and non-skid soles. Clean, sturdy shoes are
recommended for all clinical areas. Rubber boots or leather shoes provide the best
protection. They must be kept clean. For this reason, sandals and other open-toe
shoes or shoes made of soft materials are not acceptable. Rubber boots or leather
shoes are acceptable, but they must be kept clean and free of contamination from
blood or other body fluid spills. Shoe covers are unnecessary, if clean and sturdy
shoes are available for dedicated use only in the surgical area. However, Shoe
covers may be needed to minimize contamination from and of shoes. Shoe covers
are not meant to prevent transmission of bacteria from the floor but rather prevent
contamination of shoes with blood and body fluids. (AORN 2015; Bearman et
al.,2014).

Wash hands before and after donning and removing PPE

51
 Activity 4.3: Case study
Instruction:
 Form a group of 4-5 participants
 Discuss on the following case study in your group and report
the summary of discussion in the plenary (share group
response with the larger groups using flipchart)
Case studies
Sr.Hana reports to work one day. The year is 2023, and she
is feeling good because the COVID-19 pandemic is over and
there are no known cases of COVID-19 in her area.
However, she also knows that the region is experiencing a
spike in seasonal influenza (flu). As she enters the clinic,
she notices that some patients in the waiting area are
coughing.
These patients are sitting on benches in a tight crowd,
waiting to be seen by staff. Sr.Hana knows that respiratory
secretions could spread infections in the waiting area. What
are some things that Sr.Hana and her colleagues at her
health center could do to reduce the spread of respiratory
infections in this setting?
Discussion Questions
1. If this were your institution, what kind of possible
interventions would you put in place?
2.If you are in the position of Sr.Hana what would you do?
Time Allowed: 15 min. (5 min for discussion and 10 min
for presentation)

4.3. DONNING AND DOFFING OF PPE

Donning and doffing of PPE in the proper order and manner is just as important as
wearing PPE. Failure to properly put on or remove PPE could lead to exposure to or
lack of protection against infectious agents. The order of putting on and removing
PPE depends upon the purpose for which the PPE is being used. PPE is used for
Standard Precautions, operating theatres, isolation rooms during Transmission-

52
Based Precautions, and during disease outbreaks (e.g., novel respiratory disease,
VHF).

Sequence for donning on PPE for Standard and Transmission-based

Precautions

1. Put on protective boots or shoe covers (if needed).

2. Perform hand hygiene.
3. Put on a gown.
4. Put on a procedure mask/N95 respirator.
5. Put on goggles or a face shield.
6. Lastly, put on gloves.

Source: CDC 2004.

Sequence for doffing PPE

PPE should be removed at the doorway before leaving the patient room or in the
outer room:

1. Remove gloves.
2. Remove goggles/ face shield by the head band or ear pieces.
3. Remove the gown.
4. Remove the mask or respirator.
5. Dispose of single-use and reusable PPE in designated containers.
6. Remove shoe covers or boots (if used) before leaving the area.
7. Perform hand hygiene.

Sequence for donning on PPE for Sterile Surgical Procedures in the Operating
Theater

1. Change from street clothes to a clean scrub suit (one that has been
processed in the health care facility laundry). Remove all jewelry.
2. Put on non-skid, low-heel shoes with closed toes and backs, rubber boots, or
shoe covers when there is a risk of gross contamination with blood or body
fluids.
3. Perform hand hygiene.
4. Put on a plastic apron if the sterile surgical gown is not fluid-resistant.
5. Put on a surgical head cover (and facial hair cover, if needed) to ensure that

53
 hair on the head (and beard) are fully covered.
6. Put on a surgical mask, one that fits well and fully covers the mouth and the
nose.
7. Put on appropriately sized, well-fitting goggles or a chin-length face shield.
8. Perform a surgical hand scrub using soap and water and ABHR (see: HAND
HYGIENE chapter).
9. Put on a sterile surgical gown without contamination (see Figure 5-7 A and
B: Putting on and removing an Isolation Gown).
10. Lastly, put on sterile surgical gloves without contamination (see Figure 5-11:
How to wear (don) sterile gloves).

Note: There may be instances where PPE to protect the HCW from infectious
diseases may be required in addition to surgical attire, such as a respirator for
surgery on a patient with known or suspected TB or additional skin coverage for
surgery on a patient with known or suspected viral hemorrhagic fever.

Sequence for removing PPE following Sterile Surgical Procedures in the

Operating Theater

1. Remove the gloves following the recommended steps and dispose of in a waste
container; do not reprocess or reuse the gloves.
2. Remove the gown, avoid touching the outer side of the gown, and dispose of in a
waste container (if a single-use gown) or place the used gown in a container for
processing later.
3. Remove the plastic apron, if one was used, and dispose of in a waste container
(if a single-use apron) or place the used apron in a container for processing later.
4. Remove eye protection.
5. Remove the surgical mask.
6. Perform hand hygiene.
7. These steps will be performed at the end of day unless any item becomes soiled.
8. Remove the head cover (and facial cover).
9. Remove shoe covers (if worn).
10. Remove shoes.
11. Remove scrub suit.
12. Lastly, perform hand hygiene.

54
Adapted from: AORN 2015.

Activity 4.4: Demonstration: Donning and doffing of PPE

Instruction:
 Demonstrate donning and doffing of the following PPE
materials:
 Head Covering/Caps
 Google
 Face Masks
 Face Shield
 Gloves
 Gowns
 Apron
 Boots
 Shoe cover
Time Allowed: 45 min for demonstrating the above PPE.
4.4. PPE MANAGEMENT DURING OUTBREAK

List of Personal Protective Equipment

PPE recommended by the World Health Organization (WHO) for HCWs who provide
care and treatment to VHF (E.g., Ebola, COVID-19) patients includes:

 Fluid-resistant coverall or gown:

 Without an attached hood
 With thumb holes or loops
 Waterproof apron
 Waterproof boots
 Fluid-resistant isolation mask with a design that does not collapse against the
mouth
 Face shield
 Respirator—required when performing aerosol-generating procedures
 Head cover that covers head and neck (separate from the gown or coverall)
Double gloves with cuffs to mid-forearm (nitrile preferred over latex) (Ruparelia et al.
2015)

55
 4.5. SUMMARY

The use of PPE is recommended to protect HCWs, patients and visitors from
hazards encountered during their regular, daily duties.
An adequate supply of PPE should be available for use at the point of care.
Management staff should be aware when and how to replenish PPE supplies.
Health center staff should be educated and trained on the indications for PPE

56
CHAPTER 5: SHARPS AND INJECTION SAFETY

Duration: 1:45 hrs.

Chapter Description: This chapter discusses the risks and impact of unsafe
injections and help them recognize the role of healthcare workers in preventing
health risks associated with unsafe injections by avoiding unnecessary injections.

Chapter Objective

By the end of this chapter, the participants will be able to demonstrate how to safely
handle and dispose of sharps.

Enabling Objectives

 Explain the common reasons for providing unnecessary and unsafe injection
 Identify the risk and impact associated with unsafe injection
 Demonstrate how to handle sharps safely

Chapter outline

5.1. Risks and magnitude of unsafe injections

5.2. The role of prescribers and providers in injection safety
5.3. Principles of safe injection practices
5.4. Practical guidelines on handling parenteral medications
5.5. Safe handling of sharps
5.6. summary

57
 5.1. RISKS AND IMPACT OF UNSAFE INJECTION AND CONDITIONS
CAUSING THE RISKS

Activity 5.1: Individual reflections

Instruction:
 Reflect on the following questions
Discussion questions:
1. What are the risks and impacts of unsafe injection?
2. Share your experience on incidents related to unsafe
injections?
Time Allowed: 20 minutes

Safe injection can be defined as: an injection that does not harm the recipient,
does not expose the HCW to any avoidable risks, provided by skilled person, using
appropriate injection equipment and does not result in waste that is dangerous for
the community.

5.1.1. Magnitude of Unsafe Injection

WHO estimates that in developing and transitional member States, 16 billion

healthcare injections are administered each year i.e., an average of 3.4 injections
per person year.
Concurrently, it is also estimated that at least 50 % of all injections are unsafe.
Injection safety baseline studies conducted by MOH and MMIS in 2004 and 2005
showed that about 74% of injections were unsafe, about 72% of health facilities
practiced unsafe disposal and the prevalence rate of needle stick injury was 30 to
35%. Moreover, the great majority (70%) of these injections are unnecessary given
when oral medications could have been prescribed.

58
 5.1.2. Risk and Impacts of Unsafe Injection
Table 5.1: Conditions Causing Risks to Community, Patients/Clients and Providers
Community Patient/client Providers
 Unsafe waste  Use of injections when there are  Shortage or absence of
disposal system other suitable alternatives appropriate injection and
of healthcare  Applying pressure to bleeding sites safety devices
facilities with dirty material or finger  Carrying used needles
 Receiving  Drug administered at incorrect before disposal
injections from anatomical site  Placing needle on a
informal injectors  Use of unsterile syringes and surface prior to disposal
 Leaving sharps in needles (or use of ―new but  Recapping needles
accessible place damaged compromised package) (either one or two hand)
to the public,  Re-use of syringe and needles  Manually detaching
especially  Use of opened multi-use vials needles from syringes
children stored beyond recommended time  Manipulating used
 Sharing needles (contaminated drug use) sharps (cleaning,
and syringe  Using wrong diluents or wrong bending, breaking or
 Reusing needles amount cutting hypodermic
and syringes  Use of expired drugs needle)
 Syringes are loaded with different  Passing on sharps from
medications one health worker to
 Loading syringe with multiple doses another
 Drugs and vaccines are stored in  Sharps are found in
the same refrigerator unexpected places like
 Accidental switching of drugs linen
 Health workers not following aseptic  Overfilling of sharps’
techniques containers
 Patient/client moves during  Using a syringe on an
administration of injection agitated patient without
 Sharps are found in unexpected assistant or patient/client
places like linen moves during
 Self-medication administration of injection

i. Risk to patients
Unsafe injections can result in: -
 Transmission of blood born infections – example: - HBV, HCV,
HIV/AIDS…etc.
 Injection abscesses
 Paralysis
 Drug/allergic reactions shock
ii. Risk to Health Care Workers
Globally, in the course of their duties, HCWs are at an increased risk from blood
borne pathogens. It was estimated that 39% of HCV, 37% of HBV, and 4.4% of HIV
infection among HCWs worldwide are attributable to occupational exposure to
sharps injuries. (Prüss-Üstün et al., 2005).

In addition – the indirect medical costs of due to HBV, HCV & HIV/AIDS is huge and
the psycho-social impact is also immense.

59
 5.2. THE ROLE OF PRESCRIBERS AND PROVIDERS IN INJECTION
SAFETY

Activity 5.2: Group discussion

Instruction:
 In a group of 3, discuss the following questions, and reflect your
responses to the class. Each group will discuss on the following
questions.
Discussion questions:
1. What are the roles of clinicians and providers in injection
safety?
2. What are the principles of safe injection practices?
3. How do you manage sharp wastes?
Time Allowed: 20 minutes

The Role of Prescribers and Providers in Injection Safety

Promoting Rational Prescribing and elimination of unnecessary Injection
 Many injectable medications have an oral equivalent that are equally strong,
effective and much safer. Therefore, unnecessary injections should be reduced
through:
o Avoid unnecessary injections. Therefore, injections should only be used in:
 Life threatening conditions
 Mal-absorption syndromes or
 Inability to swallow
o Prescribers and Service providers should also:
 Encourage patients to accept oral medications when possible.
 Injections should be given only when necessary.
 Explain the risks associated with injections
 Inform patients the potential side effects of medications that is being
prescribed
 Explore why patients prefer injections

Educating the patients

 Encourage patients to accept oral medications; and explain the risks associated with
injections, when possible, to limit the use only when necessary.

Administer Injections Safely

60
 Table 5.2: Right Ways to Give Safe Injection

Standards
Rights Method of Verification
Always check and verify all ‘rights’
What is the name on the prescription? Is Ask patient/guardian, etc. to
1. Right Patient this the right patient? repeat name
Is the name of the drug on the prescription Verify name of drug on
the same as the injection you are about to prescription with injection to be
2. Right Drug administer? administered
If you are unsure verify with
physician or pharmacist
3. Right Could the medication be given orally Discuss with patient available
Formulation instead of as an injection? choices
Use only sterile, non-reusable syringes, Check to ensure that
4. Right Injection dental cartridge, etc syringe/needle package is
Equipment unbroken
Check dosage against patient’s age, weight Read the pharmaceutical
and the pharmacokinetics of the drug recommendations of the drug If
5. Right Dosage unsure, verify with the
physician/prescriber
Follow the specific dose interval Be mindful of the action of the
drug and why the time interval
6. Right Time should be followed. Explain the
importance of this to the patient
Be sure to use the correct route of Observe the direction of the
administration (intra-muscular, intravenous, prescriber
7. Right Route intra-dermal or subcutaneous) Check prescription or other
related records
Right temperature, Vaccine Vial Monitor Check cold chain issues including
8. Right Storage (VVM) shake test VVM
Do not recap needle. Check the safety box for correct
Dispose of used syringe and needle method of disposal
9. Right Method immediately after use in appropriate safety
of Disposal box
Or
Use the needle cutter and safety box

5.3. PRINCIPLES OF SAFE INJECTION PRACTICE

Activity 5.3: Think pair share

Instruction:
 Discuss the following question in pair and share your
opinion to the larger class.
Discussion question1:
 What are the general considerations to ensure safe
injection Practice?
Time Allowed: 10 minutes

61
Use Sterile Injection Equipment

Single use syringe and needle for each injection is recommended and Auto-disable
syringes are mandatory for all immunization injections.

Prevent Contamination of Injection Equipment and Medication

 Prepare each injection in a clean designated area where blood or body fluid
contamination is unlikely.
 Use single dose vials rather than multi-dose vials.
 If multi-dose vials must be used, always pierce the septum with a sterile
needle and avoid leaving the needle in place in the stopper of the vial.
 Select pop-open ampoules rather than ampoules that require use of a metal
file to open.
 If you are using an ampoule that requires a metal file to open, protect fingers
with a clean barrier (e.g., small gauze pad) when opening the ampoule.
 Inspect medicaments and discard those with visible contamination or
breaches of integrity (e.g., cracks, leaks).
 Follow product-specific recommendation for use, storage and handling.
 Swabbing of a new vial tops or ampoules with an antiseptic or disinfect is
unnecessary. If swabbing with an antiseptic is selected for use, use a clean,
single use swab and maintain product specific recommendation contact time.
Do not use cotton balls stored wet in a multi-use container.
 Swabbing of clean skin before giving an injection is unnecessary. Wash skin
visibly soiled or dirty with soap and water. If swabbing with an antiseptic is
selected for use, use a clean, single use swab and maintain product specific
recommendation contact time. Do not use cotton balls stored wet in a multi-
use container.
 Discard a needle that has touched any non-sterile surface.

Prevent Injuries to the Provider

Injuries may occur during procedures (health professionals), cleaning and washing
(house- keepers & laundry workers) and handling waste materials.

Precautions to take before an Injection - precautions are taken depending on the

types of procedure being carried out.

62
Anticipate and take measures to prevent sudden patient movement during and after
injection.

Do not recap, bend or break needles prior to disposal of single use needles and
syringes after giving injections. However, if there is a need to recap a needle due to
various reasons, needles must be recapped using the ―one-handed‖ recap method
as follows:

1. Place the cap on a flat surface, and then remove your hand
from the cap. With one hand, hold the syringe and use the
needle to scoop up the cap.

2. When the cap covers the needle completely, use your other
hand to secure the cap on the needle hub. Handle the cap at
the bottom, near the hub.

Figure 5.1: One handed recap method

 Do not disassemble the needle and syringe after use.

 All used syringes and needles or any other sharps should be discarded at the
point of use in a safety box and seal before being completely full.
 During injection, disposable gloves are indicated only if excessive bleeding
anticipated.

Prevent Access to Used Needles and Syringes

 Seal sharp containers for transport to a secure area in preparation for
disposal. After closing and sealing sharps containers, never open, empty or
reuse them.
 Manage/dispose sharps waste in an efficient, safe, and environment-friendly
way to protect people from voluntary or accidental exposure to used injection
equipment.
Special Note:

All patients undergoing an injection should be counseled before injection is given e.g., on
the type of drug, side effects, possible adverse effects/events following the administration of
the injection and total number of doses to be given by injection.

Self-injecting patients such as diabetic patients should be properly informed about their
medications and how to ensure safety or injection. In case a patient needs to take the
injection equipment home, he/she should be counseled on the storage, disposal and sterility
of their drugs and equipment.

63
Standards for Administering Injections
 Ensure that the patient is adequately prepared for and informed about the
procedure.
 Keep the injection preparation area free of clutter; so, all surfaces can be
easily cleaned or if contaminated with blood & body fluids clean and disinfect
with 0.5% sodium hypochlorite solution or 70% alcohol solution,
 Assemble all equipment needed for the injection: sterile, single-use needles
and syringes; reconstitution solution (sterile water or a specific diluent);
alcohol swab or cotton wool; and a sharps container
 Prepare a well-laid up tray including emergency drugs for management or
possible drug reaction.
 Wash hands with soap and water; dry
 Check for expiry date, breach, leaks, particles or any contamination.
 Use a sterile syringe and needle to withdraw the medication from the ampoule
or vial.
 Open the package in front of the patient to reassure the person that the
syringe and needle have not been used previously,
 Wipe the top of the vial with 70% alcohol (isopropyl alcohol or ethanol) using a
swab or cotton-wool ball. Allow it to dry.
 Make sure that the right drug, dose, formulation and route are used for the
right patient or client at a right time,
 Follow the manufacturer’s instruction and use the correct diluent, if needed
 Draw the right dose as prescribed, including expelling the air using right
injection equipment,
 Ensure aseptic technique while giving the injection,
 Administer the drug at the correct site,
 Dispose the used syringes and needles immediately into the sharp’s
container,
 A patient should be kept in the room for at least 5 minutes after the injection
has been given and be observed for any possible adverse effect or events.
 Thank the patient or the client.

64
 5.4. PRACTICAL GUIDANCE ON HANDLING PARENTERAL
MEDICATION

Activity 5.4: Individual reflections

Instruction:
 Reflect your thoughts on the following question
Discussion question1:
 What are the recommendations for handling parenteral
medications?
Time Allowed: 5 minutes

When using a sterile, single-use device (i.e., a syringe and hypodermic needle that
are not separated or manipulated unless necessary):

 Use a new device for every patient, including for withdrawing medication. This
practice is considered a very basic IPC precaution and is promoted by WHO
(Safe Injection Global Network [SIGN]) and the US Centers for Disease Control
and Prevention (CDC), among others.

 Inspect the packaging of the device to ensure that the protective barrier has not
been breached.

 Discard the device if the package has been punctured, torn, or damaged by
exposure to moisture, or if the expiry date has passed. (WHO 2010)

When giving medication:

 ALWAYS follow the one needle, one syringe, and one injection rule.
 DO NOT use the same mixing syringe and needle to reconstitute several vials.
 DO NOT combine leftover medications for later use.
 DO NOT use single-use vials for multiple patients, if possible.
When using single-use vials:

 Vials labeled by the manufacturer – single dose, should be used only for a
single patient.
 There may be circumstances when the contents of single-use vials must be
used for multiple patients. In this situation, contents from an unopened single-
use vial can be repackaged one time into multiple single-use syringes for

65
 multiple patients. However, this should be performed only by a trained HCW
in an area away from patient care and in accordance with strict IPC
standards. Label as described below. Store for only 24 hours.
 Check that you have the right medication vial for the patient’s prescription.
 Double-check the expiration date and if the vial has previously been opened,
the current date is within 24 hours of opening (unless a shorter or longer time
frame is otherwise specified by the manufacturer).
 Follow the principle of ― ONE SYRINGE, ONE NEEDLE, ONLY ONE TIME.
 Discard the single-use vial after use.
 If a dose has been withdrawn into a syringe and cannot be administered
immediately for any reason, cover the needle with the cap using a one-
handed scoop technique. Do not keep the medication longer than 24 hours
unless a shorter or longer time frame is otherwise specified by the
manufacturer. Inject the medication as soon as possible after withdrawing
from the vial.
When using multi-dose vials:

 If a multi-dose vial is assigned to a single patient (e.g., insulin pen), check that
you have the right vial for the patient.
 Double-check the expiration date and if previously opened, check that the vial
is labeled by the manufacturer as a multi-dose vial and the current date is
within 28 days of opening, unless a shorter or longer time frame is otherwise
specified by the manufacturer.
 Follow the principle of ― ONE SYRINGE, ONE NEEDLE, ONLY ONE TIME.
 When withdrawing medication from a multi-dose vial, avoid double dipping,
this may contaminate the contents of the vial and transmit infection to
subsequent patients.
 DO NOT store multi-dose vials in patient care areas, where they could be
inadvertently contaminated.

66
Procedure for vials with a rubber septum

Many vials have a rubber septum (stopper).

 Wipe the access rubber septum with 70% alcohol (isopropyl alcohol or
ethanol) with a swab or cotton-wool ball and allow it to dry before piercing the
vial or inserting a device into the bottle.
 Use a new, single-use, disposable, sterile syringe and needle for each
insertion into a vial.
 Never leave a needle in a multi-dose vial. This practice provides a direct route
for microorganisms including HIV to enter the bottle and contaminate the fluid
between each use.
 Once the loaded syringe and needle have been withdrawn from a multi-dose
vial, administer the injection as soon as possible.

Labeling

For multi-dose medications that DO NOT require reconstitution (e.g., lignocaine),

label the container with:

 Date and time of first piercing of the vial

 Type and volume of diluent (if applicable)
 Final concentration
 Expiry date and time after reconstitution
 Name and signature of the person first piercing the vial

5.5. SAFE HANDLING OF SHARPS

Activity 5.5: Individual reflections

Instruction:
 Share your experience on the following question.
Discussion question1:
 How do you handle sharps in your healthcare Facilities?
Time Allowed: 10 minutes

67
Sharps Safety or Boxes:

 Safety or sharps box is a puncture and leak-resistant container for disposal of

sharps including hypodermic needles, needles from IV bags, lancets, scalpels
and suture needles and it may be made of thick cards or disposable plastic
bottles with narrow necks.

Figure 5.2: Safety Box

Proper Management of Safety Box:

 Should be easily accessible to health worker for easy disposal of needles

 Should not be easily accessible for public
 Dispose when 3/4 full
 Use 1 per defined area of need.

Sharps containers do’s and don’ts

 Do put sharps containers as close to the point of use as possible, ideally

within
 arm’s reach.
 Do attach containers to walls or other surfaces if at all possible.
 Dispose all sharps in a safety box immediately after injection.
 If the syringe is a retractable one, make sure to engage the retraction feature
before disposing of the syringe.
 Don’t shake a container to settle its contents and make room for more sharps.
 Do not use boxes that are open, overflowing or punctured. Get a new one
instead Dispose safety boxes when 2/3 full.

68
  Don’t place containers in high traffic areas where people could bump into
them or be stuck by someone carrying sharps to be disposed of.
 Always put on a heavy-duty glove when handling sharps containers.
 Dispose of the sharps and sharp containers by burning, burying or
encapsulation.

Other Sharps Safety Dos and Don’ts

 Do not walk around with needles and other sharps

 Do use receivers to pass sharps to others and alert them before passing the
sharps
 Do not point needles and other sharps at yourself or others

5.6. SUMMARY

Injections present risks to patients, HCWs, and the community and should be limited
where alternative administration routes are available. Safe injection practices are
one of the components of Standard Precautions. It is the responsibility of each HCW
to ensure safe injection practice.

69
CHAPTER 6: Reprocessing of Instruments and Reusable Items

Chapter Description:
This chapter explains instrument and reusable items reprocessing by explaining and
demonstrating the importance and steps of instrument processing (cleaning, HLD
and sterilization) as well as safe storage and transport.
Chapter Objective
By the end of this chapter the participants will be able to apply reprocessing of
instruments and other items before reuse.
Enabling Objectives
By the end of this module, participants will be able to:
 Define medical instrument reprocessing practice
 Distinguish level of medical instruments disinfection or sterilization required
 List commonly used disinfectants
 Distinguish the Processes of medical instruments cleaning process,
sterilization and HLD
 Identify monitoring mechanism, safe storage and transport of
reprocessed/decontaminated reusable medical devices
Session outline
6.1. Overview of Medical instrument reprocessing
6.2. Level of disinfection or sterilization required
6.3. Commonly used disinfectants and their properties
6.4. Steps of medical instruments and other items reprocessing
6.5. Monitoring, Storage and transport of sterilized and high-level disinfected
instrument and other item
6.6. Summary

70
 6.1. OVERVIEW OF INSTRUMENT REPROCESSING

Activity 6.1: Individual Reflection

Instruction:
 Reflect on the following question
 Discussion Question:
1. How None-decontaminated medical instruments are risky
to health care workers and patients/clients
Time Allowed: 8 minutes
As the prime concern of safety procedures is to protect both patients and the staff from
infection, the transmission of infection from medical devices and equipment
contaminated with patient ‘s body fluid is the focal area of intervention in health facilities.
Healthcare workers are increasingly at risk of becoming infected with serious blood
borne viruses such as HBV, HCV and HIV.
Thus, the greatest risk results from the staff in direct contact with these life-threatening
infections while they perform or assist with surgical procedures (physicians, nurses and
midwives); process surgical instruments and equipment (staff); perform housekeeping
and waste management tasks; including disposal of infectious waste items.
Some research findings showed that there are 8 to 16 million new infections of Hepatitis
B annually due to unsterile injections in developing countries. On the other hand, it was
found that HIV survives in needles and syringes for more than 4 weeks at room
temperature.

6.2. LEVEL OF DISINFECTION OR STERIALIZATION REQUIRED

Activity 6.2: Think-Pair-Share

Instruction:
 Be in pair with someone besides you
 Share your facility experience on the following questions
Discussion question:
 How do you reprocessing medical devices that come in
contact with?
1. Intact skin but not mucous membranes
2. Mucous membranes or non-intact skin
3. Sterile areas of the body including the vascular system
Time Allowed: 10 Minutes

71
Spaulding classified instruments and patient care devices into three categories, based
upon how the device is used. Items are classified as:

 Non-critical — come in contact with intact skin but not mucous membranes
 Semi-critical — come in contact with mucous membranes or non-intact skin
 Critical — come in contact with sterile areas of the body including the vascular
system

Table 6.1: Spaulding’s Risk Classification and Level of Processing

Risk category Level of Examples

disinfection/sterilization
Critical Sterilization Reusable surgical instruments
Semi-critical High-level disinfection Respiratory instruments, specula used for
vaginal examination, endoscopes
Non-critical Cleaning Blood pressure cuffs, stethoscopes

6.3. COMMONLY USED DISINFECTANTS AND THEIR PROPERTIES

Activity 6.3: Reflection

Instruction:
 Reflect on the following questions

 Discussion Question:
1. What is the difference between antiseptic and disinfectant
2. What are the commonly used chemical disinfectants in
your healthcare settings?
Time Allowed: 5 Minutes
Commonly Used Chemical Disinfectants and their properties

A. Alcohols

 Ethyl and isopropyl (2-propyl) alcohol (60 to 90%) are disinfectants which are
relatively cheaper and commonly available.
 They are primarily used as antiseptic and as a low or intermediate-level
disinfectant (wiping oral and rectal thermometers and disinfecting external
surfaces of equipment- stethoscopes, cryoprobe tips, ultrasound probes, Ambu
bags or anatomic models).
 Should be stored in a cool and well-ventilated place for they are flammable.

72
B. Chlorine and chlorine releasing compounds

 They are fast acting, very effective against HBV, HCV and HIV/AIDS, relatively
cheaper and readily available intermediate level disinfectants (CDC, 1987; WHO,
1989).
 A major disadvantage is that concentrated Chlorine solutions (>0.5%) can corrode
metals. commonly used are Sodium hypochlorite (Chlorine bleach), Calcium
hypochlorite or chlorinated lime, Sodium dichloroisocyanurate.
NOTE: CHLORINE SOLUTIONS SHOULD NOT BE USED AS for HLD

Soaking of instruments in disinfectant prior to cleaning

According to the WHO and PHAO, soaking of instruments in 0.5% chlorine solution or
any other disinfectant prior to cleaning is not recommended for the following reasons:
 It may damage/corrode the instruments
 The disinfectant may be inactivated by blood and body fluids, which could become a
source of microbial contamination and formation of biofilm
 Transportation of contaminated items soaked in chemical disinfectant to the
decontamination area may pose a risk to health care workers and result in
inappropriate handling and accidental damage May contribute to the development of
antimicrobial resistance to disinfectants.
C. Formaldehyde

 Can be used in both liquid and gaseous forms for a chemical sterilization, as well
as a high-level disinfectant (Taylor, Barbeito & Gremillion 1969; Tulis, 1973).
Note: Formaldehyde is being used as a high-level disinfectant as well as a sterilant in
Ethiopia, but globally it’s slowly being phased out because of its toxicity. It produces a
dangerous gas (bis-chloroethyl-ether) when mixed with chlorine. Switching to less toxic
compounds such as Glutaraldehyde’s or other newer high-level disinfectants is strongly
recommended.

D. Glutaraldehyde

 Glutaraldehyde’s are widely used for chemical sterilization and HLD of medical
instruments. The most commonly used antiseptic is an alkaline-stabilized 2%
Glutaraldehyde available commercially as Cidex® or Cidex 7®. These chemicals
which are derivatives of Formaldehyde are also irritating and their fumes are very
unpleasant. Therefore, they should be used only in well-ventilated rooms.

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E. Orthophthalaldehyde (OPA)

 Have a number of features that make it a good choice for high-level disinfecting
instruments and medical devices.
Do not dilute this chemical unless specified in the manufacturer’s instructions

F. Iodine and Iodophor solutions

 Iodine solutions (1 to 3% aqueous or tincture) and Iodophor (Iodine complexes

with an organic material) have been used primarily as antiseptics.
 Allergic reactions can also occur to the staff handling Iodine solutions and
Iodophors. Therefore, they primarily used as antiseptic for skin and mucous
membranes (aqueous preparations only).
 Used for decontamination when the commercial preparation with aqueous
solutions is available but must be made fresh on daily basis.
G. Hydrogen Peroxide

 It is often available locally and is relatively cheaper than any other chemical
disinfectants and can be used to achieve HLD and sterilization. It has activity
against a wide range of microorganisms including vegetative bacteria, fungi, and
viruses.
 A 3% solution can achieve HLD using a contact time of 30 minutes at 20°C
(68°F). To achieve sterilization, a higher concentration (7.5% solution) and a
longer contact time are required (6 hours at 20°C [68°F]).
H. Other Chemical Sterilant:

 Peracetic acid (Peroxyacetic acid), Gas plasma sterilization (hydrogen peroxide

based) and Para formaldehyde are also other types of chemical sterilant

Activity 6.4: Group Discussion

Instruction:
 Be in three Groups
 All groups will work on question number one below and
 Assign
o Group 1 to work additionally on question Number two (Cleaning)
o Group 2 to work additionally on question Number three (Chemical
HLD)
o Group 3 to work additionally on question Number four (steam
Sterilization)
 Discussion Question:
1. Draw the major steps of instrument processing that how are you applying
in your facilities currently
2. Discuss on the Procedures and steps of Cleaning of medical devices
3. Discuss on the types of HLD and put the steps of HLD using chemicals
74
 4. Discuss on the Types/Methods of Sterilization and put the steps of Steam Sterilization.
Time Allowed: 20 Minutes

Storage of Disinfectants

 Chemical disinfectants should be stored in a cool and dark area.

 Never store chemicals in direct sunlight or in excessive heat (e.g., upper shelves
in a tin- roofed building)

6.4. STEPS OF MEDICAL INSTRUMENTS AND OTHER ITEMS

REPROCESSING

Each item, be it soiled metal instruments requires special handling and processing in
order to
 Minimize the risk of accidental injury or exposure to blood or body fluid to the
cleaning and housekeeping staff; and
 Provide a high-quality end product (i.e., sterile (if not available high-level
disinfected

Figure 6.1: Workflow for instrument processing and other medical

deviceEffectiveness of Methods of Processing Instruments

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 EFFECTIVENESS
METHOD (Kill or remove END POINT
microorganisms)
Cleaning (soap and
Up to 80% Until visibly clean
rinsing with water)
High-Level Disinfection 95% (does not Boiling or chemical for 20
inactivate endospores) minutes
Sterilization High-pressure steam, dry heat
100% or chemical for the
recommended time
Cleaning
Cleaning is a process of physically removing infectious agents and other organic
matters on which they live and thrive but does not necessarily destroy infectious agents.
Cleaning is the first step in reprocessing a device after use and a critical step in
instrument processing because:
 It reduces damage to instruments. Long contact with blood is corrosive and can
damage surgical instruments.
 It makes instruments easier to process. Once blood dries on an instrument, it is
difficult to clean, especially if the blood has entered the hinges and sockets.
Steps of cleaning:
Facilities with minimal resources can adequately clean and prepare devices for
sterilization with an effective manual cleaning process. However, it is vital that all
devices be disassembled so that all surfaces may be cleaned and disinfected,
irrespective of the cleaning method chose.
 Ensure that the device to be cleaned is compatible with the chemical solution
used in the facility
 Completely submerge immersible items during the cleaning process to minimize
aerosolization and to assist in cleaning
 Remove gross soil using tools, such as brushes and cloths
 Clean devices that have lumens with an appropriate brush, then manually or
mechanically
 flush with a detergent solution and rinse with potable water
 Check devices with lumens for obstructions and leakage
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 1. Put on Personal Protective Equipment (PPE) including a water-resistant gown, gloves,
face mask and head cover. If gloves are torn or damaged, they should be discarded;
otherwise, they should be cleaned and left to dry for re-use in the following day. Even
when wearing heavy-duty utility gloves, care should be taken to prevent needle sticks or
cuts when washing sharps.
2. Fill sink or appropriate basin with sufficient warm water for complete immersion of the
devices being cleaned
3. Add the appropriate quantity of detergent following the manufacturer ‘s instructions for
dosage
4. Clean the device under the surface of the water so that aerosols are not produced
5. Use appropriate brushes to properly clean box locks, lumens and other hard-to-clean
areas
A. Use soft (nylon) bristle brushes so that the surface of the instrument is not
damaged
B. Brushes used to clean lumens must be the same diameter as the instrument to
ensure that all internal surfaces can be reached
C. Brushes must also be long enough to exit the distal end of the instrument
6. In another sink or basin, completely immerse the device in clean purified water and
rinse the device thorough
7. Air-dry or hand-dry using a disposable clean, non-linting cloth

N.B: One can clean without sterilizing, but one cannot sterilize without cleaning!

Packing and Wrapping for Sterilization

Activity 6.5: Demonstration
Instruction:
 Get a wrapping material (Muslin cloth)
 One volunteer trainee Demonstrate typical wrapping
techniques how that they are applying in her/his facility.
 Participants Observe and provide feedback
 The facilitator Demonstrate the correct steps once again
Demonstration Question: Wrapping and packing of medical
devices
Time Allowed: 10 Minutes

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Wrapping items to be sterilized permit sterile items to be handled and stored without
being contaminated (Figure 6.2: Typical instrument Wrapping Techniques). Materials
used for wrappers should:
 Allow air removal and steam penetration
 Act as a barrier to microorganisms and fluids
 Capable of withstanding high temperatures
 Resist tears and punctures and be free of holes
 Be nontoxic and low lint
Not be costly

Figure 6.2: Typical instrument Wrapping Techniques

Types of materials that can be used as wrappers include:
 Muslin cloth (140 thread count) - use two double thicknesses wraps (four layers
in all) as this is the least effective of all materials used for wrapping.

 Paper - double wrapping (two layers) is recommended. Use it for steam

sterilization only and avoid reuse.

78
Tips for wrapping

 At least two layers of wrapping should always be used to reduce the possibility of
contaminating the contents during unwrapping.
 Do not wrap packages too tightly.
 If they are wrapped too tightly, air can become trapped at the center of the
packages preventing the temperature from getting high enough to kill all the
microorganisms.
 Also, wrapping with strings or rubber bands or tying linen too tightly can prevent
steam from reaching all surfaces.
 The outer wrapper of the pack can be loosely secured using linen ties.
 Packs can be secured with linen ties made from the same cloth.
 Hemmed strips of about ½ inch wide and of varied lengths.
 One or two of such strips can be used for each package. Because they can fit to
almost any size of package, they eliminate the need for an expensive and hard-to-
remove indicator tape.
 Do not wrap items in any waterproof material such as plastic or canvas for steam
sterilization as the steam cannot penetrate the material and leave the item
unsterilized.
 Wrappers should not be reused if they are torn, stained with oils or have hard or
gummy deposits.
High-Level Disinfection
High-Level Disinfection can be achieved by:

 Pasteurization/ Boiling in water,

 Steaming
 Soaking instruments in chemical disinfectants (chemical disinfection).

High-Level Disinfection by Boiling

 Pasteurization can be used to achieve HLD of instruments and medical devices.

It is carried out by heating at 770C (170.60F) for 30 minutes or boiling at 100 0C
(2120F) for 20 minutes.

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  Boiling has been a common practice for HLD of instruments and equipment used
for semi-critical and sometimes critical procedures as it was the only available
option in some low-income countries.

 Pasteurization/ Boiling in water is an effective and practical way to high-level

disinfect instruments and other items. Although boiling instruments in water for 20
minutes will kill all vegetative forms of bacteria, viruses (including HBV, HCV and
HIV), yeasts and fungi; it will not kill all endospores reliably.

Tips on Boiling

 Always boil for the required time period in a container with a lid.
 Start timing when the water begins to boil.
 Metal instruments should be completely covered with water during boiling.
 Do not add anything to the pot after timing begins.

High-Level Disinfection by Steaming

Materials needed for high-level disinfection by steaming include:

 Steamer pan without holes to hold water (such as mom steamer)

 Two to three additional pans with holes to allow steam to move to upper pan
 The pans should be deep enough to fit the largest item being steamed
 A tight-fitting lid to cover the upper pan
 An additional bottom pan for drying the processed items

80
 Figure 6.3: Steamer Used for HLD
High-Level Disinfection Using Chemicals

Although a number of disinfectants are commercially available in most countries, four

disinfectants- OPA, Glutaraldehyde’s, Formaldehyde and Peroxide-are routinely used
as high- level disinfectants.

Key Steps in Chemical High-Level Disinfection

 Thoroughly clean instruments and other items that may have been
contaminated with blood and body fluids and thoroughly clean and dry them
before placing them in the disinfectant solution.
 Completely immerse all items in the high-level disinfectant.
 Soak them for 20 minutes.
 Remove items using high-level disinfected or sterile forceps or gloves.
 Rinse well with boiled and filtered (if necessary) water three times and air dry.
 Use promptly or store in a dry, high-level disinfected and covered container.

Factors That Affect Disinfection Process

 Quantity and location of the microorganisms

 Quantity and location of organic matter
 Concentration of the disinfectant
 Physical and chemical factors
 Duration of exposure
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  Resistance of microorganism to the chemical agent

Sterilization

 Sterilization is a process in which the destruction of all micro-organisms including

bacterial endospores takes place.

 Sterilization in health facilities can be achieved by high pressure steam

(autoclaves), dry heat (oven), chemical sterilant (Glutaraldehyde or formaldehyde
solutions) or physical agents (radiation).

Note: Rinsing an item with Alcohol and then igniting it with a match (flaming) is not an
effective method of disinfection or sterilization.

Methods of Sterilization

1. High Pressure Steam Sterilization (Autoclaves)

2. Dry-heat sterilization (oven)
3. Chemical Sterilization

1. High Pressure Steam Sterilization (Autoclaves)

 Steam Sterilization is generally considered the method of choice for sterilizing

instruments and other items used in healthcare facilities.

 In settings where electricity is a problem, instruments can be sterilized in a non-

electric steam sterilizer using kerosene or other fuel as a heat source

 Steam is an effective sterilant in that it can soften any resistant and protective
outer layer of the micro-organisms allowing coagulation of the inner sensitive
portion of the micro- organisms.

 Steam sterilization (Gravity): In the usual practice, the temperature in steaming

process should be 1210C (2500F) and its pressure,106 kPa (15 lbs/in2) the time
being 20 minutes for unwrapped items; and 30 minutes for wrapped items.

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  As an alternative, it could be set at a higher temperature of 1320C (2700F) with
the pressure of 30lbs/in2; and the duration being 15 minutes for wrapped items.

Whatever the case may be, one should allow all items to dry before removing them from
the sterilizer.

Effective Sterilization Depends on Correctly Following Procedures of the Process

These include:

 Routine maintenance,
 Preparing items to be sterilized,
 Packaging and wrapping,
 Loading,
 Operating, and
 Unloading the sterilizer.
Instructions of Operating a Steam Sterilizer
STEP 1 Thoroughly clean and dry all instruments and other items to be sterilized.
STEP 2 All jointed instruments should be in an open or unlock position, while
instruments composed of more than one part or sliding parts should be
disassembled.
STEP 3 Instruments should not be held tightly together by rubber bands or any other
means that will prevent steam contact with all surfaces.
STEP 4 Arrange packs in the chamber to allow free circulation and penetration of
steam to all surfaces.
STEP 5 when using a steam sterilizer, it is best to wrap clean instruments or other
clean items in a double thickness of muslin or newsprint. (Unwrapped instruments
must be used immediately after removal from the sterilizer, unless they are kept in
a covered, sterile container.)
STEP 6 Sterilize at 1210C (2500F) for 30 minutes for wrapped items and 20 minutes
for unwrapped items; set time of the clock.
STEP 7 Wait 20 to 30 minutes (or until the pressure gauge reads zero) to permit the
sterilizer to cool sufficiently. Then open the lid or door to allow steam to escape.

83
 Allow instrument packs to dry completely before removal which may take up to 30
minutes (Wet packs act like a wick drawing in bacteria, viruses and fungi from the
environment). Wrapped instrument packs are considered unacceptable if there are
water droplets or visible moisture on the package exterior when they are removed
from the steam sterilizer Chamber. If using rigid containers (e.g., drums), close the
gaskets.
STEP 8 To prevent condensation when removing the packs from the chamber, place
sterile trays and packs on a surface padded with paper or fabric.
STEP 9 after sterilizing, items wrapped in cloth or papers are considered sterile as
long as the pack remains clean, dry (including no water stains) and intact.
Unwrapped items must be used immediately or stored in covered sterile containers.
 Maintain a steam sterilizer log including heat begun, correct temperature and
pressure achieved, heat turned down, and heat turned off.
 Each load should be monitored with mechanical (time, temperature and pressure)
and chemical (internal and external chemical test strips) indicators.
 Autoclave should be tested daily with an air-removal test to ensure proper
removal of air.
 If steam escapes from the safety valve or under the lid, the autoclave is not
working
 correctly. Rather, it is merely steaming items at low-pressure (which may be
equivalent to
 HLD, not sterilization). Then, what is to be done?
 If steam escapes from the safety valve instead of the pressure valve, the pressure
valve
 must be cleaned and inspected.
 If steam escapes from under the lid, the gasket (rubber ring) must be cleaned and
dried or
replaced
2.Dry Heat Sterilization Method

 Dry heat sterilization is caused by hot air that destroys micro-organism through
oxidation that causes slow destruction of the micro-organism’s protein.
84
  When available, dry heat is a practical means by which needles and other sharp
instruments are sterilized.
 Dry-heat sterilization can be achieved with a simple oven as long as a
thermometer is used to verify the temperature inside the oven.
3 Chemical Sterilization

 Chemical sterilization is an alternative to high-pressure steam or dry-heat

sterilization and often called―cold sterilization.
 If objects need to be sterilized and when the availing methods like high-pressure
steam or dry-heat sterilization would damage them or equipment are not available
(or operational), they can be chemically sterilized.

Formaldehyde is no longer included as a sterilant or a high-level disinfectant due

to its toxicity

Table 6.2: Liquid Chemicals Used for Sterilization

Chemical Sterilant Soak Time for Sterilization High-Level Soak Time for Effective Life
Disinfectant HLD
Yes 10 hrs. at 20– 25°C (68–77°F) Yes 20–90 min at 14 days
Glutaraldehyde 2–4% or 20–25°C (68–
7 hrs., 40 min at 35°C (95°F) 77°F)
Glutaraldehyde 3.4% and Yes 8 hrs. at 20°C (68°F) Yes 10 min at 14 days
Isopropanol 20.1% 20°C (68°F)
Yes 6 hrs. at 20°C (68°F) Yes 30 min at 21 days
Hydrogen peroxide 7.5% 20°C (68°F)
Peracetic acid 0.31– Yes 2 hrs. at 20°C (68°F) Yes 5 min at 5 days
0.38% 25oC (77°F)
Yes 5 hrs. at 25°C (77°F) Yes 5 min at 5 days
Hydrogen peroxide 8.3%
25°C (77°F)
and Peracetic acid 7%
Yes 8 hrs. at 20°C (68°F) Yes 25 min at 14 days
Hydrogen peroxide 1.0%
20°C (68°F)
and Peracetic acid 0.08%

6.5. MONITORING, SAFE STORAGE OF STERILE/ HLD

INSTRUMENT

Monitoring Sterilization Procedures

Activity 6.6: Individual Reflection
Instruction:

 Share your own facility experience sterilization procedure

monitoring techniques
85
 Time Allowed: 5 minutes

Sterilization procedures can be monitored routinely using a combination of biological,

chemical and mechanical indicators as parameters. Different sterilization processes
have different monitoring requirement.

Biological Indicators

Measurements should be performed with a biological indicator that employs spores of

established resistance in a known population. The biological indicator types and
minimum recommended intervals should be:

 Steam Sterilizers - a highly resistant but relatively harmless

(nonpathogenic) microorganism called Geobacillus stearothermophilus is used to
test steam sterilizers.
 Dry-Heat Sterilizers - Bacillus subtilis, is used as an indicator on weekly basis
and as deemed necessary.

Chemical Indicators

Chemical indicators include indicator tape or labels which monitor time, temperature
and pressure for steam sterilization and for dry-heat sterilization. These indicators
should be used on the inside and outside of each package or container.

 External Indicators - are used to verify whether the items have been exposed to
the correct conditions of the sterilization process and the specific pack has been
sterilized.
 Internal Indicators - are placed inside a pack or container in the area most
difficult for the sterilization agent to reach (i.e., the middle of a linen pack). This is
the indicator that tells if the item has been sterilized.
Chemical indicators like heat sensitive tape or glass vials containing pellets that melt at
certain temperatures and duration do not imply achieved/successful sterilization. They
do, however, indicate whether mechanical or procedural problems have occurred in the
sterilization process.

86
Mechanical Indicators

 Provide a visible record of the time, temperature and pressure of the sterilization
cycle for sterilizers. This is usually a printout or graph from the sterilizer, or it can
be a log of time, temperature and pressure kept by the person responsible for the
sterilization process that day.
Safe Storage of Sterile/ HLD Instrument
All sterile items should be stored appropriately to protect them from dust, dirt, moisture,
animals, and insects.
The storage area should be located next to the place of sterilization or connected to it in
a separately enclosed area with limited access that is used just to store sterile and clean
patient care supplies.
Handling and Transporting Instruments and Other Items
 Keep clean and highlevel disinfected or sterile instruments and other items separ
ate from soiled equipment and waste items. Do not transport or store these items
together.
 Transport high-level disinfected and sterile instruments and other items to the
procedure or operating room in a closed cart or container with a cover to prevent
contamination.
 Transport soiled supplies and instruments to the receiving/cleanup area in leak
proof and covered waste containers.
Note:
If supplies are being delivered to the surgical area; one person standing outside should
pass them through the door to a person inside the operating room.
Instructions for Storing Sterile Items
1. Keep the storage area clean, dry, dust-free and lint-free.
2. Control temperature and humidity (approximate temperature 24oC and relative
humidity <70%) when possible.
2. Packs and containers with sterile (or high-level disinfected) items should be
stored 20 to 25cm off the floor, 45 to 50cm from the ceiling and 15 to 20cm
from an outside wall.
3. Do not use cardboard boxes for storage because cardboard boxes shed dust
and debris and may harbor insects.

87
 4. Date and rotate the supplies (first in/first out). This process serves as a
reminder, but does not guarantee sterility of the packs.
5. Distribute sterile and high-level disinfected items from this area
6.6. SHELF LIFE
 The shelf life of an item (how long items can be considered sterile) after
sterilization is event related.
 To make sure items remain sterile you need to prevent events that can
contaminate sterile packs and protect them by placing them in plastic covers (thick
polyethylene bags).
 An event can be a tear or worn-out area in the wrapping, the package becoming
wet or anything else that will enable microorganism to enter the package becoming
wet or anything else that will enable microorganism to enter the package or
container.
The Shelf Life of Sterilization Depends on the Following Factors:
 Quality of the wrapper or container.
 Number of times a package is handled before use.
 Number of people who have handled the package.
 Whether the package is stored on open or closed shelves.
 Condition of storage area (e.g., humidity and cleanliness).
 Frequent or improper handling or storage.
 Use of plastic dust cover and method of sealing
Note: Maximum shelf life is 1 month period even under safe environmental
conditions
6.7. SUMMARY
 Applying Spaulding’s classification of non-critical, semi-critical, or critical items
determines the method that should be used to process instruments.
 Cleaning is the most important step in instrument processing because it makes
instruments safer for additional processing prevents bioburden
 HLD should be carried out for instruments and devices that come in contact with
mucous membranes and non-intact skin by chemical, steaming or boiling.
 Sterilization is a process in which the destruction of all micro-organisms including
bacterial endospores takes place.

88
 All sterile items should be stored appropriately to protect them from dust, dirt,
moisture, animals, and insects.
 An item remains sterile until something causes the package or container to
become contaminated

89
CHAPTER 7: LINEN MANAGEMENT

Duration: 45 Min

Chapter Description:

This chapter overview plan on standard laundry services, use proper personal
protective equipment in laundry services, demonstrate how used textiles collected,
transported sorted, washed, dried, stored, and distributed hygienically.

Chapter Objective

By the end of this chapter the participants will be able to analyze the proper linen
management in healthcare facility.

Enabling Objectives

By the end of this module, participants will be able to:

 Discuss the standard laundry service in healthcare facility

 Demonstrate the key steps in processing used linen
 Discuss patients and workers safety related to laundry service

Chapter outline

7.1. Standard laundry service

7.2. Key steps in processing linen
7.3. Summary

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 7.1. STANDARD LAUNDRY SERVICE

Activity 7.1: Think-Pair-Share

Instruction:
Please discuss on the following question with the person sitting
next to you and reflect your points to the plenary group orally?
 Explain standard laundry service
 What are key components of standard laundry service
process, premises, provider and product (4P)
 Discuss your healthcare facility experience on linen
management?
 Why is healthcare linen management so important?
Time Allowed: 5 min
In clinical areas, the management of linen has a dual purpose, namely, to keep clean
linen clean until it reaches the patient and to prevent dirty linen from contaminating
patients, staff, the environment, or other linen.
Linen management at healthcare facility is important because it can be a source of
pathogen transmission and it is key to patient safety that all potentially contaminated
laundry be handled in a way that preventions cross-transmission.
General principles to prevent infection in laundry service
 The receiving area of contaminated linen has bigger space compared with clean
areas of laundry (accordance with Ministry of Health)
 All personnel involved in collection, transport, sorting, and washing of used linens
should be adequately trained, should wear appropriate protective clothing (utility
glove, plastic or rubber apron, protective eyewear and closed shoes), and should
have access to hand-washing facilities.
 Dirty linen should be carefully removed with a minimum of agitation in order to
minimize dispersion of the microorganisms into the air. Linen should then be
placed in strong and appropriate bags or into a container at the bedside. Never
place linen on chairs or on other surfaces.
 After removal of linen, soiled linen must be handled with care at all times. It
should be placed into fluid resistant bags at the point of generation as soon as
possible. Dirty linen bags should not exceed the weight of 20 kgs and should be
91
 securely tied or otherwise closed to prevent leakage. Rinsing soiled laundry at
the point of generation should not be done.
 Assume all used linen is contaminated. No need for color coding.
 Laundry bags: Single bags of sufficient tensile strength are adequate for
containing laundry; leak-proof containment is needed as the laundry maybe wet
and can soak through a cloth bag.
 Transport of soiled linen: Soiled linen in bags or containers should not be
transported manually to the laundry processing area. If available, carts or
containers with lids should be used for this task.
 Unnecessary handling of linen should be avoided.
 Periodic monitoring and routine maintenance of laundry services should be
followed.
Note: Be sure that no miscellaneous items (e.g., needles) are collected with linen. Such
items constitute a special hazard to laundry staff

Table 7.1: Recommended PPE for Processing Textiles for different activities

Activity Type of PPE

Collecting soiled textiles Thick utility or heavy-duty household gloves
Transporting soiled textiles Closed-toe shoes to minimize the risk of accidental
injury from sharp objects or contact with blood or body
fluids
Sorting soiled textiles Thick utility or heavy-duty household gloves
Hand washing soiled textiles Protective eyewear and mask or face shield
Loading washers Fluid-resistant gowns or plastic or rubber aprons
Handling disinfectant cleaning Closed-toe shoes
solutions
Source: OSHA; Sehulster et

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 7.2. KEY STEPS IN PROCESSING USED LINEN

Table 7.2: Group Discussion

Instruction:
 Be in a group of 4-5 people and discuss on the key steps we
should follow while processing used linens and reflect your
answer to the larger group orally?
Time Allowed: 10 min

Processing linen consists of all the steps required to collect, transport and sort soiled
linen as well as to launder (wash, dry and fold or pack), store and distribute it. Safely
processing textile from multiple sources is a complex process. To reduce the risk of
contamination, procedures should be in place to safely handle, process, and store
linens.

Collecting

stor used in separet

Re Distrbuting clean area &transport to
dress service area lunder from service
area

Washing & Ironing sorting

93
  According to my assumption, the above diagram leads us what should be done
at each key step. Ensure mechanism to protect hospital acquired infection at
each segment of process of laundry service.
 Collecting

Steps in the process: -

 Collect used textiles

 Store used laundry until pickup in separate area from clean supplies or patients
 Transport laundry
 Sort in laundry - do not sort on ward
 Place in washer and wash
 Place in drier
 Fold or iron
 Store in separate covered cart and redistribute
Changing linen:

 Change bed linens daily and whenever soiled.

Laundry

Linen, surgical drapes, window curtains, rags, mops, uniforms, gowns, lab coats and
others could be laundered. Sorting in the laundry area is essential. Sorting should be
done separate from clean areas with limited traffic. Work surfaces are at or above the
waist height. The sorting area needs to be equipped with sink, disposable gloves, soap
and towels. The area should be provided by sharps containers.

The sorting system in the laundry:

Sorting of laundry should be done either before or after washing. Large health facilities
usually sort laundry before washing due to existence of high volumes of laundry.

Sorting before washing:

 Remove objects that might be attached before washing.

94
  Sort same textile, same fiber or sort by products needed or by those who
are packed together (gowns, curtains, etc.).

Sorting after washing:

 Benefits of sorting after washing includes fewer microbial exposure by the

workers, however, it shortens the life of fabrics and causes more lint on
surgical materials.

Washing, drying and storing linen:

 Linen is washed in washing machines. It is important not to overload the washing

machine. A temperature 71°C for at least 25 minutes is generally recommended.
A preheating period for at least 5 minutes should be allowed. These
temperatures along with these times are capable of killing most vegetative
bacteria and viruses. However, addition of chemicals assists in adjusting the pH
of the water- plus additional chemicals such as bleach facilitate inactivation of
pathogens that might be present in the linen.
 Addition of bleach: Bleaches provide bactericidal action and disinfect heat labile
materials when added to rinse water.
 An acidic agent (sour; e.g., vinegar) may also be added. These agents are added
to prevent yellowing of fabrics but also produce a rapid shift in pH that aids
bactericidal action.
 Facilities for manual washing of linen may be available and may offer a
temporary alternative where is there is any lack of access to or a problem with
mechanical washing processes.
 Spreading linen to dry in sunlight and open air (if away from any source of
contamination or pollution) may be possible in some situations. In addition to cost

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 reduction this allows exposure to ultraviolet sunrays, which produces natural
disinfection.
 Dryer heat is also effective in ensuring total bacterial kill. Ironing has the same
effect but linen need not be sterilized.
 Store clean linen and supplies in a separate place away from the soiled linens.
Three clean sets of linen per bed should be available.
Mattresses and pillows

 May be a major source of contamination if not properly protected.

 Wet mattresses must be changed.
 Must be covered with an impervious layer (plastic, rubber) so that they can be
cleaned thoroughly between patients.
 Covers must be cleaned with warm water and detergent.
 Never admit new patients onto soiled, stained, or contaminated mattresses
 Rubber covers can be uncomfortable in hot places. It may be possible to cover
the mattress cover with absorbable paper, which should be changed frequently.
Key Notes:

 Do not presort or wash textile at the point of use

 The workers should not carry wet and soiled textile close to their body even
though they are wearing a plastic or rubber apron.
 Presoaking in soap, water and bleach is necessary only for heavily soiled textile
 Ironing especially using a steam iron will destroy pathogens
 Handle stored textile as little as possible Sterilization is the preferred end process
for surgical gowns, textile drapes and wrappers
Periodic Monitoring
 Monitoring/inspection of the laundry unit on weekly basis (cleanness,
functionality, availability of all necessary detergent, PPE, water and all activities
including collection, storage, and recording/information (to assess work
efficiency) of the unit).
 Facility should develop monitoring check-list that includes the above requirement.

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 Include the laundry activity in weekly, monthly, quarterly and yearly plan and
report accordingly.
7.3. SUMMARY

 Health care outbreaks and HAI occur because of contaminated linens and HCWs
can experience injuries and exposures if recommendations are not followed.
 Proper storing, transporting, and distributing hygienically clean linens is important
to avoid any microbial contamination
 Periodic monitoring the laundry service functionality is very important

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CHAPTER 8: ENVIRONMENTAL CLEANING

Duration: 1:00 hrs.

Chapter Description:

This chapter describes importance of environmental in health care setting,

environmental cleaning principles, selection of cleaning and disinfectant products,
preparation of disinfectant and cleaning solution, cleaning methods and risk area
categories in primary health care setting.

Chapter Objective

By the end of this chapter, participants will be able to illustrate proper environmental
cleaning in primary health care setting.

Enabling Objectives

By the end of this module, participants will be able to:

 Discuss the importance of environmental cleaning

 Explain general principles of environmental cleaning in primary health care setting
 Demonstrate preparation of cleaning and disinfectant solutions.
 Describe cleaning methods

Chapter outline

8.1 Importance of environmental cleaning

8.2 Principles of environmental cleaning in primary health care settings
8.3 Preparation of environmental cleaning products
8.4 Cleaning methods
8.5 Area risk categorization and cleaning schedule
8.6 Summary

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 8.1. IMPORTANCE OF ENVIRONMENTAL CLEANING IN HEALTHCARE
FACILITIES

Activity 8.1: Think-Pair-Share

Instruction:
Discuss the benefits of environmental cleaning in healthcare facilities for
patients, staffs and visitors with the person sitting next to you and reflect your
answer to the larger group.
Time Allowed: 5 min
Accumulation of dust, soil and microbial contaminants on environmental surfaces is
both unpleasant and potential source of HAIs. Effective and efficient cleaning methods
and schedules are, therefore, necessary to maintain a clean and healthy environment in
healthcare settings.
The term “environmental cleaning” refers to the general cleaning of environmental
surfaces and to the maintenance of cleanliness in a health care facility. It is the physical
removal of organic materials such as soil and dirt, which removes a large proportion of
microorganisms, followed by complete drying. Environmental cleaning practices in the
healthcare facilities including: the compound, the floors, walls, various type of
equipment, tables and other surfaces.
The purpose of general environmental cleaning is to:
 Reduce the number of microorganisms that may come in contact with patients,
visitors, staff and the community; and
 Provide a clean and pleasant atmosphere for patients and staff.
To achieve the purpose of environmental cleaning, it is important that environmental
cleaning staff should be trained and supervised on a regular basis. As part of their
training, it is important that the environmental cleaning staff:
 Understand the risk of exposure to contaminated items and surfaces when
performing environmental cleaning procedures; and
 Follow recommended policies and guidelines including the use of appropriate
personal protective equipment (PPE).

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Environmental cleaning is a very simple activity which based on the above simple
practical principles but its impact in preventing a range of healthcare associated
infections is very tremendous.

8.2. GENERAL PRINCIPLES OF CLEANING AND DISINFECTION

 Scrubbing (frictional cleaning) is the best way to physically remove dirt, debris
and microorganisms.
 Cleaning is required prior to any disinfection process because dirt, debris and
other materials can decrease the effectiveness of many chemical disinfectants.
 Cleaning products should be selected on the basis of their use, efficacy, safety
and cost.
 Cleaning should always progress from the least soiled areas to the most soiled
areas and from high to low areas so that the dirtiest areas and debris falling on
the floor will be cleaned up last.
 Dry sweeping, mopping and dusting should be avoided to prevent dust, debris
and microorganisms from getting into the air and landing on clean surfaces, as
airborne fungal spores can cause fatal infections in immune- suppressed
patients.
 Instructions for mixing (dilution) should strictly be followed when using
disinfectants. (Too much or too little water may reduce the effectiveness of
disinfectants).
 Cleaning methods and written cleaning schedules should be based on the type of
the surface, the amount and the extent of the soil present and the purpose of the
area.
 Routine cleaning is necessary to maintain the standard of cleanliness. Also,
schedules and procedures should be consistent and posted.

Personal protective equipment for cleaning staff

During cleaning, workers should always wear gloves (preferably heavy utility gloves)
and shoes that cover the toes. If there is a potential for splashing or for splattering (e.g.,

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during the cleaning of toilets), they may need additional protection such as an
impermeable apron, mask, and protective eyewear.

8.3. PREPARATION OF CLEANING AND DISINFECTANT SOLUTION

Environmental cleaning and disinfectant products

There are different kinds of products available for environmental cleaning and
disinfectant, which all have distinct properties and advantages and disadvantages to
their potential use in healthcare facilities.
Cleaning products
Cleaning products include liquid soap, enzymatic cleaners, and detergents. They
remove organic material (e.g., dirt, body fluids) and suspend grease or oil. This is done
by combining the cleaning product with water and using mechanical action (i.e.,
scrubbing and friction).
Ideal Properties For all products used for healthcare environmental cleaning:
 Nontoxic: it should not be irritating to the skin or mucus membranes of the user,
visitors, and patients. Everything being equal, choose products with the lowest
toxicity rating.
 Easy to use: directions for preparation and use should be simple and contain
information about PPE as required.
 Acceptable odor: it should not have offensive odors to users and patients.
 Solubility: it should be easily soluble in water (warm and cold).
 Economical/Low cost: it should be affordable
Disinfectants

Disinfectants are only for disinfecting after cleaning and are not substitutes for cleaning.
Before disinfecting, use a cleaning product to remove all organic material and soil.

Ideal properties of disinfecting products used for healthcare environment disinfection:

 Broad spectrum: it should have a wide antimicrobial range, including those

pathogens that are common causes of HAIs and outbreaks.
 Rapid action: it should be fast acting and have a short contact time.
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  Remains wet: it should keep surfaces wet long enough to meet recommended
contact times with a single application.
 Not affected by environmental factors: it should be active in the presence of trace
quantities of organic matter (e.g., blood) and compatible with cleaning supplies
(e.g., cloths) and products (e.g., detergents) and other chemicals encountered in
use.
 Material compatibility: it should be proven compatible with common healthcare
surfaces and equipment.
 Persistence: it should have residual antimicrobial effect on the treated surface.
 Cleaner: it should have some cleaning properties.
 Nonflammable: it should have flash point of more than 65°C (150°F).
 Stability: it should be stable in concentration and use dilution

8.3.1 PREPARATION OF DISINFECTANT AND CLEANING SOLUTION

Always prepare solutions according to the manufacturer’s instructions. Most cleaning

products work at an optimum dilution—too diluted or too concentrated impacts the
effectiveness of the product and may pose unnecessary risk to staff, patients, visitors,
and the environment.

Personal protective equipment (PPE) should be required for preparation of solutions,

particularly for disinfectants (e.g., sodium hypochlorite).

Provide training and simple instructions (e.g., standard operating procedures (SOPs))
for preparing solutions according to manufacturer’s instructions.

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How to Prepare Chlorine Solution

1. Formula for making a dilute solution from a concentrated solution

 Check concentration (% concentrate) of the chlorine solution.

 Determine total parts of water using the formula below.

Equation 1-1

 Mix 1part concentrated bleach with the total parts water required
Example: Make a dilute solution (0.5%) from 5% concentrated solution

STEP 1: Calculate TP water

STEP 2: Take 1-part concentrated solution and add to 9 parts of water.

Other Environmental Cleaning Supplies

Essential supplies and equipment for environmental cleaning include:

• Surface cleaning supplies: portable containers (e.g., bottles, small buckets) for
storing environmental cleaning products (or solutions) and surface cleaning
cloths.
• Floor cleaning supplies: mops or cleaning squeegee with floor cloths, buckets,
and wet floor/caution signs.

8.4. CLEANING METHODS

Cleaning should start with the least soiled area and extend to the most soiled area and
from high to low surfaces. Common methods of cleaning are briefly described below:

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Cleaning and Disinfecting of High Touch Surfaces and Items
The identification of high-touch surfaces and items in each patient care area is a
necessary prerequisite to the development of cleaning procedures, as these will often
differ by room, ward and facility.

Common high touch surfaces includes door handle (doorknobs), sink handles, switches,
examination tables, bedrails, IV poles, bedside tables, tables where medications and
supplies are prepared, Edges of privacy curtains, screens…..

8.1: Frequently touched surfaces at health facilities

General surface cleaning process:

1. Thoroughly wet (soak) a fresh cleaning cloth in the environmental cleaning

solution.
2. Fold the cleaning cloth in half until it is about the size of your hand.
3. Wipe surfaces using the general strategies as above (e.g., clean to dirty,
high to low, systematic manner), making sure to use mechanical action (for
cleaning steps) and making sure to that the surface is thoroughly wetted to
allow required contact time (for disinfection steps).
4. Regularly rotate and unfold the cleaning cloth to use all of the sides.
5. When all of the sides of the cloth have been used or when it is no longer
saturated with solution, can be reused by cleaning it well or store it for
reprocessing.

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Wet Mopping Method for Floor Cleaning
 Single-Bucket (Basin) Technique
 Only one bucket of cleaning solution is used here.
 The solution, however, needs to be changed when dirty.
 The killing power of the cleaning product decreases with the increased
load of soil and organic material present
 Double-Bucket Technique: -
 Two different buckets are used here
 One containing a cleaning solution and the other containing water for
rinsing.
 The mop is always rinsed and wrung out before it is dipped into the
cleaning solution.
 The double-bucket technique extends the life of the cleaning solution
(fewer changes are required) saving both labor and material costs.
 Triple-Bucket Technique: -
 The third bucket is used for wringing out the mop before rinsing
 This extends the life of the rinse water.
 Flooding Followed by Wet Vacuuming Method
 It is preferable for surgical suits.
 It eliminates mopping and minimizes the spread of micro-organisms.
 It increases the contact time of the disinfectant and the area to be
cleaned.
 Preferably, it should be done at night when the traffic flow of the facility is
low.
 Wet Dusting
 Should be used for cleaning walls, ceilings, doors, windows, furniture, and
other environmental surfaces.
 Clean clothes or mops are made wet with cleaning solution contained in a
basin or bucket. The double-bucket system minimizes the contamination
of the cleaning solution.

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  Dry dusting should be avoided, and dust cloths should not be shaken
either for fear of spreading of micro-organisms.
 Should be performed in a systematic way using a starting point as a
reference to ensure that all surfaces have been reached.
 Check for a stain that may indicate possible leaks when doing high
dusting, (ceiling tiles and walls). Leaking holes or cracks should be
repaired as soon as possible because moist structure provides a reservoir
for fungal growth.
 Dry Vacuuming
 This is recommended only for cleaning carpets

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 8.5. RISK BASED AREA CATEGORIZATION AND CLEANING
SCHEDULE

Activity 8.2: Group Discussion

Instruction:
 Be in three group and discuss on the below questions and reflect
your answer to the larger team?
Discussion questions
1. Categorize your primary health care setting different areas/units
in three risk categories?
2. The recommended cleaning schedule for each listed area?
Time Allowed: 10 min

 In health facilities, Environmental cleaning activities should be scheduled.

 Environmental cleaning schedule should be planned, written and closely
followed.
 Cleaning schedules should be developed according to the need of each area.

Low-Risk Areas: Waiting Rooms, Administrative Areas

These areas are usually not contaminated with blood or body fluids or with
associated infectious microorganisms, so the risk of infection is minimal. Routine
cleaning- the kind of cleaning you would do in your home – is usually good enough
for these areas. In general, clean these areas with a cloth or mop dampened with
detergent and water at least once daily

Intermediate Risk Areas: Patient Wards

These are areas used for the care of patients who are not obviously infectious and
not highly susceptible. These areas are usually cleaned by procedures that control
dust, such as damp mopping with detergent cleaners. Dry sweeping or vacuum
cleaners are not recommended. The use of detergent solution improves the quality
of cleaning. Spills of blood and body fluids are cleaned up with a disinfectant
solution. Patient rooms should be cleaned daily and right after patient is discharged

High Risk Areas

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These are special care areas (e.g., isolation wards, intensive therapy units, operating
room, and dialysis unit). In these areas there is a greater potential pathogen
contamination with infectious materials and more of a concern about potential
infection transmission to both patient and clinic staff. These areas must be cleaned
with care using a cleaning solution and separate cleaning equipment; disinfectant-
detergent solutions are used as needed. Total cleaning is not necessary between
each case for surgical procedures. Total cleaning or terminal cleaning (mopping
floors and scrubbing all surfaces from top to bottom) of the operating room should be

Areas Level of risk Cleaned using

waiting rooms and administrative offices Low risk Soap and water

Toilets and latrines, High-risk (heavy Disinfectants like

Patient room items touched bare handedly contamination) 0.5% Chlorine or
by patients and staff Operating rooms, pre- 1% Phenol
and postoperative recovery areas, dressing
areas and intensive care units (ICUs).
Blood or body fluid spills areas

done at the end of each day.

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Table 8.1: Cleaning different areas with different risk level in health facilities

How to clean spills of blood and other body fluids

When spills of blood, body fluids and other potentially infectious fluids occur:

1. Restrict the activity around the spill until the area has been cleaned and disinfected
and is completely dry.
2. Wear appropriate PPE.
3. Confine the spill and wipe it up immediately with absorbent (paper) towels, cloths, or
absorbent granules (if available) that are spread over the spill to solidify the blood or
body fluid (all should then be disposed as infectious waste).
4. Clean thoroughly, using neutral detergent and warm water solution.
5. Disinfect by using a facility-approved intermediate-level disinfectant, typically 0.5%
chlorine-based disinfectant and allow the disinfectant to remain wet on the surface for
10 minutes and then rinse the area with clean water to remove the disinfectant
residue (if required).
6. Immediately send all reusable supplies and equipment (e.g., cleaning cloths, mops)
for reprocessing (i.e., cleaning and disinfection) after the spill is cleaned up.

How to manage spills of mercury from broken thermometer and blood

pressure equipment:

Activity 8.3: Group Discussion

Instruction:
 Be in four group and discuss on the below questions and reflect
your answer to the larger team?
Discussion Question
1. Imagine that while you are working in health center if you
face the below situation and how do you manage/clean the
area: -
 Small, large blood spills and other body fluids?
 Blood spills with broken glass?
Time Allowed: 8 min
 Put examination gloves on both hands,
 Collect all droplets of mercury with a spoon.

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  Place in a small, closed container for disposal (possibly encapsulation and
burial of the waste away from water resource area) or reuse,
 Wash or clean the area with a chlorine solution,
 Remove used gloves carefully and wash hands properly.

How to clean soiled and contaminated cleaning equipment

STEP 1, Decontaminate cleaning equipment that has been contaminated with blood or body
fluids by soaking it for 10 minutes in a 0.5% Chlorine solution or other locally
approved and available disinfectants.

STEP 2, Wash cleaning buckets, cloths, brushes, mops and the like with detergent and
water daily or right away if visibly dirty.

STEP 3, Rinse them in clean water.

STEP 4, Dry them completely before reuse. (Wet clothes and mop heads are heavily
contaminated with microorganisms).

8.7 SUMMARY

 Environmental cleaning practices in the healthcare facilities including: the

compound, the floors, walls, various type of equipment, tables and other
surfaces
 Dust, soil and microbial contaminants on environmental surfaces are
potential source of HAIs.
 Effective and efficient cleaning methods and schedules are necessary to
maintain a clean and healthy environment in healthcare settings
 Cleaning should start with the least soiled area and extend to the most soiled
areaand from high to low surfaces.
 It is important that Environmental cleaning staff be trained to perform their
assigned tasks and are supervised on a regular basis.

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CHAPTER 9: HEALTH CARE WASTE MANAGEMENT

Duration: 1:15 hrs.

Chapter Description
This chapter describes the overall health care waste management, which includes
generation, collection, transport, storage, and disposal through which they must be
handled properly because they may carry microorganisms that have the potential to
infect individuals who come in contact with them that effective waste management is
critical to infection prevention and control in the health Centers.
Chapter Objective
By the end of this chapter the participants will be able to apply appropriate waste
management.
Enabling Objectives
By the end of this module, participants will be able to:
 Define healthcare waste
 Distinguish different types of health care waste
 Discover risks related to healthcare waste
 Demonstrate how health care waste are segregated and disposed in a heath
care facility
Chapter outline
9.1. Source and Types of healthcare waste
9.2. Risk associated with healthcare waste
9.3. Management of Healthcare waste
9.4. Summary

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 9.1. SOURCES AND TYPES OF HEALTHCARE WASTE

Activity 9.1: Group discussion

Instruction:
 Form 3 groups
 Discuss the following questions in your group and report
the work in the plenary (share group response to the larger
groups using flipchart)
Discussion Question:
1. Define healthcare waste =G1
1. What are the source of health care waste = G2
2. What are the Categories of waste generated by the
health care facilities =G3
Time Allowed: 10 min for reading and discussion 5 min for
presentation
Overview of healthcare waste
Health-care waste is a by-product of health care that can be classified by type or
category waste. Potential risk and non-risk wastes. It includes all the waste
generated by healthcare establishments, research facilities and laboratories.
The types and amount of health care waste generated in a health care facility
depend upon the size of the facility as well as the range of services provided. The
larger the facility (e.g., university hospital, regional hospital) and the more services
provided (e.g., tertiary health care facility with a trauma center, cancer treatment
department), the more waste is produced, and the greater variety of waste
generated. [See Table 9.1: Categories of Waste Generated by Health Care
Facilities], as it provides examples of health care waste from different sources in
health care facilities.

Table 9.1: Categories of Waste Generated by Health Care Facilities

Non-Hazardous Descriptions and Examples
Health Care Waste
General waste Waste that does not pose any biological, chemical, radioactive, or physical hazard (e.g.,
paper boxes, newspapers and magazines, polyethylene bottles, polyester bags, wood,
other papers, metals [e.g., aluminum cans and containers], high-density polyethylene
[e.g., milk containers, saline bottles], glass, and construction/demolition materials).
Hazardous Health Care Waste
Sharps waste Used or unused sharps (e.g., hypodermic, intravenous, or other needles, auto- disable
syringes, syringes with attached needles, infusion sets, scalpels, pipettes, knives,
blades, and broken glass).
Infectious waste Waste that is potentially contaminated with blood, body fluids, waste or pathogenic
organisms, including, but not limited to, laboratory cultures, microbiological stocks,
excreta, and items soiled with blood or body fluids.
Pathological Waste Waste that contains human tissues or fluids, organs, body parts, fetuses, and unused
waste blood products.

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 Pharmaceutical Pharmaceuticals wastes that are expired or no longer needed and items contaminated
waste by or waste containing pharmaceuticals.
Cytotoxic waste Cytotoxic waste contains by-products of drugs that kill dividing cells, which are waste
used for treatment of certain cancers. It also includes waste materials that can damage
human genes (e.g., DNA) and may cause cancers or congenital deformities among
babies. This waste can include sharps, PPE, and body fluid exposed to the drugs
Chemical waste Waste containing chemical substances (e.g., laboratory reagents, film developer);
disinfectants that are expired or no longer needed; solvents; and waste with a high
content of heavy metals (e.g., batteries, broken thermometers, and blood pressure
gauges).
Radioactive waste Waste containing radioactive substances (e.g., unused liquids from radiotherapy or
laboratory research; contaminated glassware, packages, or absorbent paper; urine and
excreta from patients treated or tested with unsealed radionuclides; and sealed
sources—containers in which radioactive substances are stored and sealed).
Adapted from: World Health Organization (WHO). 2013. Safe Management of Wastes from HealthCare Activities, 2nd ed. page
4. WHO: Geneva, Switzerland. http://apps.who.int/iris/bitstream/10665/85349/1/9789241548564_eng.pdf?ua=1.

9.2. RISK ASSOCIATED WITH HEALTHCARE WASTE

Activity 9.2: individual Reflection

Instruction:
 Think about the following questions by yourself and note
down your thought in your note book and share the work
in the plenary.
Discussion Question:
1. What type of risk do you anticipate if you contact with
healthcare waste?

Time Allowed: 5 min

Anyone who comes into contact with waste, both in the community and within the
facility (Health Workforce, patients, visitors) may be at risk.
Risks from health care waste include
 Exposure to pathogenic organisms, harmful chemicals, toxins, or
radioactive substances
 Injury from sharp items
 Exposed to waste through a skin puncture, broken skin, splashes into the
mouth or eyes, inhalation, or ingestion.
 Infectious conditions potentially transmitted from health care waste include
o Gastrointestinal conditions (i.e., Diarrhea and Vomiting),
o Respiratory conditions,
o Skin and eye infections,
o Meningitis,
o Blood borne virus infections (e.g., HIV, Hepatitis B and C), and
o Hemorrhagic fever including Ebola virus disease.
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 9.3. MANAGEMENT OF HEALTHCARE WASTE

Activity 9.3: individual Reflection

Instruction:
 Think about the following questions by yourself and note
down your thought in your note book and share the work
in the plenary.
Discussion Question:
1. What are the guiding principles of healthcare waste
management?
2. What are the potential strategies to reduce the volume
of healthcare waste?
Time Allowed: 5 min

Waste management includes all activities, administrative and operational (including

transportation activities), involved in the handling of waste: generation, collection,
transport, storage, and disposal of waste.

The following are the guiding principles of HCWM:

Reduction of healthcare waste

The preferred strategies for reducing health care waste are to minimize waste
generation by preventing waste production, reducing waste production, reusing, and
recycling waste, and recovering useful substances from waste. The least preferable
strategy is treating and disposing of health care waste.

The ability of the health care facility to safely dispose of the product after it is finished
should be one of the considerations during product selection.

Segregation of waste at point of generation

While general waste is the least expensive and easiest to dispose of, infectious and
hazardous waste, which makes up 15% of waste, is more expensive and riskier to
handle. When general waste is mixed with infectious or hazardous waste, the cross‐
contamination is introduced, and all the resulting waste must be treated as infectious
and hazardous.

 Mixed waste occurs when wastes are not properly separated at the point of
generation or are mixed during any part of the waste management process.

114
  Segregation at the point of waste generation will reduce the amount of waste
that the facility must treat as infectious or hazardous and is a key strategy for
improving waste management at health care facilities.

Note: Approximately 75–90% of the general waste produced by health care facilities
is non-contaminated and poses no risk of infection for those who handle it. Similar in
nature to municipal waste, all or most general waste can be discarded in dumps or
landfills or burned in incinerators. (WHO 2014).

Activity 9.4: demonstration on Guided Practice of waste segregation and

disposal
Instruction
 Read and follow the instructions from your trainer
 Use colorful cards (6 for bins, 9 for type of wastes)
 Demonstrate how to segregate wastes
 Take color coded cards/waste type by your own
 Drop the type of waste you given beneath the
posted card with correct color of bin liner based
on the color-coding/categories for waste
segregation.
 Check your cards dropped appropriately or not
with plenary
 Recommend for their final disposal
 Summarize the topic
Time Allowed: 20 min

Use the following guidelines when disposing of infectious and general waste at the
point of generation in all types of health care facilities

 The HCW who generates the waste should segregate it where it is generated
(e.g., before leaving a patient’s room, examination room, operating theater or
laboratory).
 The waste should be separated into the local or WHO categories (based on
its potential hazard and final disposal method) [see Table 9.2 in this chapter].
 Separating wastes by hand after generation puts HCWs at risk and should not
be allowed.
 Deposit infectious waste in a labeled or color-coded, leak-proof, puncture-
resistant container.
 Use leak-proof (plastic or galvanized metal) containers with tight-fitting covers
for contaminated and hazardous wastes to protect patients and HCWs.
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  Where available and feasible, use sturdy plastic bags/bin liners inside of the
waste collection containers to assist with waste collection and transport.
o DO NOT re-use plastic bags or bin liners.
 Use puncture-resistant sharps containers for all disposable sharps (e.g.,
sharps that will not be reused).

Note: The waste containers and sharp containers should be placed at the point of use
so that HCWs do not have to carry waste items.

o There must be separate bins for at least three different kinds of waste:
general, infectious, and sharps.

Methods to encourage waste segregation include:

 Employ a ―Three-Bin System to segregate waste into separate bins for

general/ non- hazardous wastes, infectious waste, and sharps
 Use standardized, colored plastic bags (if available) or colored waste
containers or standardized, clearly labeled containers to alert HCWs to the
contents of the containers.
 Utilize tools such as a kidney dish or bowl to separate waste and transport it
safely from the point of waste generation to waste containers when waste
containers and sharps containers cannot be placed close to the point of waste
generation.
 Use workplace reminders (posters, signs) to remind staff how to segregate
waste.

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Note: It is important to train all HCWs, including clinicians and cleaning staff, and
patients to keep infectious and non-infectious waste separate.

Table 9.2: WHO recommended segregation arrangement?

Type of waste Color of Container and Markings Type of Container
Highly infectious Yellow, marked ―highly infectious‖ Strong, leak-proof plastic
waste with biohazard symbol bag or container capable of
being autoclaved
Other infectious Yellow with biohazard symbol Leak-proof plastic bag or
waste, (includes all container
pathological waste) Leak-proof plastic bag or
container
Sharps Yellow, marked ―SHARPS‖ with Puncture-proof container
biohazard symbol
Chemical and Brown, labeled with appropriate Plastic bag or rigid
pharmaceutical hazard symbol container
waste
Chemical and Brown, labeled with appropriate Plastic bag or rigid
pharmaceutical hazard symbol container
waste
General health care Black Plastic bag or container
waste
Source: World Health Organization (WHO). 2014. Safe Management of Wastes from Health- Care Activities, 2nd ed., page 79.
WHO: Geneva, Switzerland. http://apps.who.int/iris/bitstream/10665/85349/1/9789241548564_eng.pdf?ua=1.

After segregation in patient care areas, separation during collection, transport,

storage of waste must be maintained to obtain any benefit. All HCWs, including
cleaners, porters, and those collecting, transporting, storing, and disposing of the
waste, must be educated about the importance of segregation.

Collection and Transportation of Waste in Health Care Facilities

To manage waste in healthcare facilities and ensure timely and safe disposal, waste
collection and transportation systems should be developed using the following
criteria:

 Waste collection time table and routes should be carefully planned and drawn
out taking into consideration the principle of collecting from least to most
infectious waste (e.g., the laboratory would be last on a collection route).
 Collect waste on a regular basis such as daily or sooner if needed according
to the rate it is generated and the size of the waste containers.
o For example, operating theaters (if available), labor and delivery areas,
laboratories, and outpatient clinics may generate more waste at

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 different times than other areas and require more frequent collection
schedules.
Note:
 Never use hands to compress waste into containers.
 Hold plastic bags at the top.
 Keep bags from touching or brushing against the body while lifting or during
transport.

General steps for collection and transport of health care wastes:

STEP 1: Wear heavy-duty or utility gloves and closed-toe shoes when handling and
transporting all waste.
STEP 2: Collect waste containers and transport to the storage area or treatment
area for final disposal.
STEP 3: Clean infectious-waste containers each time they are emptied using
soap/detergent and water, disinfect with a low- to intermediate-level
disinfectant, and allow them to dry before reuse. Clean non-contaminated -
waste containers at least once a week or when visibly soiled.
STEP 4: Remove utility gloves and perform hand hygiene after handling wastes.
STEP 5: Wash and dry gloves
When using plastic bags/bin liners:
 Tie bags securely to provide a barrier between the waste and the HCW.
 Label bags with the date and type of waste in them.
 Do not shake or squeeze bags in an attempt to reduce volume when sealing
them.
 Carry sealed bags at the top (i.e., by their necks) to the transportation
trolley/cart/bin.
 Do not lift or hold bags by the bottoms or sides.
 Carry bags away from the body.
 Ensure that bags are not broken, opened, or dropped.
 Do not throw bags.
When bags/bin liners are not available:
 Use waste containers with lids.
 Clearly identify the containers by appropriate color/labeling, for example,
―pathological waste, ―infectious waste, and ―general municipal waste.
(WHO 2014)

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Note: Waste bags and sharps containers should NOT be filled more than three-
quarters full.
Storage of Waste in Health Care Facilities
Waste storage areas in the health care facility should be kept clean, organized,
protected from pests and the public (children or scavengers), and well-shaded to
reduce heat buildup). The area must have separate store for difference waste
categories and should have good water supply with sink for hand hygiene and
should be regularly cleaned.
Disposal of Health Care Waste
Recommended Waste Disposal Methods
Choosing the best currently available waste disposal method and working towards
safer waste disposal to protect the community and the environment is essential.
Infectious and hazardous waste should be treated prior to final disposal.

Treatment and disposal methods for sharps include:

 Sharps (e.g., hypodermic needles, suture needles, razors, and scalpel blades
require special handling because they are the items most likely to injure the
HCWs who use them as well as people in the community if these items go to
the municipal landfill without proper treatment methods.
o By autoclave, followed by shredding (mechanical), and then disposal in
a landfill or sharps pit
o By incineration (sharp objects may not be completely destroyed by
incineration, but it does make them less likely to be reused or
repurposed and less risky to handle) and disposal in an ash pit
o By shredding (mechanical) and disposal in a sharps pit (there is a risk
of exposure to staff handling non-decontaminated sharps).
 If other treatment options are not available, small quantities of sharps waste
can be encapsulated and disposed of in a landfill.

Disposal of liquid infectious waste

 Liquid infectious waste includes liquid culture media, blood, body fluids, and
human excreta. Products that can be added to liquid waste to solidify it for
safer handling may be available.

Disposal of liquid waste from highly infectious diseases

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  Chlorine solutions are not effective in disinfecting liquids with high organic
content, such as blood and stool. Therefore, in situations such as cholera and
outbreaks of viral hemorrhagic fever, feces and vomit should be mixed with
lime milk (calcium oxide) dry powder in a ratio of 1:2 for a minimum of 6 hours
of contact before disposing. Urine can be mixed with a 1:1 ratio with 2 hours
of minimum contact before disposing. (WHO 2014)

Disposal of pathological waste

 Pathological waste consists of tissues, organs, body parts, placentas, blood,

body fluids, and other waste from surgery and autopsy. It also includes human
fetuses. It is sometimes referred to as anatomical waste. Containers with
pathological waste should be appropriately labeled using recommended
labeling for infectious waste.
 Traditional options for disposal of pathological wastes:
o Burying in cemeteries or special burial sites
o Burning in crematoria or specially designed incinerators
o Placenta pit
Steps for using a placenta pit
 Construct a placenta pit and dispose of placentas in the pit.
 Open the cover of the pit and dispose of placentas and other organic waste
into the pit as soon as possible without adding any disinfection to allow
appropriate biodegradation to kill microorganisms and other cells.
 Keep the opening of the pit covered with a heavy lid or a concrete slab.
o Close the pit once it is filled up to 0.5 meter below the underneath slab.
Keep it closed for 2years.
o The contents of the pit can be safely removed and disposed of in a
sanitary landfill and the pit can be used again.
 If a placenta pit is not available, for example, in areas with high water table,
the option is to incinerate or bury the pathological waste in a burial pit. Never
leave pathological waste out in the open.

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Other Hazardous Wastes

Chemical waste
 Chemical waste includes residues of chemicals in their packaging, outdated
or decomposed chemicals, or chemicals that are no longer required.
 Chemical wastes are generally collected in containers with infectious waste
and can be incinerated at a high temperature, encapsulated, or buried. Return
the chemical waste to the original supplier, if possible.
Note: Different types of chemical waste should never be mixed. Chemical
waste should not be disposed of in a sewer system.
Chemical containers
 For plastic containers that held toxic substances such as glutaraldehyde (e.g.,
Cidex) or formaldehyde, rinse three times (dispose of rinse water as chemical
waste) with water and dispose of by burning, encapsulating, or burying. Do
not reuse these containers for other purposes.
 Wear proper PPE to protect eyes and skin from splashes and rinse glass
containers thoroughly with water. Glass containers may be washed with soap,
rinsed, and reuse.
Pharmaceutical waste
 Small quantities of non-hazardous pharmaceutical (drugs or medicines) waste
are usually incinerated, encapsulated, or safely buried. Examples of non-
hazardous pharmaceutical waste include vitamins, salts and amino acids
(ampoules and fluids), solid or semi-solid tablets, granules, powders, creams,
gels, lotions and suppositories, and aerosols (e.g., sprays and inhalers).
o All controlled substances, cytotoxic/genotoxic drugs, anti-
infective/antibiotic drugs, and disinfectants and antiseptics are
considered hazardous waste (WHO 2014). It should be noted that
temperatures reached in a single-chamber drum or brick incinerator
may be insufficient to totally destroy pharmaceuticals and therefore
they can remain hazardous.
o Water-soluble, relatively mild pharmaceutical mixtures (e.g., vitamin
solutions, cough syrups, intravenous solutions, eye drops) may be
diluted in large amounts of water and then discharged into sanitation
systems.

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  Antibiotics or cytotoxic drugs should not be discharged into municipal sewers
or watercourses.
o Return of expired pharmaceuticals to the donor or manufacturer
Waste with a high content of heavy metals
 Examples of wastes with heavy metal content include batteries that contain
cadmium, thermometers, and blood pressure machines containing mercury.

 To minimize the risk of mercury pollution (potent neurotoxin, especially during

fetal and infant development.), mercury-containing products (e.g.,
thermometers and blood pressure equipment) should be replaced with those
that do not contain mercury.
Note: Do not touch mercury droplets with your hands unless wearing non-
sterile or utility gloves.
 Waste with high content of heavy metals should not be incinerated because of
the toxic metallic vapors released in the air nor should it be buried without
encapsulation (i.e., placed in a closed, tight container) because it may pollute
groundwater.
 Disposal options include:
o Recycling—the best disposal solution, if available.
o Encapsulation, if recycling is not feasible—encapsulated waste may be
disposed of in a landfill.
Non-recyclable aerosol containers
 Pressurized containers should never be burned or incinerated because of the
risk of explosion. Before aerosol containers are buried, any residual pressure
should be released.
The following waste treatment methods are NOT recommended and should be
avoided:
Open piles of waste, because they:
 Are a risk to those who scavenge and unknowingly reuse contaminated items
 Allow persons to accidentally step on sharp items and injure themselves
 Produce foul odors
 Attract insects and animals
 Can scatter in the wind and rain

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Open burning, because:
 It is dangerous.
 Temperatures reached are not adequate to treat health care waste.
 It is unsightly
 The smoke is a pollutant.
Incineration is one method of waste disposal and involves controlled burning of
solid, liquid, or gaseous combustible wastes that result in inorganic, non-combustible
residue.
Types of Wastes That Should Not Be Incinerated
 Plastics at low temperatures
 Large amounts of reactive chemical waste
 Pressurized gas containers (e.g., aerosol cans)
 Silver salts and photographic or radiographic wastes
 Plastics containing polyvinyl chloride (e.g., blood bags, IV tubing, or
disposable syringes)
 Waste with high mercury or cadmium content (e.g., broken thermometers,
used batteries, and lead-lined wooden panels)
 Radioactive materials
 Pharmaceuticals thermally stable in conditions below 1,200°C (2,192°F) (e.g.,
5 fluorouracil) Source: WHO 2014

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 9.4. SUMMARY
Health care waste is a waste from different sources of the health facility service
areas. A health care waste is potentially hazardous and can by generally classified
as either non-hazardous or hazardous waste. The hazardous/infectious waste further
can be classified by its type (table 9.1). Contact to health care waste can cause a
risk of injury and different infections resulting in morbidity and mortality.
Waste minimization to limit the volume of hazardous waste produced and waste
segregation to minimize the proportion of the total waste are key waste management
measures in all settings.
Choosing the best available waste disposal method and working towards safer waste
disposal to protect the community and the environment is essential.
Effective waste management will save resources, reduce costs, and prevent injuries
and exposure to infectious disease.

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CHAPTER 10: FOOD AND WATER SAFETY

Duration: 45 Min

Chapter Description

This chapter describes good hygiene and food safety practices as well as measures
to be taken to prevent food contamination while transportation, preparation, storage
and serving food in the primary health care settings.

Chapter Objective

By the end of this chapter participant will be able to explain principles of food and
water safety and measures.

Enabling Objectives

By the end of this chapter, participants will be able to:

 Elaborate the standards of food safety

 Explain causes of food contamination and actions for prevention
 Elucidate how to make food and water safe in primary health care settings

Chapter outline

10.1. Principles and standards of food safety at PHCS

10.2. Main cause of food contamination
10.3. Measures to prevent food poisonings
10.4. Drinking water quality and safety measures
10.5. Summary

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 10.1. PRINCIPLES AND STANDARDS OF FOOD SAFETY AT HEALTHCARE
FACILITIES
Activity 10.1: Individual reflection

Instruction:
 Share your ideas with your facilitator and trainees on the
following discussion points
Discussion Question
1. Why the safety of food is more critical in health care
facilities?
Time Allowed: 5 minutes

Healthcare Associated diarrhea is a common problem in hospitals (Lynch et al

1997). The main factors associated with this includes; poorly trained food handling
staff, using unsafe practices involving the storage, preparation and handling of raw
meat, chicken, fish and fresh eggs as well as some vegetables and use of unsafe
drinking water.

All activities in the food service department should be monitored regularly to be sure
that safety principles and standards are being followed. These include:

Hygiene of Food Service Staff:

 Hand hygiene (hand washing or the use of waterless, alcohol-based hand

rub at critical times) plays crucial role in preventing healthcare associated
diarrhea
 Should report any gastrointestinal problems or skin lesions especially on
hands
 Food handlers should undergo quarterly medical checkup and health and
hygiene of staff Supervised by a knowledgeable person
 Food handlers with diarrhea should be immediately separated from
handling foods. They should not return to food handling or work with immune
compromised patients or intensive care or transplant patients until all
symptoms are over for 24–48 hours.
 They need to know how to inspect properly, transport, prepare and store
foods they handle;

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  Know how to clean and operate equipment they use such as knives and
dishwashers
 Kitchen staff should have access to PPE (face masks, hair covers, and
plastic aprons at a minimum). Other personal protective equipment should be
supplied as necessary
 Able to plan and conduct management of wastes.

Holding temperatures:

 Food should be hold above 60oC/140oF or below 5 0C/45oF

 Thermometers for food storage should be checked periodically.
 Warm, perishable foods should be cooled before being stored.

Cooking of food

 Food should be cooked thoroughly

 Frozen food items should be thawed before cooking to avoid the presence of
cold spots in the interior.

Cleanliness of kitchen and equipment

 Cleanliness of the kitchen has to be done on daily basis, monitored and

verified. The kitchen should be cleaned at the end of each day.
 Ensure equipment cleaning and disinfection, especially cutting boards used
for preparing raw meat.
 Utensils used to cater food and cups for drinking has to be properly washed/
sanitized using the proper dish washing methods.
 Washing food utensils: Food utensils should be washed with three
compartment washing system. These are washing, cleansing and sanitizing
compartments.

Purchasing, transportation and storage of food:

 Purchase raw food from known vendors that meet local inspection standards
/specification of the HC.
 Purchased raw food has to be transported to the health care facilities with
transportation free from biological and chemical contaminants.
 Storage of raw and cooked food should be separate and with recommended
temperature

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  Based on the type of food to be stored (for example easily perishable and
cereals) and it has to be monitored on daily basis

Educate or assist the admitted patients and care takers:

 Educate about hand washing during critical times (before preparing food,
before eating, after toilet, after contact with contaminated surface, after
wiping/blowing the nose, after handling soiled tissues, before & after giving
care for their patients)

Avoid eating and drinking in workplace:

 Prohibit health care workers consuming or storing food in areas where blood
or other potentially infectious or toxic materials are located or stored, including
refrigerators, cabinets, shelves, and counters.

10.2. MAIN CAUSES OF FOOD CONTAMINATION

Activity 10.2: Individual reflection

Instruction:

 Reflect your ideas with the facilitator and trainees on

the following discussion points.

Discussion Question
1. What are the common types of food contamination in
healthcare facilities and how can we prevent it?
Time Allowed: 5 Minutes

Food can be contaminated by the following three main hazard types:

1. Physical contamination (foreign objects) – metal, wood, glass, plastic,
etc.
2. Chemical contamination – bleach, caustic soda, detergents, pesticides,
etc.
3. Microbiological contamination – bacteria, viruses, moulds and parasites.

Please note that: Food that is contaminated with any of these hazards is
unsafe and unsuitable to eat.

Bacterial food poisoning

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  To survive and multiply, bacteria need; water, food, correct temperatures,
time, most but not all, need oxygen.
 Under these conditions, bacteria will multiply by dividing in two every 10-20
minutes. After 6 hours, 1 bacterium can multiply into 262,144 bacteria, more
than enough to cause food poisoning.
How do bacteria enter a food premises?

 Food handlers (especially their hands).

 Raw foods, such as meat and vegetables.
 Pests and animals.
 Air and dust.
 Dirt and food waste.

Causes of food poisoning

Food at incorrect temperatures
 Under ideal conditions, bacteria multiply rapidly between 5°C and 60°C (the
danger zone for food). Below 5°C, bacteria multiply slower. At freezing
temperatures, bacteria stop multiplying and become dormant. Freezing does
not kill bacteria; most bacteria are killed at temperatures above 60°C.
Cross-contamination
 It occurs when food becomes contaminated with bacteria from another
source.
 Bacteria can be transported by hands, utensils, surfaces, equipment, tea
towels, raw food and pests.
 Common examples of cross contamination include unclean hands; dirty
knives; utensils; equipment and food contact surfaces (e.g chopping boards);
blood dripping from raw foods; storing raw food with cooked foods; storing
food uncovered; and using dirty cleaning cloths and tea towels.
Poor personal hygiene
 Examples of poor personal hygiene include: Dirty hands and clothing,
uncovered cuts and wounds, long dirty fingernails, Excess jewellery on hands
and wrists, Coughing and sneezing over food, Handling food while ill, not
washing hands after going to the toilet.

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Unclean food premises
 Dirty kitchens increase the risk of cross-contamination from pests and
particles of food, grease and dirt.
Poor pest control
 Common pests found in food premises includes: flies, Cockroaches, Rats
and mice. These pests can carry food poisoning bacteria and may also cause
physical contamination of food with their droppings, eggs, fur and dead
bodies.

10.3. ACTIONS FOR PREVENTION OF FOOD POISONING

 Temperature control
o Minimise the time that potentially hazardous foods spend in the danger
zone; always remember to keep cold food cold at 5°C or colder and hot
food hot at 60°C or hotter.
o All food Health facilities are required to obtain and use a probe
thermometer, accurate to +/-1°C to monitor the temperature of
potentially hazardous foods.
 Avoid cross-contamination – to avoid cross-contamination do the following:
o Keep food covered until use,
o Separate raw and cooked, and old and new food at all times,
o Use separate equipment and utensils when preparing raw meats,
o Clean and sanitise all equipment, utensils, and food contact surfaces
and
o Store chemicals separate from food.
o Practice corrects personal hygiene – the following should be
considered:
 Clean hands and clothing,
 Minimise jewellery on hands and wrists,
 Tie-back or cover hair,
 Clean and short fingernails,
 Avoid unnecessary contact with food,
 Cover all cuts and sores with a brightly coloured waterproof
dressing,

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  Do not eat over food or on food surfaces,
 Do not prepare food when you are ill,
 Avoid touching your face and hair,
 Do not cough or sneeze over food,
 Do not taste food with your fingers or “double dip” with a spoon
and
 If wearing gloves, change frequently.
 Proper Hand Washing: When should you wash your hands?
o Before commencing or resuming work,
o After using the toilet,
o After handling rubbish,
o After using a handkerchief or tissue,
o After touching your hair or face,
o Before and after handling raw food,
o Before handling cooked food and
o After any cleaning task.
 Avail Hand washing facilities
o Must be accessible to all food handlers, to be used only for the
washing of hands, provide soap and warm potable water, provide
disposable towels for drying hands, provide a bin for the disposable
towels.
 Cleaning
o Must be continuous and ongoing; thoroughly clean and sanitise all food
surfaces, equipment and utensils with hot water and detergent and
chemicals (sanitisers). Remember that most detergents do not kill
bacteria, but hot water and sanitisers do! Implement a cleaning
schedule to ensure that cleaning is conducted on a regular basis
(including hard reaching places).
 Cleaning and sanitising with/without a dishwasher
o Wear rubber gloves to protect your hands from the hot water and
chemicals.
o Remove food particles by scraping or soaking.

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 o Wash using hot water and detergent – change the water if it becomes
cool or greasy.
o Rinse in hot water with chemical sanitiser or in very hot water (above
80°C - only if sink has heating element and rinsing baskets) and leave
to soak for 30 seconds.
o Either drip-dry or use a clean tea towel to reduce the risk of cross-
contamination.
 Pest Control
o Keep them out – seal the food premises.
o Starve them out – keep food premises clean.
o Throw them out – conduct regular pest inspections or services.
o Don’t give them a home - remove all unnecessary equipment and
items.
o Report all pest sightings or evidence of pest activity to your supervisor.
o Waste management
o Place waste in plastic lined bins.
o Remove all waste from the premises as required.
o Empty and clean waste bins regularly.
o Ensure all external bins are covered.
o Protect external waste bin area from pests and birds.

10.4. DRINKING WATER QUALITY AND SAFETY

Drinking-water should be suitable for human consumption as well as domestic
purposes.

 Contamination and chemical introduction can occur across the water supply
chain, including:
o At the catchment areas and water sources (by human and animal
feces),
o Contamination in the distribution system (through “leaking” pipes,
obsolete infrastructure, and inadequate treatment and storage) and
o Unhygienic handling of stored household water.
o Climate change can also affect the quality of drinking water.

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Method how to make water safe if it is from unsafe source

A. Water boiled for 1 to 5 minutes is considered safe to drink, while water boiled
for 20 minutes is high-level disinfected.
B. Alternatively, water can be disinfected and made safe for drinking by using
sodium hypochlorite.

Water quality surveillance and monitoring

Drinking-water supply quality surveillance refers to “continuous and vigilant public
health assessment and review of the safety and acceptability of drinking-water
supplies” (WHO, 2011). It is a careful watching and protecting of DW from possible
contamination risks.
It includes institutional inspection, sanitary survey, continuous monitoring of physico-
chemical and microbiological parameters (laboratory or spot testing of water samples
collected at different locations, i.e., at source, pipe line, reservoirs and delivery
points) and time, data processing, evaluation followed by remedial action and
preventive measures.
Monitoring the quality of water supply

A. Know the biological quality of the source.

B. Monitoring/inspections of the water quality used by the health care facilities
including the sources, collection, and storage should be done on regular basis
is very important to early detect contaminants.
C. The microbial water quality (Total Coliform and E. coli count based on WHO
guideline value or country water quality standard if available) of the source
should also be monitored on quarterly basis.
D. If it is feasible see also chemical quality.
E. Water containers and tankers should be cleaned and disinfected regularly

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 10.5. SUMMARY

Healthcare facilities are responsible to keep the principles and standards of food
and water safety measures during transportation, preparation, storage, and service
of food at all times to break the chance of contamination and food poisoning.

They need to ensure cleanliness of the kitchen has to be done on daily basis and
utensils for preparation and serving food and cups for drinking must be properly
cleaned.

It is essential to carry out regular medical checkup of food handlers and education
of hospitalized patients and care takers on need of hand washing during critical
times.

The quality of water supply in the health care facility must also be also monitored
regularly in order to early detection of contaminants to ensure water quality.

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 CHAPTER 11: TRAFFIC FLOW AND FACILITY DESIGN

Chapter Description:
This chapter describes the relationship between Infection prevention and Control
(IPC) and the design and flow of activities in primary healthcare settings to minimize
the level of microbial contamination in areas where patient care and instrument
processing take place.
Chapter Objective
By the end of this chapter the participants will be able to design traffic flow and
activity pattern in triage, procedure areas, surgical units, and work areas within a
facility.
Enabling Objectives
 Examine the significance of regulating traffic flow and defining activity patterns
in primary health facilities
 Design traffic flow and activity patterns in triage, procedure rooms, surgical
areas, and other service areas
 Identify the traffic flow requirements for different service areas
Session outline
11.1. Significance of regulating traffic flow and activity patterns
11.2. Traffic flow and activity pattern design
11.3. Traffic flow requirements of different areas.
11.4. Summary

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11.1. SIGNIFICANCE OF TRAFFIC FLOW AND ACTIVITY PATTERN
Activity 11.1: Reflection on Traffic Flow and Activity Pattern
Instruction:
 Think about the below questions by yourself and dot down
your thought in your not book and share the work in the
plenary.
Reflection Question
1. What do you understand/what meaning does it give to you,
when you hear traffic flow and activity pattern within the
healthcare setting?
2. What do you think the importance of regulating traffic flow
and activity pattern in each area or space?
3. Imagine that you are working in health center as Medical
Director and asked to design the traffic flow and activity
pattern of the health center what do you recommend?
Time Allowed: 6 minutes to thinking and jot down
Regulating the flow of visitors, patients and the staff plays a central role in preventing
disease transmission in healthcare facilities. This is so for the number of
microorganisms in a designated area tends to be related to that of the number of
people present and their activity. Microbial contamination is found to be high in
areas such as waiting rooms and places where soiled surgical instruments and
other equipment are initially processed. Microbial contamination is minimized by
reducing the number of people coming to the area and defining the activities
taking place at each place.
These include dirty and clean areas where soiled instruments, equipment’s and
other items are first cleaned and then processed and stored. It is important to direct
activity patterns and traffic flow in the above-mentioned areas to keep contaminated
areas separate from areas where procedures take place. The major areas are:
 Triage - are settings where patient information is collected, and patients are
systematically prioritized for care. It’s the sorting out and classification of
patients to determine priority of need and proper place of treatment.
 Procedure areas - are settings where patients are examined and
procedures (e.g., pelvic examinations, wound care management, blood

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 drawing, immunizations, IUD insertions and removals, and normal childbirth)
are carried out.
 Surgical units - are settings where major and minor operations are
performed. The surgical unit also includes preoperative and recovery rooms
as well as several other areas
 Work areas - are settings where instruments are being processed. These
include dirty and clean areas where soiled instruments, equipment and other
items are first cleaned and either high-level disinfected or sterilized and then
stored.
It is important to direct activity patterns and traffic flow in these areas to keep
contaminated areas separate from areas where procedures take place.
11.2. TRAFFIC FLOW AND ACTIVITY PATTEN DESIGN
Activity 11.2 Group Discussion on traffic flow and activity pattern design
Instruction:
 Be in a group of four participants and
 Discuss the below question in your group and report the
work in the plenary (share group response to the larger
groups using flipchart)
Discussion Question:
1. What is the key facility design and space requirement
considerations that we need to consider during
designing …?
 Group 1: Triage
 Group 2: Procedure areas
 Group 3: Surgical Units
 Group 4: Work areas
Time Allowed: 10 minutes for group discussion and 12 minutes
for presentation (3 minutes per group)
Microbial contamination can be substantial in highly trafficked areas and places
where soiled surgical instruments and other equipment are initially processed. The
amount of traffic and the number of individuals present in a designated area and
their activities contribute to the number of microorganisms present in that area.

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Basic principles of facility design, traffic flow, and work practices that can be applied
to reduce microbial contamination include:
 Designating appropriate traffic flow for patients, health care workers (HCWs),
and equipment to ensure safe separation between contaminated items and
clean/sterile items.
 Developing policies and procedures that establish clear authority,
responsibility, and accountability to ensure that these safe practices are
adopted and practiced.
 Regulating the flow of visitors, patients, and staff using signs (e.g., authorized
personnel only), reminders (e.g., red line on the floor), and physical barriers
(e.g., closed doors).
 Using work practices that prevent contaminated items from contacting clean
items, such as working from dirty to clean. This is especially important if
separate spaces for dirty and clean items are not available.
 Ensuring that all staff understands the policies and procedures, for example,
through new staff orientation and ongoing training, to guarantee safe handling
of clean and soiled items.
 Ensuring appropriate ventilation of Operation Theaters (OTs), procedure
areas, Central Sterile Supply Departments (CSSDs), and instrument
processing areas.
 Using fans in facilities without mechanical ventilation to optimize existing
ventilation. The air should be drawn into the area and should be exhausted
outside using one-way exhaust fans. Where mechanical ventilation or fans are
not available, the only option is to use natural ventilation with open windows
and doors fitted with mosquito nets.
In primary healthcare facilities triages should be designed to foster a system for
assessing all patients at entrance and encourage source control, allowing for early
recognition of infection. Ideally the following should be in place at triage area:
 A functional Hand hygiene stations
 A well-equipped station at the entrance to the facility, supported by trained
staff

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  Traffic flow and work practices within the triage should allow for physical
separation between patients as well as healthcare workers with a
unidirectional flow
In primary healthcare setting where only minor procedures are performed, a
procedure room with a hand washing sink is required for examining clients and
performing procedures.
Regardless of the size of the facility or the complexity of the procedure, it is critical to
ensure that there is no cross-contamination during the handling, transporting,
processing, and storage of instruments. Ideally, the following should be in place:
 Sterile supplies and instruments should not be stored in procedure areas.
 Instrument processing should be done in an area away from the procedure
rooms or operating suites, ideally in a central location such as a CSSD.
 Traffic flow and work practices within the procedure area should allow for
physical separation between clean and dirty processes to prevent cross-
contamination.

Figure 11.1 a and b: Floor Plans for Instrument Cleaning, High-Level

Disinfecting and Sterilizing Areas in primary healthcare facilities
In work areas where instruments are processed a separate room with at least one
sink for cleaning and an area for processing instruments and other items is also
desirable (Figure 11.1b). Ideally, the processing area should include more than one
room (e.g., a dirty room for receiving dirty instruments and a clean room for final
processing and storage). If only a single room is available (Error! Reference source

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ot found.a), soiled equipment should be received and cleaned in an area of the
room distant enough from areas where equipment’s are high-level disinfected or
sterilized and then stored.
As a guide, the space requirements for the types of surgery typically performed at
primary healthcare facilities are roughly the same as that of a busy surgical center or
polyclinic. These include:
 Changing room and scrub area for the clinic staff.
 Preoperative area where clients are examined and evaluated prior to surgery.
 Staff toilets
 Area for surgical hand scrub and putting on PPE
 Operating room
 Recovery area for observation of patients after surgery.
 Processing area for cleaning and sterilizing or high-level disinfecting
instruments and other items.
 Space for storing sterile packs and/or high-level disinfected containers of
instruments and other items.
11.3. TRAFFIC FLOW REQUIRMENTS IN DIFFERNET AREAS
Activity 11.3: Group work on traffic flow requirements in different areas
Instruction:
 Divide participants in to three groups
 Read the topics below and discuss in your group and
report the work in the plenary (share group response to the
larger groups using flipchart) using Session 11.3.
Discussion Question:
1. What are the recommend infection prevention and
control practices in…?
 Group 1: Isolation Room and Procedure area
 Group 2: Surgical Unit
 Group 3: Work area
Time Allowed: 10 minutes for group discussion and 12 minutes
for presentation (4 minutes per group)
The recommended infection prevention and control practices for minimizing microbial
contamination of specific areas in healthcare facilities are briefly described below.

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Isolation room
 Limit traffic to always authorized staff and patients.
 Permit only the patient and staff (performing and assisting)
 If mandated only one family member (attendant) should be allowed at a time
in one room for limited period of time in a day wearing clean attire, head-cover
and other PPE as indicated.
 Patients can wear their own clean clothing.
 Staff should wear attire and personal protective equipment (PPE) according to
procedures performed.
 Family member who reported to have acute Upper Respiratory Tract Infection
(URTI) should not be allowed to enter.
Procedure area
 Limit traffic to authorized staff and patients at all times.
 Permit only the patient and staff (performing and assisting) in the procedure
room (family members should be limited with obstetrical procedures).
 Staff should wear attire and personal protective equipment (PPE) according to
procedures performed.
 Place a clean container filled with clean water mixed with detergent (when
available use enzymatic detergents) for immediately immersing of instruments
and other items once they are no longer needed.
 Have a leak proof and covered waste container for disposal of contaminated
waste items (cotton, gauze, dressings) right after use.
 Have a puncture-resistant container for safe disposal of sharps (e.g., used
suture needles, hypodermic needles and syringes, and disposable scalpel
blades) right after use.
 Have storage space in procedure rooms for clean, high-level disinfected and
sterile supplies (Storage shelves should be enclosed to minimize dust and
debris collecting on stored items).
Surgical unit
The surgical unit is often divided into four designated areas defined by the activities
performed in each area, these are unrestricted area, transition zone, semi
restricted and restricted area. Environmental controls and use of surgical attire
increase as one move from unrestricted to restricted areas. Moreover, staff with

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respiratory or skin infections and/uncovered open sores should not be allowed in the
surgical unit.

Different Areas in Surgical Unit

Post signs in each area to clearly indicate the appropriate environmental control and
surgical attire required.
a. Unrestricted Area Note
This area is the entrance from the main corridor and is isolated from other areas of
the surgical unit. This is the point through which the staff, patients and materials
enter the surgical unit.
b. Transition Zone
This area consists primarily of dressing rooms and lockers. It is where the staff put
on surgical attire that allows them to move from unrestricted to semi-restricted or
restricted areas in the surgical unit. Thus, only authorized staff should enter this
area.
c. Semi-Restricted Area
This is the peripheral support area of the surgical unit and includes preoperative and
recovery rooms; storage space for sterile and high-level disinfected items; and
corridors leading to the restricted area. This is an area where support activities (e.g.
instrument processing and storage) for the operating room are carried out. So,
 Limit traffic to authorized staff and patients every time.
 Have a work area for processing of clean instruments.
 Have storage space for clean, sterile or high-level disinfected supplies with
enclosed shelves to minimize dust and debris collecting on stored items.
Flip flops or sandals should not be worn as they provide no protection from
dropped sharps.
 Have doors limiting access to the restricted area of the surgical unit.
 Staff working in this area should wear surgical attire and a cap.
 Staff should wear clean and closed shoes that will protect their feet from fluids
and dropped items.

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  Restricted Area
This designated area consists of the operating room(s) and scrub sink areas.
Never store instruments and other items in the operating room
 Limit traffic to authorized staff and patients at all times.
 Keep the door closed at all times, except during movement of the staff,
patients, supplies and equipment.
 Scrubbed staff must wear full surgical attire and cover head and facial hair
with a cap and mask.
 Staff should wear clean and closed shoes that will protect their feet from fluids
and dropped items.
 Masks are required when sterile supplies are open and when the scrubbed
staffs are operating.
 Patients entering the surgical unit should wear clean gowns or be covered
with clean linen and have their hair covered.
 Patients do not need to wear masks during transport (unless they seek
airborne precautions).
 Operating Room(s)
 The operating room should be enclosed to minimize dust and eliminate flies;
however, central air conditioning is necessary (If windows are the only
ventilation, provide tight- fitting screens).
 The operating room should be located away from areas of the hospital or
healthcare facility that are heavily staffed with frequent movements of the staff
and patients.
Work Area (Instrument processing area)
 According to the size and type of the healthcare facility, the work area for
processing instruments (e.g., the Central Sterile Supply Department or CSSD)
may be part of the surgical unit; or just connected to it; or an independent
area somewhere away from it.
 This is the area where instruments, surgical gloves and equipment are
processed and where the staff should be specially trained in handling,
processing, and storing instruments, equipment and other clean, sterile or
high-level disinfected items. The CSSD is considered a semi-restricted area;

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 hence all the recommendations for traffic patterns and proper attire described
above should be followed.
Permit only authorized personnel to enter this area.
Note: Develop flow patterns to help ensure that contaminated items never
come in contact with clean, disinfected or sterile items.
The function and equipment requirements for the four areas of a typical CSSD are
summarized below.

Dirty Receiving/Cleanup Area

In this area, soiled items are received, disassembled, washed, rinsed and dried.
Congruently, the Staff in the receiving/cleanup area should wear plastic aprons,
utility gloves and safety goggles or face shields to protect themselves from spills
and splashes. The “dirty” receiving/cleanup area should have:
 Two sinks, if possible (one for cleaning with detergent and one for rinsing),
with a clean water supply; and
 A clean equipment counter for drying.
Clean Work Area
In the clean work area, cleaned items are;
 Inspected for flaws or damage;
 Packaged (if indicated) and either sterilized or high-level disinfected; and
 Sent for storage as packaged or air dried and placed in a sterile or high level
disinfected container.
The clean work area should have
 A large work table;
 Shelves for holding clean and packaged items; and
 A high-pressure steam sterilizer, a dry-heat oven, a steamer or a boiler.
Staff entering the clean work area should wear clean cover gowns
Clean Equipment Storage Area
Store clean equipment in this area.
The staff of CSSD should also enter the department through this area. Equip the
area with:
 Shelves (preferably enclosed) for storing clean equipment, and
 An office or desk for record keeping.

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Sterile or High-Level Disinfected Storage Area
Store sterilized packs and covered sterile or high-level disinfected containers in this
area. This area should be separated from the central sterile supply area:
 Limit access to the storage area and/or store items in closed cabinets or
shelves. (Shelves or cabinets had better be closed as they protect packs and
containers from dust and debris. Open shelves are acceptable only if the area
has limited access and if housekeeping and ventilation practices are
controlled).
 Keep the storage area clean, dry, dust-free and lint-free by following a regular
housekeeping schedule.
 Packs and containers with sterile or high-level disinfected items should be
stored 20 to 25 cm (8 to 10 inches) off the floor, 45 to 50cm (18 to 20 inches)
from the ceiling and 15 to 20cm (6 to 8 inches) from an outside wall.
 Do not use cardboard boxes for storage. (Cardboard boxes shed dust and
debris and may harbor insects).
 Date and rotate the supplies (first in, first out). This process serves as a
reminder that the package is susceptible to contamination and conserves
storage space, but it does not guarantee sterility.
 Packs will remain sterile as long as the integrity of the package is maintained.
 Sterile or high-level disinfected containers remain so up until they are opened.
 Dispense sterile and high-level disinfected articles from this area.
11.4. SUMMARY
Irrespective of the existing layout of the facility, design traffic flow and work practices
in such a way that keeps soiled/contaminated instruments, equipment, and textiles
separate from the clean and sterile instruments, equipment, and textiles, whether in
the OT or in the CSSD. Appropriate traffic flow and work practices prevent accidental
contamination of clean items and reduce the risk of infections to patients, HCWs,
and visitors.

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CHAPTER 12: OCCUPATIONAL HEALTH AND SAFETY IN
HEALTH CARE SETTINGS

Chapter Description
The chapter describes common occupational safeties and occupational health issues
in health centers that need to be identified, prevented, and treated.
Chapter objective
By the end of this chapter participants will be able to discuss assessment and
identification of health workers occupational risks and their mitigation strategies.
Enabling objectives
By the end of this module, participants will be able to:
 List down steps of occupational health risk assessment and prevention.
 Describe the prevention and management of common occupational health
care worker infections.
 List Occupational Health safeties for Specific Groups of Health Care Workers.
 Describe steps of Post Exposure Prophylaxis for HIV and HBV exposures.
 Outline assignment considerations for HCWs with infectious health problems.
 Explain Monitoring of occupational health activities in a health center.

Chapter outline
12.1. Introduction of occupational health safety in health care setting
12.2. Hazard Identification, Risk Assessment and Risk Control
12.3. Occupational health activities for the prevention and management of
infections in HCWs
12.4. Occupational Health Activities for Specific Groups of Health Care Workers
12.5. Post Exposure Prophylaxis for HIV and HBV
12.6. Monitoring of occupational health activities
12.7. Summary

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 12.1. INTRODUCTION OF OCCUPATIONAL HEALTH SAFETY IN
HEALTHCARE SETTING
Activity 12.1: Reading and reflection
What do you think is the burden of occupational health
problems among health workers in Ethiopia?
Time: 5 min discussion.

Over 59 million health workers who are routinely exposed to a variety of health and
safety risks (WHO 2016a). These risks include exposure to infectious agents such as
blood borne pathogens, tuberculosis (TB), viral respiratory infections, vaccine-
preventable diseases, bacterial infections, and gastrointestinal infections, among
others.
Occupational exposures to sharps injuries are an example of the substantial impact
of occupational infections among HCWs. It is estimated that 39% of hepatitis C virus
(HCV), 37% of hepatitis B virus (HBV), and 4.4% of HIV infections among HCWs
worldwide are attributable to occupational exposure due to sharps injuries. This
amounts to an estimate of 16,000 HCV, 66,000 HBV, and 1,000 HIV occupational
infections annually (Prüss-Üstün et al. 2005). It is thought that more than 90% of
these are in limited-resource countries. (IFIC 2003). The practice of infection
prevention among health facilities was found to be poor in Ethiopia. One hospital has
identified that 48% of health care workers did not have gloves during a critical
procedure1.
Actual risk of infectious exposure for HCWs depends somewhat upon the job
description and the setting. Attention to IPC helps protect staff and patients in all
settings. Recent communicable disease outbreaks e.g., severe acute respiratory
syndrome (SARS), COVID19 and Ebola Virus Disease (EVD) have demonstrated
that strategies to protect HCWs from exposure to infectious risks in the workplace
are critically important and that facilities must have the infrastructure in place to be

1
Hailu et al Occupational Health Safety of Health Professionals and Associated Factors During COVID-19
Pandemics at North Showa Zone, Oromia Regional State, Ethiopia. Risk Management and Healthcare Policy
2021:14

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able to adapt to changes in emerging infectious threats. Staffs in healthcare facilities
need to be knowledgeable in IPC to conduct and support sound occupational health
activities to minimize the risk of occupational infection in HCWs and provide a safe
environment for patients and staff.
12.2. HAZARD IDENTIFICATION, RISK ASSESSMENT AND RISK CONTROL
Workplace hazard identification, assessment and control is an on-going process. It
should be undertaken at various times, including:
 If it has not been done before.
 When a hazard has been identified
 When a change to the workplace may introduce or change a hazard. Such as
when changes occur to the work equipment, practices, procedures, or
environment.
 As part of responding to a workplace incident, even where an injury has not
occurred.
 Where new information about a risk becomes available or concerns about a
risk are raised by workers
 At regularly scheduled times appropriate to the workplace.
Risk Assessment: Is defined as the process of assessing the risks associated with
each of the hazards identified so the nature of the risk can be understood. This
includes the nature of the harm that may result from the hazard, the severity of that
harm and the likelihood of this occurring.
Risk Control: Taking actions to eliminate health and safety risks so far as is
reasonably practicable. Where risks cannot be eliminated, then implementation of
control measures is required, to minimize risks so far as is reasonably practicable. A
hierarchy of controls has been developed and is described below to assist in
selection of the most appropriate risk control measure/s.
It is recommended to follow the following five steps in assessing occupational health
risk at health care settings2:
Step 1: Identifying hazards and those at risk
Step 2: Evaluate and prioritize risks
Step 3: Decide on Preventive Action

2
European Commission; Occupational health and safety risks in the health care sector: guide to prevention
and good practice.

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Step 4: Taking action
Step 5: Documentation, Monitoring and Review
Hazard Identification and Identifying those at risk:
This is the process of examining each work area and work task for the purpose of
identifying all the hazards which are “inherent in the job”. Additionally identifying
employees at increased risk (special risk) is critical. Checklists, screening
instruments or other tools and recommendations need to be used for the process.
Evaluating and prioritizing risks
Not all of the identified risks and hazards will have the same importance, nor can
they all be addressed at the same time. It is recommended to prioritize within the
risks and hazards and to agree which ones should be tackled first. Improving the
working conditions should be seen as a continuous improvement process of your
facility, which starts with more urgent risks and hazards and continuously moves on
to other related topics to establish a safe, healthy, and productive work environment.
Deciding on Preventive action
After identifying and prioritizing the risks in your facility, the next step is the
identification of the appropriate measures to eliminate or control the risks. The
following hierarchy should be considered regarding preventive measures: first
technical solutions should be considered, followed by organizational and finally
personal/individual measures.
Taking action
Implement the preventive and protective measures according to the prioritization
plan. Employees have to be informed about the results of the risk assessment and
the planned improvements. The long-term implementation of measures within the
daily work depends greatly on the participation of the workers and their acceptance
of the measures. Specialists in occupational health (focal person and committee)
and safety and quality management should compare and coordinate their activities
and establish an integrated quality, as well as health and safety, management
system.
Documentation, Monitoring and Review:
The risk assessment has to be documented. The documentation should include the
results of the risk analysis, the improvements implemented and the results of the
evaluation of the improvements. What risks were identified for the workers? How
high is the risk of being exposed to those risks? Is the risk negligible, acceptable for
a short time or not acceptable? Which measures have been taken and which ones
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planned for the future? Who is responsible for the implementation of the measures?
By when should the measures have been taken and how will their effectiveness be
evaluated?

This also involves ongoing monitoring of the hazards identified, risks assessed and
risk control processes and reviewing them to make sure they are working effectively.
Hazard identification, risk assessment and control are an on-going process.
Therefore, regularly review the effectiveness of your hazard assessment and control
measures. Make sure that you undertake a hazard and risk assessment when there
is a change to the workplace including when work systems, tools, machinery, or
equipment change. Provide additional supervision when new employees with
reduced skill levels or knowledge are introduced to the workplace. The effectiveness
of control measures can be checked through regular reviews as well as consultation
with workers.
12.3. OCCUPATIONAL HEALTH ACTIVITIES FOR PREVENTING INFECTIONS
AMONG HEALTH CARE WORKERS
The goal of occupational health activities is to protect HCWs—and thereby their
patients—from acquiring an infection or any other hazard while working in a health
care facility. This goal is achieved by implementing proper hazard identification, risk
assessment and control interventions.
Major occupational health activities
2. For newly employed Health Workers
A. Pre-employment evaluation
I. Baseline medical evaluation
II. Assessment of immunization status
III. Training/education of IPC
a) Tailored to job functions
IV. Counselling for occupational exposure infections
a) If needed on issues of prevention, preventions including PEP and risk
to family etc.
3. For all Health care workers
I. Monitoring employee health status
II. Periodic IPC trainings

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 III. Vaccinations- WHO recommended vaccines
4. Facility wide activities
I. Exposure reporting
II. Occupational health program monitoring and review
12.4. OCCUPATIONAL HEALTH AND SAFETY FOR SPECIFIC GROUPS OF
HEALTHCARE WORKERS
Activity 12.2: Group work and discussion
Make a group of 5-6 participants and discuss the question below:
document your discussions and reflect group discussions.
- Are there groups of HCWs at increased risk for
occupational health hazards?
Time: 10 min discussion 5 min for presentation
Certain groups of workers at a health care facility may require special attention
related to occupational health activities. They include pregnant staff, laboratory staff,
emergency response staff, and HCWs infected with HIV, HBV, or HCV.
Pregnant Health Care Workers
Non-immune pregnant HCWs should not care for patients with measles, rubella,
parvovirus 16, and varicella (APIC 2014b). Table 2-7 provides information on
occupational exposure to infection among pregnant HCWs, risks to their babies, and
prevention strategies. The information provided in the table will guide the
occupational health team members in making appropriate decisions. Table 2-7
describes additional pertinent facts to assist with management of relevant
occupational exposures in pregnant HCWs.
Laboratory Staff
HCWs in laboratories may be at increased risk of occupational exposure to the
pathogens with which they work. Laboratory staff should receive specific training on
the risks and how to avoid them (such as working under a bio-containment hood,
using a closed centrifuge, avoiding mouth pipetting) and have access to PPE, as
required, according to the procedures they perform and the pathogens with which
they have contact. In addition to the vaccines routinely recommended for all HCWs,
further vaccinations may be appropriate for HCWs working in a clinical or research
laboratory. National recommendations should be consulted and followed if available.

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Emergency Response Staff
HCWs who respond to emergencies and transport patients should not be overlooked
during occupational health activities. These HCWs are at a high risk of exposure to
blood borne pathogens and should have access to HBV vaccination, have adequate
PPE and thorough instruction on proper PPE use, and be taught to always apply
Standard Precautions for all patients. Furthermore, they may transport patients
before the infection status of the patient is known (e.g., meningococcal meningitis,
influenza, novel respiratory viruses, viral hemorrhagic fever) and thus should be
aware of how to apply Isolation Precautions based on disease syndromes, be
informed about patients who later develop infections of occupational health concern
and be included in exposure follow-up and relevant PEP and work restrictions.
Health Care Workers exposed TO HIV and/or Hepatitis B or C
HIV, HBV and HCV are the primary infectious agents that can be transmitted via
exposure to bodily fluids. In addition to percutaneous injury, contact of mucous
membranes or non-intact skin with blood, fluids containing blood, tissue or other
potentially infectious bodily fluids pose an infectious risk. Potentially infectious body
fluids include semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural
fluid, peritoneal fluid, pericardial fluid, amniotic fluid, pus, etc. In this case, body fluids
like feces, nasal secretions, saliva, sputum, sweat, tears, urine, and vomits are not
considered infectious unless they contain blood.
12.5. POST EXPOSURE PROPHYLAXIS
Occupational exposure to HIV
Each day, thousands of people around the world experience accidental exposure to
blood and other body fluids or tissues while performing their work duties. Hence, it
could be said that healthcare workers are especially vulnerable for infections.
 The risk of acquiring HIV after a mucous membrane exposure to blood is
approximately 0.09 % while the acquisition through a percutaneous exposure
is approximately 0.3% (Cardo DM et al., 1997).
 The risk of acquiring HIV percutaneous is associated with deeper injuries,
visibly bloody devices, and more advanced disease (likely due to a higher
viral load) in the source patient. Hollow bore needle exposures have higher
risk of transmission than that of solid bore needle exposures.

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  The use of post exposure prophylaxis against HIV infection dates back to
the early 1990s for both direct and indirect evidence suggested that the
treatment with ARVs soon after exposure to HIV decreases the risk of
transmission. Animal studies have demonstrated mixed results on the efficacy
of PEP (Black RJ, 1997).
 A retrospective case-control study demonstrated that PEP with AZT for 4
weeks was associated with an 81% reduction in transmission of HIV in
humans. In that study, approximately 70% of patients received AZT within 4
hours of the exposure (Cardo DM, 1997). It is not known how long after an
exposure PEP would turn to be ineffective. However, the data from animal
studies mentioned above, suggest that PEP is effective when initiated within
72 hours of exposure. Taking the evidence mentioned above in to
consideration, most international guidelines recommend PEP drugs to be
started for exposed persons (based on the indication) as early as possible
preferably within 2 hours of exposure but giving PEP drugs after 72 hours of
exposure is not generally advisable. Measures that should be taken on initial
management of exposure exposed persons are put on Annex 16. 1. Full
description and guidance on the management of HIV post exposure
prophylaxis is well document in the national comprehensive HIV care
and treatment guideline-trainees are advised to collaborate with ART
clinics in their facility.
Occupational exposure to Hepatitis B Virus
 HBV infection is a well-recognized occupational risk for HCP (Mast EE et al.,
1993). The risk of HBV infection is primarily related to the degree of contact
with blood in the workplace and also to hepatitis B e antigen (HBeAg) status
of the source person.
 In studies of Health Care Professionals who sustained injuries from needles
contaminated with blood containing HBV, the risk of developing clinical
hepatitis, if the blood was both hepatitis B surface antigen (HBsAg) and
HBeAg-positive was22% to 31%; the risk of developing serologic evidence of
HBV infection was 37% to 62%.
 By comparison, the risk of developing clinical hepatitis from a needle
contaminated with HBsAg-positive, HBeAg-negative blood was 1% to 6%,

153
 while the risk of developing serologic evidence of HBV infection was 23% to
37% (Werner BG et al., 1982).
Table 12.1: Recommended Post-Exposure Prophylaxis for Hepatitis B Virus
Exposure
Vaccination and antibody Treatment
response status of
exposed workers*

Source HBsAg Source HBsAg Source unknown not

positive negative available for testing
Unvaccinated Initiate HB Initiate HB vaccine
vaccine series series

NB: It is recommended that healthcare workers should be vaccinated for HBV

Occupational exposure to Hepatitis C Virus
The risk of HCV transmission from a percutaneous exposure is approximately
1.8%
Post-Exposure Management Steps (HBV, HCV, and HIV)

Activity 12.3: Group work and discussion

Instruction:
 Be in a group of 5-6 people
 Discuss the below question in your group and report the work in the
plenary (share group response to the larger groups using a flipchart)
Discussion Question:
- What are the critical activities in each step of post-exposure
management?
- Do you think these steps are applicable at the health center level?
Time: 10 min for reading and discussion 5 min for presentation

The aim of post-exposure reporting and follow-up is to start PEP as soon as

possible, within 72 hours of exposure, if indicated. The key components of managing
occupational exposure to blood borne pathogens are described below.
STEP 1: Time frame—immediately, within 30 minutes.
 Exposed HCW Provide immediate care to the exposure site:
 Wash the exposed skin and any wound with soap and water.
 mucous membranes with water for 15 minutes.
 DO NOT use any antiseptic or caustic agents such as bleach.
 After washing, immediately report the event to the person in charge of PEP
management.
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  The information reported should include identification of the exposed person,
date and time of exposure, type of fluid and nature of exposure, and details
about the source person as recommended by national PEP guidelines.
STEP 2: Time frame—immediately after reporting. Person responsible: Physician, In-
Charge of PEP management.
 Determine the risk associated with exposure (see Table 12.2) by:
o Type of fluid (e.g., blood, visibly bloody fluid, other potentially infectious
fluid or tissue)
o Type of exposure (e.g., sharps injury, mucous membrane or non-intact
skin exposure, bites resulting in direct contact with infected blood)
(CDC 2001)
o Infectious status of source (presence of HBSAg, HCV antibody, or HIV
antibody)
o Susceptibility of exposed person (hepatitis B vaccine and vaccine
response status, HBV, HCV immune status)
Table 12.2: HIV Exposure Risk and Type of Exposure

 Exposure to a small volume of blood or blood-contaminated fluids

Low-risk from asymptomatic HIV-positive patients
exposure  Following an injury with a solid needle
 Any superficial injury or mucocutaneous exposure
 Exposure to a large volume of blood or potentially infectious fluids
or blood-contaminated fluid
High-risk  Exposure to blood or body fluid from a patient with clinical AIDS or
exposure early seroconversion phase of HIV
 Injury with a hollow needle and/or deep and extensive injuries

STEP 3: Time frame—as soon as possible, preferably within 24 hours. Person

responsible: Clinician, In-Charge of PEP management, HCW.
 Evaluate the exposed HCW:
 Check history of hepatitis B vaccination (currently there is no vaccine for
hepatitis C or HIV).
 Determine immune and infection status of the exposed HCW.
 For HIV, check status and history of previous HIV testing:
 Provide HIV pretest counseling.
 Offer HIV testing if the exposed HCW provides informed consent.

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  Offer HIV post-test counseling per the national counseling and testing
guidelines.
 Refer to HIV care and treatment for those who test positive.
STEP 4: Time frame—as soon as possible, preferably within 24 hours,
simultaneously with Step 3 above. Person responsible: In-Charge of PEP
management, patient’s treating physician.
 Evaluate the exposure source:
 Obtain detailed information on clinical status of the source person.
 Determine vaccination and immune status of the source person:
 Test known source person for HBsAg.3
 Test known source person for anti-HCV antibodies.
 Check known source person for HIV status and history of previous HIV
testing.
 Conduct clinical assessment of known source person for HIV/AIDS.
 Provide HIV pretest counseling.
 Conduct HIV testing if the source person provides informed consent.
 Offer HIV post-test counseling per the national counseling and testing
guidelines.
 Refer to HIV care and treatment for those who test positive.
STEP 5: Time frame—as soon as test results return (if any), must be within 72 hours
from exposure. Person responsible: Physician, In-Charge of PEP management,
HCW.
 Establish eligibility for PEP:
 Refer to Table 12.1 to determine the PEP required for HBV exposure.
 Parenteral or mucous membrane exposure (e.g., sexual exposure, splashes
to the eye, nose, or oral cavity)
 Exposure to blood, blood-stained saliva, breast milk, genital secretions, or
cerebrospinal, amniotic, peritoneal, synovial, pericardial, or pleural fluids
 PEP is not indicated if: The exposed HCW is known to be HIV-positive, the
source person is HIV-negative.
 Exposure is limited to intact skin.

3 Hepatitis B surface antigen (HBsAg)—indicates that the person is infectious (CDC. Hepatitis).

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  Testing the source person and the exposed HCW is helpful but it is not
mandatory to have either test results to initiate HIV PEP. The decision is
sometimes based on an individual’s level of concern as well as background
HIV prevalence.
STEP 6: Prescribe PEP: Time frame—initiate PEP as early as possible but within 72
hours
 Continue ARVs for HIV for 28 days.
 Continue HBV vaccine schedule over 6 months
 Provide adherence counseling and address any drug interactions.
 Follow national guidelines or WHO recommendations for PEP
STEP 7: Time frame—72 hours―6 months after exposure. Person responsible:
Physician, In Charge of PEP Management, HCW.
Follow-up:
 Provide follow-up for adherence and any side effects of ARVs and address
questions that the individual may have.
 Arrange for an HIV test at 3 months after the exposure.
 Arrange for HBV vaccine at 1 and 6 months, if indicated.
 Link HIV care and treatment, including prevention measure for protecting
others, in case the HIV test results are positive.
 Provide additional counseling and other preventive interventions, as needed,
and if test results are negative.
 Document all PEP provided, following facility and national guidelines.
 Monitor PEP provision in the facility.
Health Care Workers Infected with HIV and/or Hepatitis B or C

Activity 12.4: Discussion using Think-Pair-Share

Instruction:
 Pair with your neighbor
 Discuss the below question in your group and report your
work in the plenary
Discussion Question:
- How should HCW with these infections should be
assigned to tasks?
- What will be the concerns while addressing these
issues?
Time: 5 min for reading and discussion 10 min for presentation

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  HCWs infected with HIV and/or HBV or HCV should inform the facility
manager of their status. The facility IPC team should strive to prevent
transmission of infections to patients and at the same time maintain the
livelihood and privacy of the infected staff members.
 These HCWs should not be prohibited from providing patient care if they are
not performing invasive procedures, the infection is well-controlled, they fully
comply with recommended IPC practices, and there are no other factors that
would prevent them from safely carrying out the patient care activities.
 HCWs with these conditions should be closely followed up by a team of
clinicians for periodical clinical monitoring, to assess treatment response and
viral suppression, when appropriate, and to revise recommendations about
duty restrictions accordingly.
 They should avoid performing procedures that may result in increased risk of
contact with large amounts of blood and body fluids. There are no restrictions
for those staff with viral loads less than designated levels. (Henderson et al.
2010)
 The Society of Healthcare Epidemiology of America (SHEA) has classified
patient care and clinical procedures into three different categories based on
the risk of transmission of bloodborne pathogens:
Category I: Procedures with minimum risk of bloodborne virus transmission.
 Clinical procedures and patient care activities that either do not involve
touching patients (e.g., history taking, counseling) or are limited to touching
patients’ intact skin (e.g., performing physical examinations) and mucous
membranes (e.g., performing vaginal examinations, performing some dental
procedures, phlebotomy).
 It also includes minor surgical procedures with very minimal exposure to
patients’ blood and body fluids (e.g., surface stitches, gastrointestinal
endoscopy procedures).
Category II: Procedures for which bloodborne virus transmission is
theoretically possible but unlikely.
 Several surgical procedures are examples of such procedures, including
ophthalmic surgery, dental surgery that requires local anesthesia, minor oral
surgical procedures, endoscopic and arthroscopic procedures, provision of

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 contraceptive methods, minor gynecological procedures, starting of central
lines, and medical male circumcisions.
Category III: Procedures for which there is definite risk of blood borne
transmission of viruses or that have previously been classified as “exposure-
prone.”
 All major surgical procedures that involve a high volume of blood and body
fluids are Category III procedures with definite risk of exposure.
 Examples of Category III procedures are: general surgery; oral surgery with
difficult access for suturing; emergency surgical procedures involving bleeding
and exposure to a high volume of blood; obstetric procedures, including
cesarean section; and orthopedic surgeries.
 Any major surgical procedure that goes beyond 3 hours and requires
changing gloves should not include staff members infected with blood borne
pathogens.
Managing HCWs infected with HIV and/or hepatitis B or C
HCWs infected with blood borne pathogens whose viral load is below the minimum
designated level should follow a six-point plan described below to safely provide
patient care and be productive.
The HCWs should:
 Not have transmitted infection to any patient.
 Obtain advice from a team of clinicians about continuing to care for patients.
 Undergo testing twice a year to demonstrate the maintenance of a viral
burden below designated levels.
 Receive follow-up by a clinician with expertise in managing blood borne
pathogen infections and
 Consent to share their results with the IPC/occupational health team at the
facility.
 Consult closely with experts on the use of optimal IPC procedures:
This may include guidance on double gloving, changing gloves during
procedures, avoiding digital palpation of needle tips, and performing all
procedures under direct view. It also includes promptly withdrawing from a
procedure if they have any injury that bleeds and informing the IPC/occupational
health team about any injuries.

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Adhere strictly to recommended procedures, including the routine use of double
gloving for Category II (such as minor surgery) and Category III (such as major
surgery) procedures and frequent glove changes during procedures, particularly
if performing technical tasks that have a potential to compromise glove integrity.
Agree in writing to comply with recommendations and guidance of the expert
clinicians as well as the facility IPC/occupational health and management team.
Adapted from: Henderson et al. 2010.
12.6. MONITORING PREVENTION OF OCCUPATIONAL EXPOSURES AND
INJURIES
 Health care facilities should evaluate the effectiveness of occupational health
interventions and practices on a routine basis. They should conduct
surveillance to collect, analyze, and disseminate data on risks to HCWs.
 There should be a system to report any occupational exposure and injury,
which should be supported by prompt management and PEP.
 The rates of injuries or exposures among HCWs should be routinely reviewed
and reported back to the staff and strategies and action plans to prevent
future injuries should be developed and updated.
 Surveillance activities can be conducted by the staff organizing occupational
health activities at the facility and/or with the assistance of IPC staff.
12.7. SUMMARY
 In the course of their duties, millions of HCWs around the world are routinely
exposed to a variety of health and safety hazards, including infectious agents.
 Hazard identification and risk assessment is critical for programming IPC in a
health center
 There is a need for risk reduction to patients while being care for by
HIV/HBV/HCV infection.
 HCWs should be provided with occupational health safety during employment
and regularly then after.
 HCW exposed for infectious hazards need to get appropriate intervention
timely as per national standards

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CHAPTER 13: CLIENT EDUCATION ON INFECTION PREVENTION
AND CONTROL (IPC)

Chapter Description:

This chapter describes the importance of educating clients on infection prevention

control for effectiveness of health facility IPC program and to empower health
professionals on the techniques for educating clients in health care facility.

Chapter Objective

By the end of this chapter the participants will be able to design effective client
education program within their healthcare facility using recommended delivery
techniques.

Enabling Objectives

By the end of this chapter the participants will be able to

 Explain the significance of client education on IPC

 Describe components of effective client Education Program
 Identify steps in client’s education on IPC
 Elaborate the models of client Education

Session outline

13.1. Significance of client education on IPC

13.2. Components of Effective client Education Program
13.3. Steps in client’s education on IPC
13.4. Models of Client Education
13.5. Summary

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 13.1. SIGNIFICANCE OF CLINET EDUCATION ON IPC

Activity 13.1: Think in pair and share on Client Education

Instruction:
Think about the below questions in a pair and dot down your
thought in your notebook and share the work in the
plenary.
Discussion Question:
5. What is client education on IPC?
6. What is significance of conducting client education
program on IPC?
Time Allowed: 5 minutes to think about and to dot down and 5
minutes for reflection

Educating and empowering patients and clients to actively participate in their care
help reduce a patient's risk of hospital acquired infections. Creating an open
dialogue, however, can be a challenge in today's healthcare system.
Client education can be defined as the transmission to the patient, family, care giver
and community of the knowledge, skills and attitude which empowers them to
actively participate in the promotion and maintenance of a safe health care facility
environment, particularly for infection prevention.
Four components have been reported as being fundamental to the process of
patient/client empowerment:
1. Patient understands of his/her own role;
2. Patient’s acquisition o f sufficient knowledge on their ability to collaborate
or involve with their healthcare provider;
3. Patient’s knowledge and skills; and
4. The presence of facilitating environment

13.2. COMPONENTS OF EFFECTIVE CLIENT EDUCATION PROGRAM

1. Have clear policies and procedures in place that guide proper
implementation of patient education and empowerment.
2. Have a clear assignment of roles and responsibilities for all steps in
patient education process to qualified individuals within a context of shared
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 responsibility and accountability. The list is inclusive of the patient’s primary
care provider, other physicians, nurses, pharmacists, and other clinicians.
The qualifications of the responsible individuals should be determined by
the healthcare organization within the limits of applicable law and
regulation.
3. Incorporate training on procedures and basic principle for patient
education into the educational curricula, orientation and continuing
professional development activities for healthcare professionals.
4. Develop and include an evaluation component that includes using both
qualitative and quantitative measures to determine not only what works, but
5. under what conditions and within which organizational context the program
works.
2. Background of evidence on effective patient/client education program

Activity 13.2: Individual reflection on Client Education

Instruction:
Think about the below questions by yourself and dot down
your thought in your notebook and share the work in the
plenary.
Discussion Question:

1. If you were assigned to provide a client education on hand

hygiene, what are the basic things/situations that you would
consider before providing your session.
Time Allowed: 5 minutes to think about and to dot down and 5
minutes for reflection

13.3. STEPS IN CLIENT’S EDUCATION ON IPC

Make the patient comfortable

The general standard on patient education also requires that the hospital provide the
patient with education on how to communicate concerns about patient safety issues.
Patients may feel cautious or apprehensive about asking questions because they do
not want to be considered a tough patient but encouraging them to speak up can go

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a long way in preventing infections.
Help the patient become an active participant
Talk to the patient about what he or she can do to optimize care, instead of focusing
solely on what the healthcare provider is going to do for the patient. Patients want to
be involved in their care. They want to be an active participant. And family members
want to be involved in any way they can.
Let patients know what their care should look like as well
Educate the patient on what dressings or catheters need to be changed on a daily
basis and what the process looks like. Showing the patient what to expect and what
techniques help prevent infections empowers him or her to look out for potential risks
when shifts change and someone else begins changing his or her dressings.
Don't forget about high-risk patients
For patients at a higher risk of infection, such as those who are diabetic, taking
immune suppressive drugs, overweight or smokers, healthcare providers need to
discuss how these issues heighten their risk for infection. Patients in the intensive
care unit are also considered high risk. Healthcare providers should encourage ICU
patients to get up and out of bed.
Understand the patient's rights of education
According to EFDA standards, the patient possesses the right to receive information
in a manner that the patient understands. In certain cases, the hospital may need to
provide interpreting or translation services to accommodate the patient's
communication needs. These needs should be determined during the initial learning
needs assessment.
13.4. MODELS OF CLIENT EDUCATION

Reminders and Motivational Messages

Patient empowerment models often include visual reminders for both the HCW and
the patient. These visual reminders usually include small badges or stickers worn by
patients with a message such as “did you wash/sanitize your hands?” If the message
is framed correctly, posters can serve as a visual reminder and encouragement for
both the patient and the HCW to participate in hygiene practices of the hands.
Role modelling
Role modelling in which the HCW’s behavior towards Hand hygiene or other positive
behavior is influenced by either peers or superiors has been observed to influence
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compliance and motivation of the patient to be empowered.
Graphic Illustrations (pictures, pictographs, models)
Research has shown that using pictures including cartoons or pictographs with
verbal explanations and use of models can greatly increase patient’s understanding
and retention of information.

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 13.5. SUMMARY

Educating and empowering patients and clients to actively participate in their care
help reduce a patient's risk of hospital acquired infections. Actionable strategies are
being developed with a strong emphasis on working in partnership with healthcare
authorities, partners, and professionals.
They are the basis of infection control precautions which are to be used as a minimal
expectation in the care of all patients. Supplementary to the practices carried out by
health workers when providing care, all individuals (including patients and visitors)
should comply with infection control practices in health care settings.

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 CHAPTER 14: ANTIMICROBIAL RESISTANCE (AMR) AND
RATIONAL USE OF ANTIBIOTICS

Duration: 1:00 hrs.

Chapter Description
This chapter discusses about what AMR is and how resistant infections occur, which
pathogens cause the biggest problems globally and in the health care setting, the
Activity 13.3: Case Study on client education program
Instructions:
Read the below case study carefully and be in a group of four and
Discuss the below questions in your group and report the work in the
plenary
Case study
You are assigned as an IPC foal person and was assigned to follow up on
the health education program on your facility.
Sr. Sara is a newly trained Nurse at XX Health Center in 2021, she has
been assigned to provide a health education to patients, attendants, and
clients on Tuberculosis focusing on pulmonary TB on a busy Monday
morning at outpatient department. She asks one of the guards to gather the
patients, attendants, and clients in the waiting area, which is very small and
confined, so that she could conduct her health education program.
After the patients, attendants, and clients gathered in the waiting area, one
of the patients seems to be coughing heavily and the audiences near the
patient seem to feel very uncomfortable.
Sr. Sara thanked the audiences and after introducing herself, she started
providing her health education on Tuberculosis by, first introducing what
Tuberculosis is? and the causes of Tuberculosis, then listed the types of
Tuberculosis diseases. She followed it up by addressing the sign and
symptoms of pulmonary TB, then she quickly winded the health education
program by address the medications required to treat the different types of
pulmonary TB cases.
Discussion Question:
Group 1: What did Sr. Sara do correctly and incorrectly in the case
study?
Group 2: What contents should she have added/considered to the
health education while educating patients about pulmonary TB?
Group 3: What feedback or recommendations would you provide Sr.
Sara to improve her health education provision techniques?
Group 4: What tailored IPC precautions should she have used?
Time Allowed: 5 minutes to read the case study, 5 minutes to discuss in
pairs groups and 20 minutes for reflection (5 minutes per group).

167
determinants and causes of AMR, rational use of antibiotics and, most importantly,
the role of IPC in reducing AMR through promotion of the rational use of antibiotics.
Chapter Objective
By the end of this chapter participants will be able to explain the basic concept of
antimicrobial resistance and the rational use of antibiotics to reduce the emergence
and spread of resistant microbes in healthcare facilities
Enabling Objectives
By the end of this chapter the participants will be able to
 Outline the Consequences and magnitude of antibiotic resistance
 Classify the Causes of antibiotic resistance
 Describe Rational use of antibiotics
 Apply Strategies for promotion of rational use of antibiotic
Session outline
14.1. Overview of Antimicrobial Resistance the rational use of antibiotics
14.2. Consequences and magnitude of antibiotic resistance
14.3. Causes of antibiotic resistance
14.4. Rational use of antibiotics
14.5. Promotion of rational use of antibiotics
14.6. Summary

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14.2. OVERVIEW OF ANTIMICROBIAL RESISTANCE AND RATIONAL USE
OF ANTIBIOTICS
Activity 14.1: Antimicrobial resistance and rational use of antibiotics
Instruction:
 Think about the following questions by yourself and dot down
your thought in your notebook and share the work in the
plenary.
Reflection Question
1. How do you describe “Antimicrobial Resistance”?
2. How does this differ from antibiotic resistance?
Time Allowed: 5 minutes to thinking and doting down and 5 minutes
to reflect

Antimicrobial resistance (AMR) is the ability of a microorganism (such as bacteria,

viruses, fungi, and parasites) to resist the effects of an antimicrobial agent using
various resistance mechanisms. Microorganism can transmit AMR characteristics
changes on to their offspring, or in some cases to other bacteria via plasmids.
Rational use of antibiotics ensures that patients receive antimicrobial agent(s) that
are appropriate to their clinical needs, in doses that meet their own individual
requirements, for an adequate period of time, and at the lowest cost to them and
their community.
Antimicrobial resistance (AMR) is a major threat to health and human development,
affecting our ability to treat a range of infections. Treatments for a growing number of
health care-associated infections (HAI) have become less effective in many parts of
the world due to increasing incidence of infections becoming resistant to
antimicrobials. However, a large proportion of these infections can be prevented by
implementing infection prevention and control (IPC) measures.
When an infection caused by a microorganism is no longer treatable by an antibiotic
or antiviral, it has developed antimicrobial resistance (AMR). Anti means
“against,” micro means “small,” and bial refers to life. In general, resistance develops

169
when microorganisms adapt and grow in the presence of the substance used against
them (that is, it resists the effects). AMR is a broad term that applies to:
 Fungi becoming resistant to antifungals;
 Parasites becoming resistant to antiparasitic drugs;
 Bacteria becoming resistant to antibiotics; and
 Viruses becoming resistant to antivirals.
Antibiotic resistance is a specific term that refers to a subset of AMR; it refers to
bacteria becoming resistant to antibiotics. In this chapter, we will focus on antibiotic
resistance. However, many of the recommended activities to reduce antibiotic
resistance can also be used to combat resistance in other microorganisms that
cause fungal, viral and parasitic diseases.
Critical aspects of the broader global response to antimicrobial resistance are efforts
to minimize the emergence and transmission of resistance to drugs used to treat
tuberculosis (TB), HIV, and malaria. The use and misuse of antimicrobials have led
to persistent expansion of antimicrobial resistance, thereby lowering the
effectiveness of some of these drugs (e.g., chloroquine and penicillin). Resistance to
the most commonly available antimicrobials requires the use of more expensive
alternative regimens. Unfortunately, while resistance has created a demand for new
treatment options, there has been a significant drop in the development of new
antimicrobial agents in recent decades. This has compromised the ability of HCWs to
treat infectious diseases and has increased health care costs. It is critical that
necessary measures to respond to the resistance crisis be taken at all levels (by
institutions as well as local and national governments). Measures should include
rational use of antimicrobials through the incorporation of careful antimicrobial
stewardship activities and programs. Ultimately, improving antimicrobial use involves
actions at the national level to guide treatment decisions made by informed HCWs
as well as the awareness and cooperation from patients. While this chapter focuses
on antibiotics, its recommendations can be applied to all antimicrobials. (WHO 2015;
WHO 2016).

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14.3. CONSEQUENCES AND MAGNITUDE OF ANTIBIOTIC RESISTANCE
Activity 14.2: Consequences and magnitude of antibiotic resistance
Instruction:
 Think about the following questions by yourself and dot down
your thought in your notebook and share the work in the
plenary.
Reflection Question
1. What are the most common health care-associated
pathogens in your facility? In your country?
2. What are the consequences of Antibiotic Resistance?
Time Allowed: 5 minutes to thinking and doting down and 5 minutes
to reflect
Antibiotic resistance has a significant impact not only on patients, but also on the
health care facility and system. When bacteria fail to respond to first- or second-line
antibiotics, patient morbidity and mortality increase often are resulting in longer
hospital stays, thereby placing a greater burden on facilities and the health care
system. A study on carbapenems-producing Enterobacteriaceae found that patients
have, on average, 1.79 times higher risk of dying in the ICU than non-colonized
patients (Dautzenberg et al).
Antibiotic resistance also increases health care costs: last line/combination
antibiotics are more expensive, patients require more diagnostic tests, and infections
result in longer hospital stays and more complications to treat. Ultimately, patients
with antibiotic-resistant infections can not only divert resources from regular delivery
of care (i.e., because they require additional supplies, isolation, etc.), but also limit
the number of available beds for other patients due to increased length of stay.
Resistance also means that there is a limited choice of older, “tried and tested”
antibiotics whose efficacy and side effects are well known. Newer antibiotics
have restricted licensing conditions due to limited availability of clinical data on their
efficacy and significant side effects.

171
Antibiotic resistance makes it harder to treat infections were effectively treated a few
decades ago leads to increased medical costs, extended hospital stays, increased
toxicity, adverse effects, and mortality. Antibiotic resistance is present in all parts of
the world and threatens the effective prevention and treatment of a long list of
infections, including multidrug-resistant Mycobacterium tuberculosis, methicillin-
resistant Staphylococcus aureus (MRSA), vancomycin resistant Enterococci (VRE),
and multidrug-resistant Neisseria gonorrhoeae. Mortality among patients infected
with resistant microbes can be about twice that of patients with infections caused by
the same species of bacteria that is sensitive to antibiotics. (NIAID 2011) The
increased use and misuse of antibiotics accelerate the emergence of drug-resistant
strains of microorganisms, which threatens our ability to treat common infectious
diseases (WHO 2016). Infections such as pneumonia, tuberculosis, bloodstream
infections (sepsis), and sexually transmitted infections are becoming more difficult,
and at times impossible, to treat due to antibiotic resistance. Magnitude of Antibiotic
Resistance WHO has classified priority pathogens into three categories for which
new antibiotics should be developed (Table 14.1).
Table 14.1: WHO Priority Pathogens List for Research and Development of New
Antibiotics
Priority 1: Critical Priority 2: High Priority 3: Medium
 Acinetobacter  Enterococcus faecium,  Streptococcus
baumannii, vancomycin resistant pneumoniae, penicillin-
carbapenem-resistant  Staphylococcus aureus, no susceptible
 Pseudomonas methicillin resistant,  Haemophiles
aeruginosa, vancomycin- influenzae, ampicillin
carbapenem resistant intermediate, and resistant
 Enterobacteriaceae, resistant  Shigella spp.,
carbapenem-resistant,  Helicobacter pylori, fluoroquinolone
Extended Spectrum clarithromycin resistant resistant
Beta Lactamase-  Campylobacter spp.,
producing fluoroquinolone resistant
 Salmonellae,
fluoroquinolone-resistant

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  Neisseria gonorrhoeae,
cephalosporin resistant,
fluoroquinolone-resistant
Adapted from: WHO 2017c.

14.4. CAUSES OF ANTIBIOTIC RESISTANCE

Activity 14.3: Causes of antibiotic resistance
Instruction:
 Think about the following questions by yourself and dot down
your thought in your notebook and share the work in the
plenary.
Reflection Question
1. Discuss on the causes Antibiotic Resistance?
Time Allowed: 5 minutes to thinking and doting down and 5 minutes
to reflect
Natural causes
Selective Pressure: Bacteria will die or stop multiplying in the presence of an antibiotic to
which they are susceptible, but if they are resistant to the antibiotic, the bacteria will survive
and continue to grow. Thus, in the presence of an antibiotic, only the resistance microbes
will continue to survive and grow and become the dominant population. This phenomenon is
called ―selective pressure‖ and results in growth of resistant bacteria that will replace the
susceptible bacteria (see Figure 14.1).

Figure 14.1: Development of Antibiotic-Resistant Bacteria.

Source: CDC 2013.

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Societal Contributions
Some antibiotic use practices by HCWs and communities create pressure that allows
resistant organisms to survive and grow. These ―societal pressures‖ can accelerate
the development of microbial resistance. Societal pressures include:
 Inappropriate selection, dosage, and duration of antibiotics prescribed by
clinicians, including issuing prescriptions for viral diseases such as diarrhea
and seasonal influenza.
 Prescribers not complying with prescribing the right drug (only when
indicated), in the right dose, for the right duration, and with the right route of
administration.
 Prescription of broad-spectrum antibiotics rather than a specific antibiotic in
situations where laboratory support is not available to identify specific
causative organisms and their susceptibility to antibiotics.
 Admission to hospitals of critically ill patients who are more susceptible to
infections and therefore are more likely to be on antibiotics. The heavier use
of antibiotics in these patients can worsen the problem by promoting the
selection of antibiotic-resistant microorganisms. The extensive use of
antibiotics and close contacts among sick patients promote the spread of
antibiotic-resistant microorganisms.
 Poor compliance with recommended infection prevention and control (IPC)
practices, such as Standard Precautions and Transmission-Based
Precautions, including respiratory infection prevention and control, contributes
to transmission of resistant microorganisms from one patient to another.
 Antibiotic use in agriculture and the poultry industry exposes animals and
humans to unnecessary and inadequate doses of antibiotics that may lead to
antibiotic resistance in humans.
 In some countries, policies and regulatory frameworks to control misuse of
antibiotics are not available. This results in antibiotics being available without
a prescription from a clinician authorized to prescribe, which increases
inappropriate use of antibiotics. (NIAID 2011; WHO 2015; WHO 2016).

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Commonly Available Antibiotics Table 14.2 Provides examples of the classes and the
individual antibiotics within each class that is commonly available. When bacteria
develop resistance to an antibiotic, resistance to other members within the same
class is possible.
Table 14.2: Commonly Available Classes of Antibiotics
Class Antibiotics
Glycopeptides Vancomycin, teicoplanin, dalbavancin, telavancin, oritavancin
Aminoglycosides Gentamicin, tobramycin, amikacin, streptomycin, neomycin, kanamycin,
paromomycin

Chloramphenicol Chloramphenicol
Ansamycins Rifampicin, geldanamycin
Sulphonamides Sulfadiazine, sulfamethoxazole, sulfasalazine, sulfamethizole
Tetracyclines Tetracycline, oxytetracycline, doxycycline, minocycline
Macrolides Erythromycin, azithromycin, clarithromycin
Oxazolidinones Linezolid, tedizolid
Quinolones Norfloxacin, ciprofloxacin, ofloxacin, levofloxacin, moxifloxacin
Lipopeptides Daptomycin
Lincosamides Clindamycin
β-lactams  Penicillins: penicillin G*
 Penicillin V, propicillin
 Aminopenicillins: amoxicillin, amoxicillin-clavulanate, amipicillin,
ampicillin-sulbactam
 Anti-staphylococcal penicillins: methicillin, oxacillin, dicloxacillin,
flucloxacillin
 Extended-spectrum penicillins: ticarcillin, ticarcillin-calvulanate,
piperacillin, piperacillin-tazobactam
 Cephalosporins:
 First generation: cefazolin, cefadroxil, cephalexin, cephalothin
 Second generation: cefoxitin, cefotetan, cefuroxime
 Third and fourth generation: cefdinir, cefpodoxime, cefotaxime,
ceftazidime, ceftriaxone, cefepime
 Fifth generation: ceftaroline
 Carbapenem: imipenem-cilastatin, ertapenem, doripenem,
meropenem
 Monobactams: aztreonam
Azole Miconazole, ketoconazole, fluconazole, voriconazole, posaconazole,
derivatives isavuconazonium sulfate
Nitroimidazole Metronidazole
Polymixins Colistin, polymixin B
* Antibiotics in bold are on the WHO list of essential medicines.

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Source: Frank and Tacconelli 2012.

14.5. RATIONAL USE OF ANTIBIOTICS

Activity 14.4: Group discussion on the rational use of Antibiotics

Instruction:
 Divide in to three groups
 Discuss the following concepts in your group and report the
work in the plenary (share group response to the larger
groups using flipchart)
Discussion Points:
 Group 1: Rational uses of antibiotics
 Group 2: Irrational uses of antibiotics
 Group 3: Promotion of rational uses of antibiotics
Time Allowed: 5 minutes for group discussion and 9 minutes for
presentation (3 minutes per group)
Medications are used rationally when they are:
 Clinically appropriate for the patient
 Prescribed in doses that meet the patient ‘s requirements
 Taken for the recommended time period
 Taken at the recommended frequency
 The lowest cost option for the patient and the community
Medications are not used rationally in the following circumstances:
 Excessive use of multiple medicines for the same purpose in the same
patient, also known as polypharmacy
 Use of injections when oral formulations would be an equally appropriate or
more preferred route of administration
 Inappropriate use of antibiotics, such as failure to narrow the therapy when
culture results are known, or use of antibiotics to treat viral infections
 Antibiotic selection that differs from what is recommended in standard
treatment guidelines
 Self-medication with antibiotics, such as buying them without a prescription
written by a health care provider

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Determinants of Irrational Use of Antibiotics
There are several determinants of irrational use of antibiotics:
 Lack of provider knowledge, particularly with regard to prescribers who are
insufficiently qualified, supervised, or supported.
 Prescriber habits (prescribing without following the guidelines).
 Non-availability of standard treatment guidelines for prescribing antibiotics
 Non-availability of a specific drug to treat a clinical condition, resulting in
prescribing a less effective or inappropriate alternative.
 Lack of unbiased, independent, government-funded continuing medical
education and supervision that include prescribing.
 Excessive promotion and incentives for prescribing offered by the
pharmaceutical industry.
 Short consultations that do not provide time to explain to the patients that there
is no need for antibiotics and that the condition will improve in a few days
without antibiotics
 Following practices of senior practitioners.
 Perceived patient demand.
 Lack of diagnostic and laboratory support.
 Inappropriate procurement of antibiotics by hospitals and the public sector
supply chain
(Radyowijati and Haak 2003; Rowe et al. 2005; Sketris et al. 2009; WHO
2002).
14.6. PROMOTING RATIONAL USE OF ANTIBIOTICS
 Promoting rational use of antibiotics and other medicines requires concerted
efforts at all levels, starting from the Ministry of Health at the national level
and extending out to the community. WHO recommends the following core
interventions to promote rational use of medicines, including antibiotics, at the
national level:
 A mandated multidisciplinary national body to coordinate the development of
medicine use policies
 Up-to-date standard treatment guidelines for prescribing antibiotics

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  An essential medicines list based on treatments of choice, consistent with
standard treatment guidelines
 Drugs and therapeutics committees to oversee antibiotic use in districts and health
care facilities
 Strengthening of pre-service curricula to include problem-based
pharmacotherapy
 Continuing in-service medical education as a regulatory requirement
 Supervision, audits, and feedback on antibiotic use
 Independent information on medicines
 Avoidance of any financial incentives in order to prevent over-prescribing
 Public education about rational use of medicines
 Appropriate and enforced regulation
 Sufficient government expenditure to ensure availability of medicines and
trained staff
(WHO 2002).
Facility-level recommendations and strategies
Ideally, facility-level activities to promote rational use of antibiotics in large hospitals
are organized by a stewardship technical working group in collaboration with the IPC
technical working group. While IPC staff can contribute significantly to reducing
antimicrobial resistance, other interventions to ensure rational use of antibiotics
should have support of the management team of the health care facility as well as
the quality improvement technical working group or other clinical staff members
interested in promoting rational use of antibiotics. Small successes can be built upon
over time to reach the goal of having an antibiotic stewardship program. (For details,
see the Antibiotic Stewardship Programs section of this chapter. The
recommendations and strategies mentioned in this section should be appropriately
adjusted for smaller health care facilities.)
 Provide continuing education: Education is a fundamental element of any
program designed to improve prescribing behavior. Education can also provide
a foundation of knowledge that will enhance and increase the acceptance of
stewardship strategies. However, education alone, without the inclusion of

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 active interventions, is not very effective in changing antibiotic prescribing
practices and will not produce a prolonged impact. (Barlam et al. 2016)
 Improve use of standard treatment guidelines: Clinical practice guidelines
are being produced with increasing frequency to improve the quality of care
(Box 2-1-1-0-1) Antibiotic stewardship programs should improve clinicians
access to and use of national, evidence-based practice guidelines that integrate
local microbiology and resistance patterns. Guideline’s implementation can be
facilitated through provider education and feedback on antibiotic use and
patient outcomes (Barlam et al. 2016; Ministry of Health, Republic of Ghana
2010).
 Streamline or de-escalate therapy: Antibiotic streamlining, or de-escalation
should be based on culture results and elimination of redundant combination
therapies to effectively target the causative microorganisms. This will ultimately
help to decrease antibiotic exposure and result in cost savings (Barlam et al.
2016; Masterton 2011).
 Changing from parenteral (i.e., IV) to oral antibiotic therapy: A pharmacist
can change antibiotic therapy from parenteral to oral in consultation with the
clinician, based on a patient ‘s ability to take an appropriate oral alternative.
This change should improve patient safety and may decrease the length of
hospital stay.
 Practice good IPC: Good IPC will reduce health care-associated infections and
the resulting use of antibiotics.
Reputable, Evidence-Based Clinical Practice Guidelines on Antimicrobial Use
The Infectious Diseases Society of America:
http://www.idsociety.org/IDSA_Practice_Guidelines/
The European Society of Clinical Microbiology and Infectious Diseases:
https://www.escmid.org/escmid_publications/medical_guidelines/
Johns Hopkins Medicine ‘s Antibiotic Guidelines 2Box 0-3017–2018:
http://www.hopkinsmedicine.org/amp/guidelines/Antibiotic_guidelines.pdf
All guidelines are updated on a yearly basis. Always ensure that you are referring to the
most up-to-date version
Minister of Health, Ethiopia. 2021.Health Sector Transformation Plan (HSTP-II) of Ethiopia.
Ethiopia, Ministry of health. 2021. Antimicrobial Resistance Prevention and Containment
Strategic Plan.

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General public/community-level recommendations and strategies
Steps should be taken at all levels of society to reduce antibiotic resistance. Patients
and the community can be educated in the following actions to increase rational
antibiotic use:
 Prevent the spread of infections through regular hand washing, good food
preparation practices, and respiratory etiquette, avoiding close contact
with sick people, and keeping individual vaccinations up to date.
 Use antibiotics only when prescribed by a licensed health care
professional.
 Take all antibiotics according to the clinician ‘s advice—right dose, right
duration (e.g., number of days), and at the right time of day.
 Do not use antibiotics left over from previous illnesses or from other
people.
 Refrain from sharing antibiotics with others.
 Refrain from pressuring the doctor to prescribe antibiotics when it is
determined that antibiotics are not indicated for the condition (such as for
viral upper-respiratory illness).
There are a variety of ways to inform patients and the community within the facility
(such as patient education and information material, posters in the clinics, direct
reinforcement from HCWs) and through community outreach (TV/radio messages,
involvement of informal leaders).

14.7. SUMMARY
 Antibiotics have been able to save many lives however, the use and
misuse of antibiotics have led to significant antibiotic resistance, thereby
limiting their effectiveness.
 AMR along with irrational antibiotic use, is a major threat to health care.
 Antibiotic resistance affects not only patients, but also the health care
facility and health system in various ways.
 Natural causes and societal contributions are the two most important
causes of antibiotic resistance.

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 Rational antibiotic use must be addressed at all levels: nations, facilities,
individual clinicians, and the general public.
 Promoting rational use of antibiotics and applying good IPC practices is
key.
 Therefore, the adoption of rational antibiotic use must be a global priority
to be addressed at all levels: nations, facilities, individual clinicians, and
the public. Measures at the facility level include activities to promote the
rational use of antibiotics using broad interventions, pharmacy-driven
interventions, and interventions targeted at effective treatment of specific
infections or syndromes. Clinicians can increase the rational use of
antibiotics in their practices by streamlining or de-escalating therapy,
changing from parenteral to oral therapy, following standard treatment
guidelines, and using good IPC practices.

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CHAPTER 15: PREVENTING HEALTH CARE ACQUIRED
INFECTIONS AT SPECIAL SERVICE AREAS IN PRIMARY HEALTH-
CARE SETTING

Duration: 1:30 hrs.

Chapter Description
This chapter discusses safely collect respiratory samples, capture epidemiological
data, conduct surveillance, control and manage the occurrence of the HCAIs in
primary health care settings.
Chapter Objective
 At the end of this chapter the participants will be able to illustrate the
techniques to control HAIs.
Enabling Objectives
At the end of this chapter, the participants will be able to:
 Identify the magnitude of HCAIs at the special health care settings
 Explain the risk factors for maternal and new-born HCAIs in primary health
care settings
 Discuss the transmission cycle of HCAIs in primary health care settings
 Identify the techniques to prevent maternal and newborn HCAIs in special
health care setting
 Discuss the recommended safe work practices to prevent HAIs in special
health care settings
Chapter outlines

15.1. Epidemiology of HAIs at primary health care setting

15.2. Risk factors for HCAIs in maternal and new-born care
15.3. IPC measures for ANC, Labor/ Delivery and Postpartum Care with in primary
health care settings
15.4. Recommended safe work practices for laboratory workers at primary health
care setting
15.5. Summary
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 15.2. THE EPIDEMIOLOGY OF HAIS IN SPECIAL HEALTH CARE SETTINGS
PRIMARY HEALTHCARE SETTING
Activity 15.1: Think-pair and share
Instructions:
 Divide in to three groups
 Discuss the following concepts in your group and report
the work in the plenary (share group response to the
larger groups using flipchart)
Questions:
1. Have you ever been encountered with a maternal or
newborn death due to HAIs in your health facility?
2. Which of the HCAIs are the causes for maternal and
newborn infections/ death?
3. Have you ever been encountered with healthcare worker
developed HCAIs in laboratory settings? What was the
cause you guess?
Time Allowed: 15 minutes
 10 minutes for discussion and 5 minutes for reflection

Definitions
Health Care Acquired Infection (HCAI): is a preventable infection that a patient
can encounter in a healthcare facility while receiving medical care. It occurs after
48h of hospital admission, up to 3 days after discharge, or up to 30 days after the
operation when someone was admitted for reasons other than infection (Sartelli,
Mckimm, Bakar, 2018:2321).
Special health care setting: is a designated area for clinical service delivery which
includes laboratory, maternal, fetal and new born care service points.
Gram-negative bacilli and staphylococcus aureus are among the most common
pathogenic organisms for hospital acquired infections. In addition to these
pathogenic organisms’ streptococcus pneumonia, pseudomonas aeruginosa,
acinetobacter species, methicillin-resistant Staphylococcus Aureus (MRSA) and
pseudomonas aeruginosa are also causes for HCAIs.

Maternal infections can be:

A. symptomatic (postpartum endometriosis) or asymptomatic (e.g., group B

streptococcus [GBS]);

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 B. primary (e.g., bacterial) or secondary (e.g., yeast);
C. chronic (e.g., syphilis) or recurrent (e.g., herpes simplex virus [HSV]);
D. Intrinsic or extrinsic sources (e.g., methicillin-resistant Staphylococcus-
aureus [MRSA]); or
E. Acquired before or during pregnancy or after the birth.

In addition, the mother’s genitourinary tract is normally colonized with various

nonpathogenic, opportunistic and/or infectious organisms, some of which may be
multidrug-resistant organisms (MDROs). In resource limited settings, postpartum
infection remains second only after postpartum hemorrhage as the leading cause
of maternal mortality and is the leading cause of serious maternal complications of
childbirth. The lifetime risk of maternal death in low-income countries, that risk can
be as great as 1 death per 41 pregnancies, with infection being one of the leading
causes of these deaths (WHO 2015b).
Colonization and infection of the mother before or during childbirth are associated
with an estimated 1 million newborn deaths annually (WHO 2015b). Such
Infections accounts for:
 40% to 70% of preterm birth caused by chorioamnionities, mostly caused by E
coli, GBS & Anaerobic bacteria
 36% of newborn deaths, ranking it as one of the three major causes of
newborn deaths worldwide (along with preterm birth and birth asphyxia).
 This number includes sepsis (6%), pneumonia (4%), tetanus (1%), and
diarrhea (1%) (UNICEF, WHO 2015).
Infections in newborns also include congenital syphilis and mother-to-child
transmission of HIV which seriously affects the well-being of the fetus or newborn.
Laboratory acquired infection (LAI) is an infection obtained through laboratory or
laboratory-related activities as a result of work with infectious biological agents. LAI
due to a wide variety of bacteria, viruses, fungi, and parasites have been described.
Although the precise risk of infection after an exposure remains poorly defined,
surveys of laboratory-acquired infections suggest that Brucella species, Shigella
species, Salmonella species, Mycobacterium tuberculosis, and Neisseria

184
meningitides are the most common causes. Infections due to the blood borne
pathogens (hepatitis B virus, hepatitis C virus, and human immunodeficiency virus)
remain the most common reported viral infections, whereas the dimorphic fungi are
responsible for the greatest number of fungal infections that could occur in
laboratories.
Table 15.1: Infection Risk Factors for Mothers and Newborns

Risk Factors that increase the risk of infection in both the

Related with
mother and newborn
Immunosuppression (eg. steroid and HIV)
Uncontrolled diabetes
Nutritional status, either a low or high (<19 or 30) body mass index (BMI)
Smoking (delays wound healing)
Related with mother Vaginal colonization/infections: which cause problems and infections in
the mother (e.g., UTI, and bacterial vaginosis)
Infection of mother: which may cause infection in the newborn (e.g., GBS,
HIV, HSV, syphilis, gonorrhea, chlamydia)
Ruptured membranes (ROM)
Preterm labor,
Prolonged ROM (usually considered longer than 24 hours)
Prolonged labor
Prolonged prenatal hospital stays
Labor-related Multiple vaginal examinations Use of internal monitoring
Trauma to the birth canal (vaginal or perineal lacerations and urethral
tears)
Use of forceps or vacuum extractor for delivery
C-section
Manual placental removal
Lower birth weight
Newborn related Younger gestational age
Co-morbidities (e.g., congenital conditions)
Prolonged stay in Intensive care unit
Presence of invasive medical devices Longer hospital stay
Parenteral nutrition
Care-related Antimicrobial therapy, which may lead to MDRO infection Overcrowding
and understaffing
Ward layout (sinks, bed spacing) Use of fetal scalp electrodes
Contact with colonized/infected family, visitors, or HCWs
Proximity of colonized neonates

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 15.3. RISK FACTORS FOR MOTHER AND NEW-BORN INFECTION

Activity 15.2: Group Discussion on risk factors for mothers and newborn
HCAIs
Instructions:
 Be in a group of four and then
 Discuss the on the following two questions in your group
and report the work in flip chart paper to the plenary (share


group response to the larger groups using flipchart).
Discussion Question:
 What are the risk factors for infection during pregnancy,
labor, and post-natal period?
o Group 1: Risk related to mother,
o Group 2: Risk related to labor,
o Group 3: Risk related to new-born and
o Group 4: Risk related to peri-natal care
Are these risks preventable? How?
Time Allowed: 25 minutes
 10 minutes for group discussion and 15 minutes for
presentation (5 minutes per group)

15.4. PREVENTION OF INFECTION DURING PREGNANCY, LABOR AND

POST-NATAL PERIOD

Activity 15.3: Group work and presentation on Prevention of infection during

pregnancy, labor, and post-natal period
Instructions:
 Divide into three groups
 Discuss on the questions in your group and report the work in
flip chart paper to the plenary (share group response to the
larger groups using flipchart).
 Tell to read notes on infection prevention during pregnancy,
labor, and post-natal period
 Get answer for the below question and write on notebook to
answer during discussion/plenary
Discussion Question:
What is the recommended practice for prevention of infection
during pregnancy, labor, and post-natal period?
186
 Time Allowed: 20 Minutes
 10 minutes for group work
 10 minutes for group presentation:
 5 minutes for summary

READ CRITICALLY THE FOLLOWING NOTES:

PLEASE NOTE THAT:

1. Infection Prevention and Control Interventions during Pregnancy: Prenatal
Care
Prenatal care is essentially caring for two inseparable, interdependent patients:
the mother and the fetus. Undetected or poorly managed maternal infections
can lead to sepsis, death, or disability for the mother and increased likelihood of
early infection for the infant, with possible serious outcomes. (WHO 2015b)
2. IPC Interventions during Birth: Intra-partum Care
Vaginal delivery does not require the aseptic conditions of an operating
theater, it does require the vigilant use of basic IPC practices during labor and
delivery to prevent infections of the mother, infant, and HCWs.

Recommended Practices for Preventing Maternal and Newborn Infection

Timely Use of partograph for prompt diagnosis of prolonged labor
management Minimization of vaginal examinations
of prolonged labor Prevention and prompt diagnosis and treatment of IAI

Clean hands—vigilant hand hygiene and new gloves for vaginal exams
Apply the Six or when handling the baby.
Cleans:
Clean perineum—feces should be wiped away and the perineum
washed prior to the birth (mother can shower or bathe).
(It is a memory
Nothing unclean introduced into vagina—hands, herbs, or other
aid for birth
substances.
attendants)
Clean childbirth surface—a plastic cover is appropriate for home
births; at facilities, the childbirth surface should be cleaned of blood and
body fluids and then wiped with disinfectant cleaning solution after
each use (e.g., hypochlorite solution).

187
 Sterile cord cutting instrument - at home, use a new razor blade.
Note: if sterile instruments are not available, high-level disinfected
items are acceptable (WHO 2016).

Clean cord care—clean, dry cord care is recommended for newborns

born in health care facilities and at home in low newborn mortality
settings.
Daily application of chlorhexidine (4% Conc) on umbilical cord stump for
first week of life is recommended for newborns who are born at home
in settings with high newborn mortality (> 30 newborn deaths/100 live
births).

Source: Partnership for Maternal, Newborn & Child Health 2006; WHO 2013b.

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NOTE-1
Intra-partum practices that reduce of infection of the mother and newborn
 In the presence of meconium-stained amniotic fluid:
 Do not perform tracheal suctioning and avoid suctioning of the mouth and nose
before initiating positive pressure ventilation for infants who do not start breathing
on their own.
 For newborns that do not start breathing on their own by 1 minute after birth, start
positive pressure ventilation with room air with a self-inflating bag and mask.
(WHO, UNICEF, UNFPA 2013)
Within the first hour of life:
 Initiate breastfeeding within 1 hour of birth. Encourage exclusive
breastfeeding.
 Apply antiseptic eye drops or ointment (e.g., Tetracycline ointment) to both
eyes only once, according to national guidelines. DO NOT wash away the eye
ointment.
 Administer vitamin K and recommended immunizations (birth dose of oral
polio vaccine and HBV vaccine), using safe injection practices and sharps
safety.
 Apply relevant IPC precautions (Transmission-Based Precautions and
prophylaxis) to those who are exposed or infected during or before birth (e.g.,
congenital syphilis, rubella, HIV, HBV, and other infectious diseases).

NOTE-2

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 2. Interventions after Delivery: Postpartum Care of the mother
A. Preventing infection in the mother during the postpartum period
Minimizing the risk of HAIs in mothers during the postpartum period includes the
following:
1. Infection prevention education:
2. Limit use of antibiotics after birth to recommended indications:
3. Preventing infection during the postpartum period for mothers who have given
birth vaginally includes the following:
4. In the immediate postpartum period, check to be sure the patient is voiding
within 6 hours and without difficulty.
5. Wear new, sterile gloves when performing perineal care or touching the
episiotomy.
6. Wear new, non-sterile gloves when handling perineal pads, touching lochia
(vaginal discharge), assisting with breastfeeding, etc.
B. Preventing infection during the postpartum period for mothers who have had
a C-section includes the following:
 Surgical wound care
 Post-operative pneumonia prevention
 Care of urinary catheter Remove the catheter as soon as possible (within 24–
48 hours).
 Maintain a closed drainage system and perform regular perineal care.
i. Care of intravascular device
Preventing infection in newborns
ii. Remove at birth
the intravascular device as soon as possible.

190
15.3. Preventing infection in newborns includes the following general
practices relevant to all newborns.
Always comply with Standard Precautions and use Transmission-Based
Precautions when indicated.
 Keep the mother separated from the baby for IPC purposes only when the
mother has multidrug-resistant TB.
 Consult to IPC staff regarding precautions for other infections in the mother.
There are few reasons to keep the mother from the baby.
 Follow patient spacing guidelines in the newborn nursery. See section on
Management if the NICU in this chapter.
 Encourage exclusive breastfeeding. Manage expressing and storage of breast
milk carefully to prevent infection.
 Manage the preparation of formula
 Screen visitors and exclude for signs of infection such as fever, respiratory
infection, diarrhea, and draining skin infection (case by case exceptions can be
made for parents with guidance from IPC staff).
 Perform recommended cord care using Standard Precautions.
Immunization and post-exposure prophylaxis
 Provide non-live vaccines to medically stable infants (including premature
infants) according to the national immunization schedule for age. Infants may
be hospitalized for long periods.
 Do not provide live vaccines such as polio and rotavirus during admission due
to the risk of transmission of vaccine virus to immune-compromised patients.
 Follow adjusted guidelines for HBV vaccine in premature infants.
 Provide post-exposure vaccination prophylaxis and/or immunoglobulin, if
available, for infants exposed from the mother or from other infants (e.g., HBV,
hepatitis A, varicella, and measles).
 Provide post-exposure antibiotic or antiviral prophylaxis, if available, for infants
exposed to pertussis, H. influenzae type b, meningococcal infection,
gonorrhea, syphilis, and infectious TB, and for certain high-risk newborns with
intra-partum exposure to GBS, HSV, or HIV. (WHO 2017a)

191
15.5. SAFE WORK PRACTICES AND IPC PRACTICES IN LABORATORY
AT PRIMARY HEALTH CARE SETTING

Activity 15.4: Group presentation on safe laboratory practice

Instructions:
 Be in group of four
 Raise the following two questions to the participants
 Prepare your answer on flip chart
 Present it to the plenary group
Self-reflection Questions:
What are the safe work practices (related to the IPC
measures) in laboratory?
Time Allowed: 20 minutes

15.4.1. Common routes of exposure that can result in laboratory acquired

Infections
The clinical laboratory is a unique area of the health care facility in which the types of
biological materials handled, along with the practices, procedures, and equipment
used, can place the health care worker (HCW) at risk of occupational infection if
recommended precautions are not taken. Error, accident, or carelessness in the
handling of specimens and pathogens is the cause of most laboratory acquired
infections. Infections such as brucellosis, tuberculosis, typhoid, hepatitis,
streptococcal infections, and others are known to have been acquired from the
laboratory. Common routes of exposure in the laboratory are
 Inhalation.
 Ingestion
 Puncture Wounds
 Contamination of Skin and Mucous Membranes
 Infected Laboratory Animals
Factors contributing to laboratory accidents
 Poor training.
 Lack of concentration.
 Carelessness and negligence.
 Overwork and fatigue-emergency conditions.

192
  Untidy and noisy working environment.

15.4.2. Safe work practices and recommended infection prevention practices

for laboratory workers
Laboratory workers in health center handling blood products, potentially
contaminated body fluids or specimens containing pathogenic microorganisms, need
to be aware of the potential hazards of these infectious agents and materials.
Correspondingly, they need to know how to protect themselves, fellow workers, and
the environment in general.
REQUIREMENTS FOR SAFE LABORATORY PRACTICE INCLUDE:
 Appropriate laboratory design (superstructure, furniture and space).
 Adequate light, water, sewage, ventilation and electrical facilities.
 Waste disposal facilities.
 Appropriate storage of facilities.
 Use of safety devices and bio-safety cabinets.
 Restricted access to laboratories

15.6. SUMMARY

 Infections at special service settings contribute for significant number of HAIs

and high number of maternal and new-born deaths.
 Majority of HAIs among mother, new-born and at laboratory are preventable by
following safe management protocols and applying standard IPC precautions
while providing services.

193
CHAPTER 16: IPC PROGRAM GOVERNANCE AND
MANAGEMENT

Duration: 1:30 hrs.

Chapter Description:
This chapter describes the recommendations of the IPC program governance and
management including the national IPC policy strategic plan in terms of establishing
facility level IPC functions, structures and the roles and responsibilities of those who
will be providing managerial and technical services within the limits and scope of
health center services.
Chapter Objective
By the end of this chapter the participant will be able to design the management
structure for specific IPC function in line with national IPC policies and strategies.
Enabling Objectives
By the end of this chapter the participants will be able to
 Outline national IPC policy and strategic plan pertaining to health centers
 Create an organizational structure for IPC program management
 Highlight the attributes of effective infection prevention and control (IPC)
programs
 Identify the major infection prevention and control program activities
 Design IPC continuous quality improvement model using multimodal
strategies
Chapter outline
16.1. Overview to the national IPC policy and strategic plan
16.2. IPC program governance and Management
16.3. The attributes of effective infection prevention and control (IPC) programs
16.4. Major infection prevention and control program activities
16.5. Using Quality improvement model and multimodal strategies to improve IPC
practices
16.6. Summary

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16.1. OVERVIEW TO THE NATIONAL IPC POLICY AND STRATEGIC PLAN
PERTAINING TO PRIMARY HEALTHCARE FACILITIES
Activity 16.1: Think in pair and share on National IPC Policy and Strategy
Instruction:
 Think about the below questions in pairs and dot down your
thought in your notebook and share the work in the plenary.
Reflection Question:
1. How many of you know the Ethiopia has National IPC policy
and strategy?
2. How is the IPC program structure/organized in your facility?
3. How would you describe the implementation in your facility or
beyond?
Time Allowed: 5 minutes to discuss and 5 Minutes to reflection
The threats posed by epidemics, pandemics and antimicrobial resistance (AMR) have
become increasingly evident as ongoing universal challenges and they are now
recognized as a top priority for action on the global health agenda. Effective IPC
Program at all levels is the cornerstone of such action.
The organization of IPC programs must have clearly defined objectives based on the
facility context according to risk assessment and functions that align with and
contribute to the prevention of HAI and the spread of AMR in health care.
Developing an IPC policy and strategy provides a framework to develop and
implement IPC guidelines and standard operating procedures (SOPs) in order to
improve the quality of service in healthcare facilities. Ethiopia has launched National
Infection Prevention and Control policy, strategy, and strategy roadmap in September
2021 which is designed based on WHO eight core components.
The rational for developing the national IPC document was to establish the foundations
for IPC programs at the national, regional, and healthcare facility levels and across
both public and private health sectors.
The policy focus areas have been identified and adopted from the WHO IPC core
components that are known to be evidence based and are recommended for use, this
includes:
195
 1. IPC Program Management and Institutional Coordination Structure
2. National Infection Prevention and Control Standards and Guidelines
3. IPC education, training, and quality improvement
4. HAIs’ surveillance
5. Multimodal strategies and policy implementation
6. Workload, staffing & bed occupancy
7. Built environment, materials & equipment
8. Research and development
9. Monitoring, Evaluation, Audit and Feedback
10. Advocacy, Social Mobilization and Partnership
11. Resource allocation and mobilization
16.2. IPC PROGRAM GOVERNANCE AND MANAGEMENT
Activity 16.2: Individual Reflection on IPC governance and management
Instruction:
 Think about the below questions by yourself and dot down your
thought in your notebook and share the work in the plenary.
Discussion Question:
12. How IPC program in healthcare facilities should be
structure/organized? Put an organogram of good IPC
Program in Primary healthcare Facilities
13. What are the successes and challenges of IPC program in
your facility?
Time Allowed: 5 minute to think and 5 Minutes to reflect
The national IPC strategy in terms of PHCU level IPC program governance and
arrangement recommend the establishment of following functions and positions. In
addition to the designated program leader, key staff and groups involved in Infection
Prevention and Control Programs and who play a major role in the oversight of a
successful program include:
Administrative leadership:
The reporting structure for the IPC program varies among health care facilities and can be
adapted to fit to the local context of the facility. One or more health care administrators will

196
supervise the leader of the IPC program and will take an active role in helping to shape and
support the program’s priorities and plans.
IPC committee:
The purpose of the committee is to guide and support the use of recommended
Practices and to review and resolve related problems that may arise. Additionally, the
committee advocates for resources required for effective implementation of the IPC
program. This committee should include representatives from different wards and
units, including procurement, laboratory, sterilization, environmental cleaning…etc. In
small facilities (e.g., health post & clinics) where these functions often overlap, the
group may consist of only two or three individuals. The IPC committee should meet on
a regular basis, at least monthly, to review the available IPC data and any problems or
issues that are identified but the IPC team (usually composed of key persons involved
in the day-today activity such as the IPC focal, the Lab personnel and the pharmacist)
may meet more frequently on need basis.
Task forces/working groups:
These may be permanent or temporary groups and may be created as needed to
provide input and oversight for a particular issue. Examples include groups focused on
disinfection and sterilization, waste management, or emergency preparedness. Task
forces/working groups should consist of individuals with multidisciplinary expertise and
should be granted authority to make decisions and advise and oversee the IPC
leadership and team in addressing the issue. IPC leadership or team members should
also be included. (WHO 2016) Organizational oversight from top facility leadership:
The person or group with organizational authority should periodically review the status
of HAIs at the facility and the effectiveness of measures designed to contain them
(WHO 2002). This process can highlight important areas of risk and opportunities for
improvement. (See the Program Evaluation section later in this chapter.)

197
National or regional public health authorities:
Public health authorities work closely with and support the facility-level IPC program,
providing expertise, partnership, assistance, guidance documents, support for
outbreak investigations, and authority to enforce IPC measures. The Facility-level IPC
team provides important front-line information to the public health authorities.
Roles and responsibilities of facility level staffs
The organization and structure of a facility’s IPC program, should have a clear concept
of the composition, roles, and responsibilities of important program staff, including the
IPC committee, program leader, IPC task forces, and facility staff. Facility leadership
should adapt the program structure based on the scope of the IPC program and the
needs of the facility small health care facilities in rural areas may have one staff nurse
or a medical officer and a few nurses, midwives, and other HCWs and limited scope of
IPC.

16.3. THE ATTRIBUTES OF EFFECTIVE INFECTION PREVENTION AND

CONTROL (IPC) PROGRAMS
Activity 16.3: Think in pair and share on attributes of effective IPC program
Instruction:
 Think about the below questions in pairs and dot down
your thought in your notebook and share the work in the
plenary.
Question:
1. What do you think are the requirements/attributes for
effective IPC program implementation at Primary facility
level?
Time Allowed: 5 Minutes for discussion and 5 minutes for
reflection

A successful IPC program must be able to effectively guide, support, and assess IPC
at the facility. Some of these attributes will be managed by senior facility leadership
and some by those designated as responsible and accountable for the facility’s IPC
program. In both cases, the following are necessary for an IPC program to succeed.
To achieve this, the program must acquire and retain the following attributes:
198
  Designated staff member/Team who is responsible and accountable for IPC at
the facility
 Competent IPC Program leaders with appropriate training and education
 Formal authority granted to the IPC program
 Tangible support from facility leadership
 Adequate resources for IPC activities
 Partnerships with key stakeholders and front-line HCWs
 Effective communication about IPC
16.4. MAJOR INFECTION PREVENTION AND CONTROL (IPC) PROGRAM
ACTIVITIES
Activity 16.4: Individual Refection on major activities on IPC
Instruction:
 Think about the below questions by yourself and dot down
your thought in your notebook and share the work in the
plenary
Question:
What are the some of the major activities that you would consider
as if assigned as an IPC program leader at your Primary facility?

Time Allowed: 5 Minutes to think and 5 minutes to reflect

Successful IPC programs are based on understanding the facility’s problems and
needs, prioritizing activities, and using available resources effectively. To achieve this,
there are major activities included within the oversight of the program. The designated
program leader should ensure that these activities are carried out:
 Facility Infection Prevention and Control Risk Assessment
 Program planning,
 Implementation strategies for evidence-based practice
 IPC Program evaluation

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 16.5. USING QUALITY IMPROVEMENT MODELS AND MULTIMODAL
STAREGY TO IMPROVE IPC PRACTICES
Activity 16.5: Individual Refection on Quality Improvement
Instruction:
 Think about the below questions by yourself and dot down
your thought in your notebook and share the work in the
plenary
Question:
 What is quality in healthcare service?
 What is quality improvement?
 What is the quality improvement model?
Time Allowed: 5 Minutes to think and 5 minutes to reflect
Quality is defined by the US Institute of Medicine as “the degree to which health
services for individuals and populations increase the likelihood of desired health
outcomes and are consistent with current professional knowledge”. There seven
dimensions of quality of care. These are.
1. Safe: avoiding injuries to patients from the care that is intended to help them.
2. Timely: reducing waits and sometimes harmful delays for both those who
receive and those who give care.
3. Efficient: avoiding waste, including waste of equipment, supplies, ideas, and
energy.
4. Effective: providing services based on scientific knowledge to all who could
benefit and refraining from providing services to those not likely to benefit.
5. Equitable: providing care that does not vary in quality because of personal
characteristics such as gender, ethnicity, geographic location, and
socioeconomic status.
6. Patient-centered: providing care that is respectful of and responsive to
individual patient preferences, needs, and values, and ensuring that patient
values guide all clinical decisions.
7. Integrated: providing care that makes available the full range of health services
throughout the life course.
A major function of an IPC program is to make healthcare facilities safer to work-in and
be cared for by identifying areas in which improvements in quality of care are needed.

200
IPC program activities (such as surveillance and observations of clinical practice)
should identify these areas.
Quality improvement (QI) consists of systematic and continuous actions that lead to
measurable improvement in health care services and the health status of targeted
patient groups.
Once areas for improvement are identified, IPC committee and facility staff need to
work together to apply evidence-based IPC strategies to change priorities, beliefs,
habits, and loyalties of staff to make healthcare facilities safer.
Quality improvement models offer a systematic approach for assessing and improving
care services. Quality improvement models are framework or roadmap that is used to
organize the work of an improvement initiative. Using QI models help an improvement
team to focus on changes that have already proven to be effective. They also provide
guidance on different ways to approach change.
Model for improvement focuses on three questions: to set the aim or organizational
goal, to establish measures/define measurements and select changes/find promising
ideas for change. It also incorporates plan-do-study-act (PDSA) cycles to test changes
on a small scale.
Central principles of improvement
Fundamental to the success of any improvement effort, is the understanding that every
improvement requires change. But not all changes result in an improvement. There are
five fundamental principles of improvement we need to take into consideration while
attempting to improve quality.
1. Know why you need to improve (aim or purpose of improvement effort)
2. Have a way to get feedback to let you know if improvement is happening
(observation, use of indicator data, feedback from service users etc.)
3. Develop a change that you think will result in improvement
4. Test a change before any attempt to improve
5. Implement a change

201
 •Establish a mulit-displanary committed team that has expet
konwlge on IPC and Qualitiy Improvemt Initiative (if availble)
Form a team •Select a team who are data driven that have good
understaning of system thinking

•Use diffent models to identify the mojor IPC gap in your healthcare facility
•Including Data form various sources, barinstorming, Risk Assessement,
Identification of
Problem/ Gap Observation or Walk through, Process map

•Using diffent models prioritize the gap

•including Petrochart, Piortization matrix,
•Develop the clear problem statmet that describles the mangnitude, time,
Prioritization of impact and where
the problems/ •Shold not include cause, aciton and correction, blame and should not
gapa address more than one problem
•Develop a clear aim statmet that is Secific, Measureble, Realistic and
Time bounded (SMRT)

•Conduct root cause analysis for the gap identified

•use Process Map, why why tree, Fish bone analysis, 5 whys, Driver
Generate Diagram,
Theory of
Change/ •Generate specific change ideas to solve the gap or problem considering
Change idea both system and process
•could be from statndards, Litratures, Bench-Marks, Experts, Brain
storming and Creativity/logical thinking

•Develop a specific indicotors incluing outcome and process indicators

•Out come indictors measure the aim statment
Measuremet •Process indicators measures the change idea
•Develop a continious data collection and feedback mechamism

Test the chanage

•Using PDSA cycle to test each of the change ideas
Idea

Figure 16.1: Major steps in quality improvement

Examples of quality improvement model commonly used by IPC programs for quality
improvement initiatives include Deming’s PDSA Cycle:
Deming’s PDSA (Plan, Do, Study, Act) Cycle was popularized by W. Edward Deming.
PDSA outlines a model for the process of continuous quality improvement.
This process has been used widely for IPC improvement projects:
 Plan—the health care facility staff design interventions to improve an IPC-
related process or to address a gap in IPC practices

202
  Do—the health care facility staff implement the intervention
 Study—the health care facility staff analyze results of the interventions that
were gathered through the timely collection of monitoring data
 Act—the health care facility staff institutionalize or reject the intervention based
on the results and plan another intervention.

Figure 16.2: Deming’s PDSA Cycle and Key Elements

A multimodal strategy consists of several of elements or components (3 or more;
usually 5) implemented in an integrated way with the aim of improving an outcome and
changing behavior at the facility to incorporate the best practices into day-to-day care.
It includes tools, such as bundles and checklists, developed by multidisciplinary teams
that take into account local conditions.
The 5 most common components include:
1. System change (that is, availability of the appropriate infrastructure and
supplies to enable IPC good practices)
2. Education and training of health care workers and key players (for example,
managers)
3. Monitoring infrastructures, practices, processes, outcomes and providing data
feedback

203
 4. Reminders in the workplace/communications and
5. Culture change with the establishment or strengthening of a safety climate
A bundle is an implementation tool aiming to improve the care process and patient
outcomes in a structured manner. It comprises a small, straightforward set of
evidence-based practices (generally 3 to 5) that have been proven to improve patient
outcomes when performed collectively and reliably.
In order to address both technical challenges for which there are knowledge to
implement a solution as well as adaptive challenges in which the priorities, beliefs,
habits, and loyalties of staff a knowledge of quality improvement methods is important
for those overseeing and implementing IPC programs (Pronovost 2011).
 Example of applying in PDSA cycle and multimodal strategies
Abebe have been assigned as an IPC leader in XX heath care facility. He asked his
multidisciplinary IPC committee and department head nurses to conduct risk
assessment on infection prevention and control to identify the major gaps/problems
within their departments using a standardized checklist. Using a pareto chart the team
prioritize the problems to focus on the most important ones and found that the major
problem in healthcare facility was hand hygiene (HH) compliance.
After prioritization, the team developed a problem statement on the top issue/gap
identified as “Over the past 2 months, 60% of the healthcare workers are not adhering
to the 5 moments of Hand Hygiene as per the WHO recommendation.” Using fishbone
analysis, they sought to identify the root causes of the problem to identify interventions
that can be implemented to alleviate the problem.
After identing the root causes of the problem, Abebe and his team used both subject
matter knowledge and literature reviews/desk review on how to improve hand hygiene
compliance in their healthcare facility. They identified 6 specific intervention activities
that needs to be tested to improve hand hygiene compliance which includes:
A. Provision of alcohol-based hand rubs,
B. Increasing access to continuous water supply and towels,
C. Training and education on HH,
D. Continuous monitoring and feedback

204
 E. Posting reminders in workplace
F. Role modeling

After identifying the intervention, they agreed that they need to test each specific
intervention activities to prove that they are effective. They laid out a detail test method
using PDSA cycle as follows:
Intervention Plan Do Study Act
Provision of Plan: We will ask XX The assigned The team We are
alcohol- department in the team will analyzes the ready to
based hand healthcare facility to place monitor and data and finds introduce the
rubs alcohol-based dispensers at record the hand that there Provision of
point of care and to provide hygiene have been alcohol-
their full staff alcohol-based compliance improvements based hand
hand rub and monitor. every day in XX in hand rubs to the
Goal: We want to improve department hygiene entire
the hand hygiene from X-Y time compliance in departments.
compliance of healthcare for one month. the 5
workers during their 5 moments of
moments of hand hygiene hand hygiene
Steps:
 The facility will provide
improvised types of hand
hygiene despisers with
alcohol and install them to
XX department,
 The facility will also provide
Y amount small bottles of
sanitizers (alcohol based)
equal to the number of
healthcare workers in XX
department.

205
Activity 16.6: Group work on PDSA quality improvement model
Instruction:
 Group the participants in to three groups
 Ask participant in the group to do a PDSA for each of the
following interventions by assigning one intervention to
one group
 Discuss the below questions in your group and report the
work in flip chart to the plenary
Discussion Question:
A. Increasing access to continuous water supply and towels,
B. Training and education on HH,
C. Posting reminders in workplace
Time Allowed: 10 Minutes for group Discussion and 15 minutes
(5 minutes for each group)
After Abebe and the team had designed their PDSA cycle they had to get small
funding to test each intervention strategies. So, they advocated to the senior
management team on the importance of hand hygiene and how each strategy that
would improve hand hygiene compliance and how they want to pilot in a test
department.
(If you want to learn more about how to advocate for a cause please visit
https://healthlearn.org/courses/advocacy-for-health-care-workers-introduction/).
Once they got the small fund from the senior management team to test these
interventions, they went ahead and tested each intervention in a different department.
The results were very good, each intervention has shown an improvement to hand
hygiene compliance as compared to the baseline, seeing the result, the again went to
the senior management and presented their results and asked the senior management
to invest more money so that they can implement the interventions in a multimodal
strategy. Once the had the green light to implement the strategy they designed their
multimodal strategies as follows.
1A. System change: Bottles of alcohol-based hand rub positioned at the point
alcohol-based hand rub of care in each ward, or given to staff
1B. System change: One sink to at least every 10 beds
Access to safe continuous Soap and fresh towels available at every sink
water supply and towels
2. Training and education All staff involved in the test phase receive training
A program to update training over the short-, medium-
and long-term is established

206
3. Observation and Setup two periods of observational monitoring to be
feedback undertaken (for training and education and reminders in
the workplace)
4. Reminders in the “How to” and “5 Moments” posters are displayed in all
workplace test wards (e.g., patients’ rooms; staff areas; out-
patient/ambulatory departments)
5. Institutional safety The chief executive, chief medical officer/medical
climate superintendent and chief nurse all make a visible
commitment to support hand hygiene improvement
during observation and feedback serving as a role model
(e.g., announcements and/or formal letters to staff)

Activity 16.6: Group work on multimodal strategies and PDSA Quality

Improvement Cycle
Instructions:
 Read the below question carefully and be in a group of
four and
 Discuss the below questions in your group and report the
work to the plenary
Question:
Identify one major problem related to infection prevention and
control in your healthcare facility and design a multimodal
strategy to improve the problem using a PDSA quality
improvement strategy.

Time Allowed: 40 Minutes (20 minutes to discuss in pairs

groups and 20 minutes for reflection (5 minutes per group))
16.6. SUMMARY
Establishing a successful IPC program in healthcare facilities is based on
understanding the problems/needs, prioritizing activities, designing evidence based
multimodal strategies using continuous quality improvement incentives to improve the
problems and using available resources effectively.
Program attributes that are integral to an effective program include responsibility and
accountability; IPC leaders with appropriate training and education, authority,
administrative and management leadership support; resources; partnerships; and
communication. In addition to the designated IPC program leader, there are other key
HCWs and groups who play a role in the oversight of a successful IPC program.

207
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CHAPTER 7: LINEN MANAGEMENT

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CHAPTER 8: ENVIRONMENTAL CLEANING

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CHAPTER 9: HEALTH CARE WASTE MANAGEMENT

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CHAPTER 10: FOOD AND WATER SAFETY

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CHAPTER 11: TRAFFIC FLOW AND FACILITY DESIGN

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CHAPTER 14: ANTIMICROBIAL RESISTANCE (AMR) AND RATIONAL USE OF
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CHAPTER 15: PREVENTING HEALTH CARE ACQUIRED INFECTIONS AT SPECIAL
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