Lecture three;

• Chain of infection

1
Introduction

• Presence of pathogen does not mean an infection

will begin
• In order for infectious disease to spread several
necessary steps must occur
• These steps are known as chain of infection

2
Chain of infections

3
 Cont..
1. Causative agent; the microorganism(bacteria, virus
or fungi)
2. Reservoir(source)
- host which allow microorganism to live and possibly
grow and multiply
- Human, animals and env, can all be reservoir of
infection
3. Portal of exit- path for microorganism to escape from
the host. Blood, respiratory tract, skin, and mucous
membranes, genito urinary tract, gastro intestinal tract,
and transplacental route from mother to her unborn
infant are some examples 4
Cont,..

4. Mode of transmission- microorganism can not

travel on their own, they require vehicle to carry
them to other people and places
5. Portal of entry- path for micro organism to get
into new host, are similar to portal of exit
6. Susceptible host – a person susceptible to the
microorganism

5
Who is at risk of infection

• Staff- service provider are at significant risk for

infection because they are exposed to potentially
infectious blood and other body fluid on daily basis
• Clients- are at risk of post procedural infection when
staff do not wash hand btn client and procedure,
when staff do not adequately prepare client for
procedure and when used instruments and other
items are not cleaned and processed correctly
• Community- are at risk of infections particularly
from inappropriate disposal of medical waste.

6
Breaking chain of infection

• As health professional, we can not provide health

care without exposure to potentially infectious
materials but we can prevent transmission in many
cases
• The only way to prevent infection is to break the
chain of infection

7
 Breaking chain 1 of infection
(Causative Agents)
1. Rapid and accurate identification of organism
- Routinely send blood culture, urine culture, skin
swabs, throat swabs, tracheal aspirate culture.
- Send endotracheal tube tip, urinary catheter tip and
certain line tip for culture after removal
2. Control or elimination of infectious agents
including
- Proper cleaning by water and mechanical action
with or without detergents

8
Cont..
- Disinfection
a. High level disinfectants ie.
i. Activated glutaraldehyde (cidex 2%)
ii. Carbolic solution 5%
iii. Bleaching powder 1%
b. Low level disinfectants
i. Methylated spirit 70%
ii. Betadine solution 10%
iii. Savlone 1%
- Sterilization of contaminated objects
9
Cont…

- Separate mops shld be used for cleaning of unit

(twice a day)
- Damp dusting should be done
- Drain should be patent
3. Handling of linen
- Keep bed sheets dry and clean
- Change sheets everyday
- Donot throw linen on floor
- Soiled linen counting shld be done in separate place
10
 Cont..
4. Pest control
- Avoid entry of pest into unit e.g. proper cleaning, sealing,
and draining
- Pt diet be kept in covered container
- Keep fly trappers on each bed side of pt
- Pesticide spray should be used weekly
5. Visitors control
- Traffic should be restricted except for staff
- Allow only one attendant (3-4hrs)
- Keep doors and windows closed
- Mobile phones should not be allowed inside the area
11
 Breaking the chain 2 of infection
(Reservoir)
• Measures to control or eliminate reservoir of infection
1. Employee health
- Immunization of health personnel e.g. hepatitis B vaccine
- Regular check up for early detection of any comm. d’ses
- Restriction from work of pt contact when infected with
comm. d’se
2. Environmental disease
- Cleaning with hospital approved clear dinsinfectants eg.
Phenol
- Cleaning of bed and equipments before admitting new pt

12
 Breaking chain 3 of infection
(Portal of Exit)
• Practice aseptic precaution
• Avoid talking directly into clients mouth to prevent
droplets infection
• Wearing mask is compulsory if you are infected or
dealing with pt who are infected
• Careful handling of waste like urine, faeces, emesis
and blood is important
• Disposable gloves should be worn to prevent direct
contact with waste or infected materials

13
Mode of transmission

- Infectious diseases and even certain contagious

disease spread through the following agencies
1. Air-borne transmission
2. Contact transimission – direct or indirect
3. Vehicle transmission (water, milk, food etc)
4. Vector transmission
5. Transplacental transmission

14
 Breaking chain 4 of infection
(Mode of transimission)
1. Contact precaution
- Single pt room
- Perform hand hygiene, put on gown / apron and
gloves prior to entering pt room and when
anticipating contact with the pt
- Remove gown/apron and gloves and perform hand
hygiene after leaving room
- Clean and disinfect non disposable equipment and
items when removed from pt room

15
Cont..

2. Droplets precaution
- Single pt room
- Staff to put on surgical mask when entering room
and remove and dispose after leaving room and
perform hand hygiene
- Instruct pt about respiratory hygiene and cough
etiquette
- Limit pt mvt outside the room
- Pt to put on surgical mask when leaving room

16
Cont..

3. Airborne precaution
- Single negatively pressured room
- Door to remain closed
- Staff to put on N 95/ P2 mask when entering pt
room and remove and dispose of mask and perform
hand hygiene
- Instruct pt abt respiratory hygiene and cough
etiquette
- Pt to put on surgical mask when leaving room

17
 Breaking chain 5 of infection
(Portal of Entry)
• Maintain integrity of skin and mucous membrane
• Prepare position of tubing may prevent injuries and
skin breakdown
• Turning and positioning of debilitated clients
• Ensure personal hygiene of client regularly
• Proper disposal of contaminated syrnges and needles
• Proper handling of catheter and drainage set etc.
care should be taken while collecting and handling
specimen

18
 Breaking chain 6 of infection
(Susceptible host)
1. Protecting susceptible host
- Regular oral hygiene
- Encouraging deep breathing exercise
- Encouraging proper immunization of children and
adult client
2. Maintaining healing process
- Promotion of intake of well balanced diet
- Help client to identify method to relieve stress and
to improve apetite

19
Cleaning and Decontamination
• Cleaning – is a systematic application of energy on a
surface to removal physical visible dirty and stain
- manual or mechanical process (automated)
- It is the first and most important step in
decontamination
• Decontamination -removal of microorganisms
contaminating an object
- It makes medical devices safes for health care staff to
handle and for use on patient

20
Cont..

• All environmental surfaces (including furniture,

walls, doors, etc.) or objects should be cleaned with
water and detergent and then disinfected using
chlorine solution, After contact time (10 – 20 min.)
is reached rinse with clean water.
• Use standard hospital disinfectants (e.g. 0.5%
chlorine solution)
• Use recommended PPE

21
Steps in cleaning

• Dry clean
• Pre rinse
• Application of detergents – cleaning agents; solvent
cleaner, acid cleaner
• Post rinse
• Application of sanitizer

22
Levels of decontamination

• Cleaning
• Disinfection
• Sanitisation
• sterilisation

23
disinfection
• Disinfection - a process that eliminates a defined scope
of microorganisms, except most spores, viruses and
prions
- the purpose - prevent transmission of certain
microorganisms with objects, hands or skin and prevent
spreading the infection
- Disinfectants - are product used to kill
microorganisms on inanimate objects or surface
- most disinfectants are chemical agents applied to
inanimate objects !

24
Cont..

• high-level disinfectants
- activity against bacterial spores
• intermediate-level disinfectants
- tuberculocidal activity but not sporocidal
• low-level disinfectants
- a wide range of activity against microorganisms but
no sporocidal or tuberculocidal activity

25
Sanitisation

• Sanitisation -removal of microbes that pose a threat

to the public health, food industry, water
conditioning
- sanitizer-an agent, usually a detergent, that reduces
the numbers of bacteria to a safe level

• Antiseptic – product that destroy or inhibit the

growth of microorganism in or on living tissue
• Aseptic – characterized by absence of pathogenic
microbes
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Sterilization

• Sterilization - destruction of ALL forms of life,

including the bacterial spores, viruses, prions
- no degrees of sterilization: an all-or-nothing process
- physical or chemical methods

27
Methods for Sterilization and disinfection
• Physical methods
1. Heat
-moist heat, dry heat
Pasteurization (eliminating food-born pathogens63-
65Cfor 30min.)
boiling (tyndallisation-an exposure of 100°C for 20)
2. Filtration - parenteral solutions (serum), vitamins,
vaccines and antibiotic solutions
3. Radiaton sterilization of disposable supplies
(syringes, bandages, catheters and gloves) and
heat-sensitive pharmaceuticals
28
 Moist Heat(autoclaves)
heat under steam pressure

sterilization method of choise for heat-stable objects

29
Dry heat (oven)

30
Chemical agents
- Alcohols
- Aldehydes
- Halogens
- Phenols
- Surfactants
- Heavy metals
- Dyes
- Gases (ethylene oxide, oxidants)

31
Chemical agents

• Alcohols -ethanol
70%,isopropanol 70%, propanol
60%
- For surgical and hygienic
disinfection of the skin and
hands

• Aldehydes -formaldehyde
(HCHO) - disinfectionof
surfaces and objects (plastic and
rubber items)
32
Cont..
• Halogens - chlorine, iodine, and their derivatives
- 2% chlorine solution is used for:
i. High spillages of blood, body fluids, excreta, vomitus;
ii. Liquid waste before disposal
iii. Corpses’ bag
- 0.5% Chlorine solution is used for:
iv. Toilets and bathrooms
v. Gloved hands
vi. Floors
vii. Beds and mattress covers
viii. Equipment
33
Cont..

• 0.05% chlorine solution is used for;

i. Bare hands and other skin
ii. Staff laundry
iii. Plates, cups, eating utensils

34
Preparation of chlorine disinfectants

• Preparing Dilute Chlorine Solutions from Liquid Bleach

(Sodium Hypochlorite Solution)
• Total parts (TP) of water = (% manufacturer concentrate) -1
(% desired dilute)
• Total Parts (TP) of water = (% manufacturer Concentrate) – 1
(% desired dilute)
• (3.5%) - 1 = 6.
(0.5%)
• • Take 1 part concentrated solution, add 6 parts of water to
make a 0.5% chlorine solution

35
Making chlorine solution from dry powder

• Grams/ Litre = (%Desired dilute) x 1000

(% Manufacturer concentrate)
• Mix measured amount of bleach powder with 1 litre of water
Example: To make a 0.5% chlorine solution from calcium
hypochlorite powder containing 35% active chlorine:
• (0.5%) x 1000 = 0.0143 x 1000 = 14.3g
(35%)
• Therefore, you must dissolve 14.3 grams of calcium
hypochlorite powder in one litr of water to get a 0.5%
chlorine solution.

36
Preparation of chlorine solutions from tablet formulations

• Follow manufacturer’s instructions since the

percentage of active chlorines in these products
varies.
• Concentration required, expressed in available
chlorine
- 0.05%= 500 ppm
- 0.5%= 5000 ppm
- 2% = 20 000 ppm

37
PRESEPT® DISINFECTANT TABLETS
2.5g
• DESCRIPTION
Each PRESEPT® Disinfectant Tablet contains 2.5g of sodium
dichloroisocyanurate
• INDICATION
• For the preparation of a wide spectrum disinfectant solution
effective against vegetative bacteria, fungi, viruses and
bacterial spores for disinfection of hard surfaces.
• PREPARATION
• To prepare a disinfectant solution of 5000ppm, add four 2.5g
PRESEPT® Tablet to 1L of water.

38
qn
• there is high spillage of blood and you have been
given 10 lts bucket full of water to prepare
disifectants for dcontamination
a) how many tabs of 5.0g SODIUM
DICHLOROISOCYANURATE with conc. 1000
ppm in a literof water are required?
b) how many lts of 8.0% liquid bleach required for
dilution?
c) how much grams of bleach powder containing 40g
active chlorine will you need to make an
appropriate conc.?
39
 Chemical Agents..

• Phenols - widely used, disinfection of hospital,

institutional, and household environment eg. lysol
• Surfactants - anionic, cationic, amphoteric, and
noninionic detergent compounds, disinfection of
noncriticial surfaces (bench tops, floors)
• Heavy metals - rarly used in clinical applications
- silver nitrate(1% eyedrop solution) used in the
prevention of eyes infections caused by Neisseria
gonorrhoeae and Chlamydia trachomatis in newborns
• Dyes - used topically as antiseptics to treat e.g. mild
burns
40
Decontamination of PPE (Gum boots, Apron,
Goggles/face shield)

• Wear appropriate PPE

• Prepare 0.5% available chlorine solution daily, indicating date
and time on container
• Immerse all instruments and other re-usable PPEs
separately(sorted) in a container with 0.5% chlorine solution
for between 10minutes
• Remove all items after 10 minutes and transfer into a basin
containing soap solution with water
• Clean/Wash instruments/PPEs thoroughly with brush/sponge
under water in the basin
• Rinse thoroughly with water and air dry or clean with clean
towel
41
Standard safety/ precaution measure

• Standard precaution is defined as “ a set of

precautionary measures including good hand
hygiene practices and use of protective barriers
during routine patient care carried out by health care
workers”
• Hand washing or hand hygiene – is the act of
cleaning ones hand with or without the use of water
or another liquid or with the use of soap for the
purpose of removing soil, dirt and/ or
microorganism

42
 Hand hygiene

• Why should you clean your hands?

- Any health-care worker, caregiver or person
involved in patient care needs to be concerned about
hand hygiene
- Therefore hand hygiene concerns you!
• You must perform hand hygiene to:
i. protect the patient against harmful germs carried
on your hands or present on his/her own skin
ii. protect yourself and the health-care environment
from harmful germs
43
5 moments for hand hygiene

44
How to clean your hands
■ Handrubbing with alcohol-based handrub is the
preferred routine method of hand hygiene if hands
are not visibly soiled
■ Handwashing with soap and water – essential when

when hands are visibly dirty or visibly soiled

(following visible exposure to body fluids)

45
How to handrub
• To effectively
reduce the
growth of germs
on hands,
handrubbing
must be
performed by
following all of
the illustrated
steps.
• This takes only
20–30 seconds!

46
How to handwash
• To effectively
reduce the growth
of germs on hands,
handwashing
• must last 40–60
seconds
• and should be
performed by
following all of the
illustrated steps.

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48
PPE

• Products designed to protect against or minimize

workplace hazards.

• Used when other measures have failed to reduce

exposure to acceptable levels (last resort).

• Designed to protect specific part of the body against

dangers of the workplace.

49
 Respiratory Tract Protection PPE
• Masks – protect staff from inhalation
of infectious aerosols or droplets,
smoke or other airborne hazards
• Types of masks
• Surgical masks- used in wards or
operating theatres
• N95 Particulate mask – used when
caring for patient with diagnosed or
suspected airborne infectious diseases

50
 Hand Protection PPE
2. Gloving
- Wearing gloves reduces contamination of
hands and minimizes the risk that a health
care workers will become infected after
contact with a patient blood or body
substances
- Wearing gloves reduces the likelihood that
staff will transmit microorganism for their
hands to patients
- Type of gloves used
i. Non sterile gloves – non sterile nitrile
gloves are suitable for most situation when
contact with any blood or body substance ,
mucous membranes or non intact skin is
anticipated 51
Cont..

ii. Sterile gloves – sterile latex gloves shall be worn

for surgical procedure where asepsis must be
maintained
- Staff involved with surgical procedure should
double glove for added protection

52
Eye and Face Protection PPE
Eye / face protection shall be worn
in any situation when splash or
splatter with blood or body
substance to the mucous membranes
of the mouth, nose and/ or eyes is
likely
- Types of eye / face protection
i. Chin length plastic face shield
ii. goggles

53
Protective Clothing

i. Plastic apron
- Disposable plastic apron are
sufficient to provide protection
from contamination
ii. Fluid resistant gown / coverall
- Long sleeved disposable fluid
resistant gowns, should be used
for contact isolation or where
there is an elevated risk of
contamination
54
Foot Protection PPE

• Rubber boots or shoes must be

worn when you work in or around
water or where there is a slip
hazard.
• When working with hazardous
chemicals, wear appropriate
chemical-resistant foot protection
in case of splashing or spilling.

• This would be impermeable rubber

or neoprene boots as shown.

55
Which is Safer for Work?

56
 Injury exposure and management

• In health care settings, injuries from needle or other

sharp instruments are the number one of the cause of
occupational exposure to blood born infections

57
sharps

• The term sharp refer to any

sharp instrument or object used
in delivery of health care
service including hypodermic
needles, IV catheters, sharp
instrument and razor blade

58
Prevention of injuries from sharp

• Use “handles – free” techniques when passing

sharps during clinical procedure
• Donot bend, break, or cut hypodermic needle before
disposal
• Do not recap the needles
• Dispose hypodermic needles and other sharp
properly

59
 Safe passing of sharp instrument
• Un capped or otherwise unprotected sharp should
never be passed directly from one person to another
- In the operating theater or procedure room, pass
sharp instrument in such a way that surgeon and
assistant are never touching the item at the same
time, this way of passing sharp is known as “hand
free” technique
- Assistant place instrument in a sterile kidney basin
or in designated “safe zone” in sterile field
- Service provider picks up the instrument, uses it and
returns it to the basin or safe
60
Managing injuries and exposure

• Studies have shown cleaning of wound with

antiseptic doesnot reduce risk of infections
- If you are accidentally exposed to blood or other
body fluids either by needle stick or other sharp
objects and splash of body fluid;
i. Wash the needle stick injury site or cut with soap
and running water
ii. Flush splashes to the nose, mouth or skin with
water
iii. Irrigate splashes to the eyes with water or saline
61