Infection Control Measures to Prevent Hospital Transmission MERS CoV Infection Control Department 2014 1 ICD-RCMC April 17, 2014 Coronaviridae Epidemiology & Clinical Management
Background Chronology Epidemiology Case Definitions Clinical Picture Clinical Management Case study (Al Hasa-KSA ) published by Dr Memish & Dr.Asiri Infection Control Department 2014 2 Background In September 2012, the World Health Organization announced the discovery of a novel coronavirus.
This virus has been named the Middle East Respiratory Syndrome Coronavirus (MERS- CoV)
Infection Control Department 2014 3 Chronology MERS-CoV, an atypical pneumonia of unknown etiology Causes severe acute respiratory illness, was recognized Novel coronavirus that emerged in 2012 First cluster of 2 cases occurred near Amman, Jordan April 2012
Infection Control Department 2014 4 Infection Control Department 2014 5 The first indication that MERS-CoV could be transmitted in health care setting was observed in J ordan in April 2012.
On 15 May 2013,the Ministry of Health in Saudi Arabia announced that 2 patients are health care workers who were exposed to patients with confirmed MERS-CoV. Approximately 132 laboratory Confirmed cases including 58 deaths. Until September 2013. A significant number of cases have been in health care workers As of March 2014, MERS-CoV has been identified in several countries in the Middle East (Saudi Arabia, Qatar, the United Arab Emirates, Jordan, Oman, and Kuwait), Europe (the United Kingdom, France, and Italy), and Tunisia.
Infection Control Department 2014 6 Infection Control Department 2014 7 14 April 2014 -WHO has been informed of an additional 16 laboratory-confirmed cases of infection with Middle East respiratory syndrome coronavirus (MERS-CoV) from Saudi Arabia and the United Arab Emirates (UAE).
15 laboratory-confirmed cases, including two deaths announced on the Ministry of Health of Saudi Arabia website and provided to WHO between 6 and 11 April
The World Health Organization (WHO) is coordinating the international responses to provide epidemiological, clinical and logistical support as required
Infection Control Department 2014 8 Infection Control Department 2014 9 Epidemiology Cause : New Corona Virus Recent evidence of new corona virus identified with etiological co-factors ? involved Highly infectious Means of transmission Evidence of person to person transmission Close contact with body fluids (especially respiratory droplets ) Contaminated hands, clothes, equipment; the environment may also be important
Infection Control Department 2014 10 Incubation period 2 10 days and up to 13 days in exceptional cases Onset and duration of infectivity unknown
Organism survival in environment Duration unknown Other corona virus are known to survive for up to 4 hours Infection Control Department 2014 11 Infection Control Department 2014 12 KSA and the WHO announced that, there are 3 main epidemiological patterns. The first pattern is the occurrence of sporadic cases in communities. The source or how these people became infected is not known at the present time. The second pattern is intra-familial infection. This is likely related to person to-person transmission limited to close contacts with a sick family member. The third pattern contains clusters of healthcare transmission. A person presenting after 1 February 2003 with a history of: High fever >38 0 C AND One or more respiratory symptoms including cough, shortness of breath or breathing difficulty AND one or more of the following: Close contact, within 10 days prior to onset of symptoms with a person diagnosed with MERS COV; History of travel, within 10 days prior to onset of symptoms to an affected area (see archive of Affected Areas at http//www.who.int./csr/mers/en/). Infection Control Department 2014 13 Suspect Case Case Definitions
Close contact : having cared for, lived with, or had direct contact with the respiratory secretions or body fluids of a suspect or probable case of MERS CoV.
Affected area : an area in which local chain(s) of transmission of MERS CoV is/are occurring as reported by the national public health authorities.
Infection Control Department 2014 14 Explanations: Probable Case
Infection Control Department 2014 15 A suspect case with chest X-Ray findings consistent with pneumonia or respiratory distress syndrome (RDS)
OR
A suspect case with an unexplained illness resulting in death, with autopsy examination demonstrating the pathology of RDS without an identifiable cause.
Infection Control Department 2014 16 Sudden onset of high fever with myalgia, chills, rigors and a non- productive cough
Most cases have bilateral pneumonia
~ 90% begin to recover from day 6 or 7 Clinical Picture Onset / Presentation
Infection Control Department 2014 17 Rapid deterioration in 10% (+/-) of cases
Acute RDS
Require ICU admission & mechanical ventilation
Case fatality rate: ~ 4%
No specific treatment available
Patients Who Should be Evaluated for MERS- CoV Infection
A person with fever ( 38C , 100.4F) and pneumonia or acute respiratory distress syndrome (based on clinical or radiological evidence); AND History of travel from countries in or near the Arabian Peninsula within 14 days before symptom onset; OR
Infection Control Department 2014 18 Infection Control Department 2014 19 Close contact with a symptomatic traveler who developed fever and acute respiratory illness (not necessarily pneumonia) within 14 days after traveling from countries in or near the Arabian Peninsula; OR Is a member of a cluster of patients with severe acute respiratory illness (e.g., fever and pneumonia requiring hospitalization) of unknown etiology in which MERS-CoV is being valuated. Collection of Laboratory Specimens Determine if patient meets PUI criteria Collect: An upper respiratory specimen: Nasopharyngeal AND oropharyngeal swab A lower respiratory specimen: Broncheoalveolar lavage, OR Tracheal aspirate, OR Pleural fluid, OR Sputum Infection Control Department 2014 21
The best specimen for testing is a lower respiratory tract specimen as nasopharyngeal swabs. It is strongly advised that lower respiratory specimens such as sputum, endotracheal aspirate, or bronchoalveolar lavage should be used when possible Serum for eventual antibody testing (tiger top tube) Should be collected during acute phase during first week after onset, and again during convalescence 3 weeks later Infection Control Department 2014 22 If patients do not have signs or symptoms of lower respiratory tract infection and lower tract specimens are not possible or clinically indicated, both nasopharyngeal and oropharyngeal specimens should be collected Infection Control Department 2014 23 The 2 can be combined in a single collection container and tested together.
If initial testing of a nasopharyngeal swab is negative in a patient who is strongly suspected to have MERS-CoV infection, patients should be retested using a lower respiratory specimen or a repeat nasopharyngeal specimen with additional oropharyngeal specimen if lower respiratory specimens are not possible
Infection Control Department 2014 24 SUPPORTIVE TREATMENT
Antibiotic Therapy : to cover causative organisms
Prophylactic Antibiotic Therapy : to prevent secondary bacterial infection
Maintain oxygenation :
intubate and ventilate as necessary Clinical Picture Management
Infection Control Department 2014 25 SUPPORTIVE TREATMENT
Avoid interventions which may cause aerosolisation of respiratory secretions: Bronchoscopy Nebulised bronchodilators Chest physiotherapy Gastroscopy Any procedure / intervention that may release respiratory secretions
Infection Control Department 2014 26 SUPPORTIVE TREATMENT
In severe cases corticosteriods and ribavirin have been used, however there is no evidence to support their general or routine use at this stage.
MERS CoV Therapy CDC suggestion The suggested Ribavirin oral dosage is 2000 mg loading dose then 1200mg q8h for 4 days, then 600mg po q8h for 4-6 days with pegelated interferon 1.5mcg/kg once per week.
Infection Control Department 2014 27 Infection Control Department 2014 28 So far there is no treatment & no Vaccine Infection Control Department 2014 29 TO PREVENT TRANSMISSION TO HCWs AND OTHERS Infection Control Precautions MUST BE PRACTICED AT ALL TIMES MERS CoV : Infection Control Goals In addition to providing the best possible clinical care:
Detect early any suspect cases Implement appropriate isolation measures Protect healthcare personnel Protect other patients Protect family and community members
Infection Control Department 2014 30 Triage for MERS CoV Admissions Where possible have a specific area for triaging patients who may have MERS CoV : Establish separate reception area for patient triage. Staff must wear full personal protective equipment (PPE). Patients must be given a surgical mask Screen patients by closely questioning them about symptoms, close contacts and travel. Admit if they meet the case definition.
Infection Control Department 2014 31 If possible, there should be separate wards/areas for each of the following categories : Patients with colds, sniffles and runny noses should be isolated in a single room / area Suspect cases Place in a single room Probable cases If cohort nursing : keep probable and suspect cases apart May share room with other probable cases : where possible use a single room for all patients Infection Control Department 2014 32 Components of MERS CoV Isolation Facility Administrative Controls Clinical Surveillance of Staff Organization of Isolation Area Protective Equipment Standard Precautions
Infection Control Department 2014 33 Administrative Controls Limit, and control points, of entry to MERS CoV ward(s) One entrance Guard to control entrance Log of permitted visitors (staff & visitors) Visitors must be restricted or preferably forbidden with NO EXCEPTIONS Limit patient travel/transport outside unit Minimize the number of staff exposure to cases Infection Control Department 2014 34 Clinical Surveillance of Staff Maintain list of all staff who worked with MERS CoV patients or on the MERS CoV ward Systematically monitor for fever Twice daily temperature for staff working in the area (baseline Chest X-Ray may be needed ) Screen for symptoms of MERS CoV -like illness among staff reporting for duty List contact information for: Persons visiting or caring for MERS-CoV patients Contacts of HCWs in close contact with MERS CoV patients Infection Control Department 2014 35 Organization of Isolation Area Signs: MERS CoV Isolation Area Designated area for clean protective equipment Instructions for using protective equipment Accessible to personnel Sufficient inventory to meet daily needs Separation of clean and dirty supplies including an area for containment of waste and soiled linen Color-coded bags and containers for contaminated waste and laundry Containers for laundry and all waste should have foot-operated lids Infection Control Department 2014 36 Personal Protective Equipment (PPE) N-95 Respirator Mask must be worn
Goggles (protective glasses)
Disposable Gowns
Disposable Gloves
Cap Infection Control Department 2014 37 Infection Control Practices
Standard Precautions (Respiratory Precautions) Exposure Risks
Hand Washing
PPE
Patient transport Patient and family education
Laboratories / Specimens Mortuary Care
Waste and Linen Handling Cleaning & Disinfection Infection Control Department 2014 38 Infection Control Practice You can minimize YOUR risk of catching
MERS CoV
by following
infection control procedures. Infection Control Department 2014 39 A,C Precautions
Designed to reduce the risk for occupational exposure to MERS CoV infection from both recognized and unrecognized sources of infection Infection Control Department 2014 40 Exposure Risks Patient: Respiratory secretions Blood Body fluids including excreta Skin lesions Staff Visitors Health Care Staff: Respiratory secretions Blood Body fluids including excreta Mucous membranes Skin lesions Sharps Visitors Infection Control Department 2014 41 Principles of Hand Washing Hand Washing : Is the single most important and effective component for preventing the transmission of infection. Is designed to remove transient microorganisms that may have been picked up from the environment. Prevents the transfer of these microorganisms to other patients, staff and equipment. Is best performed using soap (preferably liquid) and warm running water Infection Control Department 2014 42 After removing gloves Before and after patient contact After contact with blood or body fluids from any patient After taking blood pressure or vital signs from any patient Other times: After using bathroom After blowing or wiping nose Before eating Before preparing food Infection Control Department 2014 43 Handwashing When?
Drying Your Hands It is important to dry your hands thoroughly after washing them because :
Damp hands collect microorganisms Damp hands spread potentially infectious microorganisms Damp hands may become colonised with potentially infectious microorganisms
Therefore it is important to pat dry your hands thoroughly.
Pat drying also helps to prevent damage to skin.
Infection Control Department 2014 44 Handwashing Tips Infection Control Department 2014 45
Remember:
Wash hands for a minimum of 15 to 20 seconds.
Ensure you have washed all areas properly.
Dry hands thoroughly. Personal Protective Equipment for MERS CoV
Infection Control Department 2014 46 Personal Protective Equipment (PPE) Cap Gown
N-95 Respirator Mask Gloves
Goggles Infection Control Department 2014 47 Principles for Using PPE PPE reduces but does not completely eliminate the possibility of infection
PPE is only effective if used correctly
The use of PPE does not replace basic hygiene measures such as hand washing hand washing is still essential to prevent transmission of infection. Infection Control Department 2014 48 N-95 Respirator Masks
N-95 Respirator Mask
Infection Control Department 2014 49 Principles for Using the N-95 Respirator Mask
The N-95 respirator mask is used to protect health care workers, other patients, staff or visitors by preventing potentially infectious microorganisms such as respiratory secretions from : Contaminating their face including the nose and mouth. Being inhaled or ingested. Infection Control Department 2014 50 N-95 Respirator Mask For respiratory protection wear an N-95 respirator mask during all patient contact Infection Control Department 2014 51 Proper use of N-95 Respirator Mask DO NOT touch the front of the mask
Wear only one N-95 mask no need for additional respiratory protection
REMOVE the N-95 respirator mask before leaving the isolation unit / area Infection Control Department 2014 52 WHY an N-95 Respirator Mask? N-95 respirator masks offer a higher level of filtration for respiratory secretions than a surgical mask
Infection Control Department 2014 53 HOW to use an N-95 Respirator Mask Use for single shift unless excess moisture necessitates replacement during each shift Label with the wearers name
Dispose of with medical waste
NB: You must fit the mask securely over both your nose and mouth Infection Control Department 2014 54 HOW to use an N-95 Respirator Mask
Always use the correct sized mask.
The incorrect size will not fit properly and will fail the fit test.
NB: You must fit the mask securely over both your nose and mouth so size is important. Infection Control Department 2014 55 N-95 Respirator Masks - Fitting Instructions Infection Control Department 2014 56
N-95 Respirator Masks - Fitting Instructions Infection Control Department 2014 57
Inhale deeply. If there is no leakage, the negative pressure will make the mask cling to your face. A poor seal will result in prompt loss of negative pressure in the mask due to air entering through gaps in the seal. Negative Fit Test Principles for Using Goggles, Gowns, Gloves and Caps
Goggles, gowns, gloves, caps and overshoes are used to protect health care workers, by preventing potentially infectious microorganisms from : Contaminating their eyes, clothing, hands and hair Being transmitted to other patients and staff. Infection Control Department 2014 58 Goggles Infection Control Department 2014 59 Assign one pair to each worker at the beginning of a shift
Wear goggles in room with MERS CoV patients
Leave in the container in the anteroom at the end of the shift to be cleaned and disinfected
Gowns Long sleeved gowns must be worn when in direct contact with the patient Wear gown at all times in the patients room Gowns must be removed before leaving the patients room or dedicated anteroom Remove used gowns as soon as possible particularly when grossly contaminated
Infection Control Department 2014 60 Gloves Before all patient contact
Before all cleaning
Before handling soiled linen & waste
Infection Control Department 2014 61
Gloves Remove after contact with patients or lab specimens
Do not wear gloves outside of the patients room / anteroom
Do not re-use gloves
Wash hands after removing your gloves Infection Control Department 2014 62 Caps Infection Control Department 2014 63 Caps are worn to protect the hair from aerosols that may otherwise lodge on the hair and be transferred to other parts of the health care worker such as the face or clothing by the hands or onto inanimate objects. Key Points Wear N-95 respirator mask, goggles, disposable gowns, hats and gloves for all patient contact & aprons when necessary
Wash hands using soap (preferably liquid) and water when leaving the anteroom
Use an 70% alcohol-based hand rub solution after hand washing
Wash hands when leaving the unit Infection Control Department 2014 64 Patient Transport It is essential to avoid all unnecessary transport of isolated patients to control and prevent the potential spread of infection. Infection Control Department 2014 65 Patient Transport If the patient needs to be out of their room for an essential procedure, e.g. X-Ray
Transport route must avoid populated areas.
Patient must and an isolation gown.
Accompanying staff must wear : N-95 respirator mask Gloves Gown Goggles Infection Control Department 2014 66 Patient Transport Transport Ambulance No dedicated ambulance needed Mask patient (N-95 respirator mask) Transporters wear personal protective equipment N-95 respirator mask, disposable gown, goggles, gloves Disinfect ambulance after transport Standard cleaning and disinfecting or 1:100 dilution of bleach; after 10 minute contact time, clean and disinfect using standard procedures. DO NOT use spray cleaners Infection Control Department 2014 67 Patient, Family & Community Education Education for the patient, their family and the community is essential in the control and prevention of the MERS Cov.
It is particularly essential for those persons requiring hospital or home isolation to understand the necessary restrictions. Infection Control Department 2014 68 Patient, Family & Community Education Explain: What MERS Cov. is (to date)
Why isolation is required.
Precautions required including PPE
Hand washing procedures Infection Control Department 2014 69 Patient and Family Education Teach the patient and family members : about the MERS Cov. illness and the reason for the precautions being used
Teach the patient and visiting family members : how to perform hand hygiene how to wear an N-95 respirator mask, gown, gloves and goggles (if available) Infection Control Department 2014 70 Patient and Family Education Explain to the patient and family why disposable equipment is being used such as :
Eating utensils Medical equipment Patient gowns
Infection Control Department 2014 71 Laboratories Laboratory staff must ensure that their practices are meticulous.
Advance planning in each designated laboratory is essential to ensure that specimen handling, transportation and storage is managed according to the guidelines. Infection Control Department 2014 72 Specimen Collection Wear full PPE
Write clinical details on the request form
Samples should be collected by clinical staff
Label the clinical samples clearly
Change PPE between patients
Discard all disposable materials in a biohazard bag Infection Control Department 2014 73
Storage of Specimens Respiratory samples and frozen tissues : store at 70 o C
Serum : store at 4 - 8 o C for 24-48 hours or at -20 o C for longer periods Infection Control Department 2014 74
Patient Specimens Treat all patient specimens as highly infectious
Use leak proof containers for collection Do not contaminate outside of container
Transport specimens in leak-proof outer containers e.g. a sealed plastic bag Infection Control Department 2014 75 Linen Management All contaminated or soiled linen is potentially highly infectious therefore:
Wear full PPE when handling linen.
Separate grossly contaminated linen from non- contaminated linen in the patients room for ease of handling in the laundry Infection Control Department 2014 76 Waste Wear full PPE when handling waste. Clinical waste: all items from treatment areas Soiled surgical dressings Swabs Masks Gowns Other contaminated waste Infection Control Department 2014 77 Cleaning & Disinfecting the Hospital Environment and Equipment Cleaning is usually sufficient for prevention and control of infection, but for MERS Cov infection the use of a disinfectant following cleaning is essential. It is essential to clean thoroughly before disinfecting the environment or equipment. Cleaning and disinfection must be carried out at least daily and particularly when gross contamination occurs. In some instances it may be necessary to disinfect to render the item safe to handle. Infection Control Department 2014 78
Cleaning and disinfecting patient rooms and equipment is the best way to reduce transmission of infection
Wear full PPE when cleaning and disinfecting Infection Control Department 2014 79 Cleaning & Disinfecting the Hospital Environment and Equipment To communicate infection risk, use signs. MERS CoV I solation
Protect patients & staff by:
- Cleaning and disinfecting equipment.
- Cleaning and disinfecting the room and anteroom.
Infection Control Department 2014 80 Cleaning & Disinfecting the Hospital Environment and Equipment The immediate area around patients must be considered heavily contaminated.
Bedside table, bed stand, and accessible areas of bed and floors must be cleaned with detergent and twice a day.
In addition, disinfect all surfaces after cleaning.
Use disinfectant first if surfaces are grossly contaminated before cleaning to reduce the viral load. Infection Control Department 2014 81 Cleaning & Disinfecting the Hospital Environment and Equipment Contain and dispose of infectious materials in waste containers : Put waste containers near entrance / exit to patient room.
Provide dedicated patient equipment when possible.
Clean and disinfect patient care equipment immediately after use depending on the type of equipment. Infection Control Department 2014 82 When areas and inanimate objects are grossly contaminated use : 1:100 sodium hypochlorite (bleach) solution to disinfect (before cleaning) it will reduce the viral load and the potential for infection to spread.
Then use the standard cleaning and disinfecting procedures mentioned previously. Infection Control Department 2014 83 Cleaning & Disinfecting the Hospital Environment and Equipment All reusable patient items should be:
Cleaned and disinfected before being used on another patient Taken to the dirty utility room for cleaning Send to CSSD for sterilization
Staff should wear full PPE when handling contaminated equipment. Infection Control Department 2014 84 Cleaning & Disinfecting the Hospital Environment and Equipment DO NOT spray clean the room / area.
Why?
Because it : Spreads droplets
Spreads aerosols
Is not effective as a surface disinfectant Infection Control Department 2014 85 Infection Control Department 2014 86 Case SUDTY MERS-CoV EPIDEMIOLOGY & OUTCOME UPDATE www.smj.org.sa Saudi Med J 2013: vol.34 Case Study In April to May 2013, there were 27 cases and the majority of those cases were linked to different healthcare facilities in Al-Hasa, the eastern province of the Kingdom of Saudi Arabia (KSA).The majority of these cases occurred in patients with underlying comorbidities Infection Control Department 2014 87 Clinical presentation and laboratory data. Infection Control Department 2014 88 The majority of patients presented with fever (98%), fever with chills/rigors (87%), Cough (83%), shortness of breath (72%), and dry cough (56%). Infection Control Department 2014 89 Note that 21% of patients had diarrhea and 21% had vomiting. Radiographic manifestations range from unilateral infiltrate (43%), to increased bronchovascular markings (17%), bilateral infiltrate (22%), and diffuse reticulonodular pattern(4%) Infection Control Department 2014 90 Symptoms n (%) Fever 46 (98.0) Fever with chills/rigors 41 (87.0) Respiratory symptoms Cough 39 (83.0) Dry 22 (56.0) Productive (sputum) 17 (44.0) Hemoptysis 8 (17.0) Shortness of breath 34 (72.0) Chest pain 7 (15.0) Sore throat 10 (21.0) Runny nose 2 (4.0) Gastro-intestinal symptoms Abdominal pain 8 (17.0) Nausea 10 (21.0) Vomiting 10 (21.0) Diarrhea 12 (26.0) Other symptoms Myalgia 15 (32.0) Headache 6 (13.0) Infection Control Department 2014 91 Middle East Respiratory Syndrome coronavirus infection is associated with a high case fatality rate with more than 50% death among diagnosed patients. Case-fatality rates seem to be higher with increasing age, 39% in patients <50 years, to 75% in cases >60 years Infection Control Department 2014 92 The current case-fatality rate is 58%. The median age of affected individuals is 56 years (range:2-94 years), with a male-to-female ratio of 2.6-1 Infection Control Department 2014 93 Dr. Al-Assiri: Coronavirus Does not Spread Easily among Humans, and Needs Direct Contact Infection Control Department 2014 95 Infection Control Department 2014 96 MERS Resources MERS overview: http://www.cdc.gov/coronavirus/mers/ind ex.html Case definitions and guidance: http://www.cdc.gov/coronavirus/mers/cas e-def.html Additional MERS resources: http://www.cdc.gov/coronavirus/mers/rel ated-materials.html Infection Control Measures to Prevent Hospital Transmission We hope YOU have learnt something about MERS CoV and YOUR role in :
preventing transmission and infection control
Thank you for listening. Infection Control Department 2014 98