UNIT 7

INFECTION CONTROL
AND
POST EXPOSURE PROPHYLAXIS
 Unit Objectives

Describe the basic principles of infection

control and standard precautions
Demonstrate how to prevent infections
List measures to safeguard against TB and
blood-borne pathogens
Manage post exposure prophylaxis
Discuss nurses’ role in infection control

2
 What are
Standard Precautions?
• Procedures and work
practices used

– to reduce the risk of

disease transmission

– because we cannot
visually identify
whether patients are
infectious or not

3
 Basic Principles of
Infection Control

• All patients are potentially infectious

• Follow Standard Precautions for ALL

patients

• Use of Personal Protective Equipment

(PPE) is based on risk of the procedure

4
 Standard Precautions
Procedures
• Practice Hand Hygiene

• Use Personal Protective Equipment (PPE)

when handling blood, body substances,
excretions and secretions

• Disinfection and Sterilisation

• Biomedical Waste management

5
 Hand Hygiene
• When do we need to wash our hands?
• What are the common hand hygiene techniques
followed in health care setting?
• Which kind of hand hygiene technique is used for the
following procedures
– Taking blood pressure,
– Inserting a ryles tube,
– Giving oral medication,
– Conducting a delivery,
– Cleaning a diabetic foot,
– Before giving injection,
– Giving feed to a neonate
6
 Remember: For All Types of
Hand Hygiene
• Keep nails short
(1-2 mm)

• Do not wear nail polish × ×


• Remove jewellery, bracelets,
wrist watches

×
• Do not dry hands on
clothes/uniforms after hand
washing
7
 Exercise:
Steps of hand washing procedure
Wet hands thoroughly Apply plain soap Rub vigorously in all areas of hands,
fingers, forearms for 10-15 seconds

Rinse thoroughly Dry hands with disposable

with clean water
It is ok to air dry hands
paper towel or clean cloth towel

8
Steps of hand washing procedure

Video of Handwashing
(Source :WHO)

9
 List of PPE

• Shoe cover/Leggings
• Gown
• Cap
• Mask
• Goggles
• Gloves

10
 Use Personal Protective
Equipment (PPE)

• Exercise 1: Putting on and

removing sterile gloves
• Exercise 2: List PPE,
Procedures and use of PPE

11
Video of PPE

Source - MOHFW
12
 Dos and Don'ts for Use of PPE

• Do…
– Use PPE based on risk of the procedure
– Change PPE completely after each
procedure
– Discard the used PPE in appropriate
disposal bags,
– Dispose PPE as per the policy of the
hospital
– Always wash hands after removing PPE
– Educate and train all junior and auxiliary
staff in the use of PPE
13
 Dos and Dont’s for Use of PPE

• Don‘t…
– Share PPE
– Use same gloves between patients
– Reuse disposable gloves, eyewear,
masks
– Use eye wear that restricts your vision
– Use masks when wet

14
 Safety of instruments
How will you ensure the safety of
instruments you would use?
• First choice, use disposable needles
• Never reuse a disposable needle or
instrument
• Safely dispose all sharps (needles,
lancets, scalpels) after use
• Disinfect reusable
needles/syringes/instruments with
Hypochlorite first, then sterilize by
Autoclaving or boiling before re-use.
15
 Agents Used in Disinfection

EFFECTIVE against HIV: INEFFECTIVE against HIV:

• Household bleach / • Savlon - poor effect
sodium hypochlorite • Dettol solution - no effect
• Chlorhexidine 2-4%
• Lysol – poor effect
• Glutaraldehyde 2%
• Iso Propyl Alchohol(IPA),
• Ethanol 70%
• Formalin 4%
• Povidone iodine 2%

16
 Household Bleach- 10%
Contains 0.5% chlorine concentration, used
to disinfect:
• Excreta
• Bodies
• Spills of blood/body fluids
• Vehicles and tires
• Also used to prepare 1:100 bleach solution

(Source :WHO)
17
 Household Bleach- 1%
Contains 0.05% chlorine concentration,used to
disinfect
• Surfaces
• Medical equipment
• Bedding
• Reusable protective clothing before it is
laundered
• Rinsing gloves between contact with different
patients (if new gloves are not available)
(Source : WHO) 18
 Excercise

Preparation Of Bleach Solution

(WHO Guidelines)

19
 10% Bleach Solution
• Using Bleach Solution-
– Add one volume of household bleach (e.g. 1
litre) to nine volumes of clean water (e.g. 9
litres).

• Using Bleaching Powder-

– Mix 16 gm (one tablespoon) in 1 litre of water

20
 1% Bleach Solution
• Using Bleach Solution-
– Add one volume of 1:10 bleach solution
(e.g. 1 litre) to nine volumes of clean water
(e.g. 9 litres)
OR
– Add One volume of household bleach to 99
volumes of clean water (e.g. 100 ml of
bleach to 9.9 litres of clean water)

(BUT making it up from 1:10 bleach solution is much

easier) 21
 1% Bleach Solution
• Using Bleaching Powder-

– Mix 16 gm (1 tablespoon) in 10 litres of

water

22
 Things To Remember
• Bleach solutions must be prepared daily as
they lose their strength after 24 hours.
• Any time the odour is not present, discard it.
• 1:10 bleach solution is caustic. Avoid direct
contact with skin and eyes.
• Prepare the bleach solutions in a well-
ventilated area.
• For all types of blood spills, it is
recommended to use 10% bleach solution
23
 Nurse’s Role
Disinfection and Sterilization
• Prepare bleach solution every day
• Keep a separate area for disinfection of patient
care items
• Disinfect all patient care equipment
contaminated with body fluids or secretions
• Maintain separate personal care items for
patients e.g. razors, toothbrushes
• Clean daily, surfaces in close proximity to
patient (bed side rails, tables)
• Disinfect all reusable articles before sending for
sterilization
• Clean all patient area and the unit thoroughly on
discharge 24
 Exercise

Demonstration
Cleaning a blood spill on the floor

Discussion
Care of body after death of a HIV+ patient

25
 Nurse’s Role:
Waste management
• Be up-to-date on infection control practices
• Segregate hospital wastes appropriately
• Teach, train and supervise junior
staff/students and cleaning & other staff in
the ward with regard to waste segregation
and disposal
• Educate patients and family members about
waste management

26
 Standard Precautions
Against Airborne Pathogens

Nurse’s Role
 Nurse’s Role:
Separate Smear + TB and HIV + Patients

Risk of TB Transmission:

• HIV - and HIV + ( No. TB) Low Risk

• Smear + TB and HIV + High Risk

• MDRTB smear + and HIV+ Greatest Risk!

• MDRTB smear + and HIV - High Risk

28
 Nurse’s Role: Educate on
Cough Hygiene
Instruct coughing/sneezing
patients to
• Turn their heads
• Cover the mouth with a
cloth or rag
• Wash hands
• Wash / burn the cloth used

29
 Nurse’s Role
Identify Procedures risk for TB
Which procedures put Health Care
Professionals at risk for TB?

Which are the other activities which put

HCP at risk for TB in your facility?
30
 Nurse’s Role:
Ensure Good Ventilation
Ideal Airflow Direction

Health worker Patient Open window

Open
window
• Open windows
• Ensure proper airflow direction in
wards with TB patients
• Supervise proper patient placement
and spatial separation
31
 Nurse’s Role:
Use Masks Appropriately
• Use masks
– When caring for patients with
TB/other airborne diseases
– While transporting or doing
procedures on patients with TB
– When suffering from a respiratory
infection yourself

• Remember
– A paper or cloth mask gets wet in
<10 minutes, allowing bacteria to
pass
– Change when wet

32
 Nurse’s Role: Educate on
Early detection and Treatment of TB
• Encourage persons with chronic coughs
(>2wks) to get evaluated whether it’s
 you
 another staff member
 a visitor
 a volunteer
 a family member
 a patient

• Start and complete treatment without delay

(DOTS)
33
 Nurse’s Role:
Educate Patients on Prevention

Educate patients and

families
– Report and seek treatment
for signs and symptoms of
TB
– Adherence to treatment
– Cough hygiene
– Good ventilation

Take a break
34
 Standard Precautions
Against Blood Borne Pathogens
 Standard Precautions Measures :
Blood Borne Pathogens

• Hand hygiene 
• Use PPE 
• Disinfect and Sterilize 
• Proper waste management 
• Prevent accidents 
• Protect yourself from
occupational exposure 

36
Standard Precautions: Blood Borne
Prevent Accidents with Sharps
How are used needles disposed in
India?
– Needle destroyer / burner /
cutter
– Disposal of sharps into the
appropriate bin
Danger!

37
Demonstration of proper
needle disposal

38
 Nurse’s Role:
Reduce Risk of Sharp Injuries
• Do’s • Don’ts
– Use needle – Handle, empty, or
cutter/destroyer transfer used sharps
– Separate sharps between containers
from other waste – Do not recap sharps
– Use rigid, puncture before disposal
proof disposal bins
– Empty sharps
containers when they
are ¾ full

39
 Protect your self

• Take three doses of hepatitis B

vaccine. It gives you life long
protection

• Take measures to prevent accidents

• Take Post Exposure Prophylaxis

(PEP) in the event of any
occupational exposure

• Follow standard precautions at all

times
40
Occupational Exposure
 Types of
Occupational Exposures
• Needle-stick or cut with
sharp instrument
HBV: 30% (30 in 100)
• Splash to eyes, nose, HCV: 3-5% (3-5 in 100)
mouth
HIV : 0.3% (3 in 1000)

Occupational exposure to
• Direct exposure HIV Very low risk

involving non-intact skin

NACO, July 2006

42
 Which Body Fluids have Risk of HIV
transmission ?
Considered “At Risk” Considered “Not At Risk”
• Blood • Tears
• Semen • Sweat
• Breast milk • Urine and faeces
• Vaginal secretions • Saliva
• Cerebrospinal fluid
• Synovial, Pleural, Unless they contain visible
Pericardial, Peritoneal blood .
fluids
• Amniotic fluid
• Other body fluids visibly
contaminated with blood
43
 Factors that Influence
Risk for Acquiring HIV
• Type and efficacy of exposure
– Depth of injury
– Size and type of needle
– Amount of blood

• HIV status of source

• Amount of virus present in the

contaminated fluid
44
 Factors that Influence
Risk for Acquiring HIV
• Types of procedures that carry a higher risk
of transmission:
– Procedures involving a needle placed in artery
or vein
– Use of invasive devices visibly contaminated
with blood
• Whether PEP is taken within the specified
time or not

Most exposures do not result in infection

45
 Case Scenario
• While assisting in surgery, Nurse A, working in
OT punctures her finger with a contaminated
suture needle; drops the needle holder with
suture needle on the sterile field and asks the
nurse B to remove her gloves

• The wound is not bleeding much, so she

"milks" the punctured finger

• Nurse B pours Betadine over the finger and

helps Nurse A to re-glove.

• She removes the needle holder from the field

and continues assisting with the surgery. 46
 Case Scenario: Questions

1. Is this appropriate management of

needle stick injuries?

2. How should the situation have been

handled?

47
 Answers

1. No. Nurse A should place the contaminated

needle into the sharps container

2. She should remove the gloves first; A should

not squeeze the wound: instead, she should
wash her hands with soap and water; A should
report the needle stick injury to the appropriate
administrative staff and follow protocols for post
exposure prophylaxis
Occupational Exposure Protocol

49
 Steps following Occupational Exposure

1. Crisis management – Remain CALM

2. Dispose the sharp appropriately
3. First aid – Wash and irrigate the site
4. Report to the appropriate authority
5. Get evaluated for PEP and baseline testing for HIV
6. PEP should be started within 2 hours of
exposure, and not later than 72 hours
7. PEP must be taken for 4 weeks (28 days)
8. Follow-up HIV testing (6w, 3m, 6m)
9. Follow-up counseling and care

Inform doctor if pregnant or breast feeding 50

 Management of Exposure:
Immediate Measures
First Aid (depending on area of exposure)

• Wound or skin: Wash with soap and water

• Mucous membrane: Flush exposed membrane with
water
• Open wound: Irrigate with sterile saline or antiseptic
solution
• Eyes: Irrigate with clean water, saline or sterile eye
irrigants
• Mouth: Do not swallow! Rinse out several times with
cold water

Remain CALM
51
Post Exposure Prophylaxis (PEP)
 Post Exposure Prophylaxis
(PEP)

It refers to the use of antiretrovirals

prophylactically to prevent HIV infection
following an occupational exposure.

53
Guidelines for PEP

54
 General Guidelines for
PEP
• Potential benefits weighed against
potential risks and informed to the staff
• Adherence and adverse effects be
monitored
• Baseline HIV test of staff with
counselling
• Follow up
– Counseling and HIV testing
– Monitor for drug toxicity
55
 Steps for
PEP
1. Assess Nature of Exposure
2. Assess HIV status of source of
exposure
3. PEP Evaluation
4. PEP Regimens - Drugs and Dosage for
PEP
5. Follow up

56
 Nature of Exposure
Category of Exposure Definition and example

Mild exposure : Mucous membrane/non-intact skin with

small volumes
E.g. : a superficial wound (erosion of the
epidermis) with a plain or low calibre
needle, or contact with the eyes or mucous
membranes, subcutaneous injections
following small-bore needles
Moderate exposure: Mucous membrane/non intact skin with large
volumes OR
Percutaneous superficial exposure with solid
needle
E.g.: a cut or needle stick injury penetrating
gloves.
Severe exposure : Percutaneous with large volume e.g. :
an accident with a high calibre needle (>=18 G)
visibly contaminated with blood;
a deep wound (haemorrhagic wound and/or
very painful);
transmission of a significant volume of blood;
an accident with material that has previously
57
been used intravenously or intra-arterially.
 HIV Status &
Source Of Exposure
Source HIV Status Definition of risk in source

HIV negative Source is not HIV infected but consider

HBV and HCV
Low risk HIV positive and clinically asymptomatic

High risk HIV positive and clinically symptomatic

(see WHO clinical staging)
Unknown Status of the patient is unknown, and
neither the patient nor his/her blood is
available for testing (e.g. injury during
medical waste management the source
patient might be unknown). The risk
assessment will be based only upon the
exposure (HIV prevalence in the
locality can be considered)
58
 PEP Evaluation
Exposure Status Of Source
HIV+ & HIV+ & HIV Status Unknown
Asymptomati Clinically
c symptomatic
Usually no PEP
Mild Guidelines
Consider 2 for PEP
Start 2 Drug OR
Drug PEP PEP Consider 2 Drug
PEP

Start 2 Drug Start 3 Drug Same As Above

Moderate
PEP PEP

Start 3 Drug Same As

Severe Same As Above
PEP Above
59
 Dosages of the Drug for PEP
Medication 2 Drug Regimen 3 Drug Regimen
Zidovudine 300 mg Twice a 300 mg Twice a day
(AZT) day
Lamivudine 150 mg Twice a
150 mg Twice a day
(3 TC) day
Guidelines for
-Ist PEP
choice:
Lopinavir/Ritonavir-400/100
mg twice a day OR 800/200
mg Once daily with meals
Protease Inhibitors -2nd choice:
Nelfinavir (NLF): 1250 mg
twice a day OR 750 mg
three times a day with
empty stomach
60
 Dosages of the Drug For PEP
Medication 2 Drug 3 Drug Regimen
Regimen

Protease Inhibitors -3rd chioce:

-Indinavir (ind) 800 mg every
8 hour and drink 6-8 litres of
N water every day

Note: If Protease inhibitor is not available and the 3 rd drug is

indicated, one can consider using Efavirenz (EFV 600 mg, once
daily). Monitoring should be instituted for side effects of this drug
e.g. CNS toxicity such as nightmares, insomnia etc.

61
 PEP Regimens Prescribed
By Health Centres
Preferred Alternative

2 drug Ist chioce: Zidovudine 2nd chioce: Stavudine

regimen (AZT)+ (d 4 T)+ Lamivudine (3
(Basic Lamivudine (3 TC) TC)
regimen)
3 drug regimen (Expanded PEP regimen)- Consult expert opinion
for starting 3 rd drug e.g. LPV/r, NLF or IND
Not Ddl+ D4t combination
Recommen NNRTI such as Nevirapine should not be used in
ded PEP

62
 Follow Up

• Follow up for Drug toxicity monitoring:

minimally CBC and LFT at baseline and at
2 weeks.

• Repeat HIV testing of exposed staff as per

protocol ( 3 weeks-3month-6months)

63
 Requirements for the
PEP Programme
• Access to clinicians during all hours

• Easily accessible antiretroviral agents for PEP

– On-site or available within 24 hours

• Availability of trained personnel for counseling

• Display PEP protocols around clinic

• Conduct regular protocol trainings for all

employees to keep them updated
64
Key Points
 Key Points

• Standard precautions must be followed for

ALL patients
• Use of standard precautions could reduce the
risk of blood borne and airborne infections
• Nurse’s have a key role in
– Following standard precaution protocols
– Educating other health care personnel
– Preventing occupational exposure
– Protecting self and others from blood borne
pathogens including HIV
66
 Key Points

• PEP significantly reduces the risk of HIV

transmission from occupational exposure

• Existing PEP protocols should be followed

• Ideally PEP should be given within 2 hours

and not later than 72 hours after exposure

• Exposed health care providers should be

monitored for side effects and adherence67
Thank You!