Re: Saudi Arabia: 3 cases, 2 deaths due to novel animal coronavirus
Re: Saudi Arabia: 3 cases, 2 deaths due to novel animal coronavirus
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[FONT=Arial,Bold]INFECTION CONTROL ADVICE
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[FONT=Arial,Bold]SUSPECTED OR CONFIRMED NOVEL[/FONT]
[FONT=Arial,Bold]CORONAVIRUS CASES[/FONT]
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[FONT=Arial,Bold]Infection Control Advice: Suspected or Confirmed Novel[/FONT]
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Coronavirus Cases : Version 1.1 September 25 2012[/FONT]
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http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317136232722[/FONT]
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[Source: Health Protection Agency, United Kingdom, full PDF document: (
LINK). Edited.]
INFECTION CONTROL ADVICE SUSPECTED OR CONFIRMED NOVEL CORONAVIRUS CASES
This document outlines infection control and other general advice for personnel who may be involved in receiving and caring for patients, primarily within healthcare settings, who may be infected with a novel coronavirus. It should be used in conjunction with local policies.
In the absence of effective drugs or a vaccine, control of this disease relies on the appropriate management of cases, (including isolation of suspected and confirmed cases) and their close contacts. In preparation, healthcare facilities who may receive and care for any cases should:
Review their local policies and ensure that operational procedures are described and staff are familiar with them, for example where personal protective equipment is stored and how it should be used Ensure staff are aware of how to access surveillance forms from the HPA and any local record sheets etc Ensure that adequate supplies/equipment are available, including:
- supplies of FFP3 respirators
- Gloves - disposable and latex free alternatives, eg nitrile
- Gowns/Aprons - disposable fluid resistant full sleeve gowns and single-use plastic aprons
- Eye protection eg. tight fitting goggles or face shield - disposable, or if non disposable, with a wipeable surface, not with elastic straps
- Leak-proof, clinical waste disposal bags,
- Hand hygiene supplies.
- General-purpose detergent and disinfectant solutions Ensure that staff are aware of where a case will be isolated and the need for a negative pressure room Ensure that there is guidance available on actions to be taken if a case presents
Introduction
Coronaviruses are mainly transmitted by large respiratory droplets and direct or indirect contact with infected secretions. They can also be detected in faeces and urine and under certain circumstances airborne transmission can occur from aerosolised respiratory secretions and faecal material. As coronaviruses are enveloped a very wide range of disinfectants would be effective. Personal protective equipment and good infection control can be extremely useful but never completely eliminate risk as they are user dependent.
Record keeping: A record of all staff that have contact with a suspected/confirmed patient should be kept
Isolation Patients: who meet the current HPA case definition and present at the Emergency Department should be placed in a single room whilst awaiting assessment. Staff should wear protective clothing as detailed below. Rooms to be appropriately decontaminated before being used again (see below: Cleaning)
Patients requiring admission should be admitted directly to negative-pressure single rooms. If this is not possible then a single room with en-suite facilities should be used. Positive pressure single rooms should not be used . Room doors should be kept closed. If on a critical care unit, nurse patient in a negative pressure room where available, or if not available, a neutral pressure side room with closed ventilator circuit should be used Suitable written information must be placed on the isolation room door indicating the need for respiratory and enteric isolation, though there will be a need to respect patient confidentiality Essential staff only should enter the isolation room.
Protective clothing
To be worn by ALL staff and visitors entering the room (see appendix 1: putting on and removing personal protective equipment)
Long sleeved fluid-repellent disposable gown ? consideration to wearing scrubs underneath would obviate problems with laundering of uniforms and other clothing
Non-sterile surgical gloves
An FFP3 respirator conforming to EN149:2001 to be worn by all personnel carrying out clinical care or in the room during aerosol generating procedures. Fit testing should be undertaken before using this equipment. Healthcare workers should fit-check a respirator every time one is used
Goggles/visor (prescription glasses do not provide adequate protection against droplets, sprays and splashes)
It is vital that the protective clothing above is worn for all airway management including intubation
Equipment
Use dedicated equipment in the isolation room
Dispose of single use equipment as clinical waste inside room
Reuseable equipment should be avoided if possible. If used, disinfect according to manufacturer?s instructions
Ventilators should be protected with a high efficient filter eg BS EN 13328-1, and standard decontamination procedures followed
Closed system suction should be used
Crockery should be treated as normal and washed in a dishwasher
Use of equipment that re-circulates air (eg fans) should not be used as this has the potential to turn a negative pressure room into a positive pressure room.
Hand hygiene
Essential before and after all patient contact, removal of protective clothing and cleaning of the environment
Use soap and water or use alcohol hand rub if hands are socially clean Rings (other than a plain smooth band), wrist watches and wrist jewellery must not be worn by staff
Linen
Bag linen inside single room - do not carry through ward/department
Linen should be bagged in accordance with procedures for infected linen and the laundry informed of the high-risk nature
Waste
Dispose of all waste as clinical waste; in particular ensure the appropriate disposal of faeces and urine Waste to be handled as per local policy
Visitors
The number of visitors should be restricted Visitors entering the isolation room must wear protective clothing as previously detailed. Visitors should be trained in the appropriate use of protective clothing and hand hygiene
A log of all visitors should be kept
Transfers to other departments
Where possible, all procedures and investigations should be carried out in the single room. A minimal number of staff should be present in the room during any procedures
Only if clinical need dictates should patients be transferred to other departments in conjunction with the infection control team, and the following procedures then apply:
- The department must be informed in advance
- The patient must be taken straight to and from the investigation/treatment room, and must not wait in a communal area.
- Ideally patients should be at the end of a list to allow appropriate decontamination after any procedure.
- The patient should wear a 'surgical ' mask if this can be tolerated - this will prevent large droplets being expelled into the environment by the wearer.
- Portering and escort staff need not wear masks during transit if the patient is able to wear a mask.
- Gloves and gowns should be worn for direct contact with the patient.
- The trolley/chair should be cleaned with a suitable agent after use
- Staff carrying out procedures must wear the protective clothing indicated above.
- The treatment/procedure room and all equipment should be cleaned
- Coronaviruses are enveloped RNA viruses and are therefore susceptible to disinfection methods. It is, however, possible that they can survive in the environment for up to 24hrs, so environmental decontamination is vital.
Transfer to other institutions
Transfer of cases to another hospital should be avoided unless it is necessary for medical care
Patients should not be transferred solely for the purpose of accommodation in a negative pressure room
If transfer is essential, the Infection Control Team at the receiving hospital and the ambulance staff must be advised in advance of the special circumstances of the transfer
Medical procedures
Procedures that produce aerosols of respiratory secretions, eg bronchoscopy, induced sputum, positive pressure ventilation via a face mask, intubation and extubation, and airway suctioning carry an increased risk of transmission and where these procedures are medically necessary, they should be undertaken in a negative pressure room if available or in a single room. The minimum number of required staff should be present and all staff present in the room must wear personal protective equipment (PPE) as described above including goggles/visor. Entry and exit from the room should be minimised during the procedure. The large particles will fall out within seconds. The small aerosol particles will behave almost as a gas. Clearance of any aerosol is dependent on the ventilation of the room.
In hospitals this is usually around 12-15 air changes per hour and so after about 20 minutes, there would be less than 1 per cent of the starting level (assuming cessation of aerosol generation).
Coronaviruses are enveloped and a very wide range of disinfectants are effective.
Critical care
All respiratory equipment must be protected with a high efficient filter eg BS EN 13328-1, Disposable respiratory equipment should be used wherever possible. Re-usable equipment must at a minimum be disinfected in accordance with manufacturers' instructions
The ventilator circuit should not be broken unless absolutely necessary
Ventilators must be placed on standby when carrying out bagging
Protective clothing as detailed above to be worn
The use of non-invasive positive pressure ventilation equipment carries with it an increased risk of transmission of infection
Water humidification should be avoided and a heat and moisture exchanger should be used if possible
Only essential staff should be in the patient's room when airway management, cough inducing activities or nebulisation of drugs is being carried out
Theatres
Theatres must be informed in advance
The patient should be transported directly to the operating theatre and should wear a surgical mask
The patient should be anaesthetised and recovered in the theatre
Staff should wear protective clothing as detailed above
Disposable anaesthetic equipment should be used wherever possible
Re-usable anaesthetic equipment should be decontaminated in line with manufacturers? instructions
The anaesthetic machine must be protected by a filter with viral efficiency to 99.99%
Instruments and devices should be decontaminated in the normal manner.
Instruments must be transported safely
The theatre should be cleaned as per local policy
Theatres should not be used for 15 minutes after the patient leaves if conventionally ventilated or 5 minutes if ultraclean ventilation used
Cleaning
Domestic staff must be made aware of the need for additional precautions and be trained in these
Daily cleaning should be carried out and enhanced cleaning of frequent hand touch surfaces
Domestic staff to wear protective clothing as indicated above
The isolation area should be cleaned after the rest of the ward area
Dedicated or disposable equipment must be used for cleaning
Cleaning equipment must be decontaminated following use
Staff
The use of bank or agency staff should be avoided wherever possible
Staff must comply with all infection control procedures as detailed above
A record of all staff caring for the patient must be maintained (record sheet at appendix I). The record sheet should be placed at the door and all staff entering must complete this. All HCW should be vigilant for any respiratory symptoms in the seven days following last exposure to a case and should not come to work if they have a fever or cough. Advice should be sought from their infection control team/occupational health department as per the local policy. During this period, possibly infected workers should avoid close contact with persons both in the hospital and in the general community. They should contact their hospital infection control team and /or local HPU for advice on where they should be medically assessed.
Specimens
All specimens must be treated as biohazard
- Label with biohazard label
- Mark request form accordingly
- Double bag Specimens will be handled as Containment Level 3
Contact tracing
Follow up of contacts of patients will be co-ordinated by the local Health Protection Unit
Follow up of staff contacts of patients will be co-ordinated by the Occupational Health Department
Last offices
Carry out last offices using the protective clothing and medical procedures identified above. A body bag should be used
Mortuary staff and funeral directors must be advised of the biohazard risk
Summary of advice
If a patient fitting the case definition for suspected coronavirus is admitted, infection control personnel should be notified immediately. In addition to standard precautions, infection control measures for inpatients should include:
- Airborne precautions, eg
- Either an isolation room with negative pressure relative to the surrounding area or a single room with own bathroom and toilet facilities
- Use of FFP3 respirators conforming to EN 149:2001 for persons entering the room. Fit testing should be undertaken prior to using this equipment. Contact and droplet precautions (including use of long sleeve fluid repellent gown and latex or similar non-latex gloves with long tight-fitting cuffs for contact with the patient or their environment). Standard precautions to include careful attention to hand washing and hygiene. When caring for patients, clinicians should wear eye protection for all patient contact. Contact local Infection Control Team for advice. Standard precautions when handling any clinical waste, which must be placed in leak-proof clinical waste bags or bins and disposed of safely. Laundry should be classified as infected. It is not necessary to use disposable crockery or cutlery
Appendix 1
Putting on and removing personal protective equipment
Putting on PPE - The level of PPE used will vary according to the procedure being carried out, and not all items of PPE will always be required. PPE should be put on before entering a side room. If full PPE is required, for example for a potentially infectious aerosol generating procedure, all staff in the room or entering within one hour of the procedure should wear the following PPE put on in the following order:
- Gown
- FFP3 respirator
- Eye protection, i.e. goggles or face shield
- Disposable gloves.
The order given above is practical but the order for putting on is less critical than the order of removal given below.
Removal of PPE - PPE should be removed in an order that minimises the potential for cross-contamination. Before leaving the side room gloves, gown and eye protection should be removed (in that order, where worn) and disposed of as clinical (also known as infectious) waste. After leaving the area, the respirator can be removed and disposed of as clinical waste.
Guidance on the order of removal of PPE is as follows:
- Gloves Grasp the outside of the glove with the opposite gloved hand; peel off. Hold the removed glove in gloved hand. Slide the fingers of the ungloved hand under the remaining glove at the wrist. Peel the second glove off over the first glove and discard appropriately.
- Gown: Unfasten or break ties. Pull gown away from the neck and shoulders, touching the inside of the gown only. Turn the gown inside out, fold or roll into a bundle and discard.
- Eye protection: To remove, handle by headband or earpieces and discard appropriately.
- Respirator - Untie or break bottom ties, followed by top ties or elastic, and remove by handling ties only and discard appropriately.
To minimise cross-contamination, the order outlined above should be applied even if not all items of PPE have been used.
Clean hands thoroughly immediately after removing all PPE.
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