CDST_LT: General concepts in IPC

Infection prevention and control (IPC) practices are important in maintaining a safe environment for everyone by reducing the risk of the potential spread of disease.

IPC is a practical, evidence-based approach which prevents patients and health workers from being harmed by avoidable infection. It is relevant to health workers and patients at every single health-care encounter.

Biosafety measures along with Universal Precautions like hand hygiene, personal protective equipment, safe injections, respiratory hygiene and cough etiquette is important in IPC to address the safe handling and containment of infectious microorganisms and hazardous biological materials.

IPC is essential in TB as:

1. specific population groups have a higher risk of acquiring TB infection and progressing to disease once infected; these groups include people living with HIV, health workers and others in settings with a high risk of transmission of M. tuberculosis

2. incident cases of TB among children (aged <15 years) reflect ongoing community transmission

3. primary person-to-person transmission of drug-resistant TB (as opposed to acquired resistance) is the dominant mechanism sustaining the global transmission of drug-resistant TB

4. to prevent TB transmission, interventions are needed that reduce the concentration of infectious particles in the air and the exposure time of susceptible individuals

Resources

1. Guidelines on Airborne Infection Control in Healthcare and Other Settings.

2. WHO guidelines on tuberculosis infection prevention and control 2019 update (https://apps.who.int/iris/bitstream/handle/10665/311259/9789241550512-e…)

• Standard precautions are a group of infection control practices to reduce the risk of transmission of pathogens.
• These are based on the principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain
  transmissible infectious agents.
• Standard precautions are applicable to all patients in all healthcare settings and combine the major features of universal precautions, body substance isolation, and airborne precautions.
• Implementation of standard precautions is based on risk assessment in all healthcare activities.

Image

Figure: Elements of Standard Precautions; Source: Guidelines on Airborne Infection Control in Healthcare and Other Settings

Resources

1. Guidelines on Airborne Infection Control in Healthcare and Other Settings
2. Health-care facility recommendations for standard precaution

Hand hygiene is one of the most important elements of infection control. The aim of hand washing is to remove transient micro-organisms, acquired through everyday tasks in the laboratory/ clinical setting, from the surface of the hands.

Good hand hygiene protects both patients and staff.

The World Health Organization (WHO) guidelines on “Hand Hygiene in Healthcare” describe five key situations where hand washing is required:

• Before touching a patient
• Before a clean or aseptic procedure
• After body fluid exposure/risk
• After touching a patient
• After touching patient surroundings

Hand hygiene includes hand washing using soaps or hand rubbing with 70% alcohol-based formulations.

Important Considerations for Hand Hygiene

• Perform hand washing with soap and water if hands are visibly soiled and after using the restroom.
• Availability of running water supply is important for hand washing.
• If resources permit, perform hand rubbing with an alcohol-based preparation.
• Ensure availability of hand hygiene products (clean water, soap, single-use clean towels, alcohol-based hand rub).
• Alcohol-based hand rubs should ideally be available at the point of care.

Technique of Hand Hygiene (Figure)

• Handwashing (40–60 sec): Wet hands and apply soap; rub all surfaces; rinse hands and dry thoroughly with a single-use towel.
• Hand rubbing (20–30 sec): Apply enough product to cover all areas of the hands; rub hands until dry

Figure: Handwashing Technique; Source: WHO Handwashing Poster

Resources

1. Guidelines on Airborne Infection Control in Healthcare and Other Settings.
2. Health-care facility recommendations for standard precaution.
3. WHO Handwashing Poster.

Respiratory hygiene is vital to prevent the spread of TB via aerosols and person-to-person transmission.

Respiratory hygiene includes:

• Covering the nose/mouth with a tissue when coughing/sneezing and appropriate disposal of used tissues

  • If tissues are not available, cough or sneeze into the inner elbow (upper sleeve) rather than into the hand
• Keeping contaminated hands away from the mucous membranes of the eyes and nose.
• Carrying out hand hygiene after contact with respiratory secretions and contaminated objects/materials
• Using appropriate Personal Protective Equipment (PPE) during aerosol generating procedures
  • Use PPE including gloves, long-sleeved gowns, eye protection (goggles or face shields), and facial mask (or respirators) during aerosol-generating procedures 

Figure: Respiratory hygiene (Ministry of Ayush, https://twitter.com/moayush/status/1243852404640153601)

Resources

1. Guidelines on Airborne Infection Control in Healthcare and Other Settings
2. Infection Prevention and Control of Epidemic- and Pandemic-Prone Acute Respiratory Infections in Health Care
3. Ministry of Ayush, https://twitter.com/moayush/status/1243852404640153601

Assessment

Guidelines for Laboratory Cleaning

• All personnel should don appropriate Personal Protective Equipment (PPE) prior to cleaning the facility.
• Laboratory personnel should perform all daily housekeeping routines within the TB laboratories, including trash removal. Cleaning staff should only enter the laboratories under the supervision of the laboratory staff.
• All the cleaning and decontamination procedures in the TB containment laboratory should be performed only by trained laboratory staff.
• Work surfaces are decontaminated when work is finished, at the end of every workday, and immediately after any spill of viable material.
• Large equipment, such as incubators and centrifuges, will have inner and outer surfaces damp-wiped with disinfectant on a routine basis.
• Sinks in the laboratories should be cleaned and flushed with agent appropriate disinfectants
• The floor of the TB containment laboratory should be thoroughly and routinely wiped down with a suitable chemical decontaminant, and workspaces that do not get daily attention should be disinfected
• Solid waste should be decontaminated by autoclaving prior to removal from the facility and disposed off by authorized personnel

Unidirectional Flow of Cleaning

• There should be an effective separation of various sections and activities of the lab to prevent cross-contamination.
• Unidirectional flow of cleaning should be maintained in specific areas.
• Cleaning items, such as mops, buckets and brushes, used in dirty areas of the laboratory should never be used in the cleaner areas.

Good Laboratory Practices to Keep Laboratories Clean and Clutter-free

• Floors and work surfaces should be kept as free of clutter as possible.
• Materials should be stored in closed cupboards, where possible.
• Excess reagents should be boxed, labelled and stored in the storeroom.
• Check spill kit contents on a monthly basis. The fresh disinfectant must be prepared each week.
• Record in the 'Laboratory Cleaning and Maintenance Logbook'.

​Resources 

• WHO TB Lab Safety Manual, 2012, p18-19.
• WHO Lab Biosafety Manual, 3rd ed., p82-90.
   

The following work practices are recommended to ensure that microscopy laboratory technicians are not exposed to aerosols from sputum specimens.

1. Administrative Control at DMC

• The layout and design of the DMCs should include natural ventilation, mechanical ventilation (exhaust fan) and unidirectional airflow.
• The sputum collection area should be separated from the laboratory.
• Provisions for biomedical waste management in deep burial pits, sharps pits or appropriate disposal via the health facility biomedical waste management system.

2. Environment Control at DMC 

• Doors and windows should be kept open for air exchanges.
• Sputum must be collected in a well-ventilated area with direct sunlight. It should not be collected inside the laboratories, toilets, waiting rooms, reception rooms, or any other enclosed space.

3. Personnel Level Control at DMC 

• Laboratory technicians should wear laboratory coats, gloves and masks when handling sputum containers and during smear preparation and staining.
• Smears should be prepared in a well-ventilated environment near an open flame.
• Work benches should be cleaned daily with disinfectants.
• Sputum containers, applicator/ broomsticks, and used slides should be disinfected with 5% Phenol overnight before discarding.

Resources

• Guidelines on Airborne Infection Control in Healthcare and Other Settings, 2010.

Commitment at national, state and district level are required to support and facilitate the implementation of Infection Prevention and Control (IPC) measures.

The important stakeholders in IPC include:

National Airborne Infection Control Committee (NAICC) has been constituted to provide for a multi-lateral national level coordinating body, to develop national guidelines on IPC, and provide technical guidance for their implementation, evaluation, and revisions.

Composition of NAICC

NAICC has representatives from Central TB Division, Medical college, State TB Programme representatives, Directorate General of Health Services, Central Design Bureau, National Institutes, Civil society representatives and other relevant agencies

A State Airborne Infection Control Committee (SAICC) should be established for adoption and integration of the national guidelines on airborne infection control in health care and other settings in the hospital infection control plans of various health care facilities in the states

Composition of SAICC

SAICC has representatives from Mission Director, National Rural Health Mission, Director Health Services (Nodal Officer), Director Medical Education and Research, State TB Officer, Project Director-SACS, State Task Force for Medical Colleges, Representative of IMA (State Body), Architects and Engineers from State PWD, Representative of State Pollution Control Board, NGO / CBO

The airborne infection control activities at the district level should be coordinated and undertaken by the Sub-Committee on Biomedical Waste Management / Infection Control (SC-BMW/IC) under the District Health Society (DHS). They should function under guidance and close coordination with the SAICC, State Health Society and with the TB Sub-Committee under DHS (NRHM).

Composition of SC-BMW/IC

SC-BMW/IC has representatives from Medical College / District Hospital, Representative of Pollution Control Board Office at the district, Director, Nursing Administration and Training or equivalent, Representative of IMA (Local Body) / NGO / CBO

The Hospital infection control committee (HICC) is an integral component of the IPC programme of the health care facility.

The main functions of HICC include:

1. Establish the IPC programme in the health care facility, develop action plan for strengthening IPC measures for the facility and individual units within the facility with priorities based on the risk assessment

2. Constitute an infection control team to oversee IPC implementation in the facility

3. Review and revise annually infection control guidelines with policies, recommendations and working protocols with standard precautions, hand hygiene, cleaning and decontamination, disinfection and sterilization as key components

4. Organize training programmes on recommendations of the guidelines and IPC practices for staff

5. Develop an antibiotic policy and antibiotic stewardship programme

6. Conduct surveillance of antimicrobial resistance, monitor trends in hospital acquired infections (HAI), investigate outbreaks of HAIs

7. Evaluate the effectiveness of interventions for IPC, analyze the surveillance data and identify at-risk patients. Take appropriate action and implement recommendations where necessary

8. Conduct audits and quality control of IPC activities, ensure compliance with recommendations

9. Help control environmental risks for infection by liaising with appropriate departments such as healthcare waste management, provision of safe water (testing of water sources), pharmacy, housekeeping services, laundry and kitchen services

Resources

Guidelines on Airborne Infection Control in Healthcare and Other Settings.

National Guidelines for Infection Prevention and Control in Healthcare Facilities (https://www.mohfw.gov.in/pdf/National%20Guidelines%20for%20IPC%20in%20H…)

Disinfectants used in lab settings include:

1% Sodium Hypochlorite

• Broad spectrum antimicrobial action
• Used to disinfect surfaces
• Used to disinfect infectious material and disposal of used Truenat consumables (reagent bottles, cartridges, tips, chips) 
• Hazardous and corrosive, to be used with care
• Is highly alkaline so can corrode metal
• Waste soaked in Sodium Hypochlorite should not be discarded by autoclaving. 

70% Alcohol

• Bactericidal action
• Used for surface decontamination only
• Highly inflammable; keep away from fire
• Used to disinfect biosafety cabinets, laboratory benches and surface of instruments.

5% Phenol

• Used for decontaminating Cartridge-based Nucleic Acid Amplification Testing (CBNAAT) equipment and single-use items like CBNAAT cartridges prior to disposal
• Highly irritating to the skin, eyes and mucous membranes.

Preparation of these disinfectants is described below.

Preparation of 1% Sodium Hypochlorite

• Use commercially available 4% sodium hypochlorite solution.
• Dilute with distilled water to prepare required amount of 1% sodium hypochlorite
  • E.g.: To prepare 100 ml of 1% sodium hypochlorite: 75 ml distilled water plus 25 ml 4% sodium hypochlorite solution.
• Sodium hypochlorite solutions (domestic bleach) contain 50 g/l available chlorine, and should therefore be diluted to 1:50 or 1:10 in water to obtain the final concentrations of 1 g/l or 5 g/l when used as a general-purpose disinfectant for TB laboratories.
• To be prepared fresh.

Preparation of 70% Alcohol

• Use commercially available absolute alcohol.
• Dilute with distilled water to prepare the required amount of 70% alcohol
  • E.g.: To prepare 100 ml of 70% alcohol: 70 ml absolute alcohol plus 30 ml distilled water.

Preparation of 5% Phenol

• Melt 5 g of phenol by heating it.
• Dissolve in 100 ml distilled water.

Video : Preparation of TB Lab Disinfectants

Resources

• Tuberculosis Laboratory Biosafety Manual