Training Kit for Pandemic Influenza

1. Training Kit for Pandemic Influenza

2. Unit 6 - Infection Control Measures Slide 6- 2 By the end of this unit, you will be familiar with : infection control precautions for Flu Pandemic specific infection control precautions in clinic, outreach situations and Non-Emergency Ambulance Transfer Services HA infection control policy on Flu Pandemic

3. Unit 6 - Infection Control Measures Slide 6- 3 Recommendation for all individuals with respiratory symptoms Cover the nose/mouth when coughing or sneezing Perform hand hygiene if contact respiratory secretions and contaminated objects Put on a surgical mask A proper personal hygiene is important all the time and especially during Flu seasons. All persons including healthcare workers, visitors, patients, volunteers in the hospitals with respiratory symptoms are recommended and encouraged to take respiratory hygiene and cough etiquette precaution to control transmission of respiratory infections. Precautions of respiratory hygiene and cough etiquette include: Cover nose and mouth when coughing or sneezing Use tissue paper to contain respiratory secretions and dispose of them in waste basket Perform hand hygiene after having contact with respiratory secretions and contaminated objects Put on a surgical mask when respiratory signs and symptoms develop. Do not touch the external surface of mask. Reference: Centers for Disease Control and Prevention. (2004). Fact Sheet on Respiratory hygiene and cough etiquette in Healthcare Settings. Retrieved September 30, 2005, from http://www.cdc.gov/flu/professionals/pdf/resphygiene.pdf A proper personal hygiene is important all the time and especially during Flu seasons. All persons including healthcare workers, visitors, patients, volunteers in the hospitals with respiratory symptoms are recommended and encouraged to take respiratory hygiene and cough etiquette precaution to control transmission of respiratory infections. Precautions of respiratory hygiene and cough etiquette include: Cover nose and mouth when coughing or sneezing Use tissue paper to contain respiratory secretions and dispose of them in waste basket Perform hand hygiene after having contact with respiratory secretions and contaminated objects Put on a surgical mask when respiratory signs and symptoms develop. Do not touch the external surface of mask. Reference: Centers for Disease Control and Prevention. (2004). Fact Sheet on Respiratory hygiene and cough etiquette in Healthcare Settings. Retrieved September 30, 2005, from http://www.cdc.gov/flu/professionals/pdf/resphygiene.pdf

4. Unit 6 - Infection Control Measures Slide 6- 4 Modes of transmission of Influenza Human influenza Large respiratory droplets 1. Human influenza is thought to transmit primarily via large respiratory droplets. 2. However for avian influenza virus, the exact modes of transmission is uncertain Reference: Reference: HA Infection Control Plan for Avian Influenza Feb 2006 1. Human influenza is thought to transmit primarily via large respiratory droplets. 2. However for avian influenza virus, the exact modes of transmission is uncertain Reference: Reference: HA Infection Control Plan for Avian Influenza Feb 2006

5. Unit 6 - Infection Control Measures Slide 6- 5 Isolation precautions for Human influenza Standard Droplet Standard and droplet precautions are recommended for care of patients with human influenza. References: Centers for Disease Control and Prevention. (2004). Influenza (Flu) Interim Recommendations for Infection Control in Healthcare Facilities Caring for Patients with Known or Suspected Avian Influenza. Retrieved September 30, 2005, from http://www.cdc.gov/flu/avian/prefessional/infect-control.htm World Health Organization. (2004). Influenza A (H5N1): WHO Interim Infection Control Guidelines for Health Care Facilities. Retrieved September 30, 2005, from http://www.who.int/csr/disease/avian_influenza/guidelines/Guidelines_for_health_care_facilities.pdf Standard and droplet precautions are recommended for care of patients with human influenza. References: Centers for Disease Control and Prevention. (2004). Influenza (Flu) Interim Recommendations for Infection Control in Healthcare Facilities Caring for Patients with Known or Suspected Avian Influenza. Retrieved September 30, 2005, from http://www.cdc.gov/flu/avian/prefessional/infect-control.htm World Health Organization. (2004). Influenza A (H5N1): WHO Interim Infection Control Guidelines for Health Care Facilities. Retrieved September 30, 2005, from http://www.who.int/csr/disease/avian_influenza/guidelines/Guidelines_for_health_care_facilities.pdf

6. Unit 6 - Infection Control Measures Slide 6- 6 CDC Recommendations for known or suspected Avian Flu (2004) Respiratory hygiene and cough etiquette For all patients with fever and respiratory symptoms Standard precautions Hand hygiene before and after patient contact or contaminated items Contact precautions Glove and gown for all patient contact Eye protection Wear when within 3 feet of the patient Airborne precautions Negative pressure isolation room N95 respirator However, stringent precautions for health-care workers involved in the care of patients with documented or suspected cases may be prudent because of high mortality of the disease and the possibility of the virus mutating to cause efficient human-to-human transmission. Please refer to slide 5-4 for signs and symptoms. The specific isolation precautions for Avian Flu recommended by CDC includes: Respiratory hygiene and cough etiquette should be implemented for all patients with fever and respiratory symptoms. They should also be questioned regarding recent travel history in the last 7 days. (refer to slide 6-3) Implement standard precautions including hand hygiene before and after all patient contact or items potentially contaminated with respiratory secretions. Wear gloves and gown for all direct patient contact Wear goggle/face shield when within 3 feet of the patients. Place suspected and confirmed patients in negative pressure isolation rooms. Wear N95 respirator when entering these isolation rooms. Reference: Centers for Disease Control and Prevention. (2004). Influenza (Flu) Interim Recommendations for Infection Control in Healthcare Facilities Caring for Patients with Known or Suspected Avian Influenza. Retrieved September 30, 2005, from http://www.cdc.gov/flu/avian/prefessional/infect-control.htm However, stringent precautions for health-care workers involved in the care of patients with documented or suspected cases may be prudent because of high mortality of the disease and the possibility of the virus mutating to cause efficient human-to-human transmission. Please refer to slide 5-4 for signs and symptoms. The specific isolation precautions for Avian Flu recommended by CDC includes: Respiratory hygiene and cough etiquette should be implemented for all patients with fever and respiratory symptoms. They should also be questioned regarding recent travel history in the last 7 days. (refer to slide 6-3) Implement standard precautions including hand hygiene before and after all patient contact or items potentially contaminated with respiratory secretions. Wear gloves and gown for all direct patient contact Wear goggle/face shield when within 3 feet of the patients. Place suspected and confirmed patients in negative pressure isolation rooms. Wear N95 respirator when entering these isolation rooms. Reference: Centers for Disease Control and Prevention. (2004). Influenza (Flu) Interim Recommendations for Infection Control in Healthcare Facilities Caring for Patients with Known or Suspected Avian Influenza. Retrieved September 30, 2005, from http://www.cdc.gov/flu/avian/prefessional/infect-control.htm

7. Unit 6 - Infection Control Measures Slide 6- 7 In HA hospitals, isolation precautions should be implemented to break the transmission of infections. The elements includes hand hygiene, PPE, patient placement, decontamination, waste management, linen and laundry, and patient transport. Each of them will be discussed in the following presentation. Reference: HA Infection Control Plan for Avian Influenza Feb 2006 In HA hospitals, isolation precautions should be implemented to break the transmission of infections. The elements includes hand hygiene, PPE, patient placement, decontamination, waste management, linen and laundry, and patient transport. Each of them will be discussed in the following presentation. Reference: HA Infection Control Plan for Avian Influenza Feb 2006

8. Unit 6 - Infection Control Measures Slide 6- 8 Perform hand hygiene:� After touching blood, body fluid, excretions, secretions, mucus membranes, non-intact skin, contaminated items and environment Before touching face Before leaving wards and hospital/clinics After removal of gloves Before and after patient contact Alternatively, use alcohol-based handrub when hands are not visibly soiled Hand hygiene Handwashing is the single most important procedure for preventing the spread of communicable diseases. After touching blood, body fluid, excretions, secretions, mucus membranes, non-intact skin, contaminated items and environment Before touching face, (esp. the eyes, nose and mouth) Before leaving wards and hospitals/clinics, e.g. off duty, take meals Promptly after gloves are removed Before and after patient contact Alcohol based handrub can be used when hands are not visibly soiled References: Centers for Disease Control and Prevention. (2002). Guideline for hand Hygiene in Health Care Settings. Retrieved September 30, 2005, from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm Department of Health. (2001). Guidelines for good handwashing. Retrieved September 30, 2005, from http://www.info.gov.hk/dh/diseases/handwash.html HA Infection Control Plan for Avian Influenza Feb 2006 Hand hygiene Handwashing is the single most important procedure for preventing the spread of communicable diseases. After touching blood, body fluid, excretions, secretions, mucus membranes, non-intact skin, contaminated items and environment Before touching face, (esp. the eyes, nose and mouth) Before leaving wards and hospitals/clinics, e.g. off duty, take meals Promptly after gloves are removed Before and after patient contact Alcohol based handrub can be used when hands are not visibly soiled References: Centers for Disease Control and Prevention. (2002). Guideline for hand Hygiene in Health Care Settings. Retrieved September 30, 2005, from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm Department of Health. (2001). Guidelines for good handwashing. Retrieved September 30, 2005, from http://www.info.gov.hk/dh/diseases/handwash.html HA Infection Control Plan for Avian Influenza Feb 2006

9. Unit 6 - Infection Control Measures Slide 6- 9  PPE - Gloves When expose to blood, body fluid, secretion, excretions, mucous membrane and non-intact skin, and contaminated items Perform hand hygiene immediately after glove removal Personal Protective Equipment - Gloves The primary design of personal protective equipment (PPE) is to protect healthcare workers (HCWs) and reduce opportunities for transmission of microorganisms in Healthcare facilities. Gloves Wear gloves when the procedure may expose to blood, body fluid, secretion, excretions, mucous membrane and non-intact skin, and contaminated items Change gloves after contact with material that may contain a high concentration of microorganisms, e.g. it may happen between tasks and procedures on the same patient Wash hands immediately after gloves are removed. Do not disinfect clean gloves after donning and disposable gloves should not be reused References: Centers for Disease Control and Prevention. (1996). Guidelines for Isolation Precautions in Hospitals Hospital Infection Control Advisory Committee. Retrieved September 30, 2005, from http://wonder.cdc.gov/wonder/prevguid/p0000419/p0000419.asp HA Infection Control Plan for Avian Influenza Feb 2006 Personal Protective Equipment - Gloves The primary design of personal protective equipment (PPE) is to protect healthcare workers (HCWs) and reduce opportunities for transmission of microorganisms in Healthcare facilities. Gloves Wear gloves when the procedure may expose to blood, body fluid, secretion, excretions, mucous membrane and non-intact skin, and contaminated items Change gloves after contact with material that may contain a high concentration of microorganisms, e.g. it may happen between tasks and procedures on the same patient Wash hands immediately after gloves are removed. Do not disinfect clean gloves after donning and disposable gloves should not be reused References: Centers for Disease Control and Prevention. (1996). Guidelines for Isolation Precautions in Hospitals Hospital Infection Control Advisory Committee. Retrieved September 30, 2005, from http://wonder.cdc.gov/wonder/prevguid/p0000419/p0000419.asp HA Infection Control Plan for Avian Influenza Feb 2006

10. Unit 6 - Infection Control Measures Slide 6- 10 PPE - Gown 1. When splashes or sprays of blood and body fluid, secretion and excretions to skin and working clothes are likely 2. When working clothes has substantial contact with patient, environmental surfaces or patient items Personal Protective Equipment - Gown A gown is used to prevent contamination of skin or working clothes Gown Wear a gown to protect skin and to prevent soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions When the working clothes has substantial contact with the patients, patient equipment and environment in contact precautions. Gowns should be selected according to the amount of fluid encountered to ensure adequate protection. References: Centers for Disease Control and Prevention. (1996). Guidelines for Isolation Precautions in Hospitals Hospital Infection Control Advisory Committee. Retrieved September 30, 2005, from http://wonder.cdc.gov/wonder/prevguid/p0000419/p0000419.asp HA Infection Control Plan for Avian Influenza Feb 2006 Wong, T. K. S., Chung, J. W. Y., Li ,Y., Chan, W. F., Ching, P. T. Y., Lam, C. H. S., Chow, C. B., Seto, W. H. (2004). Effective personal protective clothing for health care workers attending patients with severe acute respiratory syndrome. American Journal of Infection Control, 32(2), 90-96. Personal Protective Equipment - Gown A gown is used to prevent contamination of skin or working clothes Gown Wear a gown to protect skin and to prevent soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions When the working clothes has substantial contact with the patients, patient equipment and environment in contact precautions. Gowns should be selected according to the amount of fluid encountered to ensure adequate protection. References: Centers for Disease Control and Prevention. (1996). Guidelines for Isolation Precautions in Hospitals Hospital Infection Control Advisory Committee. Retrieved September 30, 2005, from http://wonder.cdc.gov/wonder/prevguid/p0000419/p0000419.asp HA Infection Control Plan for Avian Influenza Feb 2006 Wong, T. K. S., Chung, J. W. Y., Li ,Y., Chan, W. F., Ching, P. T. Y., Lam, C. H. S., Chow, C. B., Seto, W. H. (2004). Effective personal protective clothing for health care workers attending patients with severe acute respiratory syndrome. American Journal of Infection Control, 32(2), 90-96.

11. Unit 6 - Infection Control Measures Slide 6- 11 Surgical masks and eye protection: When splashes or sprays of blood and body fluid, secretions and excretions are likely N95 Respirator Airborne isolation precautions Change PPE promptly if heavily contaminated during the procedure PPE � Respiratory & eye protection Personal Protective Equipment � Respiratory & eye protection Surgical masks and eye protection: - Wear surgical mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood and body fluid, secretions and excretions are likely . N95 Respirator - N95 respirator has the bacterial filtration efficiency of 95% of 0.3 microns particles and is used for airborne precautions. Health care workers should change PPE promptly if it is heavily contaminated during the procedure. References: Centers for Disease Control and Prevention. (1996). Guidelines for Isolation Precautions in Hospitals Hospital Infection Control Advisory Committee. Retrieved September 30, 2005, from http://wonder.cdc.gov/wonder/prevguid/p0000419/p0000419.asp HA Infection Control Plan for Avian Influenza Feb 2006 Personal Protective Equipment � Respiratory & eye protection Surgical masks and eye protection: - Wear surgical mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood and body fluid, secretions and excretions are likely . N95 Respirator - N95 respirator has the bacterial filtration efficiency of 95% of 0.3 microns particles and is used for airborne precautions. Health care workers should change PPE promptly if it is heavily contaminated during the procedure. References: Centers for Disease Control and Prevention. (1996). Guidelines for Isolation Precautions in Hospitals Hospital Infection Control Advisory Committee. Retrieved September 30, 2005, from http://wonder.cdc.gov/wonder/prevguid/p0000419/p0000419.asp HA Infection Control Plan for Avian Influenza Feb 2006

12. Unit 6 - Infection Control Measures Slide 6- 12 Recommended Staff PPE in Different Areas in HA Hospitals During Avian Flu Serious (S2) & Emergency Response Level Serious Response Level (S2) : Activate when confirmation of human case(s) of AI in HK without evidence of efficient human to human transmission. * High risk patient areas refer to triage stations of GOPDs, whole designated clinics, A&E Department (triage stations, resuscitation rooms, waiting areas/consultation rooms & isolation room in fever triage cubicles) and isolation wards for confirmed avian influenza patients or for triaging suspected avian influenza cases. All staff working in high risk patient areas should put on uniform or working clothes. ** Based on risk assessment *** Individuals with signs and symptoms of respiratory infection should put on surgical mask High-risk procedures/ activities refer to: a) Patient care procedures i) Aerosol-generating procedures, such as endotracheal intubation, nebulizer therapy, nasopharyngeal aspiration (NPA), tracheostomy care, chest physiotherapy, open system airway suctioning, diagnostic sputum induction and bronchoscopy ii) Procedures with extensively dispersal, such as high flow oxygen, non-invasive ventilation (BiPAP & CPAP) iii) Prolonged close contact with confirmed/suspected cases, such as extensive nursing care for independent, confused or uncooperative patients. B) maintenance work in high risk patient areas i) Heavily splashing procedures, such as maintenance on sewage system. ii) Particle-generating procedures, such as changing HEPA filter in isolation area or local exhaust. Reference: HA Infection Control Plan for Avian Influenza Feb 2006 Recommended Staff PPE in Different Areas in HA Hospitals During Avian Flu Serious (S2) & Emergency Response Level Serious Response Level (S2) : Activate when confirmation of human case(s) of AI in HK without evidence of efficient human to human transmission. * High risk patient areas refer to triage stations of GOPDs, whole designated clinics, A&E Department (triage stations, resuscitation rooms, waiting areas/consultation rooms & isolation room in fever triage cubicles) and isolation wards for confirmed avian influenza patients or for triaging suspected avian influenza cases. All staff working in high risk patient areas should put on uniform or working clothes. ** Based on risk assessment *** Individuals with signs and symptoms of respiratory infection should put on surgical mask High-risk procedures/ activities refer to: a) Patient care procedures i) Aerosol-generating procedures, such as endotracheal intubation, nebulizer therapy, nasopharyngeal aspiration (NPA), tracheostomy care, chest physiotherapy, open system airway suctioning, diagnostic sputum induction and bronchoscopy ii) Procedures with extensively dispersal, such as high flow oxygen, non-invasive ventilation (BiPAP & CPAP) iii) Prolonged close contact with confirmed/suspected cases, such as extensive nursing care for independent, confused or uncooperative patients. B) maintenance work in high risk patient areas i) Heavily splashing procedures, such as maintenance on sewage system. ii) Particle-generating procedures, such as changing HEPA filter in isolation area or local exhaust. Reference: HA Infection Control Plan for Avian Influenza Feb 2006

13. Unit 6 - Infection Control Measures Slide 6- 13 HA policyRecommended Staff PPEs in HA Hospitals during Avian Flu Alert Response Level Recommended Staff PPEs in HA Hospitals During Avian Flu Alert Response Level * High risk patient areas refer to triage stations of GOPDs, whole designated clinics, A&E Department (triage stations, resuscitation rooms, waiting areas/consultation rooms & isolation room in fever triage cubicles) and isolation wards for confirmed avian influenza patients or for triaging suspected avian influenza cases. All staff working in high risk patient areas should put on uniform or working clothes. ** Based on risk assessment *** Individuals with signs and symptoms of respiratory infection should put on surgical mask High-risk procedures/ activities refer to: a) Patient care procedures i) Aerosol-generating procedures, such as endotracheal intubation, nebulizer therapy, nasopharyngeal aspiration (NPA), tracheostomy care, chest physiotherapy, open system airway suctioning, diagnostic sputum induction and bronchoscopy ii) Procedures with extensively dispersal, such as high flow oxygen, non-invasive ventilation (BiPAP & CPAP) iii) Prolonged close contact with confirmed/suspected cases, such as extensive nursing care for independent, confused or uncooperative patients. B) maintenance work in high risk patient areas i) Heavily splashing procedures, such as maintenance on sewage system. ii) Particle-generating procedures, such as changing HEPA filter in isolation area or local exhaust. Reference: HA Infection Control Plan for Avian Influenza Feb 2006 Recommended Staff PPEs in HA Hospitals During Avian Flu Alert Response Level * High risk patient areas refer to triage stations of GOPDs, whole designated clinics, A&E Department (triage stations, resuscitation rooms, waiting areas/consultation rooms & isolation room in fever triage cubicles) and isolation wards for confirmed avian influenza patients or for triaging suspected avian influenza cases. All staff working in high risk patient areas should put on uniform or working clothes. ** Based on risk assessment *** Individuals with signs and symptoms of respiratory infection should put on surgical mask High-risk procedures/ activities refer to: a) Patient care procedures i) Aerosol-generating procedures, such as endotracheal intubation, nebulizer therapy, nasopharyngeal aspiration (NPA), tracheostomy care, chest physiotherapy, open system airway suctioning, diagnostic sputum induction and bronchoscopy ii) Procedures with extensively dispersal, such as high flow oxygen, non-invasive ventilation (BiPAP & CPAP) iii) Prolonged close contact with confirmed/suspected cases, such as extensive nursing care for independent, confused or uncooperative patients. B) maintenance work in high risk patient areas i) Heavily splashing procedures, such as maintenance on sewage system. ii) Particle-generating procedures, such as changing HEPA filter in isolation area or local exhaust. Reference: HA Infection Control Plan for Avian Influenza Feb 2006

14. Unit 6 - Infection Control Measures Slide 6- 14 Designated de-gowning area is preferred. Gowning down carefully Avoid touching the external surface of PPE. Perform hand hygiene immediately after PPE removal and whenever contaminated. PPE should not be worn / taken out of the workplace into non-clinical areas Disinfect reusable items and store properly to avoid recontamination Single used items should be properly disposed PPE Removal: Designated de-gowning areas is preferred. Careful gowning down is crucial in avoiding contamination. Do not gown down together in close proximity to another person As the external surface, especially the front part of the PPE is most likely to be contaminated during performing procedures. Care should be taken not to touch these parts when removing them. Perform hand hygiene immediately after PPE removal and whenever contaminated. Health care workers should take off their PPE before going out of the clinical areas or isolation areas Reusable PPE must be properly disinfected after use and stored properly to avoid recontamination Single used or disposable items should be properly disposed References: Centers for Disease Control and Prevention. (2002). Guideline for hand Hygiene in Health Care Settings. Retrieved September 30, 2005, from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm HA Infection Control Plan for Avian Influenza Feb 2006 PPE Removal: Designated de-gowning areas is preferred. Careful gowning down is crucial in avoiding contamination. Do not gown down together in close proximity to another person As the external surface, especially the front part of the PPE is most likely to be contaminated during performing procedures. Care should be taken not to touch these parts when removing them. Perform hand hygiene immediately after PPE removal and whenever contaminated. Health care workers should take off their PPE before going out of the clinical areas or isolation areas Reusable PPE must be properly disinfected after use and stored properly to avoid recontamination Single used or disposable items should be properly disposed References: Centers for Disease Control and Prevention. (2002). Guideline for hand Hygiene in Health Care Settings. Retrieved September 30, 2005, from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm HA Infection Control Plan for Avian Influenza Feb 2006

15. Unit 6 - Infection Control Measures Slide 6- 15 Strategy of Patient Placement Isolate suspected or confirmed cases in a negative pressure isolation room When single rooms are fully occupied Cohort patients with same confirmed diagnosis in same cubicles, maintaining a minimum of 1.5 metres distance from each other Confirmed and suspected cases should be nursed in separate cubicle Patient placement Suspected or confirmed cases of avian influenza should be isolated promptly in a negative pressure isolation room. However, during pandemic when single rooms are fully occupied, patients with confirmed laboratory diagnosis may be cohorted in cubicles and a minimum distance of 1.5 meters should be maintained from each other. Confirmed cases should NOT be nursed in the same cubicle with unconfirmed cases. Reference: HA Infection Control Plan for Avian Influenza Feb 2006 Patient placement Suspected or confirmed cases of avian influenza should be isolated promptly in a negative pressure isolation room. However, during pandemic when single rooms are fully occupied, patients with confirmed laboratory diagnosis may be cohorted in cubicles and a minimum distance of 1.5 meters should be maintained from each other. Confirmed cases should NOT be nursed in the same cubicle with unconfirmed cases. Reference: HA Infection Control Plan for Avian Influenza Feb 2006

16. Unit 6 - Infection Control Measures Slide 6- 16 Transport of Suspected or confirmed patient Limit patient transport unless clinically indicated Encourage patients to wear surgical mask if no contraindication Transporting high risk patients: Avoid unnecessary transport and movement of patients unless clinically indicated Encourage patients to wear surgical mask if no contraindication The ward/ area to receive the patient should be informed beforehand of the transport so as to make appropriate arrangement Transport vehicles should be cleaned / disinfected after use Reference: HA Infection Control Plan for Avian Influenza Feb 2006 Transporting high risk patients: Avoid unnecessary transport and movement of patients unless clinically indicated Encourage patients to wear surgical mask if no contraindication The ward/ area to receive the patient should be informed beforehand of the transport so as to make appropriate arrangement Transport vehicles should be cleaned / disinfected after use Reference: HA Infection Control Plan for Avian Influenza Feb 2006

17. Unit 6 - Infection Control Measures Slide 6- 17 Decontamination - Patient Care Items Dedicated non-critical patient care items for suspected and confirmed cases Clean and disinfect reusable equipment before used on other patients. Use 1,000 ppm of hypochlorite solution (i.e. add 1 part of 5.25% hypochlorite in 49 parts of water) to disinfect non-critical items Use 70% alcohol on metallic surfaces Reusable respiratory equipment should undergo high level disinfection before reused on other patients Decontamination - patient care items Dedicated non-critical patient care items for suspected and confirmed cases Clean and disinfect reusable equipment before used on other patients Use 1,000 ppm of hypochlorite solution (i.e. add 1 part of 5.25% hypochlorite in 49 parts of water) to disinfect non-critical items Use 70% alcohol on metallic surfaces Reusable respiratory equipment should undergo high level disinfection before reused on other patients Reference: HA Infection Control Plan for Avian Influenza Feb 2006 Decontamination - patient care items Dedicated non-critical patient care items for suspected and confirmed cases Clean and disinfect reusable equipment before used on other patients Use 1,000 ppm of hypochlorite solution (i.e. add 1 part of 5.25% hypochlorite in 49 parts of water) to disinfect non-critical items Use 70% alcohol on metallic surfaces Reusable respiratory equipment should undergo high level disinfection before reused on other patients Reference: HA Infection Control Plan for Avian Influenza Feb 2006

18. Unit 6 - Infection Control Measures Slide 6- 18 Decontamination - Environmental Control Disinfect isolation and procedure rooms after use by a high risk patient Set up regular schedule of cleaning and disinfection of the environment and additional session for frequently touched surfaces Use 1,000 ppm of hypochlorite solution (i.e. add 1 part of 5.25% hypochlorite in 49 parts of water) to disinfect facilities contaminated with body fluid, secretions and excretions Use 10,000 ppm of hypochlorite solution (i.e. add 1 part of 5.25% hypochlorite in 4 parts of water) to disinfect spills or splashes of blood Decontamination � Environmental Control Isolation and procedure rooms should be disinfected after use by a high-risk patient. Clean and disinfect the environment regularly and additional session for frequently touched surfaces Use 1,000 ppm of hypochlorite solution (i.e. add 1 part of 5.25% hypochlorite in 49 parts of water) to disinfect facilities contaminated with body fluid, secretions and excretions. Use 10,000 ppm of hypochlorite solution (i.e. add1 part of 5.25% hypochlorite in 4 parts of water) to disinfect spills or splashes of blood Reference: HA Infection Control Plan for Avian Influenza Feb 2006 Decontamination � Environmental Control Isolation and procedure rooms should be disinfected after use by a high-risk patient. Clean and disinfect the environment regularly and additional session for frequently touched surfaces Use 1,000 ppm of hypochlorite solution (i.e. add 1 part of 5.25% hypochlorite in 49 parts of water) to disinfect facilities contaminated with body fluid, secretions and excretions. Use 10,000 ppm of hypochlorite solution (i.e. add1 part of 5.25% hypochlorite in 4 parts of water) to disinfect spills or splashes of blood Reference: HA Infection Control Plan for Avian Influenza Feb 2006

19. Unit 6 - Infection Control Measures Slide 6- 19 Linen and laundry management Proper handling of soiled linen: Avoid sorting Minimum agitation and shaking Well pack soiled linen to prevent leakage Wear appropriate PPE when handling soiled linen Clean linen should be transported and stored separately to prevent recontamination Follow hospital policy Linen and laundry management Linen should be handled properly: Soiled linen should be bagged at point of generation Minimum of agitation and shaking Soiled linen should be bagged and packed to prevent them from dropping out Workers should wear appropriate PPE when handling soiled linen or sorting is unavoidable Clean linen should be transported and stored in a manner that prevents its contamination and ensure its cleanliness Follow hospital policy Reference: HA Infection Control Plan for Avian Influenza Feb 2006 Linen and laundry management Linen should be handled properly: Soiled linen should be bagged at point of generation Minimum of agitation and shaking Soiled linen should be bagged and packed to prevent them from dropping out Workers should wear appropriate PPE when handling soiled linen or sorting is unavoidable Clean linen should be transported and stored in a manner that prevents its contamination and ensure its cleanliness Follow hospital policy Reference: HA Infection Control Plan for Avian Influenza Feb 2006

20. Unit 6 - Infection Control Measures Slide 6- 20 Waste Management All waste generated from room/ area housing suspected or confirmed avian influenza patients should be treated as clinical waste Biohazard labeling Wear appropriate PPE when handling clinical waste Waste Management All waste from a room/ area housing suspected or confirmed cases should be treated as clinical waste. Waste disposal bags should include biohazard labeling. Staff responsible for handling clinical wastes should wear appropriate PPE. Reference: HA Infection Control Plan for Avian Influenza Feb 2006 Waste Management All waste from a room/ area housing suspected or confirmed cases should be treated as clinical waste. Waste disposal bags should include biohazard labeling. Staff responsible for handling clinical wastes should wear appropriate PPE. Reference: HA Infection Control Plan for Avian Influenza Feb 2006

21. Unit 6 - Infection Control Measures Slide 6- 21 Principles of precautions for high-risk procedures In high risk patients Limit indications of use Limit extent of procedure Limit number of persons involved Use recommended PPE Principles of precautions for high-risk procedures e.g. Nebulizers, Nasopharyngeal aspiration, BiPAP & CPAP, bronchoscopy, intubations Special caution to patients with suspected or confirmed avian influenza Perform only when deemed medically necessary or use alternative methods whenever possible, for example, use puff with spacers instead of nebulizers, Limit extent of procedures that may splash or generate aerosol, for example during autopsy - when excising the lung, avoid the use of power saws, conducting procedures under water if there is a chance of aerozolation, and avoiding splashing when removing lung tissue. Use minimal amount of equipment, or use disposable instruments and equipment. Keep the number of staff present to a minimum Use recommended PPE (refer to slide 6-12) References: Reference: HA Infection Control Plan for Avian Influenza Feb 2006 World Health Organization. (2004). Influenza A (H5N1): WHO Interim Infection Control Guidelines for Health Care Facilities. Retrieved September 30, 2005, from http://www.who.int/csr/disease/avian_influenza/guidelines/Guidelines_for_health_care_facilities.pdfPrinciples of precautions for high-risk procedures e.g. Nebulizers, Nasopharyngeal aspiration, BiPAP & CPAP, bronchoscopy, intubations Special caution to patients with suspected or confirmed avian influenza Perform only when deemed medically necessary or use alternative methods whenever possible, for example, use puff with spacers instead of nebulizers, Limit extent of procedures that may splash or generate aerosol, for example during autopsy - when excising the lung, avoid the use of power saws, conducting procedures under water if there is a chance of aerozolation, and avoiding splashing when removing lung tissue. Use minimal amount of equipment, or use disposable instruments and equipment. Keep the number of staff present to a minimum Use recommended PPE (refer to slide 6-12) References: Reference: HA Infection Control Plan for Avian Influenza Feb 2006 World Health Organization. (2004). Influenza A (H5N1): WHO Interim Infection Control Guidelines for Health Care Facilities. Retrieved September 30, 2005, from http://www.who.int/csr/disease/avian_influenza/guidelines/Guidelines_for_health_care_facilities.pdf

22. Unit 6 - Infection Control Measures Slide 6- 22 Staff Early Sickness Alert System (SESAS) serves to raise the alert to possible clustering of infectious diseases among staff that have the potential of dissemination and causing harms. When the staff is sick and has the specified sickness symptoms (i.e. fever (38�C or above), chills, running nose, dry cough or productive cough, sore throat, malign, chest x-ray with infiltration and diarrhoea), he/she should report to his/her supervisor / the designated officer(s) in his/her department immediately. The supervisor / designated officer(s) should advise the staff to go to see a doctor and to be away from his /her workplace. The supervisors / designated officer(s) concerned should then input such symptoms and sickness period / sick leave into SESAS for the staff urgently. Reference: Hospital Authority. (2005). Guidance Notes on Staff Early Sickness Alert System (SESAS). Retrieved September 30, 2005, from HA intranet at http://sesas.home/ Staff Early Sickness Alert System (SESAS) serves to raise the alert to possible clustering of infectious diseases among staff that have the potential of dissemination and causing harms. When the staff is sick and has the specified sickness symptoms (i.e. fever (38�C or above), chills, running nose, dry cough or productive cough, sore throat, malign, chest x-ray with infiltration and diarrhoea), he/she should report to his/her supervisor / the designated officer(s) in his/her department immediately. The supervisor / designated officer(s) should advise the staff to go to see a doctor and to be away from his /her workplace. The supervisors / designated officer(s) concerned should then input such symptoms and sickness period / sick leave into SESAS for the staff urgently. Reference: Hospital Authority. (2005). Guidance Notes on Staff Early Sickness Alert System (SESAS). Retrieved September 30, 2005, from HA intranet at http://sesas.home/

23. Unit 6 - Infection Control Measures Slide 6- 23 Visiting policy under Serious (S2) & Emergency Response Level In general: Children under 12 are generally not permitted Pregnant women are strongly discouraged � Volunteer activities stopped. High-risk areas: No visiting except compassionate grounds: Register on visitor�s record Adopt infection control precautions Non face to face visiting : Mobile phone, video conferencing Other patient areas: Keep number of visitors to minimum Keep track on the number of visitors Wear surgical mask and encourage hand hygiene Arrange PPE and hand hygiene facilities Supply health information on proper infection control precautions Recommended visiting policy in high risk and other areas of hospitals under Red Alert Restrictive hospital visiting policy should be instituted based on risk assessment under Serious response level S2, Emergency response level E1 and E2 1. In general: children under 12 are generally not permitted in patient care area (unless with prior approval). pregnant women are strongly discouraged from visiting the hospital. � volunteer activities within clinical areas will be stopped under Red Alert. � 2. High-risk areas: (Fever triage wards / cubicles, negative pressure isolation rooms) "No Visiting" rule applies unless on compassionate ground e.g. paediatric patients. The number of visitors should be kept to minimal. Visitors (to high risk areas under special considerations) must register on visitor�s record. Educate visitors to adopt the standards of IC precautions including PPE Other means, such as mobile phone, video-conferencing could be used to facilitate communication between patients and family members. � 3. Other patient areas: � Visiting should be kept to a minimum. If allowed, there should be no more than 2 visitors at any one time, and this is subject to control and regulation by ward manager to avoid overcrowding. The visiting hours are up to 2 hours per day. Exceptions can be made for special situations such as paediatric wards. Simple process to keep track on the number of visitors is desirable. � Visitors are encouraged to wear surgical masks in patient areas. They should comply with PPE policy in the areas of visit. � Hospital management is required to make arrangements for the provision of surgical masks and washing facilities or hand rub within their hospitals and clinics. � Health advice and information on proper infection control precautions should be available to visitors. Reference: HA Infection Control Plan for Avian Influenza Feb 2006 Recommended visiting policy in high risk and other areas of hospitals under Red Alert Restrictive hospital visiting policy should be instituted based on risk assessment under Serious response level S2, Emergency response level E1 and E2 1. In general: children under 12 are generally not permitted in patient care area (unless with prior approval). pregnant women are strongly discouraged from visiting the hospital. � volunteer activities within clinical areas will be stopped under Red Alert. � 2. High-risk areas: (Fever triage wards / cubicles, negative pressure isolation rooms) "No Visiting" rule applies unless on compassionate ground e.g. paediatric patients. The number of visitors should be kept to minimal. Visitors (to high risk areas under special considerations) must register on visitor�s record. Educate visitors to adopt the standards of IC precautions including PPE Other means, such as mobile phone, video-conferencing could be used to facilitate communication between patients and family members. � 3. Other patient areas: � Visiting should be kept to a minimum. If allowed, there should be no more than 2 visitors at any one time, and this is subject to control and regulation by ward manager to avoid overcrowding. The visiting hours are up to 2 hours per day. Exceptions can be made for special situations such as paediatric wards. Simple process to keep track on the number of visitors is desirable. � Visitors are encouraged to wear surgical masks in patient areas. They should comply with PPE policy in the areas of visit. � Hospital management is required to make arrangements for the provision of surgical masks and washing facilities or hand rub within their hospitals and clinics. � Health advice and information on proper infection control precautions should be available to visitors.

24. Unit 6 - Infection Control Measures Slide 6- 24 Infection Control for Outreach Staff PPE, hand hygiene facilities including towelette made readily available before outreach duty Outreach staff includes Community Geriatric Assessment Team, Community Nursing Service, dormitory health service etc : Outreach staff should prepare PPE, hand hygiene facilities including towelette and made readily available before outreach duty Assess the risk of infection of patient be vigilant on abnormal clustering Implement infection appropriate control measures (refer to slide 6-8 to 6-19) Outreach staff includes Community Geriatric Assessment Team, Community Nursing Service, dormitory health service etc : Outreach staff should prepare PPE, hand hygiene facilities including towelette and made readily available before outreach duty Assess the risk of infection of patient be vigilant on abnormal clustering Implement infection appropriate control measures (refer to slide 6-8 to 6-19)

25. Unit 6 - Infection Control Measures Slide 6- 25 Infection Control for Outreach staff Cardiac Life Support: Avoid direct mucosal exposure, e.g. mouth to mouth resuscitation Use alternative ventilation device: e.g. resuscitation bags, pocket mask Wear appropriate PPE When performing Cardiac Life Support: Avoid direct mucosal exposure during resuscitation, such as mouth to mouth resuscitation Resuscitation bags, pocket mask can be used as an alternative to mouth to mouth resuscitation methods where there is need for emergency resuscitation Wear appropriate PPE (refer to slide 6-8 to 6-13) Reference: Centers for Disease Control and Prevention. (1996). Guidelines for Isolation Precautions in Hospitals Hospital Infection Control Advisory Committee. Retrieved September 30, 2005, from http://wonder.cdc.gov/wonder/prevguid/p0000419/p0000419.asp When performing Cardiac Life Support: Avoid direct mucosal exposure during resuscitation, such as mouth to mouth resuscitation Resuscitation bags, pocket mask can be used as an alternative to mouth to mouth resuscitation methods where there is need for emergency resuscitation Wear appropriate PPE (refer to slide 6-8 to 6-13) Reference: Centers for Disease Control and Prevention. (1996). Guidelines for Isolation Precautions in Hospitals Hospital Infection Control Advisory Committee. Retrieved September 30, 2005, from http://wonder.cdc.gov/wonder/prevguid/p0000419/p0000419.asp

26. Unit 6 - Infection Control Measures Slide 6- 26 Infection control measures in A&E and clinic Follow Respiratory Hygiene and Cough Etiquette precautions Triage: Fever, Travel history, Occupational exposure, Contact history and Cluster of persons with fever and pneumonia symptoms. Designated areas for suspected patients while waiting for referral and arrange speedy consultation and management Wear appropriate PPE Environment and equipment cleaning and disinfection Infection control measures in A&E and clinic Health care workers should be vigilant on any suspected cases and implemented appropriate infections Implement respiratory hygiene and cough etiquette precautions for both patients and staff. (refer to slide 6-3) Implement triage assessment: risk access of patients by checking patients� temperature, ask for any recent travel history, occupational exposure, contact history and cluster of persons with fever and pneumonia. (refer to slides 4-21) Redirect suspected patients to stay in designated areas while waiting for referral and arrange consultation as soon as possible. Wear appropriate PPE while providing care for the patients. (refer to slides 6-6, 6-8 to 6-13) Clean and disinfect environment and equipment when spills or splashes occur or when contaminated and according to clinic policy. . (refer to slides 6-16, 6-17) References: Centers for Disease Control and Prevention. (1996). Guidelines for Isolation Precautions in Hospitals Hospital Infection Control Advisory Committee. Retrieved September 30, 2005, from http://wonder.cdc.gov/wonder/prevguid/p0000419/p0000419.asp HA Infection Control Plan for Avian Influenza Feb 2006 Infection control measures in A&E and clinic Health care workers should be vigilant on any suspected cases and implemented appropriate infections Implement respiratory hygiene and cough etiquette precautions for both patients and staff. (refer to slide 6-3) Implement triage assessment: risk access of patients by checking patients� temperature, ask for any recent travel history, occupational exposure, contact history and cluster of persons with fever and pneumonia. (refer to slides 4-21) Redirect suspected patients to stay in designated areas while waiting for referral and arrange consultation as soon as possible. Wear appropriate PPE while providing care for the patients. (refer to slides 6-6, 6-8 to 6-13) Clean and disinfect environment and equipment when spills or splashes occur or when contaminated and according to clinic policy. . (refer to slides 6-16, 6-17) References: Centers for Disease Control and Prevention. (1996). Guidelines for Isolation Precautions in Hospitals Hospital Infection Control Advisory Committee. Retrieved September 30, 2005, from http://wonder.cdc.gov/wonder/prevguid/p0000419/p0000419.asp HA Infection Control Plan for Avian Influenza Feb 2006

27. Unit 6 - Infection Control Measures Slide 6- 27 Non Emergency Ambulance Transfer Services (NEATS) Suspected and confirmed patients should be separated from other patients Patient to wear surgical masks unless contraindicated PPE, hand hygiene facilities and towelette made readily available Staff to wear appropriate PPE Transport compartment and equipment should be cleaned and disinfected when spills or splashes of blood, body fluid, excretions, secretions occur and after transport infectious patient Non Emergency Ambulance Transfer Services (NEATS) Maintain cohort practice throughout the transfer operation during inter hospital transfer : Patients at risk of Avian Flu must not be transported together with other patients. Patients of different risk categories of Avian Flu, (i.e. confirmed Avian Flu, suspected Avian Flu, and or with exposure history to Avian Flu) should not be transported together in the same vehicle. Suspected and confirmed patients should wear surgical masks if clinically fit during the infectious period. NEATS staff should prepare PPE, hand hygiene facilities and towelette made readily available NEATS staff should wear appropriate PPE (refer to slides 6-6, 6-8 to 6-13) Disinfect the transport compartment and equipment promptly when spills or splashes of blood, body fluid, excretions and secretions. The compartment including stretchers and wheelchairs should be disinfected after patients transfer. Reference: HA Infection Control Plan for Avian Influenza Feb 2006 Non Emergency Ambulance Transfer Services (NEATS) Maintain cohort practice throughout the transfer operation during inter hospital transfer : Patients at risk of Avian Flu must not be transported together with other patients. Patients of different risk categories of Avian Flu, (i.e. confirmed Avian Flu, suspected Avian Flu, and or with exposure history to Avian Flu) should not be transported together in the same vehicle. Suspected and confirmed patients should wear surgical masks if clinically fit during the infectious period. NEATS staff should prepare PPE, hand hygiene facilities and towelette made readily available NEATS staff should wear appropriate PPE (refer to slides 6-6, 6-8 to 6-13) Disinfect the transport compartment and equipment promptly when spills or splashes of blood, body fluid, excretions and secretions. The compartment including stretchers and wheelchairs should be disinfected after patients transfer. Reference: HA Infection Control Plan for Avian Influenza Feb 2006

28. Unit 6 - Infection Control Measures Slide 6- 28 Handling of dead bodywith known Avian Influenza Implement standard precautions when caring for the deceased patients Wear appropriate PPE when handling dead body Ensure proper covering and packing to prevent leaking Attach warning tag indicating risk category 2 (Yellow label) on outside of the body bag Cremation is not mandatory Handling of dead body Health care workers should practice standard precautions when caring for the deceased body. (refer to slide 6-8 to 6-13) Wear appropriate PPE when handling dead body (refer to slides 6-6, 6-8 to 6-13) Ensure proper covering and packing of the body sites, such as wounds, tracheostomies to prevent leaking of body fluids, secretion and excretion Attach warning tag indicating category 2 (Yellow label) on outside of the body bag Cremation is not mandatory References: Centers for Disease Control and Prevention. (1996). Guidelines for Isolation Precautions in Hospitals Hospital Infection Control Advisory Committee. Retrieved September 30, 2005, from http://wonder.cdc.gov/wonder/prevguid/p0000419/p0000419.asp Department of Health, Hospital Authority & Food and Environmental Hygiene Department. (2005). Precautions for Handling and Disposal of Dead Bodies. Handling of dead body Health care workers should practice standard precautions when caring for the deceased body. (refer to slide 6-8 to 6-13) Wear appropriate PPE when handling dead body (refer to slides 6-6, 6-8 to 6-13) Ensure proper covering and packing of the body sites, such as wounds, tracheostomies to prevent leaking of body fluids, secretion and excretion Attach warning tag indicating category 2 (Yellow label) on outside of the body bag Cremation is not mandatory References: Centers for Disease Control and Prevention. (1996). Guidelines for Isolation Precautions in Hospitals Hospital Infection Control Advisory Committee. Retrieved September 30, 2005, from http://wonder.cdc.gov/wonder/prevguid/p0000419/p0000419.asp Department of Health, Hospital Authority & Food and Environmental Hygiene Department. (2005). Precautions for Handling and Disposal of Dead Bodies.

29. End of Unit 6