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Isolation and Transportation of the Highly Infectious Patient. Craig D. Thorne MD, MPH, FACP, FACOEM Assistant Professor, Occupational & Environmental Medicine Medical Director, Employee Health & Safety University of Maryland Medical Center Brian Schwartz, MD, CCFP(EM), FCFP

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isolation and transportation of the highly infectious patient

Isolation and Transportation of the Highly Infectious Patient

Craig D. Thorne MD, MPH, FACP, FACOEM

Assistant Professor, Occupational & Environmental Medicine

Medical Director, Employee Health & Safety

University of Maryland Medical Center

Brian Schwartz, MD, CCFP(EM), FCFP

Assistant Professor, Faculty of Medicine, University of Toronto

Sunnybrook Health Sciences Centre

Vice-Chair, Ontario SARS Scientific Advisory Committee

Scientific Advisor, Emergency Management Unit, Ontario MOHLTC

  • Describe highly infectious diseases in the 21st century
  • Apply a ‘hierarchy of controls’: isolation, infection control precautions, & personal protective equipment
  • Understand proven strategies for community & workplace containment
  • Apply essentials of safe pre- & inter-hospital transportation
Working Group on Civilian Biodefense

1998 John Hopkins Center task force including:




State/Local Health Dept



sars epidemiology worldwide
SARS epidemiology – worldwide
  • Nov. 2002 - July 2003:
    • 8427 probable cases
    • 29 counties (throughout Asia, Canada & U.S.)
    • 29 U.S. cases (no deaths)
  • Primarily a nosocomial epidemic!
    • In Canada, 77% of SARS cases resulted from in-hospital exposure; In Taiwan: 94%
    • HCWS:
      • Overall, 1707 HCWs = 21% (combined community & hospital transmission)
      • Secondary (person-to-person) transmission in hospitals:
        • Hong Kong: 62% HCWs
        • Vietnam: 57% HCWs
        • Canada: 51% HCWs

WHO Update - JAMA 2003; 289

sars epidemiology worldwide cont
SARS epidemiology – worldwide (cont)
  • 813 deaths overall
  • Overall mortality rate: 3-12%. Up to 45% if over age 60
  • Public health experts are braced for possible resurgence

WHO Update - JAMA 2003; 289

why was sars so challenging
Why was SARS so challenging?
  • Nonspecific presentation: fever & respiratory symptoms (dyspnea & cough); looks like ‘flu’
  • No rapid diagnostic test: presumptive diagnosis made based on symptoms & exposure history (travel or known contact); eventual confirmation by lab detection of specific viral components
  • Definitive mechanism of transmission remains unclear: contagious by large droplets (coughing, sneezing & talking). Fomite transmission? Does SARS virus remain suspended in air (i.e., airborne transmission)?
  • No specific medication or vaccine to prevent or treat SARS
plague historical data
Plague: Historical Data
  • Three major world pandemics resulting in over 200 million deaths ( 6th, 14th, & 19th centuries)
  • Category A agent with high potential as a bio-weapon, widely available in many countries, easily aerosolized, highly contagious, high fatality rate.
  • Potential for bio-engineering of more virulent strains.
  • Potential for mass panic, civil unrest, & economic devastation.
plague clinical issues
Plague: Clinical Issues
  • Gram negative bacillus, Yersenia pestis.
  • Transmitted via three routes:
    • Aerosol- infection dose is 100 to 500 organisms
    • Contact with infected secretions, fomites
    • Bites of rodent fleas- mice, rats, squirrels, chipmunks, dogs, cats, camels, rabbits, prairie dogs.
  • Incubation period is 2-4 days
  • Clinical syndromes: Pneumonic, bubonic & septicemic
  • Malaise, myalgias, HA, fever, rigors.
  • Sepsis & pneumonia presentation with hemoptysis & leucocytosis
  • 100% mortality within 2-3 days without prompt antimicrobial treatment.
  • Isolation technique is AIRBORNE, DROPLET & CONTACT ISOLATION.
  • A disease which has existed in epidemic form worldwide for at least 3000 years.
  • Discovered by Jenner in 1796 which led to the vaccinia vaccination program & the establishment of the principals of vaccination.
  • Global eradication in 1977 in Somalia the last known naturally occurring case.
  • Vaccination worldwide ceased in 1980.
  • No known animal or environmental reservoirs.
  • A serious threat to civilian populations who are currently highly susceptible.
  • Two current smallpox caches worldwide; Atlanta, Georgia & Russia.
smallpox clinical issues
Smallpox: Clinical Issues
  • Orthopoxvirus DNA virus – same group as vaccinia, cowpox & monkeypox.
  • Person to person spread thru droplet nuclei, aerosols or direct contact.
  • Infection dose is only a few virions thru the oropharyngeal or other mucus membrane
  • Secondary attack rate of 58% & mortality rate of >30%
  • Incubation period of 12 – 14 days.
  • Presentation with fever, toxemia & a characteristic rash: Centrifugal, initially papular, then vesicular, then pustular with pitted permanent scarring upon healing.
  • No specific treatment.
  • Prevention by vaccination of live virus vaccine; vaccinia virus which effectively interrupts transmission.
  • Isolation technique is AIRBORNE & CONTACT.
  • Zoonotic viruses primarily except for filoviruses whose reservoir remains unknown
  • Well suited for aerolization of small particles 1-5 um in size but more difficult than anthrax to grow & maintain viability.
typical influenza clinical issues
Typical Influenza: Clinical Issues
  • Transmission by small particle aerosol of about 10 micrometers.
  • Incubation period of 1-2 days.
  • Attack rate of 10 - 40% over a 5-6 week period annually.
  • HA, fever, myalgia, severe prostration, pneumonia.
  • Diagnosis by culture or antigen detection in respiratory secretions.
  • Treatment with antiviral agents: amantadine, rimantadine, zanamivir, oseltamavir
  • Prevention by annual vaccination of inactivated or live attenuated vaccine produced yearly. Peak antibodies in 2-4 months.
  • Isolation technique is Droplet Precautions
what is avian flu
What Is Avian Flu?
  • Avian flu is an infection caused by bird flu virusesa
    • Occurs naturally among wild birds that carry the viruses but they usually do not get sick from them
    • Avian flu is very contagious among birds & can make domesticated birds very sick & kill them
    • Infected birds shed flu viruses in their saliva, nasal secretions & feces
  • Domesticated birds may become infected through contact witha:
    • Infected waterfowl or other infected poultry
    • Contact with contaminated surfaces (such as dirt or cages) or materials (such as water or feed)
  • Some migratory birds are carrying highly pathogenic H5N1 virusb
  • Sometimes long distances
    • Introducing virus to poultry along their migratory routes
    • Asian & European poultry affected

a. Centers for Disease Control and Prevention. Key facts about avian influenza (bird flu) and avian influenza A (H5N1) virus. Available at: Accessed October 23, 2006.

b. World Health Organization. Avian influenza ("bird flu") – Fact sheet. Available at: Accessed October 23, 2006.

current h5n1 avian flu strain is of concern to health experts
Current H5N1 Avian Flu Strain is of Concern to Health Experts
  • Highly pathogenic avian virus – represents a significant threat to human healtha:
    • Especially virulent
    • Spread by migratory birds
    • Transmitted from birds to mammals
      • Some, though limited, human-to-human transmission
  • Little to no human immunity present in populationb
  • High human mortality ratec
    • Roughly 54% mortality rate
    • 100x greater than seasonal flu
    • 22x greater than 1918 pandemic

a. US Dept of Health and Human Services. General Information. 2006. Available at: Accessed October 23, 2006. b. Centers for Disease Control and Prevention. Avian influenza: current situation. Available at: Accessed October 20, 2006. c. Stimola AN. American Council on Science and Health. Avian influenza, or "bird flu": What you need to know [e-published]. Available at: Accessed October 20, 2006.

h5n1 human infection uncommon but has occurred
H5N1 Human Infection Uncommon But Has Occurred
  • Confirmed cases of human infection from several subtypes of avian flu infection have been reporteda
    • Most have resulted from contact with infected poultry or surfaces contaminated with their infected secretions/excretions
  • It seems difficult for humans to acquire the H5N1 virus from birds & even more difficult for the virus to spread among peopleb
  • In fact, no suspected cases of person-to-person transmission of H5N1 have been confirmed, indicating that the species barrier is still fairly strongb
  • Health experts are concerned that further mutations of H5N1 could change the virus into a form easily transmitted from person to person – resulting in a worldwide outbreak of the disease or “pandemic.”b

a. Centers for Disease Control and Prevention. Key facts about avian influenza (bird flu) and avian influenza A (H5N1) virus. Available at: Accessed October 23, 2006. b. Stimola AN. American Council on Science and Health. Avian influenza, or "bird flu": What you need to know [e-published]. Available at: October 20, 2006.

human exposure to h5n1
Human Exposure to H5N1
  • Recently, most patients infected with H5N1 have had a history of direct contact with diseased poultry
    • Playing
    • Preparing, butchering, eating
    • Plucking
  • Human-to-human transmission has been suggested in several household clusters
    • Intimate contact without precautions
    • Non-intimate social contact not implicated
  • Other environmental modes of transmission theoretically possible
    • Contaminated water
    • Contaminated hands
    • Untreated poultry feces as fertilizer

World Health Organization. Avian influenza A (H5N1) infection in humans. N Engl J Med. 2005;353:1374-1385.

clinical course of h5n1 influenza in humans
Clinical Course of H5N1 Influenza in Humans
  • Clinical Course
    • Fever often first symptoma
    • Severe primary viral pneumoniab
    • Lymphopeniab
    • Impaired liver functionb
    • Renal impairmentb
  • Death
    • Death occurs an average of 9 or 10 days after the onset of illness (range, 6 to 30)c
    • More than half of the laboratory-confirmed cases have been fatald

a. Chotpitayasunondh T, Ungchusak K, Hanshaoworakul W, et al. Human disease from influenza A (H5N1), Thailand, 2004. Emerg Infect Dis. 2005;11:201-209. b. Chan PK. Outbreak of avian influenza A (H5N1) virus infection in Hong Kong in 1997. Clin Infect Dis. 2002;34(Suppl 2):S58-S64. c. World Health Organization. Avian influenza A (H5N1) infection in humans. N Engl J Med. 2005;353:1374-1385. d. World Health Organization. Avian influenza ("bird flu") – Fact sheet. Available at: Accessed October 23, 2006.

h5n1 outbreaks continue to escalate
H5N1 outbreaks continue to escalate
  • Outbreaks continuea
    • Turks & Iraqi Kurds die as poultry outbreaks spread
    • Africa, backyard poultry
    • Italy, Germany, Greece, Slovenia, Bulgaria, Azerbaijan, Iran & Austria, found in wild birds, mostly swans
    • Azerbaijan, investigations revealed contact with infected wild dead birds (swans) as the most plausible source of infection in several cases in childrenb
  • Indonesia, WHO reported unconfirmed evidence of human-to-human spreadb
    • 8 people in one family infected
    • First member likely through contact with infected poultry
    • This person then may have infected six others in the family
    • One of those six may have infected another family member
    • No further spread outside of the exposed family was documented or suspected

a. New Scientist Web site. Timeline: bird flu. Available at: Accessed October 23, 2006. b. Centers for Disease Control and Prevention. Avian influenza: current situation. Available at: Accessed October 20, 2006.

human cases since 2003
Human Cases Since 2003

World Health Organization. Human cases since 2003. WHO/Map Production: Public Health Mapping and GIS Communicable Diseases (CDS) World Health Organization 2006. Available at: Accessed October 9, 2006.

classic hierarchy of controls
Classic hierarchy of controls

1. Engineering & Environmental Controls

2. Administrative Controls & Work Practices*

3. Personal Protective Equipment

* During an infectious disease outbreak, early identification of cases (an administrative control) is critical prior to the effective implementation of engineering controls such as isolation

level 1 engineering environmental controls
Level 1: Engineering & Environmental Controls
  • CDC: ‘the separation of ill persons with contagious disease’, using physical barriers & ventilation
  • Most reliable (do not rely on worker cooperation)
  • Most cost effective
  • E.g.: permanent facilities/systems such as: negative pressure isolation, general ventilation, local ventilation, filtration, & anterooms
level 2 administrative controls work practices
Level 2: Administrative Controls & Work Practices
  • Standard procedures to reduce duration, frequency & severity of exposures to HCWs, other patients & visitors
  • E.g.: safe transport & transport of the highly infectious patient
  • Includes education, drills, updates & re-training
level 3 personal protective equipment ppe
Level 3: Personal Protective Equipment (PPE)
  • Gloves, gowns, goggles/eye shields, masks & respirators
  • Important, but:
    • Requires proper:
      • Selection (considering route of transmission, size of infectious particle, infectious dose, etc.)
      • Use
      • Maintenance & disinfection
    • Does not reduce risk 100% even when properly used. Overall:
      • N-95 mask: 85% efficacy*
      • Hooded powered air purifying respirator (PAPR): 99.9%
  • PPE supplements higher control measures

* based on: 1) NIOSH definition that an N-95 can filter out 95% of a 0.3 micron challenge, hence a maximum exposure of 5%, & 2) NIOSH assigned protection factor (APF) for a half-face respirator of 10 which allows the user to wear the respirator in a maximum of 10 times the permissible exposure limit ( PEL), hence a maximum exposure of 10 %


“The SARS outbreak illustrated the critical importance of basic infection control precautions in health-care facilities”“Nosocomial transmission of SARS was often associated with noncompliance with the basic level if infectious control precautions (standard precautions), including hand hygiene” - World Health Organization


Updated Hierarchy of Controls: Applying Lessons from SARS to Any Future Severe Respiratory Illness (SRI)

Thorne, Khozin, McDiarmid – JOEM, July 2004

1 negative pressure isolation
1. Negative pressure isolation
  • Creating a pressure differential to prevent contaminated air from leaking out of a room into other areas of a facility
2 general ventilation
2. General ventilation
  • 2-step process:
    • Dilute contaminated air using clean air, then
    • Remove diluted air
  • Must be designed & maintained by experienced engineer
  • Expert agencies have established ventilation standards or guidelines for TB control. Also useful for SARS planning
3 local ventilation
3. Local ventilation
  • Controlling contaminant immediately at, or near, source
  • Especially important for high risk patient procedures (e.g., intubation, non-invasive ventilation, & bronchoscopy)
  • Possibilities when performing procedures:
    • Completely vented enclosure
    • Externally vented hood
4 filtration
4. Filtration
  • High-efficiency particulate aerosol (HEPA) filtration removes 99.97% of particles >/= 0.3 um diameter
  • CDC: Proven highly effective to prevent spread of Aspergillus & TB
  • Should be used even if air is blown to the outdoors so as to minimize risk of contaminated re-circulated air
5 anterooms
5. Anterooms
  • Small rooms separating isolation rooms from hospital corridors to prevent the escape of infectious particles
  • Features:
    • negative pressure (or neutral) to outside corridor to prevent air from blowing outwards
    • positive pressure relative to isolation room
  • PPE should be doffed & disinfected in anterooms
6 temporary structures
6. Temporary structures
  • Tents were used in Taiwan, Toronto & North Carolina to identify & isolate suspected SARS cases before they entered the hospitals
  • Veterans’ General Hospital, Taiwan: by using a tent, was the only E.D. to remain open
  • Included radiology & laboratory capabilities
written policies procedures 1 infection control precautions
Written policies & procedures: 1. Infection Control Precautions
  • Health Care Infection Control Practices Advisory Committee (HICPAC) guidelines for SARS:
    • Standard precautions for all patients (whether deemed

infectious or not)

    • Hand washing is still most important means of reducing transmission from person-to-person
    • Wearing gloves does not replace the need to wash hands. Why? micro-tears or contamination during glove removal
    • For suspect or probable SARS, also use all 3 transmission-based precautions: droplet, contact & airborne
why all 3 transmission based precautions
Why all 3 transmission-based precautions?
  • Initial recommendations for contact precautions were based on spread through direct patient contact or indirect (patients’ belongings or surfaces); droplet precautions were based on studies that found a definitive spread of SARS through large droplets (sneezing, coughing or talking)
  • SARS-CoV isolated in sputum, tears, blood, urine & feces
  • Can survive for at least 2 days in stable room temperature. Fomite transmission?
summary of infection control precautions
Summary of infection control precautions

Healthcare Infection Control Practices Advisory Committee’s (HICPAC)

Guidelines on Infection Control

who interim infection control guidelines for avian flu

WHO Interim Infection Control Guidelines for Avian Flu

who interim infection control guidelines for avian flu1
WHO Interim Infection Control Guidelines for Avian Flu
  • All patients who present to a health-care setting with fever & respiratory symptoms should be managed according to recommendations for Respiratory Hygiene & Cough & questioned regarding their recent travel history
  • Suspected AI: Patients who present with severe acute febrile respiratory (e.g. fever > 38oC, cough, SOB) or severe unexplained illness (e.g. encephalopathy or diarrhea), who have traveled to AI infected countries within 2 weeks prior to symptoms. At a minimum, use:
  • Place a surgical mask on the patient; if no masks are available, ask the patient to cover mouth & nose with a tissue; place in a single negative pressure room or cohort with similar patients
  • Standard Precautions
    • Pay careful attention to hand hygiene before & after all patient contact or contact with items potentially contaminated with respiratory secretions.
  • Contact Precautions
    • Use gloves & gown for all patient contact
    • Use dedicated equipment such as stethoscopes, disposable blood pressure cuffs, disposable thermometers, etc.
  • Eye protection (i.e., goggles or face shields)
    • Wear when within 3 feet of the patient
who interim infection control guidelines for avian flu cont
WHO Interim Infection Control Guidelines for Avian Flu (cont)
  • Airborne Precautions
    • Place the patient in an airborne isolation room (AIR). Such rooms should have monitored negative air pressure in relation to corridor, with 6 to 12 air changes per hour (ACH), & exhaust air directly outside or have recirculated air filtered by a high efficiency particulate air (HEPA) filter. If an AIR is unavailable, consider use of portable HEPA filters to augment the number of ACH
    • When working in direct contact with suspected or confirmed AI-infected patients, particularly during aerosol-generating procedures, use a fit-tested respirator at least as protective as a National Institute of Occupational Safety & Health (NIOSH)-approved N-95 filtering face piece (i.e., disposable) respirator, when entering the room. Consider PAPR use
how long should infection control precautions be used for patients with ai sri
How long should infection control precautions be used for patients with AI/SRI?
  • Patients > 12 years of age - at time of admission until 7 days after resolution of fever
  • Patients </= 12 years of age – at time of admission until 21 days after symptoms onset (as young children can shed seasonal influenza virus at high titers for up to 21 days)
2 suspicion of disease at first contact
2. Suspicion of disease at first contact
  • Crucial to implement early isolation procedures at first point of contact
  • How?
    • Educating triage staff to briefly screen patients using standard set of questions derived from case definition & checking temperatures
    • Visual alerts for patients with pictures & simple instructions (many languages) to hand wash & use surgical mask if respiratory symptoms
    • Novel approach is outpatient triage by phone & referral to appropriate treatment center
3 restricting contact
3. Restricting contact

Restricting # of:

  • Clinicians
  • Ancillary staff (housekeepers, dietary staff)
  • Visitors – compassionate visits only on a case-by-case basis (e.g., parent of sick child)
    • Use same infection control precautions as healthcare workers
4 limiting controlling patient transport
4. Limiting & controlling patient transport

When transport is necessary (e.g., test cannot be done in room):

  • Both patient & transport personnel use appropriate infection control precautions:
    • Patient – surgical mask & gown
    • HCW – N95 or PAPR respirator, gown & goggles/faceshield, followed by hand hygiene
    • Disinfect any surfaces that patient contacts
  • Use dedicated route (including elevator) that causes least amount of exposure & person-to-person contact
5 quarantine
5. Quarantine
  • ‘Period of restriction of asymptomatic (but presumably exposed) persons from others to prevent the spread of a contagious disease’ (CDC)
  • Duration is usually based on incubation period
  • In U.S., if federal government adds infectious disease to list, individual states have power to declare quarantine & CDC enforces it
6 disinfection
6. Disinfection
  • Disposable patient care equipment whenever possible (CDC); still must safely handled & disposed of
  • For reusable equipment, method of disinfection must be determined by article, intended use, manufacturer’s recommendations, & existing hospital policy
7 control measures for high risk procedures
7. Control measures for high-risk procedures
  • >60% HCWs affected by SARS had performed procedures on an active disease patient or were present in the room at the time of procedures
  • Risk highest with aerosol-generating & cough-inducing procedures – e.g., aerosolized or nebulized meds., sputum induction, bronchoscopy, airway suctioning, intubation, PPV using face-mask, & high freq. oscillatory ventilation
7 control measures for high risk procedures cont
7. Control measures for high-risk procedures (cont)

Specific CDC recommendations:

  • Limit aerosol-generating procedures to those medically necessary & perform them in negative pressure isolation room
  • Most experienced staff
  • Minimal # of staff in room
  • Extreme attention to infection control precautions & hand hygiene
  • N95 or higher level respirator (such as PAPR)
8 medical surveillance for exposed hcws
8. Medical surveillance for exposed HCWs
  • High risk procedure & not protected: if HCW exposed during aerosol-generating procedure & infection control precautions were breached, exclude from work for 10 days, & actively monitor for fever (twice daily) & respiratory symptoms
  • Unprotected not non high-risk: need not be excluded from work but actively monitor for fever & symptoms. Serological tests for AI are available
  • Cared for SRI patient but protected: actively monitor for fever & symptoms
  • If exposed HCW develops fever or respiratory symptoms, immediately limit interactions with all others, call Infection Control or EHS, & then report to determined clinic location
  • During periods of increased SRI activity, recommendations extend to all symptomatic HCWs regardless of known exposure
recommendations for all hcws
Recommendations for all HCWs
  • Receive seasonal influenza vaccine – will not protect against AI but will help prevent concurrent infection with human influenza & AI
  • Observe good respiratory & hand hygiene at all times
  • Observe all recommended infection control precautions
  • Monitor for symptoms of flu-like illness (e.g. cough, sore throat, difficulty breathing)
  • Reassign HCWs who are at high risk for complications of influenza – pregnant women, immunocompromised persons, & persons with respiratory disease
when should hand washing be performed
When should hand washing be performed?
  • Before&after any patient contact
    • Why after if gloves are used? Concern about micro-tears in gloves & cross-contamination from PPE
  • Soap & water (with single towel) versus alcohol-based hand rub
    • If hands are visibly dirty or soiled with blood or other body fluids, or if broken skin might have been exposed to infectious material, use soap & water
what is respiratory hygiene cough etiquette
What is respiratory hygiene/cough etiquette?
  • Covering mouth & nose with a tissue when coughing & dispose of used tissues in waste containers
  • Use a mask if coughing
  • Perform hand hygiene after contact with respiratory secretions
  • Stand or sit at least 3 feet from other persons, if possible
how can respiratory hygiene cough etiquette be enforced
How can respiratory hygiene/cough etiquette be enforced?
  • Posting signs for patients & family members
  • Requesting that persons with SRI refrain from visiting the HCF. Instead, call community clinic
  • Making tissues & masks available outside waiting rooms
  • Supply alcohol-based had rubs in common areas such as waiting rooms
what is ppe
What is PPE?

Includes barrier protection to prevent mucous membrane or skin exposure, including:

  • Gloves
  • Gowns
  • Goggles/faceshields
  • Respirators
why did hcws using ppe die
Why did HCWs using PPE die?
  • April 15-21, 2003: 9 HCWs caring for the physician at time of his intubation developed SARS
  • Interviews determined they:
    • Wore N95 respirators, but
    • No anteroom, no training on correct procedure to remove it (i.e, gloves first, then respirator & goggles), & no fit-testing
is a surgical mask considered a respirator
Is a surgical mask considered a respirator?
  • NO!
  • Used in O.R. as a barrier to minimize risk to patient of wound becoming infected by HCW
  • No published filtration efficiency for infectious agents; large gaps around sides
  • Therefore, not deemed to be protective against small-particle aerosols (droplet nuclei), other particulates, or any chemicals
respirator types
Respirator types

*APR=air purifying respirator; PAPR=powered APR; SCBA=self-contained breathing apparatus

when to use eye protection
When to use eye protection?
  • Face shields, visor, or goggles
  • If sprays/splashes of secretions are anticipated & for all aerosol-generating procedures
  • Patients with AI/other SRI will have respiratory symptoms (e.g., coughing, sneezing) so eye protection should be used
can disposable ppe be reused is supplies are limited
Can disposable PPE be reused is supplies are limited?
  • Should be avoided if at all possible
  • Data is limited for influenza but reuse may increase the potential for contamination. However, risk must be balanced against the need to fully provide protection for HCWs
  • If reused, should be considered only as a urgent, temporary solution & only if the item has not been obviously soiled or damaged
  • Never leave respirators dangling around the neck
  • After discarding used PPE, perform hand hygiene
how important is training
How important is training?
  • Failure to educate HCWs about even basic infection control precautions will lead to unnecessary HCW infections & deaths
  • Incorrect use of PPE may fail to protect HCWs against the acquisition of health care-associated infections
  • May also lead to self-contamination & inoculation of infectious agents
  • PPE placement must be done before entering the isolation room, & careful removal is critical to avoid self-contamination

“Cornerstones of good infection control practices – education, regular supplies & adequate staffing, institutional climate, & leadership” - World Health Organization

useful resources
Useful Resources
  • Influenza Pandemic Preparedness – Emerging Infectious Diseases 2003 Dec; 9 (12): 1645-1648
  • CDC Influenza (Flu) Avian Flu Resources:
  • CDC Clinical Information Service: 1-800-CDC-INFO or

Veronica T. Sanchez, M.D.

Chief, Division if Infectious Diseases

Department of Internal Medicine

Sanford School of Medicine, South Dakota