Occupational Health and Safety Act, 1993 (Act No. 85 of 1993) Regulations Hazardous Biological Agents Regulations Annexure C : Precautions for Workplaces

 

[Regulations 10(1)(b), 15(a) and 16(a), (b) and (c)]

 

Five Main Routes Of Transmission :

 

 

The most important route of transmission in a workplace is by –

 

 

Droplets are generated during coughing, sneezing, talking and during procedures such as suctioning.

 

Droplets may carry organisms that can infect a new host if they are deposited on conjunctivae, nasal mucosa or the mouth.

 

Droplets do not remain suspended in the air.

 

Droplets do not travel more than one metre.

 

 

Small particles (droplet nuclei) that remain suspended in air for long periods of time have a far greater potential for spreading disease than large droplets.

 

Few organisms are carried by this route, the most important being Mycobacterium tuberculosis and the viruses causing measles and chickenpox.

 

Prevention of spread requires an enclosed area with at least six air changes per hour, or an open window that provides adequate ventilation.

 

 

Transmission by items such as food, water, devices and equipment.

 

Normal hygienic practices and proper sterilization or disinfections of equipment should make this type of spread a rare event in certain workplaces, e.g. hospitals.

 

 

Vectors such as mosquitoes, flies, fleas, etc. are hopefully not frequently encountered in workplaces as a cause of outbreaks.

 

In areas where there is a problem the appropriate measures, e.g. screens on windows and the use of insecticides must be instituted

 

Two levels of precautions are recommended :

-           Standard Precautions

These are applied at all times to all patients irrespective of their diagnosis. All body fluids (except sweat) are regarded as potentially infectious.

-           Transmission-Based Precautions

These are applied when a specific infectious disease is diagnosed or suspected.

The route by which the disease is transmitted will determine the category of precautions that must be applied.

 

 

Precautions

 

 

 

 

 

 

Administrative Controls

 

 

A system must be developed to ensure that hospital patients, employees, contractors and visitors are educated about :

-           the use of precautions.

-           the responsibility for adhering to the precautions.

 

 

Periodic evaluation of adherence to precautions must be carried out. The findings are to be used to implement improvements.

 

Precautionary Measures

 

 

Standard precautions are used for the protection of all people exposed to HBA.

 

 

-          Wash hands after touching blood, body fluid, secretions, excretions and contaminated items, whether or not gloves are worn.

-          Wash hands (when working with patients) :

-          Use plain (non-antimicrobial) soap for routine hand washing.

-          Use an antimicrobial agent or an alcohol hand disinfectant for specific circumstances (e.g. control of outbreaks or hyperendemic infections) as defined by the infection control program. (See contact precautions.)

 

 

-           Wear gloves (clean, intact non-sterile gloves are adequate) when touching blood, body fluid, secretions, excretions and contaminated items.

-           Put on clean intact gloves just before touching mucous membranes and non-intact skin.

-          Change and dispose of gloves between tasks and procedures -

-          Remove gloves promptly after use –

-          Wash hands immediately to avoid transfer of micro-organisms to other persons and environments.

 

 

-          Wear a mask and eye protection or a face shield -

 

 

-           Wear appropriate protective clothing to protect skin and to prevent soiling of clothing during procedures and activities that are likely to generate splashes or sprays of blood, body fluid, secretions and excretions.

-           Select protective clothing that is appropriate for the activity and amount of fluid likely to be encountered.

-           Remove soiled protective clothing as promptly as possible and consider it contaminated.

-           Wash hands immediately after removal of protective clothing to avoid transfer of micro-organisms to other people or environments.

 

 

-          Handle patient-care equipment soiled with blood, body fluids, secretions and excretions in a manner that prevents –

-          Ensure that reusable equipment is not used for the care of another patient until -

-          Ensure that-

 

 

-            Ensure that adequate procedures are in place for routine care, cleaning and disinfection of environmental surfaces, and other frequently used or potentially contaminated surfaces

-            Disinfection of environmental surfaces is not routinely required. Simple cleaning is adequate unless there has been significant soiling by potentially infectious body fluids.

 

 

-          Process, handle and transport used linen contaminated with blood, body fluid, secretion and excretions in colour coded, impervious containers and all possible measures should be observed to prevent -

 

 

-           Take care to prevent injuries when –

 

Never

-           Re-cap needles or manipulate them using both hands, if it is absolutely necessary to reheat a needle. A variety of mechanical devices that are commercially available must be used.

-           Use any other technique that involves directing the point of a needle toward any part of the body.

 

Do not

 

-           Remove used needles from disposable syringes by hand.

-           Bend or break or otherwise manipulate needles by hand.

 

Do

-           Place used disposable syringes and needles, scalpel blades and other sharp objects in appropriate puncture-proof containers that are as close as possible to the area in which the procedure is carried out.

-           Transport them safely to the disposal area.

 

 

Use mouthpieces, resuscitation bags or other ventilation devices as an alternative method to mouth-to-mouth resuscitation in areas where the need for resuscitation is predictable.

 

 

-           Place in an isolation area (single or private room) patients who -

-           If an isolation area is not available, consult infection control professionals regarding patient placement or other alternatives.

 

 

In addition to Standard Precautions, use Airborne Precautions for -

-           patients known or suspected of being infected with micro-organisms transmitted by airborne droplet nuclei, i.e. small particle residue of evaporated droplets containing micro-organisms that -

 

 

Ideally place patients in a private room that has -

-           monitored negative air pressure in relation to the surrounding areas.

-           6 -12 air changes per hour.

-           Appropriate discharge of air outdoors or monitored high-efficiency filtration of room air before the air is circulated to other areas of the hospital.

 

Where this is not possible

-           Use -

-           When an isolation area is not available, place the patient in a room with another patient who has active infection with the same micro-organism, and no other infection, unless otherwise recommended.

-           When a private room is not available and cohorting is not desirable, consultation with infection control professionals is advised before patient placement.

-           Keep the patient in the room and keep the door closed.

 

 

Tuberculosis:

 

-            Respiratory protection may be worn when entering the room of a patient known or suspected to have infectious pulmonary tuberculosis.

-            Measles (rubeola) and chickenpox (varicella).

-            Susceptible person should not enter the room of patients known or suspected of having measles or vermicelli if other immune caregivers are available.

-            if susceptible persons must enter the room they must wear respiratory protection.

-            Persons immune to measles or vermicelli need not wear respiratory protection,

 

 

Movement and transport of the patient should be kept to a minimum.

-           If transport or movement is necessary, the patient must wear a surgical mask to minimise dispersal of droplet nuclei.

 

 

-          Respirators –

-          Effective treatment of the patient

-           Isolation –

there is significant clinical improvement in the patient’s condition.

ideally, two negative acids fast bacilli smears must be obtained.

ideally a smear positive patient will require isolation for a minimum of two weeks.

 

 

In addition to Standard Precautions, use Droplet Precautions for patients known or suspected to be infected with micro-organisms transmitted by droplets (large particle droplets that can be generated during coughing, sneezing, talking or respiratory therapy).

 

 

Place the patient in an isolation area, e.g. private or single room

 

-          When a private room is not available and cohorting is not achievable, maintain spatial separation of at least one metre between the infected patient and other patients and visitors.

-           Additional ventilation measures are not necessary and the door may remain open.

 

 

Wear a mask when working within one metre of the patient. However, logistically some hospitals may want to implement the wearing of a mask to enter the room.

 

 

Movement and transport of the patient from the room should be kept to a minimum. If transport or movement is necessary, minimise dispersal of droplets by masking the patient.

 

 

In addition to Standard Precautions use Contact Precautions for specified patients known or suspected to be infected or colonised with epidemiologically important micro-organisms that can be transmitted by direct contact with the patient (hand to skin contact occurs when performing patient care activities that required touching the patient’s dry skin) - or indirect contact (touching) environmental surfaces or patient care items in the patient’s environment.

 

 

Place the patient in an isolation area, e.g. private or single room

-          When a private room is not available, place the patient in a room with patients who have active disease with the same microorganism but no other infection (cohorting).

-          When either a private room nor cohorting is achievable, consider the epidemiology of the microorganism and the patient population when determining patient placement.

 

Consultation with infection control professionals is advisable before patient placement.

 

 

In addition to wearing gloves and washing hands as outlined in Standard Precautions -

 

-          Wear clean gloves when entering the room.

-          Change gloves after having contact with infective material,

-          Remove gloves before leaving the patient’s environment.

-          Wash hands immediately after glove removal with an antimicrobial or an alcohol hand rub.

-          Ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient’s room to avoid transfer of micro-organisms to other patients or the environment.

 

 

In addition to wearing a gown or plastic apron as outlined in Standard Precautions -

 

-         Wear a clean, non-sterile gown and/or plastic apron as appropriate -

-          Remove the gown or plastic apron before leaving the patient’s environment.

-          After gown or plastic apron removal, ensure that clothing does not make contact with potentially contaminated environmental surfaces to avoid transfer of micro-organisms to other patients or environments.

 

 

-          Movement and transport of the patient from the room should be minimised.

-          Ensure that precautions are maintained to minimize the risk of transmission of micro-organisms to other patients and contamination of environmental surfaces or equipment.

 

 

Where possible dedicate the use of non-critical patient-care equipment to a single patient (or cohort of patients infected or colonised with the pathogen requiring precautions).

 

Avoid sharing equipment between patients

 

-           If the use of common equipment or items is unavoidable, then these must be cleaned and disinfected before use for another patient.

 

 

-          Limit antibiotic use and prevent misuse.

-          Educate staff.

-          Detect multi-drug-resistant micro-organisms early by laboratory and infection control surveillance.

-          Consult an Infection Control Practitioner regarding further management.

 

 

-           Standard and contact precautions plus additional items such as respirators, visors, water repellent gowns and boots, caps, double gloves are required.

-           Standard precautions are adequate during the non-hemorrhagic phase in cases of hemorrhagic fevers, such as Ebola and Congo-Crimean hemorrhagic fever.

 

 

-       This may be a dedicated viral hemorrhagic fever (VHF) unit or a dedicated sideward or private room, preferably with an anteroom.

 

-        The door must be kept closed, and strict access control must be implemented.

 

 

-        Impervious disposable gowns must be worn over a theatre scrub suit.

 

 

-         Two pairs are worn, the one pair on top of the other.

-         Sterile latex gloves are used because of the thicker quality and longer nori-roll cuff.

 

 

-         Impervious boots or overshoes are worn in the isolation room.

 

They must be -

 

 

-         Worn inside the isolation room.

-          Theatre caps.

A theatre cap worn with a visor providing full protection of the head and neck s preferred.

 

 

-         Masks - good quality, high-filtration respirators are necessary.

 

 

A FED pack contains all the isolation gear necessary, must be safely stored in an area not accessible to unauthorised persons. The FED pack must be immediately replenished after every usage.

 

This pack is available immediately, is portable and is used until the patient is diagnosed or transferred to an isolation unit or an infectious diseases hospital. The pack is kept in a box or in a trolley. The box (or trolley) is distinctive and kept in an easily accessible place. The pack contents are replenished as required by the infection control staff.

 

Instruction posters provide instructions for untrained personnel until infection control professionals arrive to provide guidance and instruction in VHF procedures.

 

Contents -

 

-         Sterile latex gloves of varying sizes.

-         Disposable impermeable gowns.

-         Goggles or visors.

-         Masks.

-         Shoe covers (half-leggings).

-         Theatre caps.

-          Blood tubes, labels, bio-hazard plastic specimen bags, a rigid, walled container for transportation of specimens and bio-hazard stickers.

-          Masking tape used for -

-         Plastic refuse bags for contaminated refuse.

-         Autoclavable bags for non-disposable items.

-         Clear plastic bags.

-          Sodium-hypochlorite sachets of powder (NaOCI) and liquid 1 % hypochlorite.

-          Plastic-covered instruction posters containing detailed instructions on how to -

 

 

-         All refuse bags are colour coded, double bagged and are placed into cardboard boxes.

 

-          Refuse bags are sealed and labelled with bio-hazard stickers and tape.

 

-          Containers are escorted to the incinerator.

 

-          Their immediate incineration is ensured.

 

 

-          These specimens require a special container and packaging :

 

 

Bedding

 

-         All bedding used is either disposable or condemned linen that is subsequently incinerated.

-          Mattresses must be covered with durable plastic covers

The covers are disposable.

If the mattress becomes soiled with blood or body substance it must be destroyed.

 

Linen and Refuse

 

-          All linen (disposable and condemned) is placed into plastic refuse bags

 

Terminal disinfection of equipment

 

-          All equipment is washed down well with a hypochlorite-detergent.

-          It is then dried, using a paper towel.

-          If the equipment is not autoclavable, it must .be wrapped in clear plastic bags, then -

-         Autoclavable items must be placed in Asepto type bags -

 

Furniture or environment

 

-        All furniture, walls and floors are washed down well with hypochlorite-detergent.

 

TABLE I

 

 

Abbreviations used

 

Type of precautions:

 

Standard precautions (S) are applied at all times in addition to either :

 

A       Airborne

C       Contact

D        Droplet

VHF   Viral haemorrhagic fever

 

Duration of precautions :

 

CN  until antibiotics are discontinued and culture-negative

DH  duration of hospitalisation

Dl    duration of illness (with wound lesions, Dl means until they stop draining)

U     until time specified in hours (hrs) after initiation of effective therapy.

F      footnote number under type

 

Meaning of superscript number (i.e. FE Standard precaution is applied at all times)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TABLE II

 

Clinical Syndromes or Conditions Warranting Additional Empiric Precautions to Prevent Transmission or Epidemiologically Important Pathogens Pending Confirmation of Diagnosis*

 

 

 

 

*          Infection control professionals are encouraged to modify or adapt this table according to local conditions. To ensure that appropriate empiric precautions are always implemented, hospitals must have systems in place to evaluate patients routinely according to these criteria as part of their pre-admission care.

 

**        Patients with the syndromes or conditions listed below may present atypical signs or symptoms (e.g. pertussis in neonates and adults may not have paroxysmal or severe cough). The clinician’s index of suspicion should be guided by the prevalence of specific conditions in the community, as well as clinical judgement.

 

***     The organisms listed under "Potential Pathogens’’ are not intended to represent the complete, or even the most likely, diagnosis, but rather possible etiologic agents that require additional precautions beyond Standard Precautions until they can be ruled out.

 

Synoposis of types of precautions and patients requiring the precautions

 

Abbreviations used in list of precautions.

 

α  See Table I for a complete list of infections requiring precautions, including appropriate footnotes.

 

β  Certain infections require more than one type of precaution.

 

γ   See "Guidelines for Preventing the Transmission of Tuberculosis in Health-Care Facilities" available from the Department of Health.

 

 

Use Standard Precautions for the care of all patients.

 

 

In addition to Standard Precautions, use Airborne Precautions for patients known or suspected to have serious illnesses transmitted by the airborne droplet nuclei. Examples of such illnesses include -

 

 

 

In addition to Standard Precautions, use Droplet Precautions for patients known or uspected to have illnesses transmitted by large-particle droplet.

 

Examples of such illnesses include

 

 

Other serious bacterial respiratory infections spread by droplet transmission, including

 

 

Serious viral infections spread by droplet transmission, including

 

 

 

In addition to Standard Precautions, use Contact Precautions for patients known or suspected to have serious illnesses easily transmitted by direct contact or by contact with terms in the patient's environment. Examples of such illnesses include-

 

-          Gastrointestinal, respiratory, skin or wound infections or colonisation with multidrug-resistant bacteria judged by the infection control program, based on current state, regional, or national recommendations, to be of special clinical and epidemiologic significance.

-          Enteric infections with a low infectious dose or prolonged environmental survival, including :

-         For diapered or incontinent patients: enterohaemorrhagic Escherichia coli 0157 :H7, Shigella, Hepatitis A or Rotavirus

-         Respiratory syncytial virus, parainfluenza virus or enteroviral infections in infants and young children.

 

Skin infections that are highly contagious or that may occur on dry skin, including :

 

 

 

In addition to Standard Precautions and Contact Precautions, use FED precautions for persons proven or suspected of having a viral haemorrhagic fever. Examples of such diseases are :

 

-           Ebola Viral Haemorrhagic Fever

-           Marburg Haemorrhagic Fever

-           Congo-Crimean Haemorrhagic Fever

-           Lassa Fever