INFECTION PREVENTION AND
CONTROL MANUAL

AUTHORS:

Name:
Chris Sharp
Job Title:
Matron Infection Prevention and Control,

Cambridgeshire Community Services

Name:
Lynn Rodrigues
Job Title:
Matron Infection Prevention and Control,

NHS Cambridgeshire

Name:
Clare Nathan
Job Title:
Infection Prevention and Control Nurse,

Cambridgeshire Community Services

Name:
Aileen Wilson
Job Title:
Modern Matron Infection Prevention and Control

Cambridge and Peterborough NHS Foundation Trust

KEY DIRECTORS

Name:
Tim Bryson
Job Title:
Director of Children’s Services and Nursing

RATIFIED BY

Forum:
Healthcare Governance Committee
1 December 2008

IMPLEMENTATION

Date:
December 2008

REVIEW

Date:
November 2009

Signed on behalf of the Trust
:   ………………………………

Karen Bell, Chief Executive

Elizabeth House, Fulbourn Hospital, Fulbourn, Cambs CB21 5EF Phone: 01223 726789

ACKNOWLEDGEMENTS

Consultant in Communicable Disease Control,
Dr Bernadette Nazareth
Public  Health  Protection  Unit,  Health  Protection
Agency
Infection  Control  Doctor  Consultant  Microbiologist
Dr Nick Brown
HPA
Infection Control Specialist Nurse,
Lynn Franklin
Peterborough  and  Stamford  Hospitals  NHS
Foundation Trust

2

SECTION 1: GENERAL INFORMATION
1.1 INTRODUCTION
Preface

Infection  prevention  and  control  is  the  responsibility  of  all  staff.  At  any  one  time
approximately  one  in  ten  patients  in  acute  hospitals  has  a  Healthcare  Associated  Infection
(HCAI).    Patients  who  have  a  HCAI  are  likely  to  stay  in  hospital  2.5  times  as  long  as  an
uninfected patient, an average of 11 days. Patients with a HCAI incur increased healthcare
costs for the healthcare provider.

The death rate is higher for patients who have a HCAI during the in-patient period.

Although  not  all  HCAIs  are  life  threatening  the  symptoms  may  cause  pain  and  discomfort
and  treatment  may  involve  a  long  course  of  antibiotic  treatment.  Any  of  these  can  reduce
quality of life.

This  manual  provides  the  basic  information  that  staff  need  for  effective  infection  control
within the Trust and serves as a basis for best practice.

At all times the guidelines in the manual represent the core approach to infection prevention
and  control  for  the  organisation.  Additional  clinical  information  can  be  found  in  the  Royal
Marsden Hospital Manual of Clinical Nursing Procedures.

The Infection Prevention and Control Team (IPCT) are responsible for the practical aspects
of infection control.  The IPCN team can be contacted by telephone or e mail during normal
working hours. The microbiology service includes 24 hour advice and this can be accessed
via the acute hospital switchboard.

Each department should have an Infection Control link staff with whom the ICT liaise.  Link
staff will provide advice on the infection control guidelines devised in specific areas and will
assist the clinical team to use the policies in this manual.

Reference:
Plowman et al (1999) Socio-economic Burden of Hospital Acquired Infection London: Public
Health Laboratory Service

1.2 NOTIFIABLE DISEASES
1.2.1 Statuary  Notification
Infectious diseases, which are listed in tables A and B, whether confirmed or
suspected, must be notified to the Consultant for Communicable Disease Control
(CCDC) by the attending doctor.

Prompt notification and reporting of disease is essential.

The objectives of notification are:

1.  To collect accurate and complete epidemiological information on the disease.
2.  To ensure prompt and appropriate control measures to prevent the spread of infection.

Any  doctor  who  considers  that  a  patient  is  suffering from  a  notifiable  disease  (see  Section
1.3) has a statutory duty to notify the Proper Officer (Consultant in Communicable Disease
Control) of the local authority using the standard notification procedure.

Table A - Diseases Notifiable under the Public Health (Control of Disease) Act 1984:

Cholera

Relapsing Fever
Food Poisoning
Smallpox
Plague
Typhus

Table  B  -  Diseases  Notifiable  under  the  Public  Health  (Infectious  Diseases)
Regulations 1988:

Acute Encephalitis
Ophthalmia
Neonatorum
Acute Poliomyelitis
Paratyphoid Fever
Anthrax
Rabies
Diphtheria
Rubella
Dysentery (amoebic or bacillary)
Scarlet Fever
Leprosy
Tetanus
Leptospirosis
Tuberculosis
Malaria
Typhoid Fever
Measles
Viral Haemorrhagic Fever
Meningitis
Viral Hepatitis
Meningococcal Septicaemia (without meningitis)
Whooping Cough
Mumps
Yellow Fever

Table C - Non-Statutory Notifiable Diseases

It has been agreed that although the following diseases are not statutorily notifiable,
the Consultant in Communicable Disease Control should be informed of their
occurrence:

•  AIDS
•  Legionnaires’ Disease
•  Listeriosis
•  Psittacosis
•  CJD
•  SARS

1.3 CONTACT INFORMATION

INFECTION PREVENTION AND CONTROL NURSES (Provider Organisations)
Aileen Wilson – Infection Control & Prevention Lead
Ann Hiles - Trust Nurse Lead
01223 726789
Wendy Llaneza – Healthcare Governance Senior Manager
Tim Bryson – Director of Infection Prevention & Control
For  out  of  hours  Infection  Control  advice  -  please  contact  the  on-call  microbiologist
via the acute hospital switchboard.

HEALTH PROTECTION UNIT (NSE HP UNIT)
Cambridgeshire and Peterborough
Health Protection Unit – Administration
Dr Bernadette Nazareth
Consultant in Communicable Disease Control
Dr Kate King
01480 398500
Health Protection Medical Specialist
Gillian Clark
Health Protection Nurse Specialist
Audrey Pepperman
Health Protection Nurse Specialist
Emergency contact out of hours via Medicom 01603 481221

LABORATORIES (MICROBIOLOGY)
Addenbrookes Hospital
01223 257035 / 257057
Hinchingbrooke Hospital
01480 416416
Papworth Hospital
01480 364321
Peterborough and Stamford Hospital
01733 874657
Queen Elizabeth Hospital, Kings Lynn
01553 613772

ENVIRONMENTAL HEALTH DEPARTMENTS
Cambridge City
01223 457000
Environmental Health Department
South Cambridgeshire
08450 450500
Environmental Health Department
East Cambridgeshire
01353 665555
Environmental Health Department
Fenland

Environmental Health Department
01354 654321

Peterborough Unitary Authority

Environmental Health Department
01733 747474

DEPARTMENTS OF GENITO-URINARY MEDICINE
Addenbrooke’s Hospital
01223 217239/

01223 217774
Peterborough Hospital
01733 314666/

01733 874949
Hinchingbrooke Hospital
01480 416461
Out of hours service not available

ACUTE INFECTION CONTROL TEAMS

Addenbrooke’s Hospital, Cambridge
01223 217497
Peterborough District Hospital
01733 874164
Hinchingbrooke Hospital, Huntingdon
01480 416160
Queen Elizabeth Hospital, Kings Lynn
01553 613613

OCCUPATIONAL HEALTH DEPARTMENTS
Anglia Support Partnership, Swan House, Gloucester Centre, 01733 316519
Peterborough
Hinchingbrooke Hospital, Huntingdon (Hunts area only)
01480 416263

1.4 PRECAUTIONS REQUIRED FOR INFECTIOUS DISEASES

This  Section  is  to  enable  you  to  manage  patients  with  an  infectious  disease.  They  are  a
guideline only and if you have any queries please contact the Infection Control Team.

These precautions are in addition to Standard Infection Control Precautions Section …….

CATEGORY
OF  STATUTORY
DISEASE
COMMENTS
ISOLATION
NOTIFICATION

Agranulocytosis
Protective
NO

Anthrax
High
Security  Yes
DO  NOT  ADMIT  to
(Pulmonary)
Isolation Hospital
District
General

Hospital

Anthrax
Source
Yes
(Cutaneous)

Aspergillosis
None
NO

Beta-haemolytic

NO
Until  testing  negative
streptococcus:

or
24
hours
of
  Group
A
(not  Source
appropriate  antibiotic
throat)
Source
treatment.
  Group
B
(only
SCBU
and
neonates)

Bronchiolitis
in  Source
NO
Until clinically well
infants

Brucellosis
None
NO

Burns-extensive
Protective
NO
non-infected

Campylobacter
Enteric
Yes
Until symptom free.
enteritis

Staff  sufferers  should
contact  Occupational
Health.

Chickenpox
Source
Yes
Until lesions are dry
(Varicella
Zoster
(normally  7  days  from
Virus)
start
of
eruptions).

Exclude
staff
and
others  who  are  not
immune.

Cholera
Enteric
Yes

Clostridium difficile
Enteric
NO
Please refer to policy

Cryptosporidiosis
Enteric
NO
Until symptom free.

Cytomegalovirus
None
NO
Risk
to
immuno-
compromised
and
pregnant contacts.

Diarrhoea
of  Enteric
NO
Until  symptom  free
unknown origin

and/or
cause

identified.

Diphtheria
Source  with  negative  Yes
Until tested negative.

pressure ventilation

Dysentery:

Bacillary
Enteric
Yes
Amoebic
Enteric
Yes

Erysipelas
Source
NO
24  hours  from  start  of

therapy.

Erythema
Source
NO
infectiosum
(Slapped
Face
Syndrome)

  E coli
Enteric
Yes

(Escherchi Coli)

Gastroenteritis, viral  Enteric / respiratory
Yes
Contact
Infection
(Norwalk,SRSV,)
Control Team.

German Measles
Source
Yes
Exclude  non-immune

(rubella)

pregnant staff.

Giardiasis
Source/Enteric
NO

Glandular fever
None
NO
(Epstein
Barr
varius)

Gonorrhoea
None
NO
Please contact GUM

Hepatitis:

  HAV
   Enteric
Yes

Hepatitis:


None
No
  HBV
  HCV

Herpes simplex
Source (for infants)
NO
Staff
affected
to
(Cold sores)

contact  Occupational
Health.  Lesions  to  be
covered.

Herpes zoster
Source
NO
Until
lesions
dry.
(Shingles)
Exclude  staff  who  are
not immune

HIV (AIDS)
None
Yes

Impetigo
Source
NO
Until negative cultures

Usually 24 hours

Influenza
Respiratory
NO

Influenza other
Respiratory
NO
Contact ICT
e.g. SARS, Avian flu

Legionnaires
Nil
NO
Contact Microbiologist
disease

Leptospirosis
None
Yes

Listeriosis
Enteric
Yes

Malaria
None
NO

Measles
Source
Yes
Normally  7  days  from
onset of rash. Contact
ICT.

Meningococcal
Source
Yes
Contact  the  ICT  and
Meningitis

HPA.

Isolate for 24 hours.

Close  contacts  may

require
antibiotic
prophylaxis  48  hours
after
onset
usually
through GP.

Meningo-
Source
NO

encephalitis
(Acute)

MRSA
Source
NO
Please refer to policy

Mumps  (Infectious  Source
Yes
For 9 days after onset
Parotitis)
of  parotid  swelling.

Notify ICT.

Ophthalmia
Source
NO
24 hours treatment
Neonatorum

Parasalmonellatyph
Source/Enteric
NO
3
negative
stool
oid
Fever
and
cultures.
carriers

(typhoid fever)

Plague
High
Security  Yes
DO  NOT  ADMIT  to
Isolation Hospital
District
General

Hospital

Pneumonia:

NO
  Pneumococcal

  (lobar)
None

  Staphylococcal
None
  Broncho-atypical
None
  Pneumocystis
None

Poliomyelitis (Acute)  Source/Enteric
Yes

Psittacosis
Source/Respiratory
NO
Until symptom free.

Puerperal Sepsis
Source
NO

Pyrexia (of unknown  Source
NO
Until  symptom  free
origin)

and or cause known.

Rabies
Source
NO
Contact
Consultant
Microbiologist

Respiratory
Source/
NO
Until clinically well
Syncytial Virus
Respiratory

Rotavirus
Enteric
NO

Salmonella
Enteric
NO

Scabies
Source
NO
Please refer to policy

Scarlet Fever
Source
NO
24 hours treatment

Shigella
Enteric
NO

Tuberculosis:

Contact
TB
Nurse
  Suspected
or  Source/Respiratory
Yes
Specialist.
Smear positive

  (Acid fast bacilli

  seen in sputum)



Smear negative
None

Multi Drug Resistant  Source/Respiratory
(known
or
suspected)

Variant  Creutzfeldt-
None
Yes
Consult ICT.

Jakob
Disease
Please refer to Policy
(vCJD)

Viral  Haemorrhagic  High
Security  Yes
DO  NOT  ADMIT  to
Fever
Isolation Hospital
District
General
E.g.
Marburg
Hospital
Disease

Whooping Cough
Respiratory
Yes

SECTION 2: MANAGEMENT ARRANGEMENTS FOR INFECTION PREVENTION
AND CONTROL
2.1 INTRODUCTION
Cambridgeshire  and  Peterborough  Foundation  Trust  are  committed  to  improving  a  high
standard of infection prevention and control throughout the Trust.  Infection Prevention and
Control is everybody’s responsibility and the key principles should be embedded in everyday
practice.

This  section  outlines  the  Trust’s  approach  to  the  management  of  Infection  Prevention  and
control  including  duties  and  responsibilities,  assurance  framework,  training  and  monitoring
compliance with Infection Prevention and Control policies.

2.2 DUTIES AND RESPONSIBILITIES
Chief Executive
The  Chief  Executive  is  the  Trust  responsible  officer  for  quality  and  safety.    The  Chief
Executive  is  responsible  for  ensuring  that  effective  arrangements  for  Infection  Prevention
and Control are in place within the Trust.

Trust Board
The  Trust  board  are  responsible  for  providing  resources  necessary  for  the  delivery  of
Infection Prevention and Control.

Director of Infection Prevention and Control (DIPC)
The  DIPC  is  the  overall  executive  lead  for  the  management  of  Infection  Prevention  and
Control within the Trust. The DIPC reports directly to the Chief Executive.

The Infection Control Committee (ICC)
The  Infection  control  committee  meets quarterly  and  reports  to the  Healthcare governance
committee.  The  ICC  are  responsible  for  overseeing  compliance  with  the  Health  Act  2006.
They are also responsible for:
•  Advising  the  Trust  Board  and  the  Trust  Executive  Management  group,  via  the
Healthcare  Governance  committee  on  all  aspects  of  infection  control  and  make
recommendations on measures to ensure effective infection control.
•  Endorsing the annual Infection Prevention and Control Programme
•  Advising  on  the  most  effective  use  of  resources  available  for  the  implementation of
the programme and for contingency measures.
•  Advising on and approve Infection Control policies and procedures, and review their
implementation.
•  Taking  responsibility  for  major  decisions  regarding  Infection  Control,  and  discuss
problems identified by the Infection Control team.
•  Providing an annual report to the Healthcare Governance committee
•  Making  recommendations  to  other  Trust  committees  or  departments  on  Infection
Control matters.
•  Ensuring effective liaison over infection control matters with acute Trusts and PCTs,
Learning  Disability  Partnerships  and  all  other  partner  Agencies  including  relevant
private and voluntary sector organisations.
•  Provision  of  advice  on  equipment  and  facilities  to  ensure  that  infection  risks  are
minimised.
•  Planning    and  facilitating  education,  training  and  sharing  of  best  practice  for  all
grades of staff on Infection Control issues

Infection Prevention and Control Team
The  Trust’s  Infection  prevention  Control  team  includes  the  Modern  Matron  –  Infection
Prevention  and  Control,  the  Trust  Nurse  Professional  Leads,  and  the  Director  of  Infection
Prevention  and  Control.  Infection  Control  Doctor  Cover  is  provided  by  the  Consultant
Microbiologists  in  the  acute  Trusts.    The  Trust  has  an  Infection  Control  Committee  that
reports  to  Quality  and  Healthcare  Governance  Committee.    The  team  liaises  with  NHS
Cambridgeshire  Infection  Control  Committee  and  NHS  Peterborough  Infection  Control
Committee.

Modern Matron Infection Prevention and Control
The Modern Matron Infection Prevention and control is responsible for:
•  Ensuring the Implementation of the Health Act 2006
•  Implementing the Infection Prevention and Control Annual Programme
•  Ensuring that infection control policies are evidence based and comply with national
and professional guidance
•  Reviewing and updating Infection Prevention and Control Policies regularly
•  Ensuring the provision of Infection Prevention and Control mandatory and induction
training.
•  Implementing a programme of audit and surveillance.
•  Providing support and training for Infection Control Link staff
•  Providing Infection Prevention and Control advice to staff  and service users

Professional Nurse Leads
The Professional Nurse Leads are responsible for ensuring the implementation of infection
Prevention  and  Control  Guidance,  Including  the  Health  Act  2006,  within  their  areas  of
responsibility.

Senior Managers/Team managers/Ward Managers
Unit managers/Charge Nurses are responsible for:
•  Ensuring that infection control policies are accessible to all staff
•  Ensuing  that  the  required  facilities  and  equipment  are  available  to  enable
compliance with the policies.
•  Ensure  that  all  staff  within  their  area  of  responsibility  have  received  training  in
Infection Prevention and Control
•  Monitoring  compliance  with  infection  control  policies  and  practices  in  their  clinical
area in accordance with Trust and National guidelines.
•  Designating an Infection Control Link person for their clinical area/s

Each Member of the Health Care Team
Infection prevention and control is Everyone’s responsibility. Each individual member of the
Health care team is responsible for:
•  Making themselves familiar with the Trust infection Prevention and Control Manual.
•  Ensuring that they follow the Infection Prevention and Control guidelines competently
and  informing  their  line  manager  of  any  difficulties  encountered  in  applying  the
policies and guidelines.
•  Ensuring  that  they  have  received  appropriate  Infection  Prevention  and  Control
training.

Link Staff
Each clinical area should have an infection Control Link Person.  Infection Control Link staff
will work closely with The Modern Matron/Lead Nurse Infection Prevention and Control and
will liaise with the ICT in relation to Infection Prevention Control issues in their clinical area .
Link staff are responsible for:
•  Ensuring that  Infection Prevention  and  Control audits  are  carried  out  in  accordance
with the Trust Infection Prevention and Control audit programme.
•  Implementing the ‘cleanyourhands’ programme in their clinical area.

Health Protection Agency Unit
The  unit  provides  support  to  all  the  health  Providers  and  Commissioning  Trusts  to  ensure
that they are able to cover their health protection responsibilities for communicable disease
surveillance and control, chemical incidents and emergency planning. All notifiable diseases
and outbreaks of infection must be reported to the HPA unit

2.3 ASSURANCE
The Infection Control Team report quarterly to the Infection Control Committee with regard to
infections, audit programme and training.  The Infection Control Committee reports annually
to  the  Quality  and  Health  Care  Governance  Committee.    Exception  reports  also  go  to  the
Quality and Health Care Governance Committee. Minutes from the Quality and Health Care
Governance  Committee  go  to  the  Board  of  Directors.      The  Trust  has  an  Infection  Control
Strategy which is available via the Trust website.

2.4 INFECTION PREVENTION AND CONTROL TRAINING
Induction Training
All new employees to the Trust must undertake Infection Prevention and Control training as
part  of  the  Induction Training  Programme. This  includes  voluntary  workers  and  contractors
who will have face to face contact with service users.  Induction training must include hand
hygiene, Standard Infection Control Precautions and Sharps Safety.  Attendance records are
maintained on a training database by Anglia Support Partnership.

Mandatory Training
All clinical staff are required to undertake infection prevention and control update training on
an annual basis. Clinical staff must attend a face to face training session at least every two
years  but  may  complete  the  NHS  core  learning  unit  ‘National  Infection  Control  Training
Programme’  online  in  alternate  years.  Non  clinical  staff  are  required  to  undertake  Infection
Prevention and Control update training every five years.  Mandatory Training includes Hand
Hygiene,  Standard  Precautions  and  Sharps  Safety.    Records  of  attendance  at  Mandatory
Training sessions are maintained by Learning and Development and records of completion
of  the  National  Infection  Control  Training  Programme  are  accessed  by  the  Infection
Prevention and Control trainer.

Reporting
A summary of Infection Prevention and Control Training will be included in quarterly reports
to  the  Infection  control  Committee  and  the  Annual  Report  to  the  Quality  and  Healthcare
Governance Committee

2.5 MANADATORY REPORTING OF HEALTHCARE ASSOCIATED INFECTIONS
The Trust are required to report the following to the Health Protection Agency
•  Methicillin Resistant Staphylococcus aureus (MRSA) bacteraemia.
•  Clostridium difficile toxin  (CDT) disease
•  Serious Untoward Incidents (SUIs) relating to Infection Control

Notifiable diseases and outbreaks of infection must also be reported.

Mandatory HCAI surveillance results, outbreak summaries and SUIs will  be included in the
quarterly report to the Infection Control Committee and the annual report to the Quality and
Healthcare Governance Committee.

2.6 DISSEMINATION OF INFORMATION
Policies and Guidance
•  Infection Prevention and Control policies will be reviewed and updated on and annual
basis or if national guidance alters.

•  The  Infection  Prevention  and  Control  policies  and  guidance  will  be  disseminated
throughout  the Trust following  ratification.   Policies  and guidelines  will  be  published
on the Trust public website.

•  Awareness of Infection Prevention and Control policies and guidelines will be raised
during Induction and Mandatory training sessions.

General Public Information
•  Posters and leaflets in relation to hand hygiene are available in clinical areas as part
of the ‘cleanyourhands’ campaign.

•  Information  on  the  ‘cleanyourhands’  campaign  and  patient  information  leaflet  on
infection control are available on the Trust public website.

•  Leaflets  relating  to  MRSA  and  CDT  disease  will  be  available  from  the  infection
control team on request.

•  Information  regarding  environmental  cleaning,  including  the  cleaning  schedule,  is
displayed on notice boards in clinical areas.

2.7 MONITORING AND COMPLIANCE
Compliance  with  infection  prevention  and  control  policies  and  the  Health  Act  2006  will  be
monitored by the following:

•  Annual reassessment by the Infection Control Team using the ‘essential steps’ tool.

•  A rolling programme of Infection Prevention and Control Audit.

•  Quarterly  reports  by  the  Infection  Prevention  and  Control  Team  to  the  Infection
control Committee

•  Annual  report  from  the  Infection  Control  Committee  to  the  Quality  and  Healthcare
Governance Committee

•  Annual  review  and  revision  of  Infection  Prevention  Policies  and  Guidance,  also
revision and review if national guidance alters.

SECTION 3: INFECTION CONTROL
3.1 STANDARD INFECTION CONTROL PRECAUTIONS
Standard precautions can be defined as a standard of care which should be used routinely
to  minimise  the  risk  of  spread  of  infection  (Wilson,  2006).    Standard  precautions  are
applicable in all healthcare settings including hospitals clinics and service users’ own homes.
Many  infections  have  an  ‘incubation’  period  before  symptoms  appear,  during  this  time  the
individual  may  not  be  aware  that  they  have  an  infection.  It  is  not  possible  to  identify  all
infected  individuals  therefore  everybody  should  be  considered  as  potentially  infected.
Standard  precautions  should  be  applied  to  everyone  irrespective  of  individual  diagnosis  or
lifestyle factors.  The aim of standard precautions is to protect both staff and service users
from transmission of infection.

The principles of standard precautions are underpinned by the health and Safety at Work Act
1974 and the Control of Substances Hazardous to Health (COSHH) 1988 regulations. The
Health  and  Safety  at  Work  Act  requires  that  safe  systems  of  work  are  used  at  all  times.
COSHH regulations require that a risk assessment is made prior to contact with hazardous
substances  in  order  to  decide  the  correct  level  of  precautions  to  be  taken.  COSHH
regulations apply to hazardous microorganisms present in body fluids and tissues as well as
chemicals and carcinogens. Staff should assess the risk of contact with blood, body fluids,
non intact skin or mucous membranes and apply the appropriate precautions.

Precautions include:

Hand decontamination.

Personal Protective Equipment.

Management of sharps and needlestick injury

Safe handling of specimens.

Immunisation of staff.

Management of spillage.

Safe disposal of contaminated waste.

Decontamination of reusable instruments and equipment

Decontamination of the environment

Each of these principles are dealt with in more detail later in this section.

Body Fluids
Body fluids include:

Blood
Cerebrospinal fluid
Peritoneal fluid
Pleural fluid
Pericardial fluid
Synovial fluid
Amniotic fluid
Semen
Vaginal secretions
Breast milk
Urine
Faeces
Vomit
Respiratory secretions e.g. sputum
Saliva (in relation to dentistry or human bites)

Standard  precautions  should  be  used  for  contact  with  all  body  fluids,  non  intact  skin  and
mucous membranes. Safe working practices must be followed at all times.

REFERENCES – Section 3.1

Control of Substances Hazardous to Health Regulations 1988 London: HMSO

Health and Safety at Work Act 1974 London: HMSO
Wilson J (2006) Infection Control in Clincial Practice, 3rd Edition, London: Balliere Tindall

3.2 HAND DECONTAMINATION

3.2.1  The Importance of Good Hand Cleaning Technique
Hand washing is THE SINGLE most important measure in reducing the spread of infection.
Hands  are  the  principle  route  of  cross  infection.    The  level  of  hand  hygiene  will  be
determined by the activity or area of practice.

Social handwash
Using liquid soap.
Aseptic/hygiene handwash
Using an antiseptic solution.
Surgical handwash
Using  an  antiseptic  solution.    More  prolonged  and  thorough
hand  wash  prior  to  gowning  and  gloving  in  ultra  clean
environments.

3.2.2  When to clean hands
This  is  determined  by  actions  - those completed  and  those  about to  be performed.    A  non
exhaustive list is given  below. Hands should be cleaned at the point of care as part of the
Cleanyourhands campaign (Appendix 1 and 2)

3.2.3  Routine washing of hands

Before preparing, eating, drinking or handling food.

Before and after smoking.

Before and after visiting the toilet or assisting patients with this activity.

Before  starting  work  (remove  jewellery,  e.g.  rings)  and  after  leaving  an  occupational
area.

After  handling  contaminated  items  such  as  dressings,  bedpans,  urinals,  urine  drainage
bags and nappies.

Before putting on gloves and after removing them.

Before and after removing any protective clothing.

After blowing your nose, covering a sneeze.

Whenever hands become visibly soiled.

3.2.4  Hand Care

Staff must comply to Trust clothing policy

Keep nails clean and short.

Do not wear artificial or gel nails or nail polish.

When washing hands, wrist watches should be removed.

Sleeves should be rolled up to the elbow.

Nail brushes should not be used for routine hand washing as they damage the skin and
encourage shedding of cells.

Nail  brushes,  in  specialist  units,  must  be  single  use  disposable  or  single  use
autoclaveable after each use.

3.2.5  Sequence of Events Appendix 3

Only use designated hand washing basin.

Wet hands under running water.

Dispense one dose of soap into cupped hand.

Hand wash for 10-15 seconds vigorously and thoroughly, without adding more water.

Rinse hands thoroughly under running water.

Dry hands with a disposable paper towel or under hot air dryer.

Dispose the paper towels in a foot operated bin. The lid should not be opened by hands.

3.2.6  Hand Sanitisers/Alcohol Rubs and Gels
These solutions are an effective decontamination agent, but should only be used on visibly
clean  hands.  Build  up  may  occur  after  consecutive  uses  in  which  case  hands  must  be
washed with soap and water.

Dispense the required amount of solution onto the hands.

Rub vigorously, using handwashing technique, ensure solution covers all hand surfaces
until hands are dry.

When  visiting  service  users  in  their  home,  it  is  important  to  do  a  risk  assessment  of  hand
washing  facilities.    If  these  are  not  adequate  then  alcohol  gel  may  be  used  to  impregnate
visibly  clean  hands.    Disposable  wipes  could  be  used  on  soiled  hands  followed  by  hand
sanitisers/gel.

It  is  recommended  (NICE  2003)  that  everyone  involved  in  providing  healthcare  in  the
community must be trained in hand decontamination, This includes service users, carers and
healthcare personnel.

Apply an emollient hand cream regularly to protect the skin from the drying effects of regular
hand  decontamination.  If  a  particular  hand  hygiene  product  causes  skin  irritation  seek
occupational health advice.

3.2.7  Hand wipes – Use of
These are appropriate for use in a number of situations, e.g. for community staff, when hand
washing is compromised by inadequate facilities available to them.  This should be followed
up by the use of alcohol hand gel.

Inpatients should be routinely offered hand wipes when unable to use the hand wash basin
facilities.  This is particularly important after using a commode, bedpan or urinal and before
eating a meal or snack.  Service users and their relatives should be encouraged to provide
hand wipes whenever possible to ensure that this is carried out.

REFERENCES – SECTION 3.2

Coello R, Glenister H,  Fereres J, (1993) The Cost of Infection in Surgical Patients : A case
Control Study.  Journal Hospital Infection 93, pp239-250.

Hand  Decontamination  Guidelines  published  by  the  Infection  Control  Nurses  Association
(ICNA) 2002.

McGinley  K,  Larson  E,  Leyden  J.    (1988)  ‘Composition  and  density  of  microflora  in  the
subungual space of the hand.’  Journal of Clinical Microbiology 26, pp 950 –3.

Teare L (1999), Handwashing, BMJ, 318, p686.

NICE Guidelines, Prevention and Control of Healthcare Associated Infection in Primary and
Community Care.  June 2003.

(NPSA) EOESHA Principles for inclusion in HHPS.

All hand hygiene products must be approved for use in the organisation by the I P & C team.

Please refer to NPSA Hand hygiene Posters as Appendix 1, 2 and 3.

3.3 PERSONAL PROTECTIVE EQUIPMENT (PPE)
3.3.1  Gloves
Disposable gloves must be worn for direct contact with blood, body fluids and non-intact skin
or  mucous  membranes.  Gloves  must  be  discarded  after  each  procedure  and  always
between patients.  The use of gloves is not an alternative to thorough hand-washing.

3.3.2  Risk Assessment
The risk assessment should take account of various factors that include:

Nature of the task to be undertaken.

Risk of contamination to either patient or user.

Barrier efficacy of gloves, both surgical and examination gloves can fail.

Whether there is a need to double glove

Requirement for Sterile or non-sterile gloves.

Allergy/sensitisation.

Handling chemicals (including cleaning agents) or disinfectants, which could cause skin
irritation or are COSHH regulated.

As a general rule, if the risk is to the patient then ‘Sterile’ gloves are required.   If the risk is
to  the  user  then  ‘Non-sterile’  gloves  will  probably  be  sufficient.    When  handling  chemical
disinfectants you may need to wear industrial or household gloves.

Following the risk assessment, the next issue is what type of glove should be used:

Figure 2 - Glove Usage

PROCEDURE TO BE PERFORMED
TYPE OF GLOVE
•  All aseptic procedures
Sterile, non-powdered, examination gloves:

latex  or  synthetic  alternative  (nitrile  or  vinyl
pigmentised powder free).

•  Sterile pharmaceutical preparations
Non-sterile, non powdered gloves:
latex  or  synthetic  alternative  (nitrile  or
polychloroprene).
•  Handling aldehydes
Use  nitrile  or  polychloroprene  for  handling
aldehydes.
•  Cleaning with detergent.
Vinyl gloves – non powdered.
•  Food handling, preparation and serving.
Vinyl gloves – non powdered.
If  staff  have  an  allergy  to  a  particular  type  of  glove  they  should  be  referred  to  their
occupational health department
Reference: Adapted from ICNA, 1999

3.3.3  Gowns and aprons
Disposable plastic aprons must be worn whenever contamination of clothing is possible.
As with handwashing this is determined by risk assessment of tasks to be undertaken.

Remember:  Aprons are single use items.

Disposable gowns should be worn where there is a risk of contamination of the arms

3.3.4  Face Protection
Protective face wear should be worn where risk of blood or other bodily fluids splashing onto
the  face.  This  includes  the  preparation  of  some  cytotoxic  chemotherapy  and  during  the
manual  decontamination  or  cleaning  of  instruments.  The  wearing  of  full  face  visors  is
recommended.

3.3.5 Single Use

Remember  gloves  and  aprons  are  single  use  items.  The  use  of  disposable  visors  is
recommended however, if reusable visors are used, they must be decontaminated between
uses.    Personal  protective  equipment  should  be  changed  between  ‘clean’  and  ‘dirty’  tasks
and  between  service  users.  Hands  must  be  washed  following  removal  and  disposal  of
personal protective equipment.  If used correctly PPE can be very effective in preventing the
transmission of infection however if used incorrectly it becomes a hazard.

3.3.6 Contamination of work wear
It is recommended that staff launder work clothing separately, this is of particular importance
where  clothing  has  been  contaminated  with  blood  or  body  fluid.  Clothing  should  be
laundered at 60ºC or as high a temperature as the fabric will withstand.  Clothing should be
ironed at as high a temperature as it will withstand.

REFERENCES – SECTION 3.3

Beck W,  Belkim  N,  Meyer  K,  (1995)  ‘Divide  and  conquer  –  protection,  comfort  and  cost of
the surgeons gown’.  American Journal of Surgery Vol. 169, pp 286-287, March.

Callaghan I, (1998)  ‘Bacterial contamination of nursing uniforms’ Nursing Standard, Vol. 13,
No 1, pp 37-42; September 23rd

Eason S (1995) ‘Are cover gowns necessary in the NICU for parents and visitors?’ Neonatal
Network, Vol. 14, No 8, p50 December.

Granzow J, Smith J, Nicholas R, Waterman R, Muzik A,  (1998) ‘Evaluation of the protective
value of hospital gowns against blood strike-through and Methicillin resistant staphylococcus
aureus  penetration’.    American  Journal  of  Infection  Control  Vol.  26,  No  2,  pp  85  -93  April
1998.

Infection Control Nurses Association (1999) ‘Glove Usage Guidelines’, September 1999.

Medical  Devices  Agency,  June  1998    Latex  Medical.  Powdered.  Latex  Medical  Gloves.
MDA SN9825.

Health Service Circular.  Latex Medical Gloves and Powdered Latex Medical Gloves.  HSC
1999/186.

NICE Guidance, June 2003.  Prevention and Control of Healthcare Associated Infections in
Primary and Community Care.

3.4 ASEPTIC TECHNIQUE

3.4.1 Rationale
Aseptic  technique  refers  to  practice  used  to  prevent  the  risk  of  infection.    Some  of  these
practices  will  also  reduce  the  healthcare  worker’s  risk  of  exposure  to  potentially  infectious
blood and tissue during clinical procedures.

Aseptic  technique  is  vital  in  reducing  the  risk  of  healthcare  associated  infection,  and
associated  morbidity  and  mortality,  caused  by  invasive  procedures.    An  aseptic  technique
should be used during any invasive procedure which breaches the body’s natural defences,
i.e. the skin or mucous membrane, or when handling equipment which will enter a normally
sterile body cavity, such as urinary catheters.

3.4.2General recommendations
The  principles  of  asepsis  must  be  observed  when  undertaking  any  invasive  clinical
procedure.

Key principles of asepsis:-
•  Keep the exposure of the susceptible site to a minimum
•  Appropriate personal protective equipment to be worn
•  Sterile packs should be checked for evidence of damage or moisture penetration and
for expiry date
•  Contaminated or non-sterile items must not be placed on the sterile field
•  All disposable items must be disposed of in accordance with the  waste policy
•  Single use items must not be re-used
•  Activity  should  be  reduced  in  the  immediate  vicinity  of  the  area  in  which  the
procedure is to be performed.

Procedure for surgical hand decontamination using antiseptic solution
•  Wet the hands under tepid running water
•  Wash all surfaces with an aqueous antiseptic solution for 3 minutes
•  Rinse hands well and dry thoroughly

Skin Preparation for a clinical procedure
Good  skin  preparation  helps  to  reduce  the  risk  of  infection  by  lowering  the  chances  of
bacteria from the patient’s skin will enter the wound.

Before giving an injection
If the site appears clean no further cleaning is necessary.   If there is visible dirt, wash the
injection site with soap and water (DH 2006). Then use 2% Chlorhexidine gluconate in 70%
Isopropyl alcohol e.g.  ChloraPrep and allow to dry before proceeding to insert the needle. ).
Povidine iodine 10% alcoholic solution can be used where there is chlorhexidine sensitivity

Before phlebotomy
The  site  should  be  visibly  clean  and  then  disinfected  and  allowed  to  dry  thoroughly.    For
disinfection ideally use 2% Chlorhexidine gluconate in 70% Isopropyl alcohol

Before taking blood cultures
Blood cultures should not normally need to be carried out in the Mental Health setting.  If in
exceptional circumstances this is done, strict aseptic technique must be followed according
to the DH 2007 Saving Livings guidance on Taking Blood Cultures at:-

http://www.clean-safe-care.nhs.uk/toolfiles/80 blood%20cultures v2.pdf

3.4.3 Creating and maintaining a sterile field
A  sterile  field  is  an  area  created  by  placing  sterile  towels  or  sterile  drapes  around  the
procedure site and on the surface/trolley used for sterile instruments and other items needed
during the procedure.

Sterile items are free of potentially harmful micro organisms, once a sterile object comes into
contact  with  a  non-sterile  object  or  person  or  with  dust  or  other  airborne  particles,  it  no
longer sterile.

To maintain the sterile field
•  Do not place sterile items near open windows or doors
•  Place only sterile items within the sterile field
•  Do not contaminate sterile items when opening, dispensing or transferring them
•  Do not touch non-sterile items with sterile gloves
•  Do not touch sterile items with non-sterile gloves
•  Be conscious of where your body is at all times and move within or around the sterile
field in a way that maintains sterility

Creating a safe environment
Specific rooms  should  be  designated for  performing clinical  procedures  and for  processing
instruments and other items.  Limiting the traffic and activities in these areas will lower the
risk of infection.

To maintain a safe environment:
•  Limit the number of people who enter these areas
•  Close doors and windows during procedures to minimise dust and eliminate insects
•  Before  a  new  patient  is  brought  into  the  room,  clean  and  disinfect  all  surfaces  that
may  have  been  contaminated  during  the  last  procedure  –  including  examination
couches, dressing trolleys and examination/operating lamps

Prophylactic  antibiotics  are  often  inappropriately  used,  can  contribute  to  the
development  of  resistant  micro-organisms  and  are  no  substitute  for  good  infection
control practice.

3.5 SHARPS MANAGEMENT

3.5.1  Important Points
Safe handling and disposal of sharps is a vital component of Standard Precautions.  Injuries
with contaminated sharps can transmit infections, particularly blood borne viruses.

Good practice involves:

Correct assembly of the sharps bin, with particular attention to the lid.

Completion of the details on the bin label following assembly, locking and disposal.

Filling to no more than to the fill line.

Being aware of the first aid treatment and action following a needle-stick injury.

Being aware of the follow up treatment available after a used needle-stick injury.

Provision  of  training,  sufficient  numbers  of  sharps  boxes  and  safe  systems  of  work
are a health and safety responsibility of the management of the Trust

3.5.2  Disposal of Sharps
Sharps containers must:

•  conform to BS 7320 and UN 3291.
•  when in use be sited so that they cannot be tampered with.
•  be sealed and replaced when contents reach the fill line.

•  be taken to the point of use for the subsequent disposal of each sharp item.
•  be marked with the ward/department/unit name or number, the name of the person who
assembles  it,  the  name of  the  person  who  locks  it  and finally  the  name of  the person  who
disposes of it.
•  be stored securely and be accessible only to authorised handlers.

It is the personal responsibility of any person using a sharp item, to dispose of it correctly.

All used sharp items must be discarded into an approved sharps bin, immediately after use.

Syringes and needles should be discarded intact as one unit.

An adequate number and size of sharps bins, should be available in clinical areas.

Needles must not be re-sheathed, bent or broken.

No attempt is to be made to retrieve items from sharps containers.

Large  pieces  of  broken  glass  and  china  should  be  placed  into  an  approved  container  for
disposal (other than sharps bin).


REFERENCES – Section 3.5

AYLIFFE GAJ, FRAISE AP, GEDDES AM, MITCHELL K (2000) Control of Hospital Infection
A Practical Handbook London: Arnold

British  Medical  Association  (1990)  ‘A  Code  of  Practice  for  The  Safe  Use  and  Disposal  of
Sharps’  reprinted 1993.   BMA House, London.

British  Standards  Institute  (1990)  BS7320.      ‘Specification for  Sharps  Containers’.    London
BSI 1990.

Health Service Advisory Committee (1992).  ‘Safe Disposal of Clinical Waste’.  London.

Perry C, (1999) ‘Using the Audit Cycle to Monitor Sharps Disposal Practice’.   British Journal
of Infection Control,  May 1999.  pp 6-8.

The Environmental Protection Act (Duty of Care) Regulations 1991.  London, HMSO.

United Nations - Standard 3291.

NICE Guidance June 2003.  Prevention and Control of Healthcare Associated Infections in
Primary and Community Care.

3.6 INNOCULATION INJURIES, BLOOD CANTAMINATION AND POST EXPOSURE
PROPHYLAXIS (PEP)

This is to be read in conjunction with the Trust’s Sharps Policy

3.6.1  Main Risks from Inoculation Injury and Blood Contamination
The main concern is the transmission of blood-borne viruses, i.e.:

HEPATITIS B (HBV)

HEPATITIS C (HCV)

HUMAN IMMUNODEFICIENCY VIRUS (HIV)
3.6.2  Risk From Injuries
The risk of transmission is higher (particularly for HIV) when there is:

A deep injury, i.e. when the injury is deeper than a superficial scratch drawing blood.

Visible blood on the device that caused the injury (including teeth).

Injury with a needle that had entered from the source patient’s blood stream.

3.6.3  Following  a  inoculation  Injury,  from  a  needle  contaminated  with  blood  or
Highly Suspected Person to another Recipient the Risks are:

Hepatitis B
1:3
HBV

Hepatitis C
1:30
HCV

Human Immunodeficiency Virus  1:300
HIV

It  has  been  estimated  that  the  risk  of  acquiring  HIV  through  mucous  membrane  exposure
(e.g.  splashed  with  contaminated  body  fluids)  is  much  less  probably  1  per  1000  injuries
(0.1%).

Remember  if  post  exposure  prophylaxis  for  HIV  is  to  be  given  it  should  ideally  be
given as soon as possible, preferably within an hour of injury.

3.6.4  Action in the Event of any inoculation Injury, Bite or Contamination with Blood

Encourage bleeding, squeeze the injury, do not suck.

Wash the skin thoroughly with soap and water, do not scrub.

Irrigate contaminated mucous membranes, e.g. mouth and eyes with large quantities of
water or splash kits where provided.

Cover  the  injury  with  waterproof  dressing  and  Inform  the  nurse  in  charge  or  the  line
manager.

Report  to  Occupational  /  Staff  Health  or,  out  of  hours  contact  A  &  E  who  will  discuss
appropriate procedure and Post Exposure Prophylaxis.

Complete incident/adverse event form.

REFERENCES – Section 3.6
Guidance  for  Clinical  Health  Care  Workers:  Protection  against  Infection  with  Blood  Borne
Viruses, UK Health Departments (1999).

Exposure  To  Hepatitis  B  Virus:  Guidance  On  Post  Exposure  Prophylaxis  Communicable
Disease Report.    Vol. 2, Review No 9, August 1992.

Guidance  on  the  Investigation  of  Management  of  Occupation  Exposure  to  Hepatitis  C  -
Communicable Disease Public Health (1999),  pp 2258-2262,  Ramsey.

HSC 2002/011  Hepatitis C Infection.  HCW 2002.

Post  Exposure  Prophylaxis:    Eye  of  the  Needle.    Guidance  from  the  UK  Chief  Medical
Officer, DoH.  February 2004.

3.7 MANAGEMENT OF LABORATORY SPECIMENS
A  specimen  is  defined  as  any  bodily  substance  taken  from  a  person  for  the  purpose  of
analysis, such as blood or urine.  All specimens should be regarded as potentially infectious,
and  all  members  of  staff  involved  in  collecting,  handling  and  transporting  specimens  must
follow infection control precautions to prevent transmission of infection.

To reduce risks, the number of persons handling specimens should be kept to a minimum.
Everyone  handling  specimens  should  be  trained  and  should  be  aware  of  related  infection
control policies.

3.7.1 General recommendations
Everyone  involved  in  collecting,  handling  and  transporting  specimens  should  be  educated
about standard infection control precautions and trained in:-
•  Hand hygiene
•  The use of personal protective clothing
•  The safe use and disposal of sharps

Patients and their carers should be given advice on the collection, storage and transportation
of specimens, where appropriate.

3.7.2 Principles of specimen collection
The clinician  or  person  taking  any  specimens must  ensure that  the following  principles  are
followed:
•  Effective  hand  washing  is  performed  before  and  after  collection  of  the  specimen  in
accordance with the Hand Hygiene Policy (ICC 02)
•  Appropriate protection clothing is worn when collecting the specimen i.e. non-sterile
gloves, aprons and, where splashing is possible or expected, goggles or visor
•  Measures are taken to prevent contamination of the sample
•  The specimen is taken at the correct time
•  The correct specimen container is used
•  The specimen container is tightly sealed to prevent leakage
•  The outside of the container is free from contamination with body fluid
•  The  sample  is  appropriately  labelled  with  patients  name,  date  of  birth,  hospital
number (if applicable) as well as the date and time that the specimen was obtained
•  The  appropriate  request  form  is  completed  with  details  of  the  patient’s  relevant
medical history, investigation required and dates of any antibiotic treatment received.
Please  ensure  that  the correct  name  is  on  the  specimen  container  and  the  request
slip
•  The specimen container must be placed in an approved specimen bag and sealed,
with the request form in the separate pouch which is attached
•  The specimen is stored correctly and transported to the laboratory promptly
•  The patient’s confidentiality is maintained at all times
•  All
specimen
containers
should
be
checked
for
exterior
contamination and disinfected

3.7.3 High risk specimens
All  clinical  specimens  should  be  regarded  as  potentially  infectious.    Specimens  known  or
suspected  to  contain  high-risk  pathogens  such  as  Tuberculosis  or  blood-borne  viruses
should be marked using a biohazard sticker on both the specimen container and the request
form.

3.7.4 Microbiological specimens
Microbiology  results  are  crucial  for  identification  of  appropriate  antibiotic  therapy  and
application of infection control measures.

To ensure that accurate microscopy, culture and sensitivity results are obtained, steps must
be  taken  to  avoid  contamination  of  the  specimen  with  the  service  user’s  or  clinician’s  own
normal flora.

Antibiotic  therapy  may  affect  the  specimen  and  inhibit  bacterial  growth  in  the  laboratory
cultures,  and  may  produce  misleading  results.    If  possible  the  sample  for  microbiological
investigation  needs  to  be  collected  prior  to  commending  antibiotic  therapy.    However,  if
collected  during  antibiotic  therapy,  the  specimen  should  ideally  be  collected  immediately
before a dose is administered.

3.7.5 Faeces
Stool specimens should ideally be collected during the first 48 hours of illness.  The chance
of  identifying  pathogens  diminishes  as  time  after  acute  illness  passes.    A  spatula  must  be
used to collect a walnut-sized sample of solid stool or appropriate 15mls of liquid stool into a
specimen bottle.  This should be sufficient for microbiological investigation.  If viral infection
is suspect the specimen bottle should be ¾ full.

In  an  outbreak,  stool  specimens  should  be  collected  from  all  the  affected  persons  for
bacteriology  and  virology.    The  sample  for  bacteriology  should  be  sent  for  culture  and  the
sample for  virology  should  be  sent for  electron microscopy.  They  should  ideally  reach  the
laboratory  on  the  day  of  collection.    If  necessary,  stool  specimens  can  be  stored  in  a
designated specimen refrigerator for no longer than 24 hours.  Do not freeze faeces.

3.7.6 Urine
A mid-stream specimen of urine is the best sample for culture and sensitivity.  Bladder urine
is sterile but it can easily be contaminated during collection by bacteria, which colonise the
perineum.  The perineum must therefore be cleaned with soap and water prior to specimen
collection  to  help  reduce  bacterial  contamination.    Discarding  the  first  several  millilitres  of
urine  and  collecting  5-10  mls  of  midstream  urine  in  a  sterile  container  will  reduce
contamination.  The infecting organism is more likely to be detected in concentrated or early
morning urine.

A specimen of urine from a urinary catheter should be obtained by aspiration with a sterile
5ml syringe and a fine bore sterile needle from the self-sealing sampling port.

The port should be cleaned with a steret or alcowipe (70% Isopropyl alcohol) and the needle
inserted through the port.

The catheter should never be disconnected to obtain a sample as this will break the closed
system and serve as a portal of entry for micro-organisms.

Indiscriminate  sampling  should  be  avoided  and  sampling  should  only  be  carried  out  when
strictly necessary.

Urine samples collected for culture should be examined within two hours of collection, or 24
hours if kept in a designated specimen refrigerator at 4-8◦C.

3.7.7 Sputum
Sputum  samples  should  ideally  be  collected  in  the  morning  before  eating,  drinking  or
cleaning teeth.

The  service  user  should  be  asked  to  cough  up  material  from  deep  in  the  lungs  and
expectorate without saliva into a specimen container.  Saliva or mucous from the back of the
nose should not be provided as sputum.  The specimen should be delivered to the laboratory
as soon as possible, or within 24 hours if refrigerated.

3.7.8 Wound swabs
Taking  a  wound  swab  is  only  recommended  when  clinical  signs  of  infection  are  identified
and  the  information  gained  will  affect  treatment.    Routine  swabbing  should  be  avoided
(Gould 2001; Parker 2000).

As  with  all  investigations  the  findings  must  be  reviewed  alongside  clinical  information  and
treatment should not be based on swab results alone.

If pus is present, a sample obtained by aspiration with a syringe will be the most informative.
Loose  debris  on  the  wound  should  be  removed,  as  this  is  likely  to  contain  high  levels  of
bacteria, which are not representative of the infective organism.

If the wound is dry, moisturising the swab with sterile normal saline makes it more absorbent
and increases the survival of bacteria prior to culture (Donovan 1998; Gilchrist 1996).  The
swab must touch all areas by  wiping in a zigzag and rolling motion over the surface of the
wound.  The swab should then be placed directly into a tube and carefully labelled and sent
to the laboratory as quickly as possible.

It is important that the specimen is supported with sound clinical information recorded on the
microbiology  request  form.    Details  relating  to  the  patient’s  symptoms  of  infection  and
treatment  history  will  assist  the  microbiologist  in  making  an  accurate  diagnosis  and
appropriate recommendations for management.

Sensitivities  for  antibiotic  treatment  are  not  always  returned  with  culture  results  because
many isolates reflect bacterial colonisation, rather than infection.  It is worthwhile obtaining
advice from the laboratory to discuss results and treatment of the case.

3.7.9 Storage of specimens
For accurate results to be obtained, specimens should be received by the laboratory as soon
as possible.

If for microbiological investigation, urine and sputum specimens should ideally be examined
in the laboratory within 2 hours of collection, and stool samples within 12 hours.  However,
where this is not possible, urine and sputum specimens must be stored within a designated
fridge,  but  only  for  a  maximum  of  24  hours,  at  4-8◦C.    This  will  help  prevent  bacteria  and
contaminants from multiplying and giving misleading results.

However,  it  must  be  noted  that  samples  taken  for  blood  culture  must  not  be
refrigerated,  but  must  be  transported  to  the  laboratory  as  soon  as  possible  for
incubation  at  37◦C.    Samples  obtained  for  non-microbiological  investigation  also  do
not need to be refrigerated.

If any clinical specimens are to be sorted in a refrigerator, it is essential that:
•  There is a refrigerator for the purpose of specimen storage only
•  The  temperature  in  the  refrigerator  is  kept  between  4-8◦C  (minimum  and  maximum
temperature to be checked and recorded daily)
•  The specimen refrigerator is not accessible to the public
•  The specimen refrigerator is cleaned on a weekly basis, defrosted regularly, cleaned
and  disinfected  after  any  spillage  or  leakage (see  Spillage  of  Blood  and  Body  Fluid
Policy ICC 04)

3.7.10 Transportation of clinical specimens
Under  the  Health  &  Safety  at  Work  Act  (1974)  all  staff  have  an  obligation  to  protect
themselves  and  others  .e.g.  the  public,  from  inadvertent  contamination  from  hazardous
substances.

All  staff  must  therefore be  aware  of  how  to  deal  safely  with  clinical  specimens  and  how  to
avoid any spillage or leakage of body fluids.

All  specimens  must  be  collected  by  portering/transport  staff  in  a  secure,  robust,  leakproof
container with a biohazard label.  These containers must be cleaned and disinfected weekly
and after any visible spillage.

All  clinical  staff  transporting  specimens from  a  patient’s  home to  a  surgery,  clinic  or  health
centre must be provided with a rigid, robust, leak proof container with a tight fitting lid.  This
container must be identified with both a biohazard sticker and contact telephone number in
case the box is lost.  Clinical staff must not transport specimens unless such a container is
used.

Appendix 2- Section 3.7
Daily temperature check – specimen fridge

The  temperature  of  the  specimen  fridge  must  fall  between  4-8◦C.    If  the  temperature  falls
outside of this range, the fridge thermostat must be adjusted accordingly and advice sought
from the labs as to whether this will adversely affect analysis.

If  the  temperature  remains  outside  of  this  range,  the  fault  must  be  reported  and  the  fridge
repaired as soon as possible.  If it cannot be reported, a new fridge should be purchased.

Date
Temperature recorded in ◦C
Action taken  Signature
if required

Actual
Min
Max

3.8 STORAGE, DISTRIBUTION AND DISPOSAL OF VACCINES
Guidance is available in the UK Guidance on Best Practice in Vaccine Administration which
has been distributed to each practice.  The guidance can also be downloaded from the
website:  http://www.vaccine-administration.org.uk/main_using.html.

3.8.1  Storage of Vaccines Equipment Fact Sheet
This is the information obtained from the Department of Health identified in the ‘Green Book’.
The  fact  sheet  contains  information  on  some  of  the  equipment  currently  available  in
connection  with  vaccine  storage  and  distribution.      It  is  intended  as  an  aid  for  those  in
handling of vaccines and does not claim to be comprehensive.

3.8.2  World Health Organisation Product Information Sheets
Contain  technical  and  purchasing  information  on  selected  equipment  for  the  storage,
transport and the administration of vaccines for the Expanded Programme on Immunisations
(EPI).    Most  of  the  equipment  included  has  been  independently  tested  at  the  WHO
authorised  laboratories,  but  little  of  it  is  manufactured  in  the  UK,  therefore  is  not  always
readily available.  Some items, nevertheless, may be of interest.

Please contact WHO at the address below or website address to obtain a copy:
http://www.who.int/vaccines-documents/DocsPDF00/www518.pdf

World Health Programme
Expanded Programme on Immunisation
Cold Chain
Switzerland
Fax: 00 41 22 788

REFERENCES – Section 3.8
Department  of  Health  (1999).  Current  vaccine  issues:  action  update.    PL/CMO/99/5,
PL/CNO/99/9, PL/CPHO/99/4.

Department of Health (1996).  ‘Immunisation against infectious Disease’ Salisbury D M,
Begg N T (Eds) London HMSO.

Kassianos G C (1998).  Immunisation Childhood and Travel Health.  Third Edition.
Blackwell Science Ltd.

Northern  and  Yorkshire  Regional  Health  Authority,  ‘The  Vaccine  Cold  Chain  from
Manufacturer to Patient’.

Wakefield ‘Child Immunisation Policy’.  November 1996.

APPENDIX 1 – Section 3.8
SAFE IMMUNISATION – COLD CHAIN RESPONSIBILITY

NOMINATED PERSON

DEPUTY

NAME:
___________________________________________________________

DESIGNATION:_________________________________________________________

LOCAL WRITTEN PROCEDURE

TEMPERATURE CONTROL MIN/MAX


TEMPERATURE RECORD

STORAGE/POSITION IN REFRIGERATOR

CLEANING/DEFROSTING

ACTIONS:

COLD CHAIN FAILURE

DISPOSAL VACCINES

DISPOSAL CONTAMINATED WASTE

DATE TRAINING COMPLETED:____________________

3.9 DEALING WITH SPILLAGES
(To be read in conjunction with the Organisation’s Waste Policy)
It  is  vital  that  any  spillage  is  attended  to  as  soon  as  possible.    Under  the  Control  of
Substances  Hazardous to  Health  Regulations  1994  (COSHH),  assessment  of  hazards  and
associated risks to health must be undertaken to ensure the health and safety of employees,
patients and other visitors to the healthcare premises.

3.9.1  Responsibilities
All staff involved in the clinical care of patients or the safe handling of waste must be aware
of how to deal safely with any spillage which may occur.

3.9.2  Mercury Spillages

Mercury should be avoided where possible.  The aim is to minimise risks from mercury
spillages and, the ideal would be to reduce the use of Mercury in the occupational area
by using alternative equipment. Where equipment containing Mercury is used a mercury
spillage kit should be available.

The hazards resulting from mercury exposure are inhalation of fumes, or skin absorption.   It
is  recognised  that  mercury  exposure  is  of  a  relatively  low  risk  but  it  remains  important  for
spillages to be dealt with quickly and effectively.

Spills fall into two categories:

3.9.3 Large spills
Large  spills  are  usually  dealt  with  by  a  specialist  service.    However,  before  specialist  help
arrives the following points will need to be remembered:

The area will need to be evacuated and marked off to restrict entry of personnel.

Ventilate by opening doors and windows.

Remove all sources of heat, either by switching off or removing from the area.

3.9.4 Small spills
Members  of  staff  using  the  following  points  will  be  able  to  deal  with  a  small  spill  using  a
mercury spillage kit:

Avoid  direct  skin  contact  with  the  mercury  (ensure  to  wash  any  mercury  from  the  skin
should contamination occur).

Protective  clothing  should  be  used,  i.e.  disposable  plastic  apron  and  non-powdered,
non-sterile gloves.

Use a  Mercury Spill Collector, carefully soak up  the mercury in the sponge and reseal
the container.

Place the container in a plastic bag, seal and mark ‘Mercury Contamination’.

Arrange for collection.

Wash hands and arms carefully.

After all procedures are actioned, complete an incident/accident form as per policy.

3.9.5  Body Fluid Spillage
Body fluid spills are divided in to two categories, those which are visibly contaminated with
blood and those which are not:-
3.9.5a Blood Spillage

Spillage of blood should be dealt with as soon as possible.

Splashes of blood (or any body fluid) on the skin should be washed off immediately
with soap and water.

If there is broken glass do not touch even with gloved hands – use a paper or plastic
scoop and dispose in the sharps box.

Ensure staff use Personal Protective Equipment (wearing non-sterile, non-powdered
latex  gloves  and  plastic  apron)  and  either  sprinkle  sodium  hypochlorite  releasing
granules, e.g. Presept or Sanichlor tablets diluted to cover and soak up the blood.

The  sodium  hypochlorite  concentration  used  should  be  equivalent  to  10,000  parts
per million (ppm) of available chlorine.  In general, this corresponds to a 1:100 (1%)
dilution  of  household  bleach,  but  it  is  emphasised  that  the  strength  of  individual
brands of bleach may vary. Please read the manufacturer’s instructions before use.

Chlorine granules can be used for spillages of up to 100mls.

Leave for 2-5 minutes.

Wipe up with paper towels (or use a disposable scoop for granules) and place in the
appropriate waste disposal (see Section 2 – 2.9)

Dispose of soiled gloves and apron and wash your hands.

Domestic cleaning using detergent and water should follow.

If the area is a carpet it is inappropriate to use bleach, clean by:
-
Using paper towels.
-  Then wash detergent and water.
-  Finish with a carpet cleaner or steam cleaner.

An Important COSHH Hazard notice has been attached to Chlorine Releasing Granules:

Do not use in poorly ventilated areas

Do not use if suffering from a known chest condition or asthma.

3.9.5b
Urine Spills Visibly Contaminated with Blood
Chlorine  releasing  agents  should  not  be  used  for  urine  spillages  even  if  it  contains
visible blood.  If a chlorine releasing agent is used, i.e. Domestos, Titan or Presept with
urine the resulting fumes are considered a hazard.  The recommended practice is:

Wear non-sterile, non-powdered latex gloves (or other suitable glove – see figure 2,
page 14 and plastic apron.

Soak up with paper towels.

Use detergent and water on area after soaking up the spill.

A chlorine-releasing agent may now be used on the area if necessary.

Discard gloves, waste materials and apron in a clinical waste bag for incineration.

Wash hands thoroughly.

3.9.5c
Spillages of Body Fluids not Visibly Contaminated with Blood
These spillages will include faeces, vomit, urine and sputum.

Always  wear  protective  clothing,  i.e.  plastic  disposable  apron,  disposable  powder-
free, non-sterile latex or similar (see Section 2 – 2.3  ‘Protective Clothing’).

Use paper towels to soak up the spill.

Discard paper towels and any other waste from the spillage into clinical waste bags.

Clean the contaminated area with hot water and detergent.

Discard gloves and apron in a clinical waste bag.

Wash hands.

Please contact infection control for advice concerning the use of disinfectants where there is
a known infection.

REFERENCES – SECTION 3.9
Bond W W, Favero M S, Petersen N J, et al.  (1981) ‘Survival of hepatitis B virus after drying
and storage for one week’ Lancet 1:550.

Control of Substances Hazardous to Health regulations 1994.

Health and Safety at Work Act (1974).

HSE Environmental Hygiene Guidance Note Number 17.

Substances Hazardous to Health Emergency Spillage Guide – Croner Publications.

Royal College of Pathologists (1995) HIV and the Practice of Pathology.  Report of the HIV
Working Party of the Royal College of Pathologists.  London Royal College of Pathologists.

The  Senate  of  Surgery  of  Great  Britain  and  Ireland  (1998)  ‘Blood  borne  viruses  and  their
implications for surgical practice  and training’  Senate  Paper  4  –  September  1998,  London:
McKenzie Graham.

UK Health Departments (1993)  Protecting Healthcare Workers and Patients from Hepatitis
B.  Recommendations of the Advisory Group on hepatitis.  London: Department of Health.

3.10 WASTE SEGREGATION
The following guidance is to be read in conjunction with the Trust’s Waste policy.

Waste generated is segregated into four principal streams for disposal.

Black bags
Use for all domestic-type wastes e.g. paper, food, dead flowers.
The  waste  must  not  provide  an  infection  risk  and  will  not  derive  from
patient treatment.
Many of these wastes may be recycled, and should be wherever possible.

Yellow bags
Use  for  all  non-sharp  wastes  arising  from  patient  care.  This  will  include
dressings; gloves and other protective equipment; and used equipment.
The wastes will be treated as having an infection risk and will classified as
“hazardous” for disposal.
None  of  these  materials  should  be  contaminated  with  any  cytotoxic  or

cytostatic medicines.

Sharps bins

(yellow lid)
Use  for  infectious  and  non-infectious  sharps  (needles,  blades  etc.),
syringe  bodies  (including  those  containing  partially  discharged
medicines);  used  ampoules  and  vials;  dropped  and  refused  medicines;
and associated equipment.
None  of  these  materials  should  be  contaminated  with  any  cytotoxic  or

cytostatic medicines.
Add an absorbent pad to each new bin to soak up any excess liquid

Sharps bins
(purple lid)
Use  for  similar  materials  as  described  above  (yellow-lidded  sharps  bin)
but contaminated with cytotoxic or cytostatic materials.
This  bin  should  also  be  used  for  any  surplus  or  expired  cytotoxic  or
cytostatic medicines (rather than return to pharmacy).

Add an absorbent pad to each new bin to soak up any excess liquid

Do not discharge part-filled syringes into the sharps box.

If  any  dressings  etc  normally  placed  in  the  yellow  bag  are  contaminated  with  Cytotoxic  or
cytostatic  materials,  they  must  either  be  placed  in  a  yellow  bag  with  a  purple  stripe  or  the
yellow bags must be clearly labelled to indicate cytotoxic contents

Cytotoxic  and  cytostatic  wastes  must  be  segregated,  as  they  require  destruction  by
incineration and under different conditions than infectious wastes.

The  adoption  of  a  simplified  segregation  system  means  that  hazardous  and  non-
hazardous materials are mixed in the same container. This is permitted only where no
adverse  reaction  will  occur  or  where  the  future  treatment  of  the  waste  will  not  be
compromised.

Other  specialised  containers  may  be  in  use  for  certain  dedicated  activities.  For  example,
amalgams from dental units will be kept in white plastic pots.

3.10.1  Assessment of “Infectious”
Infectious  waste  is  essentially  a  waste  that  poses  a  known  or  potential  risk  of  infection,
regardless  of  the  level  of  infection  posed.  Even  minor  infections  are  included  within  the
definition of infectious.

General assumptions

Healthcare waste generated from Healthcare practices, or produced by healthcare workers
in  the  community,  is  considered  to  be  infectious  waste  unless  assessment  to  the  contrary
has  taken  place.  A  healthcare  practitioner  bases  this  assessment  on  item  and  patient-
specific clinical assessment.

Municipal  waste  from  domestic  minor  first  aid  and  self-care  that  does  not  require  staff
involvement  is  assumed  to  be  non-infectious  unless  indicated  otherwise.  Therefore,  soiled
waste  such  as  nappies,  sanitary  products  and  plasters  are  not  considered  to  be  infectious
unless a healthcare practitioner the producer gives advice to the contrary.

Municipal-type  waste  from  industrial  and  commercial  premises  is  assumed  to  be  non-
infectious  providing  that  a  risk  assessment  has  been  conducted.  Therefore,  soiled  waste
such  as  plasters  and  sanitary  products  are  not  considered  to  be  infectious  unless  a
healthcare practitioner the producer gives advice to the contrary.
2.10.2  Offensive / Hygiene Waste
The  term  “offensive”  has  been  introduced  to  describe  waste  which  is  non-infectious  and
which  does  not  require  specialist  treatment  or  disposal,  but  which  may  cause  offence  to
those coming into contact with it.

Examples of offensive waste include:
•  incontinence and other waste produced from human hygiene;
•  sanitary waste;
•  nappies.

Although non-infectious offensive wastes may be landfilled in suitably licensed facilities, this
waste  (at  least  that  produced  in  quantity)  should  not  be  placed  in  the  domestic  refuse  but
should be collected separately.

The offensive waste stream should not include any of the following:
•  sharps;
•  body parts, organs or blood products;

•  waste chemicals;
•  medicinal waste that consists of pharmaceutically active substances;
•  dental amalgam;
•  wastes  containing  residual  medicines  excreted,  secreted  or  otherwise  present  in  any
bodily fluid.

Although the waste stream must be assessed to determine whether the waste is likely to be
infectious,  the  general  assumption  made  is  that  such  waste  presents  no  risk  of  infection
unless  indicated  by  a  healthcare  practitioner  e.g.  If  a  person  is  undergoing  treatment for  a
known  or  suspected  Urinary  Tract  Infection,  the  waste  is  likely  to  be  considered  infectious
and disposal via incineration or treatment arranged accordingly.

If it is decided that such wastes may be confidently isolated from infectious waste streams,
they may be packaged in yellow bags with a black stripe (“tiger bags”) and sent for landfill at
an appropriate facility.

3.10.2  Spillage Procedures
Individual  units  should  produce  clear  written  procedures,  specific  to  local  situations  and
waste arisings, for dealing with spillages which:
•  specify the reporting and investigation procedures;
•  specify the use of a safe system of work for clearing up the waste;
•  set out appropriate requirements for decontamination;
•  specify the protective clothing to be worn.

The ready availability of appropriate spillage kits helps ensure the correct action in the event
of a spillage. Such kits are particularly useful at storage, waste treatment and waste disposal
sites, and should be carried on all vehicles carrying healthcare waste.

Spillage kits may contain, for example:
•  disposable gloves;
•  a disposable apron;
•  an infectious waste sack/sharps bin;
•  paper towels;
•  disposable cloths;
•  disinfectant recommended;
•  a means of collecting sharps.

Appropriate equipment for collecting spilled waste and placing it in new containers should be
provided. Sharps must not be picked up by hand.

Spilled  waste  and  any  absorbent  materials  need  to  be  placed  in  an  infectious  waste
container for disposal.
3.10.3  Container closure and labelling
Black bags
The bags should be sealed when ¾ full by either tying a knot in
the neck or by securing with a tag or tape. Staples must not be
used, as the bag will tear.

Yellow bags
The bags should be sealed when ¾ full by securing with a tag
bearing  a  unique  number.  The  tags  are  issued  to  each
producer  from  a  central  source.  The  unique  numbers  are
recorded  and  provide  an  audit  trail  back  to  the  producer.
Staples  must  not  be  used,  as  the  bag  will  tear.  The  bags  will
likely be printed “For Incineration Only”.

Sharps bins
The bins should be sealed either when ¾ full or after 3 months
(whichever is sooner). The label shall be completed on the box
indicating the name of the person sealing the bin and the date
on which it was sealed.

Do not place sharps bins inside any bag for disposal.

3.10.4  Other wastes
There are a limited number of options available to community healthcare workers for
the  handling  and  disposal  of  the  non-sharps  waste  that  that  is  generated  during
treatment of the patients in their home.

Disposal via domestic waste bin
If  patients  are  treated  in  their  home  by  a  community  nurse  or  a  member  of  the  NHS
profession, any waste produced as a result is considered to be the healthcare professional's
waste.

National  guidance  states  that  wastes  generated  by  a  healthcare  worker  within  a  patient’s
home  must  not  be  disposed  of  within  the  domestic  waste  bin.  This  is  because  under  the
Environmental Protection Act 1990 it is unlawful to deposit, recover or dispose of controlled
waste  without  a  waste  management  licence,  contrary  to  the  conditions  of  a  licence  or  the
terms  of  an  exemption,  or  in  a  way  which  causes  pollution  of  the  environment  or  harm  to
human health. Infectious healthcare waste is prohibited from landfill.

The  Duty  of  Care  placed  upon  the  healthcare  worker  requires  that  the  waste  is
managed  properly,  recovered  or  disposed  of  safely  and  is  only  transferred  to
someone  who  is  authorised  to  keep  it.    Householders  are  exempt  for  their  own
household waste.
.
There are two options available for the removal (in yellow bags) of wastes generated
by a healthcare worker at a patient’s home:
•  Removal by the healthcare worker to their work base; or
•  Collection by a third-party contractor e.g. local authority.

Mixed  domestic  waste  does  contain  small  amounts  of  plasters,  small  dressings  and
incontinence  products.  Where  the  healthcare  worker  produces  the  same  or  similar  items,
these  –  with  the  following  considerations  –  can  be  placed  in  the  domestic  refuse  (with  the
householder’s permission).

The following should be considered:

• the size of the dressing – small dressings no larger than a dressing pad (that is, 130 mm
× 220 mm) can be disposed of as domestic refuse;

• the type of dressing – specialised antimicrobial types of dressing should be disposed of
as offensive/hygiene or medicinal waste as appropriate;

• the quantity produced – where a number of small dressings are produced regularly over
a  period  of  time,  it  may  be  appropriate  to  dispose  of  these  as  offensive/hygiene  waste.  If,
however, the amount produced is relatively small and consistent with that likely to be found
in the household waste stream, it may be discarded in the domestic refuse;

Where  such  waste  is  placed  in  the  domestic  refuse,  the  waste  should  be  wrapped  in  a
plastic sack. The wrapping should not be yellow but ideally  white or opaque e.g. sandwich
bags and bin liners.

If  a  patient  treats  themselves  in  their  own  home,  any  waste  generated  as  a  result  is
considered to be their own, it is not subject to the same restrictions, and may be placed in a
domestic waste stream. Only where a particular risk has been identified (based on medical
diagnosis) does such waste need to be treated as hazardous clinical waste. In these cases,
local  authorities  are  obliged  to  collect  the  waste  separately  when  asked  to  do  so  by  the
waste holder, but may make a charge to cover the cost of collection.

3.10.5  Removal via community healthcare practitioner
Yellow bags
Use for all non-sharp wastes arising from patient care. This will
include dressings; gloves and other protective equipment; and
used equipment.
The wastes will be treated as having an infection risk and will
classified as “hazardous” for disposal.

None  of  these  materials  should  be  contaminated  with  any
cytotoxic or cytostatic medicines.

Note:
If any dressings etc normally placed in the yellow bag are contaminated with
cytotoxic or cytostatic materials, they must either be placed in a yellow bag with a purple
stripe or the yellow bags must be clearly labelled to indicate cytotoxic contents.

3.10.6  Pharmacy
Waste


No cytotoxic or cytostatic medicines should be returned to the supplying pharmacy.
All such materials should be disposed off in a purple lidded sharps’ container

The following range of medicines – all non-cytotoxic or non-cytostatic – may be returned to
the supplying pharmacy (under agreement) for subsequent disposal:
•  Expired or surplus medicines;
•  Patients’ own medicines;
•  Inhalers and aerosols (full and part-used) – empty units into yellow bags;
•  Potassium permanganate tablets (in container);
•  Caustic sticks.

The medicines will normally be moved in a secure pharmacy box or bag.

The  medicines  must  be  kept  secure  pending  collection  from  the  nominated  point  by  the
waste carrier.

REFERENCES – Section 3.10

Health Technical Memorandum 07-01: Safe Management of Healthcare Waste
Environmental Protection Act (1990) Part 2.

APPENDIX 1 Section 3.10
LIST OF CYTOTOXIC AND CYTOSTATIC MEDICINES

Aldesleukin
Alemtuzumab
Alitretinoin
Altretamine
Amsacrine
Anastrozole
Arsenic trioxide
Asparaginase
Azacitidine
Azathioprine
Bacillus
Calmette-
Bicalutamide
GuerinBexarotene
Bleomycin
Busulfan
Capecitabine
Carboplatin
Carmustine
Cetrorelix acetate
Chlorambucil
Chloramphenicol
Choriogonadotropin alfa
Cidofovir
Cisplatin
Cladribine
Colchicine
Cyclophosphamide
Cytarabine
Cyclosporin
Dacarbazine
Dactinomycin
Daunorubicin HCl
Denileukin
Dienestrol
Diethylstilbestrol
Dinoprostone
Docetaxel
Doxorubicin
Dutasteride
Epirubicin
Ergonovine/methylergonovine
Estramustine phosphate Estrogenprogestin
Estradiol
sodium
combinations
Estrogens, conjugated
Estrogens, esterified
Estrone
Estropipate
Etoposide
Exemestane
Finasteride
Floxuridine
Fludarabine
Fluorouracil
Fluoxymesterone
Flutamide
Fulvestrant
Ganciclovir
Ganirelix acetate
Gemcitabine
Gemtuzumab
Gonadotropin chorionic
ozogamicin
Goserelin
Hydroxyurea
Ibritumomab
tiuxetanIdarubicin
Ifosfamide
Imatinib mesilate
Interferon alfa-2a
Interferon alfa-2b
Interferon alfa-n1
Interferon alfa-n3
Irinotecan HCl
Leflunomide
Letrozole
Leuprolide acetate
Lomustine
Mechlorethamine
Megestrol
Melphalan
Menotropins
Mercaptopurine
Methotrexate
Methyltestosterone
Mifepristone
Mitomycin
Mitotane
Mitoxantrone HCl
Mycophenolate mofetil
Nafarelin
Nilutamide
Oxaliplatin
Oxytocin
Paclitaxel
Pegaspargase
Pentamidine isethionate
Pentostatin
Perphosphamide
Pipobroman
Piritrexim isethionate
Plicamycin
Podoflilox
Podophyllum resin
Prednimustine
Procarbazine
Progesterone
Progestins
Raloxifene
Raltitrexed
Ribavirin
Streptozocin
Tacrolimus
Tamoxifen
Temozolomide
Teniposide
Testolactone
Testosterone
Thalidomide
Thioguanine
Thiotepa
Topotecan
Toremifene citrate
Tositumomab
Tretinoin
Trifluridine
Trimetrexate glucuronate
Triptorelin
Uracil mustard
Valganciclovir
Valrubicin
Vidarabine
Vinblastine sulfate
Vincristine sulfate
Vindesine
Vinorelbine tartrate
Zidovudine

3.11 DECONTAMINATION (CLEANING, DISINFECTION AND STERILISATION OF
EQUIPMENT)
3.11.1 Introduction
Cleaning,  disinfection  and  sterilisation  are  processes,  which  remove  or  destroy
microorganisms.  The method of decontamination selected will depend on the infection risk
associated  with  the  medical  device,  the  nature  of  the  contamination,  time  available  for
processing, the heat, pressure, moisture and chemical tolerance of the item, the availability
of  processing  equipment  and  risks  associated  with  the  decontamination  method.    Heat
sterilization or disinfection is preferred, but if the item is heat sensitive, chemicals may have
to be used.

All  reprocessing  of  surgical  instruments  and  other  medical  devices  should  be  undertaken
outside the clinical environment preferably in central reprocessing suites e.g.  CSSD.  Local
reprocessing in individual departments should be avoided.  Please refer to BDA guidance.

All  health  care  workers  involved  in  the  processes  of  cleaning,  disinfection  and  sterilisation
must be aware of the guidance issued by the DoH on Decontamination.  HSC 2000/032.

3.11.2  Cleaning
Physical cleaning removes micro organisms and the organic material on which they thrive.  It
is always the essential prerequisite to disinfection or sterilisation.   Cleaning does not
destroy the organisms, but removes them and other contaminants which will adversely affect
the  performance  of  further  decontamination  procedures.    If  thorough  cleaning  is  not
performed, blood or other matter may remain on the item during other processes.

3.11.3  Disinfection
This process aims to inactivate micro organisms reducing them to a level below that which is
associated with infection. This process does not however kill spores.   Disinfection is usually
appropriate for those items which are not used for invasive procedures.

3.11.4  Sterilisation
This process kills micro organisms including spores.  It renders reusable medical devices
safe for the procedure to be undertaken. It is recommended that all items penetrating or in
contact with mucous membranes or body cavities must be sterile at point of use.

APPENDIX 1 – Section 3.11
CLASSIFICATION OF INFECTION RISK ASSOCIATED WITH THE DECONTAMINATION
OF MEDICAL DEVICES

Risk
Application
Recommendations

Items in close contact with a break in the skin  Single  Use  disposable  /
High
or  mucous  membrane  or  introduced  into  a  Central Sterilisation
sterile body area.
Items  in  contact  with  intact  skin,  mucous  Single  Use  disposable  /
membranes  or  body  fluids,  particularly  after
Intermediate
Sterilisation  or  high  level
use  on  infected  patients  or  prior  to  use  on  disinfection
immuno-compromised patients.
Single  Use  disposable  /
Items  in  contact  with  healthy  skin  or mucous  Cleaning
to
Low
membranes or not in contact with patient.
manufacturers
recommendations

APPENDIX 2 – SECTION 3.11

DECONTAMINATION OF EQUIPMENT CHART (A-Z)

A
B
EQUIPMENT OR SITE
ROUTINE USE
INFECTED PATIENT
Auroscope Ear Pieces
Single  use  -  disposable  is  Single  use  -  disposable  is

the preferred option.
the preferred option.
Airways  and  endotracheal  Steam sterilisation (CSSD)
Steam sterilisation (CSSD)
tubes.
or use disposable.
or use disposable.
Ambu –masks
Single  use  -  disposable  is  Single  use  -  disposable  is
the preferred option
the preferred option
Baby scales
Renew  paper  after  each  Renew  paper  after  each
baby  and  clean  the  scales  baby  or  immediately  after
with  a  detergent  wipe  at  the  soiling  and  clean  the  scales
end of each session.
with  a  detergent  wipe  at  the
end of each session.
Baths,  wash  basins  and  Clean  with  detergent  and  Clean  with  detergent  and
showers
water.
water.
Baby baths.
Wash  with  detergent  and  Wash  with  detergent  and
warm
water/or
use
a  warm
water/or
use
a
detergent wipe.
detergent wipe.
Babies changing mat
Change  paper  after  each  Clean  mat  after  each  baby.
baby,  clean  mat  after  each  If
contaminated
with
session  and  if  contaminated  detergent  and  water,  or
wash  with  detergent  and  detergent wipe.
water,  or  use  a  detergent
wipe.
Change  paper  after  each
baby.
Bathing scoop
Clean  with  detergent  and  Contact IPCN

water or detergent wipe after

use.  Store dry.
Bed frames
Clean
with
water
and  Use
0.1%
Hypochlorite
detergent  and  dry,  or  use  a  solution.
detergent wipe.
Bed pans:

Community hospitals
Disposable.
Disposable.

Home patient
Disposable  or  wash  with  Disposable  or  wash  with
detergent  and  water  and  air  0.1% Hypochlorite solution.
dry
Bed pan frames
Clean  with  detergent  and  Clean
with
0.1%
water  and  dry,  or  use  Hypochlorite  solution  and
detergent wipe.
rinse.
Bottles and teats
Use  disposable  or  return  to  Use  disposable  or  return  to
CSSD,
or
in
special  CSSD.
circumstances
contact
ICPN.
Bowls (Surgical)
Return to CSSD
Return to CSSD
Bowls (Washing)
Wash  with  detergent  and  Wash
with
0.1%
water,  rinse  and  dry  after  Hypochlorite  solution  rinse
each  use.    Store  inverted  and dry.
and separated.

A
B
EQUIPMENT OR SITE
ROUTINE USE
INFECTED PATIENT
Brushes (lavatory)
Store dry.  Rinse thoroughly  Store  dry.    Use  o.1%
in  toilet,  flush  and  hang  to  Hypochlorite solution.
dry in open sided holder.
Bubble columns
Empty  and  clean  monthly
wearing PPE.
Buckets
Wash  with  detergent  and  Use
1%
Hypochlorite
water, rinse and dry.
solution, rinse and store dry.
Carpets:

Community hospitals
Vacuum  daily  in  patient  Should  not  be  nursed  in

areas.    Spillages  should  be  carpeted rooms

cleaned
immediately,

removing  any  excess  with

paper towels before washing

the  area  with  detergent  and

water.  Following this, larger

spills  may  require  steam

cleaning.  All carpets should

be steam cleaned annually

Offices should be vacuumed

at least weekly.

Patient’s home
Detergent and water.
Couches (examination)
Wash  with  detergent  and  Contact IPCN
water,  rinse  and  dry  or  use
detergent  wipe.    Cover  with
disposable  paper  between
patients.
Curtains:

Inpatients
Send  to  central  laundry  Disposable  or  alternatively

every  6  months  or  sooner  if  change  after  an  infection

soiled.
outbreak or sooner if soiled.

Vertical blinds
Vacuum  monthly  as  good

practice or damp dust as per

manufacturers instructions.

Venetian blinds
Suggest wipe with detergent
and water monthly.
Damp dusting (all surfaces)
Detergent and water.
Wipe with 0.1% Hypochlorite
solution.

A
B
EQUIPMENT OR SITE
ROUTINE USE
INFECTED PATIENT
Denture pots:

Community hospitals
Single  use  -  disposable  is  Single  use  -  disposable  is
the preferred option.  If own,  the preferred option.
clean  daily  with  detergent
and water.  Store dry.
Diaphragms
(Trial)
and  Single  use  -  disposable  is  Single  use  -  disposable  is
IUCD instruments
the preferred option.
the preferred option.
Drainage and suction jars:

1. Disposable vacuum
Use
Vernagel
gelling  Use
Vernagel
gelling

containers.
granules.  Place  in  double  granules.    Place  in  double

yellow bag for incineration.
yellow bag for incineration.

2. Suction jars.
Wash  with  detergent  and  Use disposable

water, rinse and store dry, or  or send to CSSD.

send to CSSD.

3. Under-water seal bottles.
Return to CSSD.
Return to CSSD
Drains
Use washing soda crystals

Duvets
Plastic  Type  -  Wash  with  Plastic  Type  -  Wash  with

detergent  and  water,  rinse  detergent  and  water,  rinse

and dry.
and dry.
Duvet covers:

Community hospitals
Send  to  central  laundry  as  Send  to  central  laundry  as

per policy.
per policy.

Patient’s home
Cotton  Cover  -    Wash  as  Cotton  Cover  -    Wash  as
recommended
by
the  recommended
by
the
manufacturer.
manufacturer.
Earphones
Wipe  with  detergent  and  Wipe with 0.1% Hypochlorite
water or alcohol wipes.
solution.
Ear  pieces  (Stethoscopes,  Wipe  with  detergent  and  Wipe  with  detergent  and
hearing aids)
water,  then  70%  alcohol  water,  then  70%  alcohol
wipe.
wipe.
ECG leads and machines
Wipe  with  detergent  and  Wipe  with  detergent  and
water, or detergent wipe.
water or detergent wipe.
Endoscopes
Thoroughly
clean
and  Thoroughly
clean
and
disinfect
according
to  disinfect
according
to
manufacturers instructions:
manufacturers instructions:

a) Between patients.
a) Between patients.

b)  Before  and  after  session  b) Before and after sessions
(see Departmental Policy).
(see Departmental Policy).
Enuresis Mats
Single  patient  use  -  wash  Single  patient  use  -  wash
with detergent and water, or  with detergent and water.
follow
manufacturers
instructions.
Floor Mops:
Wash  out  thoroughly  and  Use disposable.
Community hospitals
hang to dry daily

GPs
Weekly.

A
B
EQUIPMENT OR SITE
ROUTINE USE
INFECTED PATIENT
Floors (dry)
Vacuum  clean  (disposable  Vacuum  clean  (disposable
dust bag).
dust bag.
Check bags and filters.
Ensure filter changed.
Floor (wet)
Clean  with  detergent  and  Clean  with  detergent  and
water, rinse and dry.
water,  rinse  and  leave  as
dry as possible.
Furniture and fittings
Damp  dust  with  detergent  Damp  dust  with  detergent
and water.
and water.
Flower Vases
Wash  the  vases  in  water  Contact IPCN
and
detergent
when
changing  flowers  and  after
use. Store dry
Humidifiers
Drain once each day.
Drain once each day.
Refill  with  sterile  bottled  Refill  with  sterile  bottled
water
or
follow  water.
manufacturer’s instructions.
Instruments (Surgical)
Return  to  CSSD  or  if  using  Return to CSSD.
autoclave
ensure
compliance with policy.
Jugs and drinking glasses
Preferable
to
use
a  Preferable
to
use
a
dishwasher
for
thermal  dishwasher
for
thermal
disinfection or hot water and  disinfection or hot water and
detergent.
detergent.
Mattresses and pillows
Clean  plastic  covers  with  Clean  plastic  covers  with
detergent  and  water,  and  detergent  and  water,  and
dry.
dry.    If  contaminated  with

body
fluids
use
0.1%
This  should  be  after  patient  Hypochlorite solution.
is  discharged  or  monthly  for
longer term stay, or sooner if
soiled.
Nebulisers - Disposable
Single  patient  use.    Between  Single  patient  use.    Between

use  wash  the  chamber  and  uses  wash  the  chamber  and

mask  thoroughly  with  water  mask  thoroughly  with  water

and  detergent,  rinse  and  dry  and  detergent,  rinse  and  dry

thoroughly.  Replace  weekly  thoroughly.    Replace  weekly

or if heavily soiled.
or if heavily soiled.

Non-Disposable
Disinfect  daily  after  cleaning,  Disinfect  daily  after  cleaning,
as  above,  by  immersion  in  as  above,  by  immersion  in
0.1% Hypochlorite solution for  0.1% Hypochlorite solution for
20  mins.  rinse  with  sterile  20  mins.  rinse  with  sterile
water and dry with disposable  water and dry with disposable
paper towel. Store dry.
paper towel. Store dry.

A
B
EQUIPMENT OR SITE
ROUTINE USE
INFECTED PATIENT
Nebuliser Tubing
Single patient use ONLY.
Single patient use ONLY
Razors - safety or electric
Use  disposable  or  patients  Use  disposable  or  patients
own.
own.
DO NOT ALLOW SHARING   DO NOT ALLOW SHARING
Rehabilitation equipment
Please
refer
to  Please
refer
to
manufacturers  instructions.   manufacturers instructions.
Need  to  identify  a  planned  Need  to  identify  a  planned
cleaning  schedule  in  place.   cleaning  schedule  in  place.
Items  should  be  wiped  over  Items  should  be  wiped  over
after
each
use
with  after
each
use
with
detergent  and  water,  or  a  detergent  and  water,  or  a
detergent wipe.
detergent wipe.
Scissors
Use  single  use  disposable  Use  single  use  disposable
or autoclavable.
or autoclavable.
Sterile  scissors  must  be  Sterile  scissors  must  be
used for wound dressings.
used for wound dressings.
Skin Disinfection:

Handwashing
in
clinical  Liquid Soap.
Liquid soap / hand sanitizer,
areas  (wards,    sluice  rooms
as advised by the IPCN.
and  outpatients  examination

rooms)

Hibiscrub (4% Chlorhexidine
Handwashing pre-operative
Hibiscrub (4% Chlorhexidine  with  detergent)  or  Povidone
with  detergent)  or  Povidone  Iodine surgical scrub.
Iodine surgical scrub.

Venepuncture
Clean
skin
with
70%  Clean
skin
with
70%

Isopropyl  alcohol    and  2%  Isopropyl  alcohol  and  2%

chlorhexidine  gluconate  and  chlorhexidine  gluconate  and

allow to dry.
allow to dry.

Diabetics
-
Glucose  Clean  Digits  with  soap  and
Monitoring
water only.

Skin  Disinfection  prior  to  IV  Clean
skin
with
70%  Clean
skin
with
70%
Cannulation
Isopropyl  alcohol  and  2%  Isopropyl  alcohol  and  2%
chlorhexidine  gluconate  and  chlorhexidine  gluconate  and
allow to dry.
allow to dry.

Slide sheets/hoist slings:

Community hospitals
Designate  as  single  patient

use.    Return  to  cental

laundry  for  cleaning  after

use or sooner if soiled.

Patient’s home
Single  person  use.    Return
to joint loans for laundering.
Space blankets
Disposable – single use.
Disposable – single use.
Sphygmomanometer cuffs
70% alcohol wipes.
70% alcohol wipes.
Staff cases
Wipe  over  with  detergent
Community
and
water,
or
use
a

detergent  wipe,  weekly  or
sooner  if  soiled,  or  follow
manufacturers’ instructions.
Telephone/telephone
Clean  weekly  with detergent  Clean
after
use
with
trolley
and
water,
or
use
a  detergent  and  water,  or  use
detergent wipe.
a detergent wipe.  Wipe with
0.1% Hypochlorite
Solution.
Thermometers:

Electronic
Single  use.    Use  disposable  Single  use.    Use  disposable
sheath.
sheath.
Toothbrushes
Single patient use only
Single patient use only
Toothmugs
Single  use  -  disposable  is  Single  use  -  disposable  is
the preferred option.  If own,  the preferred option.
clean  daily  with  detergent
and water.  Store dry.
Toys
Wash  with  detergent  and  Wash  with  detergent  and

water.

If
heavily  water.

If
heavily
Soft
toys
are
not  contaminated  -  dispose  of  contaminated  -  dispose  of
recommended
item.
item.
Trolley Tops - Dressings
Wash  with  detergent  and  Wash  with  detergent  and

water,  and  dry.    Wipe  with  water,  and  dry.    Wipe  with
alcohol wipe before use and  alcohol  wipe  before  and
between dressings.  If visibly  after each use.
contaminated
wash
with
detergent/water and dry.
Tourniquets
Wipe  between  each  patient  Disposable  /  Wipe  between
with 70% alcohol wipe.
each
patient
with
70%
alcohol wipe.
Urinals:

Community hospitals
Single use disposable.
Single use disposable.

Patients own – community
Wash out with detergent and
water after each use.
Vaginal Specula
Send to CSSD or single use  Send to CSSD or single use

disposable.
disposable.
Vaginal Cones -
Single patient use.  Between  Single patient use.  Between
Disposable
uses  clean  with  detergent  uses  clean  with  detergent

and  warm  water,  rinse  and  and  warm  water,  rinse  and

dry,
then
soak
in
1%  dry,
then
soak
in
1%

Hypochlorite  for  20  minutes.   Hypochlorite  solution  for  20

Rinse  thoroughly  with  water  minutes.    Rinse  thoroughly

and  dry.    Patient  should  with  water  and  dry.    Patient

keep  the  cone  and  bring  to  should  keep  the  cone  and

session.
bring to session.

Non-disposable
Autoclave
as
per  Autoclave
as
per
instructions with equipment.
instructions with equipment.
Walking Aids:

Community
Clean periodically with dilute  Wipe with 0.1% Hypochlorite

detergent and water.
solution  if  there  is  faecal

contamination,  if  not  use

detergent and water.

Inpatients
Clean after each patient use
(single  patient  use)  or  when
grubby  with  detergent  and
water  or  use  a  detergent
wipe.
WC
Wash  with  detergent  and  Wipe with 0.1% Hypochlorite
Lavatory seats
water,  and  dry  after  each  solution  if  there  is  faecal
Commode chairs
patient
use
or
use
a  contamination,  if  not  use
Raised toilet seats
detergent wipe.
detergent and water.
Wheelchairs
Clean periodically with water  Clean  with  detergent  and
and detergent, and dry.
water, and dry.
X-Ray Equipment
Damp  dust  with  detergent  Wipe with 0.1% Hypochlorite
and
water
or
use
a  solution.
detergent wipe.

APPENDIX 3 – Section 3.11
DECLARATION OF CONTAMINATION STATUS

Prior to the Inspection Servicing.  Repair or Return of Medical and Laboratory Equipment

To:
Make and description of Equipment

Model/Serial/Batch No:

Trust's Ref:
Recipient's Service or Returns
or Order No:
Authorisation Reference or Contact Name:

Tick box A if applicable. Otherwise complete all parts of B, providing further information as requested or appropriate.

A

This equipment/item has not been used in any invasive procedure or been in contact with blood,

other body fluids, respired gases or pathological samples. It has been cleaned, in accordance with

the Control of Infection Disinfecting Policy, in preparation for inspection, servicing, repair or

transportation.

B (1)
Has this equipment/item been exposed internally or externally to hazardous materials as indicated below?

Provide further details here:

YES/NO Blood, body fluids, respired gases, pathological samples:

YES/NO Other biohazards:

YES/NO Chemical or substances hazardous to health:

YES/NO Other substances hazardous to health:

YES/NO Other hazards:

(2)  Has this equipment/item been cleaned and decontaminated?

YES
Indicate the methods and materials used:

NO
This equipment could not be decontaminated.

Indicate reason:

Advice  should  be  obtained  from  your  Head  of  Department  or  Control  of  Infection  Manager  before  any  dismantling,
inspection, servicing or repair works carried out.

Such  equipment  must  not  be  returned/presented  without  the  prior  agreement  of  the  recipient  whose  reference  or
contact name must be given above.

(3)  Has the equipment/item been suitably prepared to ensure safe handling /transportation?
  YES/NO, Indicate Reason:

I declare that I have taken all reasonable steps to ensure the accuracy of the above information, in accordance with
HSG(93)26.

Authorised signature:
Unit:
Name (printed):
Dept:
Position:
Tel No:
Date:

Copies of Certificates to be sent to:

Top Copy- To accompany equipment,   Second Copy -To remain in the certificate book for reference

Section
1
Page
50(a)HMP-71

This page is intentionally left blank

SECTION 4 - DISEASE RELATED INFORMATION

4.1 BLOOD BORNE VIRUSES
In  Great  Britain,  four  main  types  of  Hepatitis  are  recognised  B,  C,  D  and  E.    All
hepatitis infections are notifiable to the Consultant in Communicable Disease Control
(see Section 1).

Hepatitis  B  and  C  infections  are  major  causes  of  chronic  liver  disease  and  liver
cancer across much of the world. While the United Kingdom has been classified
as a very low prevalence country for these infections, they still pose a significant
challenge in terms of potentially preventable mortality and morbidity.

4.1.1  Hepatitis B
The severity of Hepatitis B (HBV) disease ranges from mild infections that can only
be  detected  by  liver  function  tests,  and/or  the  presence  of  serological  markers  of
infection  (see  Figure  4),  to  fulminating  cases  of  acute  hepatic  necrosis.      The
incubation  period  is  40-160  days,  average  is  60-90  days,  and,  of  those  cases
admitted  to  hospital,  the  fatality  rate  is  1%.    The  variation  in  incubation  period  is
related to the inoculum and the mode of transmission as well as to host factors.  The
prognosis for hepatitis B carriers who develop progressive liver disease is uncertain;
some  develop  cirrhosis  and  are  at  increased  risk  of  developing  hepatocellular
carcinoma.

Understanding Serological Markers

MARKER
FULL NAME
INDICATES

HBsAg
Hepatitis B surface antigen  Carrier or current infection.

HBeAg
Hepatitis B ‘e’ antigen
Current
infection/highly
infectious/chronic
carrier.

Anti-HBsAg
Antibody to HBsAg
Previous infection/immunisation/immunity.

Anti-HBeAg
Antibody to HBeAg
Hepatitis  B  surface  antigen  carrier  with  low
(anti-HBe)
risk of infectivity.

Anti-HBc
Antibody  to  Hepatitis  B  Persons who have had hepatitis B infection in
core antigen
the  past  or  have  acute  infection.      It  is  not
induced by immunisation.

IgM Anti-HBc
Igm antibody to Hepatitis B  Acute or recent Hepatitis B infection.
core antigen

Hepatitis
B  Virus DNA
Viral replication and high infectivity.
virus DNA

Patients who exhibit persistent hepatitis B surface antigen (HBsAg) for more than 6
months are defined as chronic carriers, although a small proportion (I-2%) may clear
the  virus  each  year.    Chronic  carriers  have  traditionally  been  divided  into  those  of
high, intermediate and low infectivity, having in addition either the soluble ‘e’ antigen
(HBeAg), no ‘e’ markers, or antibodies to the ‘e’ antigen (HBeAb) respectively.  It is
now recognised, however, that some chronic carriers may be ‘e’ antigen negative yet
highly  infectious  due to  the  presence  of mutant  strains  of  HBV  which  are  unable  to
express ‘e’ antigen.

Treatment with interferon may clear ‘e’ antigen in a proportion of cases.

In  developed  countries  Hepatitis  B  infection  is  usually  acquired  during  adulthood,
predominant  routes  being  sexual  and  parental.      About  2-10%  of  those  infected  as
adults  become  chronic  carriers  with  hepatitis  surface  antigen  (HBsAg)  persisting
longer than 6 months.   Persistent HBsAg, and chronic infectious carriage of Hepatitis
B,  is  more  frequent  in  those  infected  as  children  and  rises  to  95%  in  neonates
infected  perinatally.      Among  carriers  of  the  virus  those  in  whom  HB  e-antigen
(HBeAg) is detectable are most infectious. Those with antibody to HBeAg (anti-HBe)
are, generally, of low infectivity.

The  blood  of  those  infected  with  Hepatitis  B  has  been  shown  to  be  infective  many
weeks  before  the  onset  of  first  symptoms  and  remains  infective  through  the  acute
clinical course of the disease and during the chronic carrier state, which may persist
for  years.    Hepatitis  B  Virus  Surface  Antigen  (HBsAg)  may  be  found  in  blood  and
virtually all body fluids of patients with acute hepatitis B and carriers of the virus, but
blood, semen and vaginal fluids are mainly implicated in the spread of HBV Infection
(Figure 4).

4.1.2  Vaccination and Control
The Control of Substance Hazardous to Health (COSHH) (1994) Regulations require
all employers to make their own risk assessments and bring into effect measures to
protect their employees.  Therefore, it is the employer that decides whether there is a
risk of infection of hepatitis B within the work place, and what measures are required,
e.g.  vaccination education and protective clothing.

The primary course consists of three injections of the vaccine, the second following
one month after the first, with the third administered at six months.  More rapid
courses are now available, which are useful, for example, when the traveller presents
late for vaccination or as prophylaxis following exposure to the virus.  Each course
consists of three injections either given at monthly intervals with a booster at 12
months, or 0, 7, 21 days, also with a booster at 12 months.  Antibodies can be
checked 4 weeks after course completion to determine whether or not there has
been a response.

Hepatitis  B  infection  can  be  transmitted from  infected  mothers  to their  babies  at,  or
around, the time of birth (perinatal transmission).   Babies acquiring infection at this
time have a high risk of becoming chronic carriers of the virus.   The development of
this  carrier  status  can  be  prevented  in  around  90-95%  of  cases  by  appropriate
immunisation  of  babies  born  to  infected  mothers.    The  recommended  vaccination

schedule  of  infants  born  to  Hepatitis  B  Surface  Antigen  (HBsAg)  Positive  women
(identified through antenatal screening) is shown in Figure 5.

Breast Feeding:  There is no contraindication to breast feeding when a baby born to
a carrier mother begins immunisation at birth and proceeds with a complete course of
immunisation.

Vaccination of infants born to hepatitis B surface antigen positive
women (identified through antenatal screening)

MOTHER
Hepatitis B Surface antigen
positive (HBsAg)
Anti HBe
positive
Yes
HBEAG POSITIVE
or
HBeAg negative and
Give Hepatitis B specific
Anti HBe negative
Immune Globulin within
30 minutes of birth
OR
(contralateral site from
vaccination)
Yes
GIVE HEPATITIS B
1st dose vaccine at
birth
2nd dose at 1 month of age
3rd dose at 2 months of age
4th dose at 12 months of age
Check antibody level 2-4
months after third dose

Response  rates  to  the  vaccine  are  at  around  95%  in  young  adults  (especially
women),  children  and  newborn  babies,  whereas  the  rate  may  fall  in  older  men  to
around  80%,  with  the  immuno-suppressed  patient  showing  the  lowest  rates.
However, immunity is known to decrease with age, especially in those over 40 years,
but  what  is  not  known  is  whether  or  not  boosters  are  necessary  for  babies  and
children to provide life-long immunity.

It is normally accepted that protective anti-HBs titre levels should be above 100
miu/ml, however vaccines whose anti-HBs titres are in excess of 500 miu/ml are
likely to maintain adequate levels for at least 5 years.  It should be noted that
variations in virus challenge doses and infectivity of the source has resulted in the
impossibility of defining a minimum protective level of anti-HBs.  Low or non-
responders need to be informed that they are not protected and should seek passive
immunisation if they suffer accidental exposure (via needlestick injury, etc).

Health  care  workers  who  have  been  successfully  immunised  should  be  boosted
following  accidental  exposure,  unless  they  are  definitely  known  to  have  adequate
protective anti-HBs levels.  (See Section 2 – 2.5.)

Healthcare  workers  who  carry  blood  borne  viruses  will  be  advised  regarding  their
involvement  in  exposure  prone  procedures  (EPP)  by  their  Occupational  Health
Department.
4.1.2a  Index case contacts
Household  and  sexual  contacts  of  the  index  case  should  be  vaccinated  with  an,
accelerated course.  Although screening to exclude people with pre-existing anti-HBs
is not required prior to immunisation, it may be desirable where there are high levels
of pre-existing infection.

Passive immunisation with specific immunoglobulin can be administered if immediate
protection is required.  Hepatitis B Immunoglobulin (HBIG) is used and it is
administered at the same time as the hepatitis B vaccination using a different site.
HBIG must be given as soon as possible, preferably within 24 hours of the exposure
(needle stick injury) or following sexual exposure, it is recommended that it be given
within 14 days.  If infection has already occurred, severe illness, and the
development of carrier status, may be prevented.

4.1.3  Hepatitis C (HCV)
The incubation period is about six to eight weeks, but antibodies may not appear for
a further four to six weeks.  Although infection is usually asymptomatic, HCV results
in the development of a chronic carrier state in at least 85% of cases.  Chronic liver
disease, including cirrhosis and hepatocellular carcinoma, develops in approximately
70% of all HCV infected persons.

Hepatitis  C  is  the  main  cause  of  what  was  previously  known  as  Non  A  -  Non  B
hepatitis.  HCV is most frequently acquired by direct blood to blood contact and the
commonest  mode  of  transmission  in  the  UK  is  the  sharing  of  blood  contaminated
injecting equipment by injecting drug users.  Both sexual and perinatal transmission
can  occur  but,  in  general,  these  are  less  efficient  modes  of  transmission.    The
incidence of HCV amongst intravenous drug users is believed to be high.

Routine  screening  tests  for  HCV  detect  antibodies  to  the  virus.      If  individuals  are
found to be anti-HCV positive, additional tests are carried out, looking for HCV RNA
by polymerase chain reaction (PCR) in order to determine whether they are viraemic.

Treatment with Interferon plus Ribavirin may clear the infection, but a proportion will
relapse  when  treatment  is  stopped.    The  involvement  of  a  hepatologist  should  be
considered.

There is no effective vaccine against HCV.

It is recommended that individuals with HCV be vaccinated against hepatitis A
virus.    As  the  liver  may  already  compromised,  cirrhosis  may  be  advanced  by
hepatitis A infection.

Long-term  follow  up  is  recommended  for  HCV.    As  new  information  is
becoming available, individual assessment for medical intervention is, ongoing.

4.1.4  Hepatitis D (HDV)
Hepatitis  D  causes  infection  only  in  those  who  have  active  hepatitis  B  infection.
Hepatitis D infection can occur either as co-infection with HBV or as a superinfection
of an HBV carrier.  Since hepatitis D depends on an HBV infected host for replication,
prevention  of  hepatitis  B  infection  by  immunisation  will  also  prevent  hepatitis  D
infection.

4.1.5  Human Immuno-deficiency Virus (HIV)
Human  immuno-deficiency  virus  interferes  with  the  body's  immune  response  to
infection.    An  individual  infected  with  HIV  may  experience  an  initial  acute  illness
followed by a period in which there are no signs or symptoms, although antibodies to
the virus may be detected in the blood.  People with HIV infection can remain well for
several years.

Ultimately,  if  the  virus  continues  to  replicate,  there  is  reduction  of  CD4  cells  with  a
resultant  immunodeficiency,  infected  persons  becoming  at  increased  risk  of
opportunistic infections and certain tumours.

Routine  screening  tests  for  HIV  detect  antibodies  to  HIV-1  or  HIV-2.    Such  tests
should  only  be  carried  out  with  informed  consent.    If  the  screening  test  is  reactive,
this result is then confirmed by two different additional assays.  A provisional report is
issued requesting an additional blood sample before sending out a final HIV report.

All individuals, other than neonates, who have antibodies to HIV also have the virus;
viral nucleic acid may be detected by polymerase chain reaction (PCR) and the level
of  viraemia  quantified.    It  should  be  stressed  that  antibodies  to  HIV  do  not  appear
immediately  after  primary  infection.    The  median  time  is  3-6  weeks  but,  during  this
‘window period’, patients may have a high viral load and be highly infectious.

In  general,  HIV  is  the  least  infectious  of  the  blood  borne  viruses,  with  HIV-2  being
considerably less infectious than HIV-1.

4.1.6 Acquired Immune Deficiency Syndrome (AIDS)
Acquired  immune  deficiency  syndrome  is  diagnosed  when  a  person  with  HIV
infection  is  found  to  have  one  or  more  of  a  number  of  specific  infections,  such  as
Pneumocystis  pneumonia,  Kaposi  sarcoma  or  Tuberculosis.    These  infections  are
described as opportunistic, and become life threatening due to the breakdown of the
individual’s immune system or the direct effect of the virus on the nervous system.

Control is by prevention of acquisition of the virus.  This is accomplished by applying
vigorous  universal  infection  control  precautions,  education  about  safe  sex  and  the
use of needle exchange facilities for intravenous drug users.

Post exposure prophylaxis for HIV is also available (see Section 2 – 2.5).

REFERENCES - Section 4.1
Advisory  Committee  on  Dangerous  Pathogens  (1996)  ‘Protection  Against  Blood-borne
infection in the Workplace, HIV and Hepatitis’ - London MMSO.
Bedford H, Elliman D, 1998, Childhood Immunisation: A Review volume 1.  Health
Education Authority.

Benenson A S, Editor (1995) ‘Control of Communicable Diseases Manual’, sixteenth
Edition, American Public Health Association.

CDSC/PMLS Hepatitis Subcommittee (1993) Hepatitis C Virus.  Guidance on the
risks and current management of occupational exposure.  CDR Weekly 3(10)
September 135-139.

Department of Health 1996   ‘Immunisation against infectious Disease’ Salisbury DM,
Begg N.T.  (Eds) London HMSO.

Greenwood D, Slack R, Peutherer J.  (Eds) 1997  ‘Medical Microbiology’ 15th  edition;
Churchill Livinstone UK.

Kassianos  G.    C.(1998)  ‘Immunisation  :  Childhood  and  travel  health’  3rd    edition.
Oxford: Blackwell Science Ltd.

NHS  Executive  HSC  1998/063  Recommendations  of the  Expert  Advisory  Group  on
AIDS  and  the  Advisory  Group  on  Hepatitis.    Guidance  for  Clinical  Healthcare
Workers - Protection Against Infection with Blood Borne Viruses.

Sagliocca  L,  Amoroso  P,  Strffolini  T,  Adamo  B,  Tosti  ME,  Lettieri  G,  Esposito  C,
Buonocore  S,  Pierri  P,  Mele  A.    ‘Efficacy  of  hepatitis  A  vaccine  in  prevention  of
secondary hepatitis A infection: a randomised trial’.  Lancet (1999): 353;1136-9.

The Senate of Surgery of Great Britain and Ireland (1998) ‘Blood borne viruses and
their  implications  for  surgical  practice  and  training’  Senate  Paper  4  –  September
1998, London: McKenzie Graham.

UK  Health  Departments  (1997)  PL  ICO  (97)  1  -  Guidelines  on  Post-Exposure
Prophylaxis for Healthcare Workers Occupationally Exposed to MIV.

4.2 MENINGOCOCCAL MENINGITIS/SEPTICAEMIA
The infective agent is Neisseria meningitidis.   Different strains of meningococci are
groups A, B, C, Y and W135.  The most common strains of meningococcal meningitis
in the UK are groups B and C.

Meningococcal disease can affect any age group although babies, children and
young people in their teens and early 20’s are most at risk.  It usually presents as
sporadic cases, but localised outbreaks do occur.  Cases occur throughout the year,
but the incidence is highest in winter.

Droplets from nose or throat of infected persons transmit the organism from one
person to another.   Between 10-25% of the population at any one time are
asymptomatic carriers.  Carriage rate varies from time to time and tends to be higher
in closed communities such as schools, colleges and army barracks.  The incubation
period varies from 2-10 days, however it is commonly 3-4 days.  The period of
communicability is until the meningococci bacteria are eliminated from the
nasopharynx.  This is usually within 24 hours of Rifampicin therapy.  Penicillin
treatment does not reliably eradicate the organism from the nasopharynx.

Meningococcal disease and all types of meningitis are statutory notifiable diseases
(Section 1, Table B).  The Consultant in Communicable Disease Control (CCDC)
should be notified by telephone, by the Doctor in charge, of all cases, or suspected
cases, of meningitis and meningococcal disease, in order that contact tracing is
promptly carried out.

4.2.1   Vaccination

4.2.1a  Meningococcal Group C Conjugate Vaccine
This was introduced in 1999 and the objective is to achieve a major impact on Group
C  Neisseria  meningitidis,  which  is  responsible  for  40%  of  cases  of  meningococcal
disease in this country.   Most other cases are from Group B infection and there is, as
yet, no effective vaccine against sero-group B.

It  is  immunogenic  in  children  from  2  months  of  age  and  induces  an  effective
immunological memory.  Babies 2, 3 and 4 months: three doses of the new vaccine,
given  with  DTP,  Hib  and  Polio  vaccines.    No  booster  is  recommended  for  the
meningococcal Group C conjugate.

4.2.1b  Plain Polysaccharide Meningococcal Group A and C vaccines
The meningococcal Group plain polysaccharide A and C vaccines are effective for 3
to  5  years  from  18-24  months  of  age.    Studies  have  shown  that  boosting  with  a
second  or  third  dose  in  adults  tends  not  to  produce  a  response.      Pasteur  Merieux
Vaccine may be boosted every 3 years, SmithKline Beecham vaccine every 5 years.

Travellers  to  Sub-Saharan  Africa from  Senegal  and  Gambia  in the  west  to  Ethiopia
and  Somalia  in  the  east  (anywhere  within  the  meningitis  belt)  are  advised  to  be
vaccinated  with  the  plain  A  and  C  polysaccharide,  if  visiting  for  longer  than  one
month.  Protection is required for the ‘A’ sero-group portion of the vaccine, which is
not available separately.

It is particularly important to be vaccinated if the traveller is to be in close contact with
the local population or staying for long periods.  On this basis the risk is usually small
for  package  tourists.    Travellers  to  Saudi  Arabia  attending  Mecca  during  the  Haj

annual pilgrimage require immunisation for immigration purposes and will be required
to produce a certificate on arrival and  when obtaining a visa.  Quadrivalent vaccine
gps  A,C,W125  and  Y  is  recommended for  these travellers,  with  further  advice  from
the regional epidemiologist.   The A and C vaccine is effective from 7 days.

A subject who has already received a scheduled conjugate vaccine may require the
travel polysaccharide vaccine.  This can be administered after a period of two weeks.
Giving conjugate vaccine after polysaccharide vaccine - If the polysaccharide vaccine
has  been  given  first  then  a  gap  of  6  months  is  suggested  before  the  conjugate
vaccine is administered.

University  students  e.g.  first  years  not  already  vaccinated  should  be  given  the
conjugate gp.  C vaccine

4.2.2  Control

4.2.2a Index Case Contacts
The  Health  Protection  Agency  (HPA)  has  developed  a  policy  for  the  control  of
meningococcal  meningitis  and  septicaemia.      A  précis  of  this  policy  has  been
included,  to  give  an  understanding  of  the  present  action  taken  following  the
presumptive diagnosis of a case in Cambridgeshire.

Definition of an outbreak, or cluster, of meningococcal disease exists when there are
two or more linked cases, within a four-week period.

The index case should be treated with antibiotics as soon as a presumptive diagnosis
is  made.    The  general  practitioner  should  start  treatment  with  Benzylpenicillin  if  a
diagnosis of meningococcal disease is suspected, prior to admission to hospital.  As
Benzylpenicillin will not reliably eradicate the organism from the nasopharynx of the
patient,  a  two-day  course  of  Rifampicin  should  be  given  prior  to  discharge  from
hospital  to  ensure  eradication.   This  prevents  the  re-introduction  of  the organism to
the household and other close contacts.

Once the Health Protection Unit has been notified of an individual (presumptive) case
the  communication  and  information  cascade  will  commence  for  which  the  CCDC  is
responsible.
•  A professional from the HPU office will be available, during office hours, to
answer questions from any professionals (see Section 1 - 1.4).
•  The HPU will carry out any contact tracing necessary outside of the hospital.
The  hospital  will  provide  prophylaxis  to  household  contacts  able  to  visit  the
hospital.

The aim of prophylaxis is to prevent secondary cases by eliminating nasopharyngeal
carriage of N.  meningitidis in close contacts of the index case, thereby reducing the
risk of invasive disease in other susceptible members of the household.

Chemoprophylaxis  should  be  given  as  soon  as  possible  (ideally  within  24  hours  of
diagnosis  of  index  case)  to  all  close  contacts.      Rifampicin  is  licensed  for  this
purpose, but ciprofloxacin is an acceptable alternative and cetriaxone should be used
for pregnant women.

4.2.2b  Prophylaxis
Is recommended for:

All  household  contacts,  i.e.  living  in  the  same  house  during  the  preceding  7
days before the illness occurred.

Kissing contacts (girl/boyfriends) of the case also within the last 7 days.

Room mates, close friends in boarding schools or other residential institutions
if they share a dormitory.

A child-minder looking after one or more children for many hours daily – may
fall into the ‘household’ setting.

Adult
over 12 years
Ciprofloxacin 500mg as single dose

Rifampicin 600mgs BD for 2 days

Pregnant female
Ceftriaxone 250mgs IM as single dose

Child
over 1 year
Rifampicin 10mg/kg BD for 2 days

Infants   under 1 year
Rifampicin 5 mg/kg BD for 2 days

Is not recommended:

After a single case in a school, playgroup or nursery, but it is important to give
information.

Medical and nursing staff caring for the case, unless they have given mouth-
to-mouth resuscitation or encountered splash contamination.

The  hospital  clinician  caring  for  the  index  case  will  normally  be  responsible  for
provision  of  prophylaxis  for  household  contacts  (able  to  visit  the  hospital)  within  24
hours  of  a  diagnosis  being  made.    The  Health  Protection  Unit  is  responsible  for
identifying all non-household close contacts.  The CCDC or officer on call will inform
the  GPs  of  the  other  contacts,  who  have  been  identified.    These  GPs  will  be
responsible for prescribing the prophylaxis.  When there are contacts in other Health
Districts,  it  is  the responsibility  of  the  CCDC  to  provide  details  of  contacts  requiring
prophylaxis in that area to the appropriate CCDC.

Single case occurring in child attending a pre-school group
Family household contacts should be managed as previously described.  Information
about the case, and about meningococcal disease, should be disseminated to carers,
parents and local GPs, because early diagnosis can improve outcome.

Single  case  occurring  among  those  attending  primary  or  secondary  schools,
colleges or universities
Prophylaxis  with  antibiotics  or  vaccine  should  not  be  offered  to  contacts  in  the
educational  setting,  unless  the  proximity  and  duration  of  contact  has  been
comparable to that experienced in households (e.g. dormitory contacts in a boarding
school).

Immediately  after  a  case  has  arisen  in  a  nursery,  playgroup,  school  or  other
institution,  the  Consultant  for  Communicable  Disease  Control  or  other  professional
from the department should liaise closely with the Principal to inform parents that:

A case has occurred.

The chance of another case is very small.

Antibiotics are not normally given to students after a single case.

It  is  important  to  know  the  signs  and  symptoms  of  Meningococcal
Disease.

When two or more cases occur in secondary schools, higher learning institutions and
other institutional settings, decisions about further actions should involve the Health
Protection Agency.

A polysaccharide meningococcal vaccine for protection against sero-group A and C
is available and licensed for use in the UK (it is now mostly used as a travel vaccine).
A quadrivalent vaccine for protection against A, C, W, Y is also available on a named
patient basis, though not licensed for routine use.  If the index case is confirmed as
group C or A (or W135, Y) vaccination should be offered to those contacts who were
given oral antibiotic prophylaxis.  The CCDC will make a decision on which vaccine
should  be  administered,  however,  this  will  usually  be  the  conjugate  vaccine  rather
than the polysaccharide.

REFERENCES-Section 4.2
Borrow  R,  Clark  S,  Findlow  J,  Kaczmarski  E  B,  Richmond  P,  Miller  E,  Jones  G,
Barker M, McCann R, Hill J - ‘Immunological hyporesponsiveness in adults induced
by  licensed  meningococcal  A/C  polysaccharide  vaccine’  Unpublished  presentation,
12  May  1999;  One-day  symposium  –  Immunology  and  meningococcal  disease,
Queens Medical Centre, Nottingham.

Cartwright  K  A  V,  and  Ala’Aldeen  D  A  A,  (1997)  ‘Neisseria  meningitidis:  Clinical
aspects’ review article, Journal of Infection 34, pp.  15-19.

Cartwright K A V, Hunt D, Fox A, (1995) ‘Chemoprophylaxis fails to prevent a second
case  of  meningococcal  disease  in  a  day  nursery’  CDR  Review  -  Communicable
Disease Report, 5 (13), 8 December, p R199.

CDR  Review  (1997)    ‘Management  of  clusters  of  meningococcal  disease’  CDR
Review - Communicable Disease Report, 7 (1), 10 January, pp R3-5.

CDR Review (1995)  ‘Control of meningococcal disease: guidance for consultants in
communicable disease control’, Communicable Disease Report, 5 (13), 8 December,
pp R189-R195.

CDR  (Communicable  Disease  Report)  (1999)  ‘First  quarter’  CDR  weekly
(Communicable Disease Report), 9 (17), 23 April, p.148.

Chin J, 2000 Control of Communicable Disease Manual 17th Ed Amer.   Public Health
Assn

Department  of  Health  ‘Meningococcal  C  (Meningitis  C)  vaccine  factsheet,  October
1999
pp 1-6.

Fallon R J, Slack R C B,  (1997) ‘Neisseria and moraxella (branhamella)’ chapter 24
Medical  Microbiology:  a  guide  to  microbial  infections:  pathogenesis,  immunity,
laboratory diagnosis and control, 15th edition.   Greenwood D, Slack R CB, Peutherer
J F.   Editors, London: Churchill Livingstone, pp 243-251.

Greenwood  B  M,  (1996)  ‘Meningococcal  infection’  part  7.11.5:  Oxford  textbook  of
medicine;  Volume  1,  3rd  Edition,  Weatherall  D  J,  Ledingham  J  G  G,  Warrell  D  A.
Editors; Oxford: Oxford University Press, pp.  533-544.

Greenwood  D  (1997)          ‘Morphology  and  nature  of  micro-organisms’  chapter  2
Medical  Microbiology:  a  guide  to  microbial  infections:  pathogenesis,  immunity,

laboratory  diagnosis  and  control,  15th  edition.      Greenwood  D,  Slack  R  C  B,
Peutherer J F.   Editors, London: Churchill Livingstone, pp 8-24.

Riordan T (1997) ‘A college outbreak of group C meningococcal infection: how widely
should investigation and prophylaxis extend?’ CDR Review - Communicable Disease
Report, 7 (1), 10 January, pp R5-R9.

Wenzel R P, Editor (1997) Prevention and control of nosocomial infections   (3rd
edition), Maryland USA: Williams and Wilkins, pp.  413-414.

4.3 CREUTZFELDT-JAKOB DISEASE AND VARIANT CREUTZFELDT-JAKOB
DISEASE (CJD & VCJD)

4.3.1  Background
Creutzfeld  Jacob  Disease  (CJD)  is  one  of  a  group  of  conditions  known  as
transmissible  spongiform  encephalopathies.    They  are  caused  by  agents
currently  thought  to  be  infectious  proteins  known  as  prions,  which  do  not
share  the  normal  properties  of  viruses  and  bacteria  and  are  resistant  to
conventional chemical and physical decontamination methods.
The  greatest  risk  of  transmission  is  from  neural  tissue  of  an  infected
individual.    Spinal  fluid  and  lymphoreticular  tissues  pose  a  lower  risk  and
blood,  other  body  fluids  and  most  other  tissues  a  negligible  risk  of
transmission.    Although  these  conditions  do  not  appear  to  be  highly
contagious,  there  have  been  documented  cases  of  spread  via  contaminated
medical instruments or contaminated human pituitary hormone.

Standard  infection  control  practice  is  sufficient  in  most  circumstances  to
prevent  spread.    Isolation  of  patients  with  CJD  is  not  necessary.    Additional
precautions  are  necessary  during  invasive  interventions  involving  the  brain,
spinal cord and eye on a patient known, suspected or at risk of having CJD.

4.3.2  Symptomatic patients
•  Patients who fulfil the diagnostic criteria for definite, probable or possible CJD
or vCJD
•  Patients  with  neurological  disease  of  unknown  aetiology  who  do  not  fit  the
criteria  for  possible  CJD  or  vCJD  but  where  the  diagnosis  of  CJD  is  being
actively considered

Asymptomatic  patients  at  risk  from  familial  forms  of  CJD  linked  to  genetic
mutations
•  Individuals  who  have  been  shown  by  specific  genetic  testing  to  be  at
significant risk of developing CJD or other prion disease
•  Individuals  who  have  a  blood  relative  known  to  have  a  genetic  mutation
indicative of familial CJD
•  Individuals  who  have  or  have  had  two  or  more  blood  relatives  affected  by
CJD or other prior disease

4.3.3  General Ward procedures
Available  epidemiological  evidence  does  not  suggest  that  normal  social  or
routine  clinical  contact  with  a  CJD  or  vCJD  patient  presents  a  risk  to
healthcare  workers,  relatives  and  others  in  the  community.    Isolation  of
patients  with  CJD  or  vCJD  is  not  necessary  and  they  can  be  nursed  in  an

open ward using standard infection control precautions in line with those used
for all other patients.

4.3.4  Blood
Careful  attention  to  standard  infection  control  precautions  will  minimise  any
risks  from  blood.    Drug  administration  by  injection  should  involve  the  same
precautions  used  for  all  work  of  this  type  with  any  patient  i.e.  avoidance  of
sharps injuries and other forms of parenteral exposure and the safe disposal
of sharps and contaminated waste.

4.3.5  Invasive medical procedures and sample labelling
Because of the unusual resistance of the TSE agents, single use disposable
equipment  should  be  used  wherever  possible,  and  all  other  small  items  of
equipment contaminated whilst obtaining specimens should be destroyed by
incineration (please refer to waste guidance).

4.3.6  Spillages
The  infectious  agent  associated  with  TSEs  is  unusually  resistant  to
inactivation techniques.  Dilution is the most important element in cleaning up
spillages in general.

4.3.7  Occupational exposure
Although cases of CJD/vCJD have been reported in healthcare workers, there
have been no confirmed cases linked to occupational exposure.  However, it
is prudent to take a precautionary approach.  The highest potential risk in the
context  of  occupational  exposure  is  from  exposure  to  high  infectivity  tissues
through  direct  inoculation  (e.g.  as  a  result  of  ‘sharps’  injuries,  puncture
wounds  or  contamination  of  broken  skin)  and  exposure  of  the  mucous
membranes (e.g. conjunctiva) should also be avoided.

Healthcare  personnel  who  work  with  patients  with  definite,  probable  or
possible  CJD  or  vCJD,  or  with  potentially  infected  tissues,  should  be
appropriately  informed  about  the  nature  of  the  risk  and  relevant  safety
procedures.

4.3.8  Storage of instruments for research purposes
In  some  cases,  instruments  which  are  destined  for  disposal  by  incineration
may be retained for uses in research.  Anyone considering such a course of
action  should  contact  the  Surgical  Instrument  Store,  Health  Protection
Agency,  Porton  Down  on  01980  612643  (answer  phone  on  out-of-hours)  to
discuss  whether  it  would  be  helpful  to  retain  a  particular  instrument  for
research, and where and how it should be stored.

4.3.9  Community healthcare
No  special  measures  over  and  above  standard  infection  control  precautions
are required for caring for CJD patients in the community.  Although CJD and
vCJD are not though to present a risk through normal social or routine clinical
contact, those caring for patients at home should be advised of the standard
infection control practices that would apply to any patient.

Spillages of body fluids, including blood, should be removed using absorbent
towels  e.g. kitchen  paper  and  the  surface  washed  thoroughly  with  detergent
and warm water.  Disposable gloves and an apron should be worn.

4.3.10  Dentistry

The risks  of transmission  of  infection from  dental  instruments  are  thought  to
be  very  low  provided  optimal  standards  of  infection  control  and
decontamination  are maintained.   General  advice  on  the  decontamination  of
dental  instruments  can  be  found  in  guidance  prepared  by  the  British  Dental
Association (BDA) on ‘Infection control in dentistry’.

There  is  no  reason  why  any  patients  or  their  relatives  should  be  refused
routine dental treatment.  Such people can be treated in the same way as any
member of the general public.

4.4 TUBERCULOSIS

Tuberculosis  (TB)  is  an  infectious  disease  caused  by  Mycobacterium  tuberculosis
and rarely by Mycobacterium bovis, or Mycobacterium africanum.   The lungs are the
most  frequently  affected  site  although  miliary  TB  (the  result  of  blood  borne  spread)
may affect the meninges, kidneys or bone.

TB  infection  is  said  to  occur  when  TB  bacteria  are  in  the  body,  but  the  immune
system controls them and the infection heals spontaneously.   Disease may develop
over the coming weeks and months and in about 10% of people infection reactivates
in later life causing active disease.  People with TB infection have no symptoms, and
cannot spread TB to others.

TB  disease  is  said  to  occur  when  TB  bacteria  are  present  in  the  body  and  cause
symptoms  making  the  person  feel  unwell.    These  symptoms  may  include  a  cough,
weight loss, fever, fatigue, night sweats and loss of appetite.  Sometimes people with
TB in the lungs may also cough up sputum streaked with blood.  Symptoms in some
people may be only mild and in others more severe, but all will be likely to spread the
infection before treatment is commenced.

4.4.1  Transmission
The  infection  can  be  acquired  in  several  ways,  but  by  far  the most  important  is  the
inhalation  of  organisms  in  airborne  droplets  coughed  by  a  person  with  TB  of  the
lungs.  Prolonged, close contact is usually required for transmission of infection from
person to person.  The people likely to be affected would include people living in the
same  house  as  the  case  and  those  with  whom  they  socialise  on  a  frequent  basis.
The type of work environment will be assessed for risks to colleagues from the case.

4.4.2  Prevention
Prompt  identification  of  cases  and  contacts  is  necessary  to  reduce  the  spread  of
infection.    The  notification  of  each  case  to  the  Health  Protection  Unit,  by  the
clinician in charge of the case is a statutory requirement, and facilitates the contact
tracing  process  where  it  is  not  carried  out  by  respiratory  nurses.    The  National
Enhanced Surveillance forms, should be used for this purpose.

Bacillus Calmette-Guerin (BCG)  immunisation confers a degree of immunity and has
been  shown  to  protect  against  TB  with  an  efficacy  of  greater  than  70%  in  British
schoolchildren,  with  protection  lasting  at  least  15  years.      There  is  a  schools
programme of immunisation within Cambridgeshire.

Neonatal BCG is recommended by the DoH and British Thoracic Society (BTS) for
babies  born  to  immigrants  from  countries  with  a  high  prevalence  of  TB,  i.e.  where
local incidence exceeds 40/100,000 population per year.

Health  care  workers  who  have  contact  with  infectious  patients  or  their  specimens
should also be protected  by immunisation.

All entrants to the UK planning to stay longer than 6 months should be screened for
TB Port forms are part of this process and if appropriate entrants will be contacted to
attend a chest clinic for investigation.

4.4.3  Control
Early identification and treatment of cases especially sputum smear positive is vital
in  the  control  of  TB,  and  good  communication  networks  between  health  care
professionals  is  essential.    Prompt  identification of  close  contacts  is  necessary for
screening  purposes.      Screening  of  new  arrivals  and  refugees  and  asylum  seekers
should be undertaken.

4.4.4  Treatment
This  is  usually  for  a  minimum  of  6  months  and  during  this  period  patients  should
receive  regular  checks  not  only  to  ensure  that  they  are  compliant  with  their
medication  but  to  provide  support  and  note  if  there  are  any  side  effects.      Patients
who  have  infectious TB  are  not  usually  considered  infectious  after  2  weeks  of  anti-
tuberculous therapy.

Multi-Drug Resistant TB

This can occur if treatment is not completed as prescribed.

Drug resistance is more common in people who:

have spent time with someone with drug resistant TB;

do not take medication regularly;

do not take all the prescribed medication;

develop TB disease again, after having taken TB medication in the past;

come from areas where drug resistant TB is prevalent.

Multi-Drug  Resistant  TB  is  a  very  serious  problem,  which  must  be  monitored  by  a
specialist respiratory clinician in consultation with the Consultant Microbiologist.
4.4.5  Quick reference guide
A quick reference guide for health professionals is also available from the NICE
website (WWW.NICE.ORG/CG033QUICKREFGUIDE) or from the NHS Response
Line (telephone 0870 1555 455; quote reference number N1008).

REFERENCES – Section 4.4
UK Health Departments - Immunisation Against Infectious Disease (1996).

The Interdepartmental working Group on TB  - The Prevention and Control of TB in
the UK
Recommendations for the Prevention and Control at Local Level  (DoH 1996).

Joint Tuberculosis Committee of the British Thoracic Society, Control and Prevention
of TB in the UK, Code of Practice (2000), Thorax,55, pp 887-901.

Joint  Tuberculosis  Committee  of  the  British  Thoracic  Society,  Guidelines  on  the
Management of TB and HIV Infection in the UK, BMJ (1992) 304, pp 1231-1233.

Joint Tuberculosis Committee of the British Thoracic Society.  Chemotherapy and
Management of TB in the UK,Thorax  (1998)  53, pp 536-548.

APPENDIX 1 – Section 4.4
Isolation decisions for patients with suspected respiratory TB

Known or

suspected MDR
TB, based on risk

assessment?

Admit to single room
Admit to negative-pressure room

Sputum smear
Yes
positive (1 or
No
more from 3

samples)?

Yes
No
No
Risk for
Yes
Risk for
MDR TB?
MDR TB?

Does ward
No
Yes
have immuno-

compromised
patients?

Negative-pressure
Single
r
oom (irrespective
room on
of HIV status).
ward

Molecular probe
Negative-
for rifampicin
pressure
resistance
Standard

room
ward

4.5 GASTRO-INTESTINAL DISEASES

4.5.1  Hepatitis A
The  illness  caused  by  Hepatitis  A  is  usually  mild,  symptoms  usually  improve  and
disappear as jaundice develops.  Fulminating disease can occur, but this is found to
be overall less than 0.5%.  Only 5% of children under 3 years develop jaundice, but
this  rises  to  about  50%  in  adults.    The  fatality  rate  also  rises  with  age  to
approximately 2% in adults.

The  Department  of  Health  recommends  vaccination  against  Hepatitis  A  for  certain
occupational  groups  such  as  sewerage  and  laboratory  workers  who  may  come  into
contact with it during their work.  There is no evidence available that identifies health
care workers as high risk, therefore, routine vaccination is not recommended.   Other
areas such as residential institutions for those with learning disability and challenging
behaviours should conduct a risk assessment and provide measures to protect both
staff and residents.

A  much  more  serious  illness  may  occur  when  patients  with  chronic  liver  disease
become infected.  Although these people are at no greater risk of acquiring Hepatitis
A than the rest of the population they should be considered for immunisation.  This
group  may  include  intravenous  drug  abusers  with  chronic  liver  disease  and
haemophiliacs.  The  local  environmental  office  must  be  informed  of  cases  of
Hepatitis A.

4.5.2  Vaccination and Control
Hepatitis A is not part of the routine UK childhood schedule.

The regime for adults is a single dose of vaccine.   A booster dose at 6-12 months
results in a substantial increase in antibody titre and will give immunity for up to 10
years.   The regime for children up to 15 years is a single dose of vaccine, however,
immunity can be boosted by giving a second dose between 6-12 months.

Active protection for Hepatitis A normally starts approximately 2 weeks after the first
dose  of  vaccine  although  some  evidence  suggests  that  this  may  be  sooner.
Immediate passive protection is offered by Hepatitis A immunoglobulin.

Vaccination  is  recommended  for  travellers  to  high  risk  areas  and  can  be  given  to
infants from 1 year of age.  It is worth noting that those with a history of jaundice or
who have lived for a long time in endemic areas may have become naturally immune
as a result of infection.

In  common  with  other  inactivated  viral  vaccines  the  manufacturers  advise  caution
during  pregnancy  or  lactation  unless  the  risk  of  infection  is  substantial.    Passive
vaccination with pooled immunoglobulin (a blood product with its own potential risks)
is an alternative.  This can be useful when active vaccination may be ineffective, e.g.
in  the  immunocompromised.    There  is  now  evidence  that  active  vaccination  gives
good  protection  against  illness  even  if  administered  shortly  before,  or  immediately
after exposure.  There are no carriers of the virus.   Virus is normally excreted in bile
7-14  days  before  the  onset  of  jaundice,  excretion  then  declines  over  the  next  5-7
days.  Virus is present in both urine and faeces of infected patients.

Human  immunoglobulin  (HNIG ) offers short term protection against hepatitis A for
up to 4 months and is sometimes used in the control of an outbreak where it should

be given to close household contacts within 14 days of the inset of symptoms.

Hepatitis  A  vaccination  in  a  defined  population  has  been  used  to  prevent  further
infections.  However guidance should be sought from the Health Protection Unit.
4.5.3  Hepatitis E (HEV)
The clinical course of this infection is similar to that described for hepatitis A.  There
is no evidence of a chronic form and the case fatality rate is generally the same as
hepatitis A.

Diagnosis  depends  on  clinical  and  epidemiological  features  and  exclusion  of  other
aetiologies of hepatitis, especially A, by serological means.

Primarily the faecal-oral route transmits hepatitis E.  Outbreaks of HEV and sporadic
cases  have  occurred,  principally  in  countries  with  inadequate  environmental
sanitation.

Period of communicability is not known; it has been detected in stools 14 days after
onset  of  jaundice  and  approximately  4  weeks  after  oral  ingestion  of  contaminated
food  or  water.      Control  of  infection  is  the  same  as  that  described  for  hepatitis  A,
although no vaccine is available.

4.5.4  Salmonella, Shigella and Campylobacter
These  are  notifiable  infections  and  some  of  the  most  common  causes  of
gastrointestinal disease.

A  stool  sample  is  usually  required  to  provide  a  definitive  diagnosis  but  notification
should be made on an index of suspicion to the environmental health department.

Salmonella  is  the  second  most  commonly  reported  cause  of  infectious  intestinal
disease  in  the  UK  and  can  result  in  large  outbreaks  particularly  due  to  food  borne
transmission.  All cases are reviewed by the environmental health officers and follow
up of cases carried out.   Person to person spread may occur through the faeco oral
route  without  food  as  an  intermediary.      This  risk  is  highest  during  the  diarrhoeal
phase  of  the  illness  and  risks  are  greater  among  babies  and  toddlers  and  faecally
incontinent adults.   Incubation ranges from 6 hours to 3 days or occasionally longer
and  the  period  of  infectivity  varies  considerably,  but  is  usually  a  few  days  to  a  few
months.    However  approximately  1%  of  adults  and  5%  of  children  under  5  will
excrete the organism for at least a year.

Shigella  are  a  group  of  bacteria  that  cause  intestinal  infection  including  bacillary
dysentery.    Numbers  of  reports  have  decreased  dramatically  since  the  fifties  and
sixties  when  20-40,000  cases  were  reported  annually.    Shigellosis  is  primarily  a
disease of children with the highest rates in the under fives, followed by the  5-14 age
group.      Common  settings  for  outbreaks  of    S.Sonnei    are  schools  and  nurseries.
Man is the only significant reservoir of infection and transmission is via the faeco oral
route  either  directly  or  by  contaminated  food  or  water.      Food  borne  outbreaks  are
relatively rare.

The  incubation  period  is  between  12  and  96  hours,  but  may  be  up  to  a  week  for
some strains.  The infective dose is very low; and may follow ingestion of as few as
10 organisms.   Cases may maintain low levels of infectivity for up to 2-4 weeks.

Campylobacter  species  causes  diarrhoeal  and  systemic  illness  in  humans  and

animals and is the most commonly identified cause of infectious intestinal disease in
developed countries.  Campylobacter is found in the gastrointestinal tract of birds and
mammals  and  animals  develop  a  lifelong  carrier  state.    Although  food  borne
outbreaks are rarely identified occasional large outbreaks due to contaminated water
or milk may occur.

Campylobacter  infection  may  vary  from  asymptomatic  (about  25%)  to  a  severe
disease similar to ulcerative colitis or acute appendicitis.  Most cases settle after 2-3
days of diarrhoea.  Incubation is related to the dose ingested usually about 3 days,
but  with  a  range  of  1-10  days.    Person  to  person  may  occur,  but  is  likely  to  be
associated  with  poor  hygiene.    Duration  of  excretion  may  be  up  to  7  weeks  falling
exponentially after the end of symptoms.

Campylobacters  are  commonly  found  in  bulked  raw  milk  samples,  but  properly
conducted pasteurisation destroys the organism.

If  any  of  the  above  are  suspected  every  effort  should  be  made  to  segregate  the
person  if  in  a  residential  setting,  and  specimens  collected  and  precautions  taken
such as use of gloves and aprons and thorough hand washing.

VIRAL INFECTION

4.5.5  Small Round Structured Virus (SRSV)
This  section  covers  gastroenteritis  caused  by  calciviruses,  particularly  Norwalk  like
agents.    Although  generally  causing  mild  illness,  spread  particularly  in  institutions
may  be  rapid.    Other  causes  of  viral  gastro  enteritis  include  rotavirus,  adeno  virus
and  astrovirus.      All  ages  are  affected  and  although  cases  are  reported  throughout
the year greater numbers are notified in the cooler months.  Recorded outbreaks in
the  UK  occur  mainly  in  hospitals  or  residential  institutions  such  as  nursing  homes
although outbreaks have occasionally been reported in hotels, ships and schools.

This  must  be  notified  to  relevant  infection  control  team/environmental  health
departments and health protection unit.

SRSV infection is relatively mild, lasting 12-60 hours.  Abdominal cramps and nausea
are usually early symptoms, followed by vomiting and/or diarrhoea.  Forceful vomiting
is especially characteristic.   Diarrhoea is usually mild with no blood mucus or white
cells.  Other symptoms may include anorexia, lethargy, myalgia, headache and fever.
Illness may be debilitating in the elderly.

Transmission  is  person  to  person  via  the  faecal-oral  route  either  directly  through
contaminated  food  or  water,  or  indirectly  through  contamination  of    environmental
surfaces and other items.   SRSV can remain viable for many days on curtains and
carpets which might explain spread in some outbreaks.   Humans are the only known
reservoir of SRSV and the infectious period lasts until 48 hours after the resolution of
symptoms.    Every  effort  should  be  made  to  segregate  any  individual  suspected  of
infection  and  specimens  collected.    Thorough  handwashing  and  use  of  protective
clothing is important in reducing spread.

Electron  microscopy  of  faecal  specimens  collected  early  on  is  the  mainstay  of
confirmation of the infection.  Specimen forms should clearly state a request for
virology ? SRSV.

If  laboratory  confirmation  is  lacking,  clinical  symptoms  can  be  used  to  assess  the
likelihood of an outbreak.

4.5.6  Rotavirus
Rotaviruses are the commonest cause of childhood diarrhoea.  Peak incidence is at
6 months to 2 years of age and clinical infection is unusual above 5 years.   Onset is
usually sudden with vomiting and diarrhoea but illness usually only lasts a few days.
Confirmation is by electron microscopy and serology may also be used.   Spread is
person  to  person  via  the  faeco  oral  route  although  there  may  also  be  spread  from
respiratory secretions and sometimes contaminated water.  Outbreaks may occur in
any setting where the virus may contaminate the environment.   Incubation is usually
1-3  days.    Every  effort  should  be  made  to  segregate  a  person  with  infection  and
specimens  should  be  collected  and  sent  to  laboratory  promptly.  Thorough
handwashing and the use of protective clothing will help in the reduction of spread to
other susceptible individuals.

REFERENCES – Section 4.5

Hawker J, Begg N,  Blair I,  Reintjes R and Weinberg J  (2001), Communicable
Disease Control Handbook,  Blackwell Science.

4.6 METHIILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA)

Staphylococcus  aureus  is  a  type  of  bacterium  carried  in  the  nose  and  on  the  skin
usually without causing harm.  However, in certain circumstances, particularly when
the  patient  is  elderly  and  living  in  residential  care  or  terminally  ill  in  a  hospice  or  at
home,  staphylococcus  aureus  can  cause  infections.      Staphylococcus  aureus  also
represents problems to certain acute hospital units, especially surgical, intensive care
and burns, where the patient is immuno compromised and the skin is not intact due
to invasive procedures such as wounds and intravenous infusion.

Some strains of staphylococcus aureus have become resistant to methicillin (a once
commonly  used  antibiotic),  as  well  as  to  other  antibiotics.    Methicillin  resistant
staphylococcus  aureus  (MRSA)  behaves  in  the  same  way  as  ordinary
staphylococcus  aureus  and  does  not  cause  more  severe  or  different  infections.
However, MRSA is more difficult to treat as there are fewer antibiotics with which to
treat  it,  and  some  of  these  antibiotics  must  be  given  by  injection  or  infusion.    They
may  also  have  unpleasant  side  effects.      MRSA  rarely  causes  infection  in  healthy
people.

Outside  acute  hospital  units  people  may  carry  MRSA  without  it  causing  harm  to
themselves  or  others.    They  are  said  to  be  MRSA  carriers  or  to  be  colonised  with
MRSA.    Although  attempts  are  made  to  eradicate  colonisation  in  acute  hospital
patients,  this  is  not  always  necessary  for  patients  in  low-risk  clinical  areas  of  the
hospital,  or  anywhere  where  the  situation  is  similar  to  that  found  in  community
residential or nursing homes.

Carriage  of  MRSA  is  not  a  contraindication  to  the  transfer  of  a  patient  to  a
nursing  or  residential  home  or  their  own  home.    There  is  also  no  indication  for
routine  screening  before  hospital  discharge  to  the  community.    MRSA  carriage
should not be a reason for discriminating against individuals.  Should a patient need
to be admitted to hospital, then they should inform the hospital that the patient is, or
has been, positive for MRSA.

4.6.1  Control and Care in the Community

Isolation  of  MRSA  carriers  is,  generally,  not  necessary  in  residential/nursing
homes.

A colonised person  without open wounds may share a room if the other person
does  not  have  open  lesions,  but  a  colonised  person  who  has  open  wounds
should be in a single room, if one is available.

All  cuts  or  breaks  in  the  skin  of  staff  or  patients  should  be  covered,  with  an
impermeable dressing.

The patient should be encouraged to practice normal hygiene with hand washing
after using the toilet and before eating.

If  a  resident  of  a  nursing  home,  the  patient  may  also  join  other  residents  in
communal areas, such as sitting or dining rooms, providing any sores or wounds
are covered with a dressing.

No special precautions are necessary with crockery or cutlery.

Clothes  and  bedding  should  be  machine  washed,  preferably  on  a  hot-wash
setting,  or  dry-cleaned  if  unsuitable  for  machine  washing,  or  in  accordance  with
manufacturers instructions.

Equipment that has been in contact with the patient such as a commode should
be thoroughly cleaned with detergent and water.

Positive  patients  may  be  transported  with  other  patients  in  the  same  vehicle
without  special  precautions  (other  than  those  mentioned  above).    No  extra
cleaning of the vehicle is usually necessary.

All staff should maintain good infection control practice when carrying out nursing
procedures on all patients regardless of MRSA status.

4.6.2  Eradication of MRSA in colonised patients
Good  hand  washing  practice  by  staff  and  patients  is  the  single  most  important
infection  control  measure  and  is  essential  to  prevent  spread  of  MRSA  as  well  as
other infections.

Older people who are generally healthy, but frail are at minimal risk of developing an
infection  when  colonised  with  MRSA.    It  is  not  always  possible  to  eradicate  MRSA,
and routine screening is not necessary unless there is a clinical reason (e.g. a wound
is getting worse).   In this situation, swabs should be taken for general microbiological
investigation,  not  just  MRSA  screening,  although  the  laboratory  will  need  to  be
informed that the resident is, or has been, positive.

In  certain  cases  it  may  be  necessary  to  attempt  to  eradicate  colonisation.    Frail,
elderly people recovering from surgery or serious illness may not be able to tolerate
MRSA  sensitive  antibiotic  treatment,  whilst  topical  antiseptics  may  exacerbate  pre-
existing skin conditions or cause irritation.   However, if the benefits clearly outweigh
any potential drawbacks, medical staff may prescribe an eradication programme.   In
1998 the Working Party recommended in the ‘Revised Guidelines for the Control of
Methicillin-Resistant  Staphylococcus  Aureus  Infection  in  Hospitals’  the  following
prescribed treatment of carriers, colonised sites and infections.
3.6.3  Nasal carriage
2% Mupirocin in a paraffin base (Bactroban Nasal) 3 times a day to each nostril for 5
days.  Swab 2 days later.  If the patient is still positive - repeat treatment once.  If still
positive contact should be made with the consultant microbiologist.
3.6.4  Skin carriage
MRSA  in  any  site  –  bathe  daily  for  5  days  with  Octenisan.    Moisten  skin,  apply
solution thoroughly to all areas before rinsing in bath or shower.  Wash hair in same

solution twice a week (day 2 and 4). Pay special attention to axilla, groin, perineum
and buttock area.   If not eradicated, the course may be repeated.   It is necessary to
change towels and flannels/cloths daily, as well as bed linen.

Daily damp dusting of the patient’s bedroom, careful hygiene and general domestic
cleaning should be thorough.

Systemic treatment should be considered only in special circumstances or if there is
significant local skin infection.
3.6.6  Follow-up
Three  negative  swabs  from  previously  positive  sites  should  be  obtained  before
accepting  that  MRSA  has  been  cleared.  However  there  may  be  individual
circumstances  where  patients  are  frequently  positive.  Indivial  guidance  can  be
obtained through the Consultant Microbiologist.

Risk factors for acquisition of MRSA apart from antibiotic treatments include frequent
to healthcare settings and nursing / residential homes.

Please  note:    There  may  be  some  local  variation  between  the  acute  trusts  in
their  management  of  MRSA  colonisation/infection.    Where  appropriate  please
follow the advice given for individual cases.

4.6.3  Care of the Patient in their Own Home
Carers who attend a patient with MRSA in their own home usually require no special
management  apart  from  routine  practice  of  hand  decontamination  and  use  of
protective  clothing for  procedures  where  contamination  is  possible.    This  should  be
no different to care delivered to other patients.  However, the minimal risks to other
patients  could  be  reduced  further  by  seeing  patients  with  infections  or  MRSA
colonisation at the end of the shift although this may not always be practicable.

If a patient has a wound with MRSA healing is the priority not eradication.  Regular
swabbing  is  rarely  recommended  as  MRSA  usually  clears  once  healing  has  taken
place.

4.6.4  Wound Carriage
Dressings  containing  certain  antiseptics  i.e.  silver  may  be  applied  to  infected  or
colonized wounds. These are unlikely to eradicate the organisms but should prevent
further growth.

REFERENCES – SECTION 4.6
Department of Health, (1998)  ‘MRSA What Nursing and Residential Homes Need to
Know’ August, HMSO.

Department of Health, PHMEG (1996) Guidelines on the Control of Infection In
Residential and Nursing Homes.

Working Party Report,  (1995) ‘Guidelines on the control of Methicillin-Resistant
Staphylococcus Aureus in the Community’ Journal of Hospital Infection , 31: 1-12.

Working Party Report,  (1998) ‘Revised guidelines for the control of Methicillin-
Resistant Staphylococcus Aureus infection in hospitals’ Journal of Hospital Infection,
39: 253-290.

A simple guide to MRSA.  DH pamphlet.

MRSA

What is MRSA?
How is MRSA spread?
MRSA  stands  for  Methicillin  Resistant  On  the  hands  of  those  caring  for  people
Staphylococcus  Aureus.    Staphylococcus  who are carrying MRSA.  It survives on skin,
aureus  is  a  common  bacterium,  which  is  and  as  dust  contains  dead  skin  cells  the
carried by 20- 40% of the population.
environment  should  be  maintained  in  a

clean state.
Methicillin  is  an  antibiotic  in  the  same  group
as penicillin.  MRSA therefore means that the  What can I do to stop MRSA spreading to
staphylococcus  aureus has  become  resistant  others?
to treatment with these types of antibiotics.  If  Careful hand washing after helping with any
someone  has  MRSA  infection  there  are  a  personal hygiene, for example, helping with
limited number of antibiotics that can be used  a wash or taking the person to the toilet.
to treat the infection.

Health care workers should wear gloves and
Is  MRSA  any  more  harmful  than  ordinary  aprons when they are undertaking personal
Staphylococcus?
care or dealing with body fluids.
No.  The MR part makes no difference to the
virulence of the infection.
Why  then  do  people  who  are  just

colonised  with  MRSA  get  isolated  in
What  is  the  difference  between  being  hospital?
colonised and infected with MRSA?
This  is  done  to  stop  MRSA  spreading  to
Colonisation means that the MRSA is present  other patients in hospital who may have had
on skin, nose or sometimes on leg ulcers, but  surgery  or  have  other  risk  factors.    It  is  not
it is not causing any harm to the person.
necessary  to  isolate  people  when  they  are

in the community.
However,  sometimes  Staphylococcus  aureus
(and therefore MRSA) can cause an infection.   Can MRSA be treated?
This may be in any wound or the urine when  Yes.    This  is  referred  to  as  ‘decolonisation’
the  bacterium  damages  tissue.    These  types  and  you  can  discuss  this  option  with  your
of  antibiotic-  resistant  infections  are  more  doctor.  Decolonisation is sometimes not as
common in vulnerable patients.
successful
when
people
have
skin

conditions  like  eczema  and  psoriasis,  or  if
Where does MRSA live on the body?
they  have  a  catheter,  a  drip  or  a  large
MRSA  lives  in  the  nose,  armpits,  groin,  wound.
wounds and any tubes or drains which is why
these  are  swabbed  when  looking  for  MRSA.   Where can I get more information?
It can also survive for a short time on hands,  More information is available from:
which  is  why  good  hand  hygiene  should  be

Your GP or Practice Nurse.
maintained  especially  after    skin  contact  with

Your District Nurse.
the person.

Manager of the

nursing/residential home.
How  do  you  know  whether  the  person  is

The  Public  Health  Protection  Team
colonised or infected?
Nurse
or
Community
Infection
When  a  person  is  infected  they  will  have
Control Nurse.
signs
and
symptoms
of
an
infection
diagnosed  by  the  Doctor.      If  they  are
colonised they are not ill and will not have any

signs or symptoms of an infection.
APPENDIX 1 – Section 4.6
ADVICE FOR PATIENTS, RELATIVES AND FRIENDS

4.7 SCABIES, HEADLICE AND WORMS
4.7.1  SCABIES
What should you know about scabies?
Scabies  is  a  parasitic  infestation  caused  by  a  whitish,  translucent  mite,  Sarcoptes
scabiei that can burrow tunnels in the epidermis.

Transmission of scabies occurs by prolonged skin to skin contact and is increased in
those  individuals  who  harbour  a  greater  number  of  parasites,  e.g.  immunodeficient
patients.

The full life cycle of Sarcoptes scabiei from egg to adult takes 10 to 15 days.  It has
four stages: egg, six legged larval stage, eight legged nymphal stage and adult.

The fertilised adult female lives and lays eggs in the epidermis in small linear burrows
that she forms by tunnelling.  After the eggs hatch, the six legged larvae excavates a
new  burrow  in  a  skin  fold  or  hair  follicle.  Adult  males  move  more  actively  between
burrows seeking to mate.

When should you suspect scabies?
There  are  three  main  clinical  manifestations  of  scabies:  classic  (the  form  that  is
usually seen), atypical and crusted scabies.

Classic scabies
Individuals  present  with  an  itchy  symmetrical  allergic  rash,  especially  worse  at
night. Other allergic lesions such as papules or vesicles may accompany it.

Normally, the incubation period in adults is 3 weeks, but in re-exposed individuals
symptoms can present after 1 to 4 days.

The areas that are particularly affected by lesions include the:

-
Interdigital web spaces of the hands.
-
Flexor surfaces of the wrists and elbows.
-
Axillae.
-
Male genitalia.
-
Women’s breasts.

Atypical
In the atypical form, individuals usually have very minor symptoms with no itching
or a diffuse papular lesion.

Crusted scabies
The  crusted  form  is  characterised  by  hyperkeratotic  skin  lesions  (Norwegian
scabies).

Itchy  bullous  lesions,  lichenification  and  or  erthrodermic  reactions  may  also  be
present.
Lesions are particularly found on the:

-
Palms and soles, nail beds of hands and feet and wrists.
-
Buttocks and penis.

What should you do?

DIAGNOSE  The definitive diagnosis of scabies is made by microscopic
identification of the mites, eggs or mite faeces. Skin scrapings and
detection of the mite at the end of its burrow are both recommended
methods.
TREAT
The infested individual and their close physical contacts should be
treated at the same time.  This includes household family contacts.

The  lotion  or  cream  is  applied  to  the  whole  body  with  particular
attention  to  the  groin,  fingernails,  toenails  and  behind  the  ears.  The
product should be washed off as instructed by the manufacturer leaflet
and clothes and bed linen changed.

The  classic  form  of  scabies  usually  responds  to  one  or  two
applications of permethrin or malathion.
Benzyl benzoate is not first choice treatment because it is not ovicidal,
multiple treatments are required, and it is an irritant.

In  the  crusted  form  of  scabies  at  least  three  treatments  may  be
necessary, 48 hours apart.

ADVISE
Patients  should  be  advised  that  itching  could  persist  for  up  to  1-2
weeks after the end of correctly applied scabicide therapy.

All staff MUST inform Occupational/Staff Health if they suspect that they are infected.

4.7.2  Head Lice
What should you know about head lice?
The adult louse is 3mm long and spends its whole life cycle on human hair.
They can live on the scalp for up to 4 weeks but cannot live free of the head.

They do not jump or fly, and can only be spread by prolonged contact of more
than one minute.

Infection with head lice is most common in children aged 6-11 years.

It  is  usually  asymptomatic  (only  15-35%  of  people  experience  itching)  although  re-
infections are likely to produce itching.

When should you suspect head lice?
A diagnosis of head lice can only be made if a living, moving louse is found.

It cannot be based on the presence of nits (the empty shell) alone, as nits can remain
stuck to hair long after an infection has been eradicated.

Head  lice  and  live  eggs  are  difficult  to  see,  and  in  most  infections  at  any  one  time
there are approximately 10-12 lice on the scalp.

Usually, it is easier to find head lice on damp hair using a specially designed plastic
detection comb.  Ideally, combing should be done over a pale piece of paper.

What should you do?

DIAGNOSE
t  is  essential  to  make  the  correct  diagnosis,  verified  by  direct
observation.  Ask  for  verification  from  the  parent  by  instructing
them  to  bring  the  louse  stuck  to  a  piece  of  paper  with  sticky
tape.
TREAT
Treatment is only required for those who are infected, there is
no need to automatically treat all household members.

Insecticides
This  is the only  treatment for  which  there  is  clear  evidence  of
effectiveness.  There are three types of head lice insecticides
available: malathion, pyrethoids and carbaryl.
Recommended products
First choice:
-
Malathion: Suleo M, Derbac M Lotions
-
Pyrethoids: Lyclear creme rinse, Full Marks liquid, lotion or
mousse

For  treatment  failures  try  Carbaryl:  Carylderm  liquid  or  lotion
(prescription only).

Each  application  will  require  a  minimum  of  50  mls  (a  small
bottle),  people  with  thick  hair  may  need  up  to  three  bottles.
Lotions and liquids need a contact time of at least 12 hours or
overnight.   Two  applications  are recommended, 7  days  apart.
A  maximum  of  one  treatment  per  week  for  three  consecutive
weeks should not be exceeded.

Bug Busting
An alternative treatment method is Bug Busting.  This involves
washing  hair  with  shampoo,  applying  conditioner  thoroughly,
and  combing  hair  with  a  plastic  detection  comb.    The  hair  is
combed until no more lice are found.

Each treatment session takes about 30 minutes, and has to be
repeated every 3 to 4 days for a minimum of 2 weeks.  At least
three combing sessions are needed after the last adult louse is
found.  Bug Buster kits are available from pharmacies.

4.7.3 WORMS: A QUICK GUIDE

Wuchereria bancrofti (bancroftian filariasis)

Filariasis
Brugia malayi (Malayan filariasis)

Loa loa (loiasis)
Onchocerca
volvulus
(onchocerciasis-river
blindness)

Drancunculiasis
Drancunculus medinensis (guinea worm)

Toxocariasis
Toxocara canis or T.cati

(visceral/ocular larva migrans)

Trichinosis
Trichinella spiralis
Nematode

(trichinellosis)
(roundworms)

Enterobiasis
Enterobius vermicularis (threadworm)

Ancylostoma duodenale (hookworm anaemia)

Hookworm
Ancylostoma brazilienese or A. caninum

(cutaneous larva migrans-creeping eruption)

Necator americanus (hookworm anaemia)

Trichuriasis
Trichuris trichiura

Ascariasis
Ascaris lumbricoides (roundworm)

Strongyloidiasis
Strongyloides stercoralis

Schistosoma mansoni

Schistosomiasis
Schistosoma japonicum

(bilharziasis)
Schistosoma haematobium

Trematodes
Fascioliasis
Fasciola hepaitca (liver fluke)
(flukes)

Clonorchiasis
Clonorchis sinensis (oriental liver fluke)

Fasciolopsiasis
Fasciolopsis buski (intestinal fluke)

Taeniasis
Taenia saginata (beef tapeworm)

Taeniasis
Taenia solium (pork tapeworm) (cysticercosis)
Cestodes
(tapeworms)
Diphyllobothriasis
Dipphyllobothrium latum (fish tapeworm)

Hydatid disease:
Echinococcus granulosus
cystic

Hydatid disease:
Echinococcus multilocularis
Alveolar

Reference:Medicine vol 25:2 1997

4.7.4 FILARIASIS
What causes it?
The nematodes Wuchereria bancrofti, Brugia malayi, Brugia timori.

Where is it found?
It is endemic in most of the warm humid regions of the world: Latin America, Africa, Asia
and the Pacific Islands.

How do you get it?
It is transmitted by the bite of a mosquito that harbours infective larvae.

What are the symptoms?
They may be asymptomatic or present with recurrent fever, lymphadenitis, elephantiasis
of the limbs and pulmonary eosinophilia syndrome. They are long threadlike worms that
dwell in the lymphatic system.

How do you make the diagnosis?
It is diagnosed by the appearance of characteristic sheathed microfilariae on microscopic
examination of peripheral blood.  It usually takes three to six months before microfilariae
appear in the blood for B.malayi and 6 to 12 months in W.bancrofti.

Is it communicable?
It is not transmitted from person to person.

4.7.5 SCHISTOMIASIS OR BILHARZIA
What causes it?
The trematodes Schistosoma mansoni, S. haematobium and S.japonicum

Where is it found?
Africa,  Arabian  Peninsula,  Brazil,  Suriname,  Venezuela,  Middle  East,  China  and
Philippines.

How do you get it?
By an individual working, swimming or wading in water contaminated with free swimming
larval  forms  of  Schistosoma  (cercariae).   The  cercariae  develop  in  snails  but mature  in
the  human  lung  and  liver  by  entering  the  skin  and  then  bloodstream.    The  adult  forms
migrate and remain in the veins of the abdominal cavity.  Their eggs are deposited in the
venules, but may escape or lodge in other organs including the liver and the lungs.

What are the symptoms?
The symptoms depend on the number and location of the eggs in the human host.    For
S.Mansoni  and  S.japonicum  the  symptoms  include  diarrhoea  and  abdominal  pain.
S.Haematobium  usually  gives  urinary  symptoms  such  as  dysuria,  frequency  and
heamaturia at the end of micturition.

How do you make the diagnosis?
Demonstrating live eggs in urine, stools or in a biopsy specimen.

Is it communicable?
It is not communicable form person to person.

4.7.6 ASCARIASIS OR ROUNDWORM INFECTION
What causes it?

The nematode Ascaris lumbricoides

Where is it found?
It is a common infection worldwide with a high occurrence in tropical countries.

How do you get it?
By the ingestion of infective eggs of A. lumbricoides from soil contaminated with human
faeces or from uncooked produce contaminated with soil containing infective eggs.

Eggs  when  they  reach  the  soil  become  embryonated  (infective)  after  2  to  3  weeks
(summer temperatures) and may remain infective for several months or years.

The ingested infective eggs hatch in the gut lumen, and then the larvae penetrate the gut
wall to reach the lungs via the blood stream.  The larvae grow and develop in the lungs
passing  into  the  alveoli,  and  then  ascend  the  trachea  and  are  swallowed.    They  reach
the small intestine where they mature 14 to 20 days after the eggs have been ingested.

The usual life span of an adult worm is 12 months.

What are the symptoms?
Usually,  there  are  few  or  no  symptoms.    Live  worms  can  be  passed  in  the  stools  or
occasionally  from  the  mouth  or  nose.    Some  may  develop  lung  symptoms  caused  by
larval migration and characterised by wheezing, coughing, fever and blood eosinophilia.

How do you make the diagnosis?
Microscopic examination of faeces for eggs.

Is it communicable?
It is not directly communicable from person to person.

4.7.7  HOOKWORM INFECTION
What causes it?
The  nematode  Nector  americanus,  Ancylostoma  duodenale,  A  ceylanicum  and  A.
caninum.

Where is it found?
It is endemic in tropical and subtropical countries.  N.americanus is a common species
found in South East Asia, sub Saharan Africa and tropical America.

How do you get it?
Human infection occurs when the infective larvae penetrate the skin, usually the foot.

Under favourable conditions of moisture, temperature and soil type, larvae develop from
eggs deposited on the ground in faeces.  They become infective in 7 to 10 days.

The larvae of A. caniinum die within the skin having produced cutaneous larva migrans.

The other types of larvae enter the skin to the lung alveoli via the lymphatic system and
bloodstream.  They migrate up the trachea, are swallowed and reach the small intestine
where  they  attach  to  the  wall.    They  mature  after  6  to  7  weeks  and  then  produce
thousands of eggs a day.

What are the symptoms?
Larval  penetration  of  the  skin  can  lead  to  intense  local  itching  whilst  larval  migration to
the  lungs  can  lead  to  respiratory  symptoms  such  as  a  cough  and  tracheitis.    Larval

attachment to the gut wall is often asymptomatic, but in heavy infestations anaemia may
result.

How do you make the diagnosis?
By microscopic examination of stools for eggs.

Is it communicable?
It is not transmitted from person to person.
However, infected people may contaminate the soil for several years.

4.7.8  STRONGYLOIDIASIS
What causes it?
The nematode S.stercoralis

Where is it found?
It is widely distributed in the tropics but it can occur in temperate climates.

How do you get it?
Free  living  adults  produce  eggs,  rhabditiform  larvae  (noninfective)  and  filariform  larvae
(infective).
The filariform  larvae  can  directly  penetrate  the  skin to  enter  the  circulation  to  the  lungs
becoming adults in the intestinal tissues.
In some individuals, rhabditiform larvae may develop to the infective stage before leaving
the body and penetrate the intestinal mucosa and perianal skin.

What are the symptoms?
The  most  common  symptoms  are  a  rash  and  pruritus  at  the  larval  entry  site.    Larval
migration may cause symptoms such as pneumonitis and intestinal symptoms can occur
on maturation.  The intestinal symptoms comprise epigastric pain, diarrhoea, flatulence
and vomiting.

How do you make the diagnosis?
By identification of the larvae in stools.

Is it communicable?
As long as living worms remain in the intestine.

This page is intentionally left blank

4.8 MANAGEMENT OF CLOSTRIDIUM DIFFICILE POLICY

4.8.1  Introduction
Clostrium  difficile  (C.Difficile;  C.Diff)  is  a  spore-bearing  anaerobic  bacterium  that  is  a
major  cause  of  healthcare-associated  diarrhoea.    It  is  often  a  compilation  of  broad-
spectrum  antibiotic  therapy  and  is  particularly  associated  with  the  use  of  Clindamycin,
Ampicillin or Cephalosporins.

Clinical onset of Clostrium difficile associated with diarrhoea (CDAD) often occurs when
patients are on antibiotics or within four weeks of finished a course of antibiotics.

Antibiotic  prescribing  should  be  in  accordance  with  the  Trusts  prescribing  guidelines,
inappropriate  administration  of  broad-spectrum  antibiotics  should  be  avoided,  and
prescribing should be regularly monitored, with feedback to prescribers as appropriate.

Diarrhoea may be self-limiting in some cases.  Stools may be watery and/or bloody with
a  distinctive  foul  smell  and  green  or  yellowish-brown  appearance.    Patients  may  have
related  fluid  and  electrolyte  disturbance  and  a  low-grade  temperature.    In  some  cases
pseudo-membranous colitis may result, which can be fatal.

The risk of colonisation with Clostrium difficile increases with the proximity of an infected
person and the length of inpatient stay.  Patient groups at risk are surgical, renal, older
people  and  oncology.   The  incidence  increases significantly  in  patients  over  the  age of
fifty years.

Transmission of infection can occur owing to the large numbers of organisms shed by an
affected  patient  and  from  spores  that  can  survive  for  prolonged  periods  in  a  dry
environment.  Prevalence of infection tends to be higher in the winter.

All  cases  of  diarrhoea  (3  or  more  loose  stools  in  24  hours),  and  particularly  more  than
one  case  of  diarrhoea  on  a  unit  within  48  hours,  must  be  reported  to  the  Infection
Prevention & Control Team.

For more than one case of diarrhoea out of office hours, staff should contact the senior
manager on call who should contact the on call microbiologist.

The Consultant in Communicable Disease Control (CCDC) at the Health Protection Unit
should  be  called  on  to  investigate  and manage  outbreaks  of  diarrhoea  of  any  cause  in
independent care homes.

Any diarrhoea should be suspected of having an infective cause until proven otherwise.
Standard  infection  control  precautions  must  be  used  for  contact  with  faecal  matter,  in
particularly gloves and aprons must be worn and effective hand hygiene practiced.

4.8.2  Management of patients suspected of having Clostrium difficile associated
diarrhoea (CDAD)
Patients must not be admitted of transferred into any inpatient unit if they have had any
diarrhoea within the previous 48 hours.

The transferring hospital or unit must send a fax (signed by the nurse-in-charge) to the
PCT  unit  to  confirm  that  the  patient  has  not  had  diarrhoea  in  the  preceding  48  hours.
This should arrive on the PCT unit before the patient leaves the transferring unit.

If  a  patient  is  admitted  or  transferred  in  with  diarrhoea  e.g.  because  of  inaccurate
information  being  supplied  by  the  transferring  hospital,  an  incident  form  must  be
completed  and  the  Modern  Matron  and  Infection  Prevention&  Control  Team  must  be
notified.    Staff  must  make  every  effort  to  obtain  accurate  patient  information  from  the
transferring hospital to avoid this situation occurring.

Admission  of  a  patient  with  diarrhoea  on  to  an  open  ward,  or  to  a  double  room  in  a
nursing  home,  could  put  other  patients  at  risk  of  infection.    Therefore  the  points  above
must be strictly enforced in these areas.

Patients must not be transferred from ward to ward or from floor to floor within a unit if
they  have  diarrhoea,  unless  this  is  necessary  to  move  them  to  single  room
accommodation.    Movement  to  other  departments  must  be  restricted  and  only  on  the
advice of the Infection Prevention Control Team.

If a patient is suspected of having CDAD, follow these guidelines:-
•  Maintain  standard  and  contact  infection  control  precautions  and  use
soap  and  water  for  effective  hand  hygiene  as,  in  the  presence  of
bacterial spores, alcohol hand gel is less effective.  Wash hands after
any contact with the patient or their immediate environment.
•  Patients with diarrhoea should be isolated in a single, where possible,
en  suite  room.    Any  excess  equipment  should  be  removed  from  the
room before the patient is isolated.
•  Where isolation is not possible, due to a lack of single rooms, patients
may need to be transferred back to single room accommodation at the
hospital  or  unit  from  which  they  came.    Please  discuss  this  with  the
Infection Prevention & Control Team.
•  If the patient is incontinent, wear gloves and apron from contact with
faecal  matter  and  dispose  of  these  and  other  contaminated  material
as clinical waste.
•  Treat  contaminated  laundry  as  infectious  and  place  in  a  red  alginate
bag inside a clear outer laundry bag.
•  If  the  patient  is  mobile,  a  toilet  should  be  dedicated  for  his  or  her
personal  use,  if  this  is  feasible.    Alternatively  a  commode  should  be
designated for the use of a patient/patients with CDAD.
•  On units with affected patients, there may be significant contamination
with  Clostridium  difficile  on  toilets,  bedpans,  floors,  the  bed  area,
lockers, patient call buttons and the hands of personnel.  Spores can
survive for prolonged periods in the environment.  Therefore thorough
daily cleaning of equipment and the environment and disinfection with
chlorine-releasing solution (e.g. Presept 1,000 ppm) is essential.
•  Clean  and  disinfect  toilet/commode  seat,  commode  arm  rests  and
toilet flush lever after each use by a patient with CDAD.
•  Clean and disinfect frequently touched surfaces such as taps and door
handles at regular intervals (i.e. 6 times per day) during an outbreak of
CDAD.
•  Separate  cleaning  equipment  must  be  clearly  marked  and  used  for
isolation  rooms  and  toilets  used  by  patients  with  CDAD.    Disposable
cloths must be disposed of after each use.

Specimens  must  be  sent  to  the  laboratory  as  soon  as  possible.    A  diarrhoeal  sample
occupies  the  shape  of  its  container.    Non-diarrhoeal  stools  should  not  be  sent  for
Clostridium difficile screening.  For any patient with potentially infectious diarrhoea, send

a specimen of stool (five to ten millilitres) for ‘bacteriology, including Clostridium difficile
toxin testing,’ to the laboratory immediately following collection.

Collect  a  further  stool  specimen  from  the  same  episode  of  diarrhoea  for  virology
9electron  microscopy)  to  eliminate  other  infective  causes,  such  as  norovirus  and
rotavirus.

In consultation with medical staff, check the prescription chart and stop laxatives and iron
supplements  if  currently  prescribed.    Consider  the  use  of  Brewer’s  Yeast,  which  has
been  found  to  be  effective  in  alleviating  CDAD.    Dietary  changes  may  help  to  relieve
symptoms.

Request  that  medical  staff  review  antimicrobial  medication  (particularly  if  the  patient  is
receiving  broad-spectrum  antibiotics)  and  discontinue  antibiotics  if  clinically  indicated.
Discuss alternative treatment with Microbiology or the Pharmacist if necessary.

Anti-diarrhoeal  agents  should  be  avoided  if  Clostridium  difficile  is  suspected,  as  these
may aggravate colitis symptoms, which could lead to toxic megacolon.

Isolation of the patient may be discontinued when the patient has not had diarrhoea for
48 hours.  Transmission of Clostridium difficile to others does not occur in the absence of
diarrhoea  and  there  is  no  need  for  further  stool  samples  to  be  sent  for  toxin  testing.
However, it should be recognised that the stools may remain positive for the toxin some
time after resolution of symptoms.

After  the  patient  comes  out  of  isolation,  the  room  should  be  terminally  cleaned,  i.e.  all
surfaces  cleaned  with  hot  water  and  detergent,  following  by  disinfection  with  Presept
1,000 ppm and all curtains laundered.

Microbiology  and  Pharmacy  should  be  consulted  for  advance  on  further  antibiotic
treatment.

REFERENCES – Section 4.8
Department of Health
High  impact  intervention  no.  6:  reducing  the  risk  of  infection  from  and  the  presence  of
Clostridium difficile.
Saving  lives  –  a  delivery  programme  to  reduce  healthcare  Associated  Infection,  May
2006

Department of Health
Infection caused by Clostridium difficile.
Professional letter: PLCMO/PLCNO 2005

Department of Health
Surveillance of Clostridium difficile associated disease.
The Stationery Office, London 2005

Hawker J; Begg, N; Blair I; Reintjes R; Weinberg;
Communicable disease control handbook
Blackwell Science 2001

Healthcare Commission & Health Protection Agency
Management, prevention and surveillance of Clostridium difficile – interim findings from a
national survey of NHS acute trusts in England.
December 2005

Healthcare Commission
Investigation into outbreaks of Clostridium difficile at Stoke Mandeville Hospital
Buckinghamshire Hospitals NHS Trust July 2006

National Clostridium Difficile Standards Group
Report to the Department of health
The Stationery Office, London February 2003

Appendix 1 – Section 4.8
A simple guide to Clostridium difficile for staff

This guide explains that Clostridium difficile is, how it has developed and ways in which it
can cause infection.

Clostridium  difficile  is  the  major  cause  of  antibiotic-associated  diarrhoea  and  colitis,  a
healthcare  associated  intestinal  infection  that  most  affects  older  people  with  other
underlying diseases.

Background
Clostridium  difficile  is  a  bacterium  of  the  family  of  Clostridium  (the  family  also  includes
the  bacteria  that  cause  tetanus,  botulism  and  gas  gangrene).    It  is  an  anaerobic
bacterium (i.e. it does not grow in the presence of oxygen) and it produces spores that
can  survive  for  a  long  time  in  the  environment.    Its  usual  habitat  is  the  large  intestine,
where there is very little oxygen.  It can be found in low numbers in small proportion (less
than 5) of the health adult population.  It is kept in check by the normal ‘good’ bacteria of
the  intestine.    It  is  common  in  the  intestine  of  babies  and  in  fact  but  does  not  cause
disease  because  its  toxins  (*the  points  sit  produces),  do  not  damage  their  immature
intestinal cells.

Although Clostridium difficile was first described in the 1930’s, it was not identified as the
cause of diarrhoea and colitis following antibiotic therapy until the late 1970’s.

What does it cause?
Clostridium difficile can cause diarrhoea ranging from a mild disturbance to a very severe
illness  with  ulceration  and  bleeding  from  the  colon  (colitis)  and,  at  worst,  perforation  of
the intestine leading to peritonitis.  It can be fatal.

Generally  it  only  able  to  do  this  when  the  normal  healthy  intestinal  bacteria  have  been
killed off by antibiotics.  When not held back by the normal bacterial, it multiplies in the
intestine and produces two toxins (A & B) that damage the cells lining the intestine.  The
result is diarrhoea.

Who gets Clostridium difficile infection?
Patients who have been treated with broad spectrum antibiotics (those that affect a wide
range of bacteria, including intestinal bacteria) are at greatest risk of Clostridium difficile
disease.  Most of those affected are older people with serous underlying illnesses.  Most
infections  occur  in  hospitals  (including  community  hospitals)  and  nursing  homes,  but
infections can also occur in primary care settings.

How does it spread?
Although some people can be healthy carriers of Clostridium difficile, in most cases the
disease develops after cross infection from another patient, either through direct patient
to patient contact, via healthcare staff, or via a contaminated environment.  A patient who
has  Clostridium  difficile  diarrhoea  excretes  large  numbers  of  the  spores  in  their  liquid
faeces.    These  can  contaminate  the  general  environment  around  the  patient’s  bed
(including bed tables, lockers, call buttons, equipment), toilet areas, sluices, commodes
and bed pan washers.  Spores can survive for a long time and can be a source of hand-
to-mouth infection for others. If these others have also been given antibiotics, they are at
risk of Clostridium difficile disease.

How is it diagnosed?

A sample of diarrhoeal faeces is tested for the presence of the Clostridium difficile toxins
(A and B).  This is the main diagnostic test and gives a result within a few hours.

In  outbreaks,  or  for  surveillance  of  the  different  types  circulating  the  population,
Clostridium  difficile  can  be  cultured  from  faeces  (this  involves  the  local  laboratory
sending specimens on to the regional Health Protection Agency laboratory) the isolates
can  then  be  sent  on  to  the  anaerobe  reference  Laboratory  (National  Public  Health
Service,  Wales;  Microbiology,  Cardiff)  for  ribo  typing  and  testing  for  susceptibility  to
antibiotics.

How common is it?
When  Clostridium  difficile  was  first  recognised  as  the  cause  of  antibiotic-associated
diarrhoea and colitis in the late 1970’s, laboratory diagnosis was difficult and the number
of  cases  was  not  monitored.    Since  1990,  laboratories  have  reported  the  number  of
cases diagnosed to the Health Protection Agency in a voluntary system.  The number of
reports increased from less than 1,000 in the early 1990’s to 22,000 in 2002, 28,000 in
2003 and 44,488 in 2004.  Some of this increase was due to improved diagnostic tests
and  improved  reporting  by  laboratories,  but  there  has  clearly  been  a  very  significant
increase in the number of cases.

Since  January  2004  Clostridium  difficile  has  been  part  of  the  mandatory  surveillance
programme for healthcare associated infections in acute Trusts.

What is Type 007 and why is it of concern?
The typing system analyses part of the Clostridium difficile DNA (chromosome) in a test
called ribotyping.  Over 100 types have been identified.  Type 007 was  rare in the UK,
the first isolate was identified in 1999 and the second in 2002.  Individual isolates were
identified  in  2003-5.    When  outbreaks  at  Stoke  Mandeville  and  the  Royal  Devon  and
Exeter  Hospitals  were  investigated  in  2004-5,  Type  027  was  found  to  predominate  in
their cases.  The same type has caused a large outbreak of severe disease in hospitals
in  Canada  (Quebec)  and  north  eastern  USA  since  2000.    Type  027  produces  greater
quantities of the toxins than most other types of Clostridium difficile because a mutation
has  knocked  out  the  gene  that  normally  restricts  toxin  production.    It  causes  a  greater
proportion of severe disease and appears to have a high mortality.  It also seems to be
very capable of spreading between patients.

Prevention and control
Important components in the prevention and control of Clostridium difficile disease are:
•  Antibiotic prescribing policies to reduce the use of broad spectrum antibiotics
•  Isolation  of  patients  with  Clostridium  difficile  diarrhoea  and  enhanced  infection
control practice
•  Hand washing (not replying solely on alcohol gels as these do not kill the spores)
•  Wearing  gloves  and  aprons,  especially  when  dealing  with  bed  pans  and
commodes
•  Enhanced  environmental  cleaning  and  use  of  a  chlorine-releasing  disinfectant
where  there  are  cases  of  Clostridium  difficile  disease,  to  reduce  environmental
contamination with the spores.

Appendix 2 – Section 4.8
Information for patients and carers on Clostridium difficile

What is Clostridium difficile?
C.diff stands for Clostridium difficile, which is bacterium (germ).  Clostridium difficile lives
in the bowel of some people without causing any illness.

Why does Clostridium difficile make people ill?
Clostridium difficile makes people ill  when the germs increase in the bowel and start to
produce a toxin (poison) which causes diarrhoea.

Antibiotics  can  contribute  to  Clostridium  difficile  illness  as  they  kill  the  normal  ‘good’
bacteria that live in the bowel.  Clostridium difficile is resistant to these antibiotics so it is
able to increase in number and then produce the toxin, resulting in the infection.

What is the treatment?
How  we  treat  Clostridium  difficile  will  vary  from  one  person  to  another  because  every
patient is an individual case.  There are specific antibiotics that can be given to reduce
the number of Clostridium difficile germs in the bowel.  Whenever possible you will stop
taking the antibiotics that were originally prescribed.  This will give your bowel a chance
to recover and the normal protective bacteria will start to grow again.

Will I be isolated?
Clostridium  difficile  can  be  passed  from  one  person  to  another.    You  may  be  given  a
single room if one id available.  Alternatively you may need to be placed at one end of a
ward or in the same area as other patients with the infection, to make it easier to protect
those that not affected.

You  should  wash  your  hands  very  thoroughly  with  soap  and  water  after  using  the
lavatory and before any meals.  If you have any concerns about standards of cleanliness
on the ward or unit, please speak to the nurse in charge.

Are my visitors at risk?
No, not if they are in good health.  It is also safe for pregnant women to visit you.  Your
visitors  do  not  normally  need  to  wear  gloves  or  an  apron,  but  they  should  thoroughly
wash and dry their hands with soap and water before leaving your room or bed area.

Further information
Thank you for reading this leaflet.  We hope you have found it useful.  If you need any
further  information,  please  ask  the  nurse  or  doctor  who  is  attending  to  your  care.    If
necessary,  they  can  arrange  for  you  to  speak  to  one  of  the  Infection  Prevention  &
Control nurses.

SECTION 5 : OUTBREAKS

5.1 INTRODUCTION AND PURPOSE
This  is  a  clinical  policy  for  use  in  the  organisation’s  inpatient  services  within
Cambridgeshire Community Services. This document provides guidance on outbreak of
communicable diseases which would not engage the Major Outbreak Policy.

The  purpose  of  this  document  is  to  provide  clear  infection  control  guidelines  and  a
management process for the closure of an inpatient setting following the identification of
an  outbreak  of  transmissible  infection.    It  supplements  the  guidance  provided  in  the
Organisation’s Outbreak Plan/Policy.

5.2 DEFINITIONS
Outbreaks  of  infection  within  a  hospital  or  healthcare  setting  vary  greatly  in  extent  and
severity; ranging from a few cases restricted to a single ward or area to a hospital wide
outbreak  involving  many  services,  patients’  staff  and  visitors.    The  number  of  cases
required for a situation to be regarded as an outbreak varies according to the infectious
agent, severity of symptoms and number of cases in a given time, period and location.
National  Health  Protection  definitions  are  followed  by  the  Infection  Prevention  and
Control Team (IPCT).  The decision to classify a situation as an outbreak will be made by
the IPCT in consultation with the Director of Infection Prevention and Control (DIPC) and
the  Consultant  in  Communicable  Disease  Control  (  CCDC  Health  Protection  Agency).
The  IPCT  will  have  the  discretion  as  to  whether  or  not  to  instigate  an  outbreak  plan.
Individual ward closures can be initiated without the activation of an outbreak meeting.  If
the safe operation of the hospital is compromised then an outbreak meeting will be called
by the DIPC with expert advice from the consultant in Communicable Disease Control.

An outbreak is normally characterised by a cluster of similar infections occurring in one
area  of  the Trust  within  a  concentrated  period  of  time.   Total  or  partial  closure  may  be
necessary  to  prevent  transmission  if  significant  risks  to  patients  and  staff  are  identified
following a risk assessment.

5.2.1    Definition of Ward/Department Closure
A  closed  ward/department  is  unable  to  accept  new  admissions  or  inter
ward  transfers;  neither  can  it  discharge  patients to  other  health  or  social
care premises.

5.2.2  Major Outbreak
Full guidance on the management of a major incident can be found in the
organisation’s Major Outbreak Policy.

5.3 CLOSURE OF A WARD/DEPARTMENT
Where two or more patients are complaining of diarrhoea and vomiting, the IPCT should
be notified immediately during normal working hours. Out of hours the on call consultant
microbiologist  should  be  notified,  ensuring  that  the  IPCT    have  been  contacted  on  the
next working day.

The  IPCT  will  assess  the  situation.    Following  a  risk  assessment  the  final  decision  to
close a ward or department will be made by the IPCT.

5.3.1  If deemed necessary, the DIPC will convene an Outbreak Control Team meeting:

a)
Membership of Outbreak Control Team:
•
Infection Control Doctor (Consultant Microbiologist)
•
DIPC
•
Lead Nurse of Infection Prevention & Control
•
Consultant in Public Health (Health Protection)
•
Modern Matron
•
Medical Director
•
Communication Lead

b)
The following may also be present:
•
Occupational health Advisor
•
Catering Manager (if outbreak is food poisoning)
•
Other Trust Managers, depending on nature of outbreak
•
Director of Pharmacist Lead

c)
The remit of the Outbreak Control team will be to:
•
Discuss  the  situation  relating  to  the  outbreak  and  plan  the  appropriate
action
•
Ensure that the outbreak is reported to relevant public health bodies
•
Ensure that infection control measures are in place and are working
•
Monitor  that  adequate  additional  resources  are  available  i.e.
pharmaceutical supplies, cleaning, portering and laundry supplies
•
Monitor progress and arrangement of containment
•
Update the organisation’s board on developments
•
Provide infection control advice to health professionals and others
•
Provide briefing for staff and patients/visitors
•
Provide  relevant  information  to  the  Communication  Lead  in  the  event  of
press enquiries for the outbreak investigation
•
Review  the  outbreak  when  it  is  over  and  provide  a  final  report  with
recommendation to the CE

5.3.2  For  the  duration  of  any  period  of  closure  the  CE  will  be  regularly  informed  and
updated by the DIPC.

5.3.3  Guidance on caring for patients that require any additional or specific advice will
be provided by the IPCT.

5.3.4  Staff transfers both into and out of departments should cease unless agreed by
the MIPC.

5.4 REOPENING THE WARD
5.4.1  Ongoing  review  of  the  need  for  closure  will  be  undertaken  by  the  IPCT  and
reported  to  the  interested  parties  and  Outbreak  Control  Meetings  (where
appropriate).  The IPCT will recommend the re-opening of a ward as soon as it is
appropriate.

5.4.2  Once re-opening is sanctioned arrangements for terminal cleaning of the area will
be made by the ward/unit manager and undertaken in advance of the re-opening.

SECTION 6 - QUALITY ISSUES AND AUDIT TOOLS

6.1 STANDARD SETTING, AUDIT AND CLINICAL GOVERNANCE
The effective control of preventable infections has always been seen as an indicator of
the quality of care a patient may receive.  Elements incorporated into a quality assurance
framework  continue  to  sit  within  an  infection  control  strategic  plan.    Activities  such  as
standard  setting  and  audit  programmes  have  become  essential  components  of  an
infection control programme.  Clinical governance is now emerged as an umbrella term
of  all  these  quality  assurance  programmes.    Its  broad  aim  is  to  reassure  people  that
quality is the essence of healthcare at all levels of the organisation.

Accountability and responsibility for risk assessment and quality of care will be an issue
for all health professionals not just those involved in clinical activity.  Managers, including
Chief  Executives  of  NHS  Trusts,  have  a  clear  responsibility  for  their  risk  assessments
and the quality of the service they provide.

All practitioners will be expected to follow practices that are clinically safe, effective and
evidenced  based.    Particular  commitment  will  be  given  to  following  the  guidelines  and
recommended  practices  introduced  by  the  National  Institute  for  Health  and  Clinical
Excellence (NICE).

The  commissioning  PCT  will  monitor  performance  of  NHS  Trusts.    This  statutory  body
will offer support and advice to any NHS Trust that may be experiencing difficulties.

6.1.1  Clinical Governance
Clinical governance established the importance of canvassing the opinion of all service
users  particularly  patients/clients.    Users’  opinions  will  be  sought  and  valued.
Encouragement  of  service  users  becoming  involved  with  planning  the  future  NHS  will
become a key element in clinical governance.

Embodied  into  clinical  governance  is  the  commitment  to  life  long  learning  for  all
professionals, and a recognition of individual responsibility to identify learning needs and
maintain professional development.
Points to be considered when reviewing practice:

What systems are there in place?

What risk assessments are required?

Are the systems  effective?

Is there a need to review  activity?

There are elements of clinical governance that are familiar such as:

Standard setting.

Clinical audit.

Evidence based practice.

Risk management.

Life long learning.

Team building.

Peer review.

Clinical leadership.

There are also more unfamiliar elements of clinical governance such as:

Users involvement.

Clinical supervision.

Management of poor practice.

Reflective practice.

6.1.2  Infection Control Programmes
Infection control in all health care settings is gaining a higher profile.  In practice, large
numbers of patients are seen and the potential for cross infection is substantial if good
practice is not maintained.  It is essential to maintain public confidence by the production,
implementation and audit of robust policies and the documentation of  activities such as
sterilisation processes.

All action plans should commence with the setting of standards for infection control.  An
audit  tool  can  be  used  to  monitor  infection  control  practices  and  provide  data  on
compliance with policies within the primary setting.  This data has other uses, including
the  planning  of  educational  needs  or  evaluating  the  overall  effectiveness  of  infection
control programmes.

Following  an  audit  it  is  important  that  all  relevant  staff  are  given  the  opportunity  to
discuss the findings.  Urgent problems identified in the audit would have to be addressed
at that time.

A  report  should  be  written  that  highlights  areas  of  good  practice  as  well  as  those  of
concern,  along  with  recommendations  and  time  scales  for  the  recommendations  to  be
put into practice.

Re-audit of the area will ensure that recommendations have been accepted.
REFERENCES – Section 6.1
Griffiths-Jones  A  (1999)  Clinical  Governance  –  Infection  Control  British  Journal  of
Infection Control p20 May 1999

Infection  Control  Nurses  Association  (1998)  ‘Community  Infection  Control  Audit  Pack’.
April 1998, reprinted June 1999 and February 2000.  Edgbaston Birmingham

Document Outline