B.1.1. Hand hygiene

Hand hygiene is one of the most important measures to prevent and control spread of disease in health-care facilities, and is a major component of Standard Precautions (215). Although hand hygiene is a simple procedure, numerous studies have shown that compliance is low. Its implementation is complex, requiring continued reinforcement and multidisciplinary team coordination. The use of alcohol-based hand rubs in health-care facilities has been implemented in recent years, in an attempt to increase compliance with hand hygiene. The main points are as follows:

• If hands are not visibly soiled, hand hygiene should be done using an alcohol-based hand rub, or by washing hands with soap and water, and drying them using a single-use towel.
• If hands are visibly dirty or soiled with blood or other body fluids, or if broken skin might have been exposed to potentially infectious material, hands should be washed thoroughly with soap and water.

Perform hand hygiene:

• before and after any direct contact with patients;
• immediately after removal of gloves;
• before handling an invasive device not requiring a surgical procedure, including central intravascular catheters, urinary catheters or peripheral vascular catheters;
• after touching blood, body fluids, secretions, excretions, non-intact skin or contaminated items, even if gloves are worn;
• when moving from a contaminated to a clean body site on the same patient;
• after contact with inanimate objects in the immediate vicinity of the patient; and
• after using the lavatory.

For additional information on hand hygiene, see:

• WHO guidelines on hand hygiene in health care, 2009 (215).

B.1.2. Selection of personal protective equipment based on risk assessment

• Routinely assess the risk of exposure to body substances or contaminated surfaces before any anticipated health-care activity.
• Select PPE based on the assessment of risk.
• Ensure that appropriate PPE is available at all times, so that it can be used in the event of an unexpected emergency.

B.1.3. Respiratory hygiene

Controlling the spread of pathogens from infected patients (source control) is key to avoiding transmission to unprotected contacts. For diseases transmitted through large droplets or droplet nuclei, respiratory hygiene should be applied by all individuals with respiratory symptoms (90). Respiratory hygiene refers to covering the mouth and nose during coughing or sneezing using medical masks (Annex A, Section A.2.2), cloth masks, tissues or flexed elbow, followed by hand hygiene to reduce the dispersal of respiratory secretions containing potentially infectious particles.

Health-care facility management should promote respiratory hygiene as follows:

• Promote the use of respiratory hygiene by all health-care workers, patients and family members with ARIs.
• Educate health-care workers, patients, family members and visitors on the importance of containing respiratory aerosols and secretions to help prevent the transmission of ARI pathogens.
• Consider providing resources for hand hygiene (e.g. dispensers of alcohol-based hand rubs and handwashing supplies) and respiratory hygiene (e.g. tissues); prioritize areas of gathering, such as waiting rooms.

B.1.4. Environmental controls: cleaning and disinfection

The viruses and bacteria that cause ARIs can survive in the environment for variable periods of time (hours to days). The bioburden of such microorganisms can be reduced by cleaning, and infectious agents can be inactivated by the use of standard hospital disinfectants. Environmental cleaning and disinfection is intended to remove pathogens or significantly reduce their numbers on contaminated surfaces and items, thus breaking the chain of transmission. Disinfection is a physical or chemical means of killing microorganisms (but not spores), and should be used for non-critical medical equipment used or shared by patients.

• No disinfection is required for surfaces and equipment that do not come into direct contact with patients. These surfaces or equipment should be thoroughly cleaned between patients.
• Clean equipment or surfaces in a way that avoids possible generation of aerosols; this process alone significantly reduces the bioburden of microorganisms.
• When disinfection is required, ensure that cleaning is done before disinfection. Items and surfaces cannot be disinfected if they are not first cleaned of organic matter (e.g. patient excretions, secretions, dirt and soil).
• Follow the manufacturer's recommendations for use or dilution, contact time and handling of disinfectants.
• The viruses and bacteria that cause ARIs are inactivated by a range of disinfectants (99, 216-220). However, in some countries, regulatory agencies will control the types of disinfectant available for hospital use. Common hospital disinfectants include:

  –

  sodium hypochlorite (household bleach);

  –

  alcohol;

  –

  phenolic compounds;

  –

  quaternary ammonium compounds; and

  –

  peroxygen compounds.

• Sodium hypochlorite and alcohol are available in most countries. The use of these two disinfectants is detailed in Annex G.

B.1.5. Waste management

Waste disposal should be safe for those handling the waste and for the environment. Definitions of clinical (infectious) waste may differ according to local regulations and legislation.

• Classify waste as directed by relevant state, territory or national legislation and regulations. If waste from ARI-infected patients is classified as infectious, then consider all waste from the patient-care area as clinical waste, and treat and dispose of it according to the health-care facility's policy, and in accordance with national regulations pertaining to such waste (8).
• Handle faeces with caution to avoid possible generation of aerosols (e.g. during removal of faeces from bedpan, commode or clothing, or when spraying reusable incontinence pads with water) (233).
• Flush liquid waste (e.g. urine) or solid faecal waste into the sewerage system, if there is an adequate system in place (239, 240).
• Ensure that health-care workers use appropriate PPE whenever there is risk of splash or spray during handling of waste (95).

B.1.6. Packing and transporting patient-care equipment, linen and laundry, and waste from isolation areas

• Place used equipment and soiled linen and waste directly into containers or bags in the isolation room or area.
• Contain the used equipment and soiled linen and waste in a manner that prevents the containers or bags from opening or bursting during transport.
• One layer of packing is adequate, provided that the used equipment and soiled linen and waste can be placed in the bag without contaminating the outside of the bag. Double-bagging is unnecessary.
• Ensure that all personnel handling the used equipment and soiled linen and waste use Standard Precautions, and perform hand hygiene after removing PPE. Heavy-duty tasks (e.g. cleaning of the environment) require more resistant PPE (e.g. rubber gloves and apron, and resistant closed shoes).

B.1.7. Prevention of needle-stick or sharps injuries

Although it may not be crucial for prevention and control of ARIs, prevention of needle-stick or sharp injuries is a component of Standard Precautions. It targets the reduction and elimination of transmission of bloodborne pathogens to health-care workers, other patients and people with any possible contact with the related waste.¹

• Take care to prevent injuries when using needles, scalpels and other sharp instruments or devices when handling sharp instruments after procedures, when cleaning used instruments and when disposing of used needles.
• Never recap used needles.
• Never direct the point of a needle towards any part of the body except before injection.
• Do not remove used needles from disposable syringes by hand, and do not bend, break or otherwise manipulate used needles by hand.
• Dispose of syringes, needles, scalpel blades and other sharp items in appropriate puncture-resistant containers. Such containers should be located as close as practicable to the area in which the items were used.
• Avoid the use of reusable syringes.

Personal protective equipment

When entering the isolation room or area, or when providing care to a patient with an obligate or preferential airborne infectious disease in other settings, use a particulate respirator that is at least as protective as a NIOSH-certified N95 or equivalent (Annex A).

Patient placement

• Place the patient in an Airborne Precaution room (3).
• If a ventilated isolation room is not available, place patients in separate well-ventilated rooms.
• If single rooms are not available, cohort patients according to the same etiological diagnosis in well-ventilated places.
• To perform any aerosol-generating procedures associated with pathogen transmission, use appropriate PPE in an Airborne Precaution room.

Patient transport

• Limit patient movement and ensure that patients wear medical masks when outside their room or area.

Personal protective equipment

• At a minimum, use a medical mask (surgical or procedure mask) if working at a distance of less than 1 m from the patient (247-249).
• When performing aerosol-generating procedures associated with pathogen transmission, use a particulate respirator that is at least as protective as a NIOSH-certified N95, EU FFP2 or equivalent, and wear gloves, gowns and eye protection (e.g. goggles) (86, 120, 250).

Patient placement

• Use adequately ventilated rooms. Group patients according to the laboratory-confirmed etiological diagnosis (cohorting) or suspected diagnosis (special measures) (31, 148). If more than one patient is housed in a room, place patients so that they are at least 1 m apart.
• Airborne Precaution rooms are not obligatory. If they are available, prioritize them for patients with airborne-transmitted diseases (31, 148).
• To perform aerosol-generating procedures associated with increased risk of pathogen transmission, use adequately ventilated single rooms (101, 102, 153, 251).

Patient transport

• Limit the movement of patients and ensure that they wear medical masks when outside their room or area.