TABLE OF CONTENTS - Ottawa Inner City Health · Web viewSharps such as needles, blood syringes, lancets, or clinical glass—should be disposed of in a biohazard container and disposed

Shaping our future togetherwww.ottawa.ca

AHealth Education Resource

forINFECTION CONTROL

in Sheltersand

Drop-In CentresFor use by service providers

Developed by:The City of Ottawa

People Services Department, Public Health and Long Term Care BranchChronic Disease and Injury Prevention Division

Street Health Program

February 2002

First Edition

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For Information about Infection Control,or

to Report a Communicable Disease,Please Call:

The City of OttawaCommunicable Disease Control Program:

724-4224

Evenings, weekends, and holidays:Medical Officer of Health

on call580-2400

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TABLE OF CONTENTSTABLE OF CONTENTS

Page

INTRODUCTION.................................................................................................................................1

1) RECOMMENDATIONS FOR SERVICE PROVIDERS..............................................................2Immunizations...............................................................................................................................3Tuberculosis Screening for Employees and Volunteers in Shelters and Drop-In Centres.................4Policy: TB Screening for Employees and Volunteers in Shelters and Drop-In Centres....................5Needlestick Injury / Accidental Exposure Protocol Chart...............................................................6

2) CHAIN OF INFECTION...............................................................................................................7Modes of Transmission of Microorganisms....................................................................................9Precautions to Prevent Transmissions of Microorganisms............................................................10

3) ROUTINE PRACTICES..............................................................................................................12Hand Washing.............................................................................................................................14Gloves.........................................................................................................................................20Gowns.........................................................................................................................................21Masks and Eye Protection............................................................................................................22Cleaning and Disinfecting Client Care Equipment........................................................................23

Major Classes of Chemical Disinfectants and Relative Advantages and Disadvantages........25 Directions for Household Bleach Preparation......................................................................27

Housekeeping..............................................................................................................................28 Cleaning Procedures for Common Items.............................................................................29 Cleaning Blood Spills.........................................................................................................31

Laundry.......................................................................................................................................32Managing Untreated Waste (Blood & Body Fluid Waste / Gloves & Dressings / Sharps).............34

4) GUIDELINES FOR COMMUNICABLE DISEASE AND OTHER HEALTH ISSUES...........35Methicillin-Resistant Staphylococcus Aureus (MRSA)................................................................36Vancomycin-Resistant Enterococci (VRE)...................................................................................40Summary Table: Guidelines for Communicable Disease and Other Health Related Issues in Shelters and Drop-In Centres.......................................................................................................45Report of Designated Communicable Diseases to the Medical Officer of Health (MOH)(list of Reportable Communicable Diseases and the Reporting Form)...........................................64

5) ADDITIONAL INFORMATION Hepatitis B, Hepatitis C, HIV, Head Lice, Scabies, TuberculosisHealth Facts, Positive Skin Test; TB Booklet—What I Need to Know; What to Do With Used Needles; Be Careful With Needles!......65

Resources....................................................................................................................................66Appendices..................................................................................................................................67

Appendix I — Table 6: Transmission Characteristics and Empiric Precautions by Clinical Presentations:Recommendations for Acute Care CentresAppendix II — Table 7: Transmission Characteristics and Precautions by Specific Etiology:Recommendations for Acute Care Centres

Glossary Of Terms.......................................................................................................................68References...................................................................................................................................72

(Dec. 2001) A Health Education Resource for Infection Control in Shelters & Drop-In Centres

INTRODUCTIONINTRODUCTION

PURPOSEThe Health Education Resource for Infection Control in Shelters and Drop-In Centres is a practical guide to assist service providers in preventing the transmission of infection, while protecting him or herself from exposure to infection.

This resource for Infection Control in Shelters and Drop-In Centres can be used to develop guidelines for local use — taking into consideration conditions within the shelters, risk of infections, type of care provided, and the personnel providing the care.

This resource should help set a standard for infection control within the individual shelters and enhance communication across shelters. This resource is a compilation of information from mainly Health Canada and the City of Ottawa’s Public Health Branch; and has been reviewed by the City of Ottawa’s Associate Medical Officer of Health— Health Protection Division.

BACKGROUNDThe Ottawa Inner City Health Project, sponsored by the University of Ottawa, received federal government SCPI (Supporting Communities Partnerships Initiative) funding in March 2001, to provide health care to the chronically homeless at three residential sites: The Home Hospice at the Mission, the Special Care Unit at the Salvation Army, and the Management of Alcohol Program at the Shepherds of Good Hope. In addition, services are available to women at Cornerstone — a women’s emergency shelter.

Community health practitioners from organizations such as Victorian Order of Nurses, Community Care Access Centre, community health centers, Department of Medicine at the University of Ottawa, and the City of Ottawa—Public Health Branch (Street Health Program), will work collaboratively with service providers to facilitate a coordinated health care service for these clients.

FORMATThis Health Education Resource for Infection Control in Shelters and Drop-In Centres has been organized into five components:

1) Recommendations for Service Providers

2) Chain of Infection

3) Routine Practices

4) Guidelines for Communicable Diseases and Other Health Issues

5) Additional Resources, Appendices and Glossary of Terms

The information and additional resources contained in this resource should help service providers develop and/or reinforce an understanding of infection control, and offer knowledge to provide care.

(Dec. 2001) A Health Education Resource for Infection Control in Shelters & Drop-In Centres 1

A HEALTH EDUCATION RESOURCE FOR INFECTION CONTROLA HEALTH EDUCATION RESOURCE FOR INFECTION CONTROLIN SHELTERS AND DROP-IN CENTRESIN SHELTERS AND DROP-IN CENTRES

Recommendationsfor

Service Providers

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2

RECOMMENDATIONS FOR SERVICE PROVIDERSRECOMMENDATIONS FOR SERVICE PROVIDERS

IMMUNIZATIONS

VACCINES INDICATIONS

Measles: One dose for those born in 1957 or later, with no documented proof of disease, vaccination after 1st birthday or serologic immunity.

Mumps: One dose. No documented proof of vaccination after 1st birthday or serologic immunity.

Rubella: One dose for those born in 1957 or later with no documented proof of disease, vaccination after 1st birthday or serologic immunity.

Measles, mumps and rubella vaccines may be given as one vaccine: MMR.There is no harm in giving MMR to a person who has previously had one of these diseases, or vaccines:

Tetanus and Diphtheria: Every 10 years as Td.

Poliomyelitis: Persons who have not been given a full primary course should have the series with IPV regardless of the interval since the last dose.Booster doses of IPV are not required for health care workers in Canada.

Hepatitis B: Three-dose course. Post-vaccination testing for anti-HBs should be performed between one and six months after completion of series.

Influenza: Annual immunization for all service providers.

Note: all immunizations, hepatitis B serology results, and TB mantoux skin test results, should be on a yellow immunization card to be retained by the employee.

Health Canada (1998). Canadian Immunization Guide. (5th Edition). Ottawa, ON: Canadian Medical Association, 54-57.

City of Ottawa, Public Health and Long Term Care Branch, Health Protection Division, Communicable Disease Program (2000). A Health Education Resource for Designated Officers of Emergency Services. (2nd Edition). Ottawa, ON: City of Ottawa, Communicable Disease

Program.



TUBERCULOSIS (TB) SCREENING FOR EMPLOYEES AND VOLUNTEERSIN SHELTERS AND DROP-IN CENTRES

BACKGROUNDTuberculosis is a disease often called TB, which is spread by tiny bacterial germs that can float in the air. The TB germs may spray into the air if a person with TB disease coughs, shouts or sneezes. The people nearby can breathe TB germs into their lungs and get TB infection.

Most people with TB infection will not get sick or spread TB to others. Some people will get sick and have TB disease.

TB disease usually attacks the lungs, but sometimes it attacks the kidneys, brain or spine. People who have TB disease need medical care because they could die. They can also spread TB to other people.

Tuberculosis—a reportable communicable disease, is well managed in the City of Ottawa, but is still present—over the past 15 years, there have been about 40-90 cases of TB per year. In someone who has HIV infection, the risk of TB infection (not ill, & not contagious) progressing into TB disease increases dramatically.

People who are at risk of developing TB include: Those infected with HIV; Those with risk factors for HIV infection; Aboriginal Canadians who have lived in communities with a high rate of TB; Clients of socially and economically depressed inner city areas; Injection drug users; Alcoholics; Persons from countries with a high prevalence of TB; People with medical conditions that increase the risk of TB disease (e.g. silicosis, gastrectomy,

diabetes, end-stage renal disease, immunosuppressive therapy, prolonged steroid therapy, lymphomas, etc.);

Those employed under circumstances where a higher than average risk exists for acquiring TB; and Staff and clients of long-term institutions.

RATIONALE FOR TUBERCULOSIS SCREENINGThe City of Ottawa, Public Health recommends that your organization requires all employees and volunteers to be assessed for the presence of TB infection or disease for the following 3 reasons: Provides a good baseline result in the event of a future exposure to someone with TB disease.

Any positive test after a negative baseline test, means that you are newly infected; Identifies those who have TB infection; and Identifies the rare case of TB disease among employees and/or volunteers.

Ontario Ministry of Health (1995). Health Facts TB Infection /TB Disease. 100M/12/95 CAT# 4129492, Toronto, ON: Queens Printer for Ontario.

City of Ottawa, Public Health and Long Term Care Branch, Health Protection Division, Communicable Disease Program (1997). Tuberculosis Screening and Contact Management: Recommendations and Notes. Ottawa, ON, City of Ottawa, Communicable Disease Program.



POLICY — TB SCREENING FOR EMPLOYEES AND VOLUNTEERSIN SHELTERS AND DROP-IN CENTRES

All staff and volunteers are to be screened for tuberculosis within 4 weeks of start of employment and/or volunteering.

Individuals whose Mantoux TB skin test status is unknown, and those previously identified as negative Mantoux TB skin test, require a baseline two-step Mantoux TB skin test.

Individuals, who have documentation of a negative test during the preceding 12 months, require a single-step test.

Two-step testing means that if your first Mantoux TB skin test is negative, you need a second test1-4 weeks later.

Individuals with a previously positive Mantoux TB skin test, require a chest x-ray to rule out active TB, unless they have had a chest x-ray within the preceding 12 months.

Many individuals with a positive Mantoux TB skin test, indicating a latent TB infection, will benefit from preventive antibiotic treatment, to prevent future TB disease.

Individuals with TB disease must be treated. Employers must maintain a list of all employees and volunteers, with the date of the

Mantoux TB skin test or chest x-ray. The employer is not responsible for reviewing results or follow-up.

TB skin test and or chest x-ray result and date are to be recorded on a yellow immunization card.

SUGGESTED LOCATIONS FOR TUBERCULOSIS SCREENING Ask employees and volunteers to make an appointment with their family physician; or Employer makes arrangements with a health care facility, e.g. health clinics.

Note: Some family physicians may charge a fee for the Mantoux TB skin test.

TUBERCULOSIS FACT SHEETS RE: TUBERCULOSIS AND POSITIVE SKIN TEST Located in the “Fact Sheets” section of this resource

Ontario Ministry of Health (1998). Tuberculosis Control Protocol, Ministry of Health, Public Health Branch, Mandatory Health Programs Service Guidelines. Toronto, ON: Queens Printer for Ontario.

City of Ottawa, Public Health and Long Term Care Branch, Health Protection Division, Communicable Disease Program (2001). Policy for Tuberculosis Screening in Shelters and Drop-In Centres. Ottawa, ON: City of Ottawa, Communicable Disease Program.



NEEDLESTICK INJURY/ACCIDENTAL EXPOSURE NEEDLESTICK INJURY/ACCIDENTAL EXPOSURE PROTOCOL CHARTPROTOCOL CHARTfor use in shelters and drop-in centresfor use in shelters and drop-in centres

Manage exposure using described first aid care and infection control guidelines for cleaning,

disinfecting and waste management. Allow injured areas to bleed freely. Remove clothing that is contaminated with body fluids. Thoroughly flush exposed area with water or sterile saline. Clean area with soap and water and dry injured area. Apply antiseptic to wound.

Employee notifies supervisor or delegate

Supervisor or delegate completes the required report as per individual agency

Employee Proceed immediately for risk assessment, to the emergency

department of the Ottawa Hospital (Civic or General campus), Montfort Hospital, or Queensway-Carleton Hospital.

Source Client Supervisor or delegate will attempt to obtain client

consent for testing. Client will be sent to the closest hospital for testing.

Call ahead to notify ER triage nurse that client is coming. Request source be tested for HIV, Hepatitis B&C and to send blood STAT to the Public Health Lab.

Hospital staff will: Assess risk and suggest appropriate base line blood test. Post exposure vaccine or medication will be offered to

employee.

Hospital staff will Test source client.

RESPONSIBILITIES

Supervisor (or delegate) To supply safety equipment and guidelines. To encourage employees to be immunized. To identify safety hazards and address them. To obtain source client consent if necessary. To immediately refer employees for occupational exposure

management. To arrange for transportation of employee and/or source

client if necessary. To complete appropriate reports (Incident/Accidental Injury).

Employee To utilize safety equipment. To take appropriate precautions to prevent occupational

exposures. To immediately report an incident to the supervisor or

delegate. To complete required program incident report

(if applicable).

HOSPITALS AND EMERGENCY ROOM TELEPHONE NUMBERSMontfort Hospital: 748-4908Ottawa Hospital, Civic Campus: 761-4621Ottawa Hospital, General Campus: 737-8000Queensway-Carleton Hospital: 721-4710

City of Ottawa. Public Health and Long Term Care Branch. Health Protection Division. Communicable Disease Program (2001).Needlestick Injury/Accidental Exposure Protocol Chart for use in Shelters and Drop-In Centres. Ottawa, ON: City of Ottawa, Communicable Disease Program.



Chain of Infection

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7

CHAIN OF INFECTIONCHAIN OF INFECTION

MICROORGANISMS are organisms that are not visible to the naked eye. They are found in food, soil, air, on and in humans and animals. Most organisms are harmless but some can cause infection or disease. For infection to occur, the organism must enter the body, grow and multiply, thus causing a local or systemic infection. The body’s defenses such as healthy skin and mucous membranes, healthy immune system, proper nutrition, adequate sleep, good hygiene, and routine preventive practices help to avoid infection.

CHAIN OF INFECTION:

Agent: is the infectious microorganism which causes infection or disease.Examples of agents are:

virus, e.g. HIV or hepatitis B or C; bacteria, e.g. tuberculosis, neisseria meningitidis; fungus, e.g. candida; and larger parasites, e.g. lice.

Susceptible Host: the person getting the pathogen (infection) due to the invasion and multiplication of the microorganism in the body.

Portal of Entry: is the point where the agent enters the host’s body.

Reservoir: is the place where the agent lives and multiplies—either on a person, in body fluids or in/on items.

Portal of Exit: is the point where the agent exits the body (e.g. draining lesions, cough).

Health Canada (1999). Infection Control Guidelines: Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Health Care. Canadian Communicable Disease Report. Ottawa, ON: Health Canada, 1-83.


Susceptiblehost

Agent

Mode oftransmission

Portal ofexit

Portal ofentry

ReservoirSusceptiblehost

Agent

Mode oftransmission

Portal ofexit

Portal ofentry

Reservoir


MODES OF TRANSMISSION OF MICROORGANISMS…refers to how the agent travels to the host. There are four routes of transmission:Contact (direct, indirect, droplets); Airborne; Vehicle; and Vectorborne.

CONTACT TRANSMISSION

Direct Contact occurs with skin-to-skin contact between the infected or colonized person and the host. Contact

precautions should be taken with those who have diarrhea with unknown cause, major burn wound infections, extensive skin disorder with infection or colonization, skin rashes, draining infected wounds or abscesses, or antimicrobial-resistant organisms. Contact and droplet precautions should be taken for viral respiratory tract infections.

Indirect Contact involves passive transfer of microorganisms to a host by an object or surface that was

contaminated by an infected person. Strict cleaning measures are necessary to avoid transmitting organisms to the client from contaminated objects or equipment.

Droplet Transmission are large droplets generated by the infected person when he/she coughs, sneezes or talks.

The droplets are projected in the air a short distance and deposited on the nose, eyes, or mouth mucosa of the new host. Examples of infections transmitted by droplets include respiratory tract infections such as pneumonia, meningitis, streptococcus A and influenza.




MODES OF TRANSMISSION OF MICROORGANISMS

Airborne Transmission refers to very small droplets that are generated by the infected person when he/she talks, coughs or

sneezes. These droplets stay suspended in the air and travel through air currents that are inhaled by the new host. Tuberculosis is an example where precautions should be used to prevent transmission of this highly infectious disease.

Common Vehicle Transmission refers to a single contaminated source such as food, water or equipment, which serves to transmit

infection to multiple hosts.

Vectorborne Transmission refers to transmission by infected insects or animals, which transmit the agent to the host, e.g., rabies.

PRECAUTIONS TO PREVENT TRANSMISSION OF MICROORGANISMS Contact Precautions include: Washing hands; wearing gloves; wearing gowns if there is a risk of

splashing or spraying; and cleaning client-care equipment. Droplet Precautions include: Washing hands; wearing masks for diagnosed infectious diseases; and

cleaning client-care equipment. Airborne Precautions include: Washing hands; wearing mask for diagnosed infectious diseases;

and cleaning client-care equipment.

For specific precautions related to Clinical Presentation and Specific Etiology refer toAppendices I & II: TABLE 6 : Transmission Characteristics and Empiric Precautions by Clinical Presentation:

Recommendations for Acute Care Centres

TABLE 7 : Transmission Characteristics and Precautions by Specific Etiology: Recommendations for Acute Care Centres




Risk of transmission of microorganisms between clients involves factors related to the microbe, the source client, the client-care environment, and the new host. (Table 1)

TABLE 1: RISK FACTORS FOR TRANSMISSION AND DISEASE AFTER EXPOSURE TOINFECTED OR COLONIZED SOURCE CLIENT

HIGHER Risk of Transmission LOWER Risk of Transmission

SOUR

CE C

LIEN

T Incontinent of stool; stool not contained by diapers Diarrhea Draining skin lesions or wounds not covered by dressings Copious uncontrolled respiratory secretions Client requiring extensive hands-on care Client has invasive devices Poor compliance with hygienic practices and infection

control precautions (e.g. confused client)

Continent Good hygiene Skin lesions or wounds covered by

dressings Able to control respiratory secretions Capable of self-care Able to comply with infection control

precautions

MIC

ROOR

GANI

SM

Able to survive in the environment(e.g. VRE, C.difficile, rotavirus)

Presence of large inoculum Low infective dose (e.g. Shigella) High pathonenicity, high virulence Airborne Spread by contact Able to colonize invasive devices Propensity for asymptomatic/carrier state

Unable to survive long in the environment

Presence of low inoculum High infective dose

(e.g. Salmonella) Low pathogenicity, low virulence Short period of infectivity

ENVI

RONM

ENT Inadequate housekeeping

Shared patient care equipment without cleaning between clients (e.g. thermometer bases, commodes)

Crowded facilities Shared facilities (e.g. toilets, bath, sinks) High patient-nurse ratio Absence of negative pressure rooms (if airborne)

Appropriate housekeeping Dedicated equipment Adequate spacing between beds Own bathroom facilities Low patient-nurse ratio

HOST

PAT

IENT

Patient in intensive care unit or requiring extensive hands-on care

Patient has invasive procedures or devices Non-intact skin Debilitated, severe underlying disease Extremes of age Recent antibiotic therapy Immunosuppression

Able to do self care No indwelling devices Intact skin and mucous membranes Strong immune system




Routine Practices

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ROUTINE PRACTICESROUTINE PRACTICES

ROUTINE PRACTICES:Formerly known as Universal Precautions, is a system of practice where service providers assume that all clients are considered to be carriers of infectious pathogens. The shelter population is becoming increasingly immunocompromised and at greater risk for infection. Some persons may have symptoms of infection and others may not. It is recommended that all service providers handle blood and body substances as if infected with pathogens. Precautions should be taken when handling blood and body fluids—including secretions and excretions, and drainage from open wounds.

Blood and certain body fluids can be infected and transmit blood-borne pathogens such as HIV, hepatitis B and C. Body substance precautions imply that all body substances may be infectious. These precautions apply to blood, semen, vaginal secretions, and saliva for hepatitis B and C and HIV—if contaminated with blood. Saliva can be contaminated with hepatitis B even though blood is not present. Body substances such as feces, nasal secretions, sputum, tears, urine and vomitus are not implicated in the transmission of HIV, hepatitis B and C unless visibly contaminated with blood.

Risks of exposure to infection can be greatly reduced if the following interventions are in place: Keep immunization up-to-date—immunizations reduce the chances of becoming infected with

certain diseases; Wash your hands—hand washing is the single most important measure for preventing infection; Use disposable gloves when in contact with blood, body fluids, secretions and excretions, and non-

intact skin and mucous membranes; Wash hands after removing gloves—gloves do not replace hand washing; Wear masks and protective eyewear when there is a risk of contamination to mucous membranes

from splashing or spraying (eyes, nose, mouth); Encourage clients to wash hands regularly; Do not eat, drink, smoke, apply cosmetics or lip balm, or handle contact lenses in a situation/

environment where there is potential for exposure; Comply with guidelines on cleaning and disinfection; Ensure used needles are disposed of in a biohazard container.


College of Nurses of Ontario (2000). Infection Control Guidelines. Toronto, ON, College of Nurses of Ontario, 3-10.

(The) College of Physicians and Surgeons of Ontario (1999). Infection Control in the Physicians’ Office.Toronto, ON. the College of Physicians and Surgeons of Ontario, 1-41.

A Health Education Resource for Infection Control in Shelters & Drop-In Centres 13


HAND WASHINGDisease-causing microorganisms can frequently be isolated from the hands. Hand carriage of bacteria is an important route of transmission of infection between clients or from the health care worker to the client. Guidelines from national and international infection prevention and control organizations have repeatedly acknowledged that, hand washing is the single most important procedure for preventing infections.

Hand washing with plain soap (detergents) is effective in removing most transient microbial flora. The components of good hand washing include using an adequate amount of soap, rubbing the hands together to create some friction, and rinsing under running water. This technique decreases the number of germs on your hands.

RECOMMENDATIONS ON HAND WASHING

1) Hands must be washed:

between direct contact with individual clients;

before performing invasive procedures;

before preparing, handling, serving or eating food, and before feeding a client;

when hands are visibly soiled;

after situations or procedures in which microbial or blood contamination of hands is likely;

after removing gloves; and

after personal body functions, such as using the toilet or blowing one’s nose.

2) Hand washing is encouraged whenever a health care provider is in doubt about the necessity for doing so. As well as between client contacts, hand washing may be indicated more than once in the care of one person, for example, after touching excretions or secretions, and before going on to another care activity for the same person.

3) Hand washing facilities should be conveniently located throughout the health care setting. They should be available in or adjacent to rooms where health care procedures are performed. If a large room is used for several individuals, more than one sink may be necessary. Sinks for hand washing should be used only for hand washing and not for any other purpose, e.g., as a utility sink. There should be access to adequate supplies and proper functioning soap and towel dispensers or hand dryers.

Health Canada (1998). Infection Control Guidelines: Hand Washing, Cleaning, Disinfection and Sterilization in Health Care.Canadian Communicable Disease Report. Ottawa, ON: Health Canada, 1-58.



HAND WASHING

RECOMMENDATIONS ON HAND WASHING

4) To avoid recontaminating hands, faucets with foot- wrist- or knee-operated handles should be installed wherever possible. If automated faucets are not available, single-use towels should be supplied for the user to turn off faucets.

5) Hands should be dried thoroughly with either a single-use towel or electric air dryer.

6) Hand lotion may be used to prevent skin damage from frequent hand washing. Lotion should be supplied in disposable bags in wall containers by sinks or in small, non-refillable containers to avoid product contamination.

7) Liquid hand wash products should be stored in closed containers and dispensed from either disposable containers or containers that are washed and dried thoroughly before refilling.

8) Hand washing with plain soap is indicated in routine health care and for washing hands soiled with dirt, blood or other organic material. Plain soap and water will remove many transient organisms.

9) Hand washing with an antiseptic agent is indicated prior to performing invasive procedures or when caring for individuals with antibiotic-resistant organisms.

10) Hand washing with waterless/alcohol-based agents should be made available where access to water is limited — agents are not effective if hands are soiled with dirt or heavily contaminated with blood, or other organic material. Follow manufacturer’s instruction for use.

11) Clients in settings where hygiene is poor should have their hands washed. Clients should be helped to wash their hands before meals, after going to the bathroom, and before leaving their room.




HAND WASHING

TABLE 2. SOAPS AND ANTISEPTIC AGENTS FOR HAND WASHING

Product Indications Special ConsiderationsPlain soap, bar soap, liquid*, granules

For routine care of clients. For washing hands soiled

with dirt, blood or other organic material.

May contain very low concentrations of antimicrobial agents to prevent microbial contamination growth in the product.

Waterless alcohol hand-hygiene solutions:

Demonstrated alternative to conventional agents.

For use where hand washing facilities are inadequate, impractical or inaccessible.

For situations in which the water supply is interrupted.

Not effective if hands are soiled with dirt or heavily contaminated with blood or other organic material.

Follow manufacturer’s recommendations for use.

Efficacy affected by concentration of alcohol in product. Use at least a 60% alcohol product.

Hand creams should be readily available to protect skin integrity; or use alcohol hand wash with emollients.

Antiseptic agents May be chosen for hand scrubs prior to performance of invasive procedures.

When caring for severely immunocompromised individuals.

Based on risk of transmission (e.g., specific microorganisms).

When caring for individuals with antimicrobial resistant organisms.

Antiseptic agents may be chosen if it is felt important to reduce the number of client flora or when the level of microbial contamination is high.

Antiseptic agents should be chosen when persistent antimicrobial activity on the hands is desired.

They are usually available in liquid formulations*.

Antiseptic agents differ in activity and characteristics.

Routine use of hexachlorophene is not recommended because of neurotoxicity and potential absorption through the skin.

Alcohol containers should be stored in areas approved for flammable materials.

* Disposable containers are preferred for liquid products. Reusable containers should be thoroughly washed and dried before refilling, and routine maintenance schedules should be followed and documented. Liquid products should be stored in closed containers and should not be topped-up.


(Adapted for use by shelters August, 2001).







HAND WASHING

TABLE 3: HOW TO WASH HANDS

Procedure RationaleRemove jewelry before hand-wash procedure.Rinse hands under warm running water. This allows for suspension and washing away of the

loosened microorganisms.Lather with soap and, using friction, cover all surfaces of the hands and fingers.

The minimum duration for this step is 10 seconds; more time may be required if hands are visibly soiled.

For antiseptic agents — 3-5 ml are required. Frequently missed areas are the thumbs, under

fingernails, backs of fingers and hands.Rinse under warm, running water. To wash off microorganisms and residual handwashing

agent.Dry hands thoroughly with single-use towel or forced-air dryer.

Drying achieves a further reduction in number of microorganisms.

Reusable towels are avoided because of the potential for microbial contamination.

Turn off faucet using a paper towel. To avoid recontaminating hands.Do not use fingernail polish or artificial nails.

Artificial nails or chipped nail polish may increase bacterial load and prevent visualization of soil under fingernails.




GLOVES

GLOVES ARE WORN TO: Provide an additional protective barrier between health care providers’ hands and blood, body

fluids, secretions, excretions and mucous membranes; and Reduce the potential transfer of microorganisms from infected clients to health care providers,

and from client-to-client via health care providers’ hands.

Glove use should be an adjunct to, not a substitution for, hand washing. If all personnel perform hand washing carefully and appropriately, gloves are not necessary to prevent transient colonization of health care providers’ hands and subsequent transmission to others.

RECOMMENDATIONS ON GLOVE USE

1) Gloves should be used as an additional measure, not as a substitute for hand washing.

2) Gloves are not required for routine client care activities if contact is limited to a client’s intact skin, e.g., when transporting clients.

3) Clean, non-sterile gloves should be worn: if exposure is anticipated to blood and body fluids capable of transmitting bloodborne

infection, e.g., hepatitis B, hepatitis C, and HIV; if exposure is anticipated to potentially infectious body substances such as pus, feces,

respiratory secretions or exudate of skin lesions;and when the health service provider has non-intact skin on his/her hands.

4) Gloves should be changed:

between client contacts; if a leak is suspected or the glove tears; and between care activities and procedures on the same client, after contact with materials

that may contain high concentrations of microorganisms.

5) Hands must be washed after gloves are removed.

6) Potentially contaminated gloves should be removed prior to touching clean environmental surfaces (e.g., lamps, blood pressure cuffs).

7) Single-use disposable gloves should not be washed or reused.

8) Non-latex gloves should be available for individuals with latex sensitivity.

9) For housekeeping activities, instrument cleaning and decontamination procedures, general purpose reusable household gloves (e.g., neoprene, rubber, butyl) are recommended. Medical gloves are not durable enough for these activities.




GOWNS The routine use of gowns is not recommended. Gowns should be used to protect uncovered skin and prevent soiling of clothing during procedures

and client-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions, or where soiling of clothing is anticipated.

WHEN USING GOWNS, THE FOLLOWING POINTS SHOULD BE OBSERVED: gowns should be located conveniently; hands must be washed before gowning; the gown must be long enough to cover the clothes, and the sleeves must be no shorter than just

above the wrist; the gown is put on with the opening at the back, with edges overlapping, thus covering as much

clothing as possible; the gown is tied at the waist and neck; the neck and waist ties are undone and the gown removed without touching the clothing, then turned

inside on itself, rolled up and placed in laundry hamper; hands are washed; gowns are preferably used only once. For routine client care, if a gown is used more than once, it

should be used for a single client only, and discarded if wet, soiled, or at the end of the health care worker’s shift; and

wet gowns must be removed immediately to prevent a wicking action that facilitates the passage of microorganisms through the fabric.

If clothing is soiled with body fluids: change clothing; shower if necessary; bag soiled clothing; and launder with hot water and soap.





MASKS AND EYE PROTECTION Masks and eye protection or face shields should be worn where appropriate to protect the mucous

membranes of the eyes, nose and mouth during procedures and client care activities likely to generate splashes or sprays of blood, body fluids, secretions or excretions.

N.B. : Each service provider should carry a pocket resuscitation mask—in a case or on a belt.Use a pocket mask for CPR but DO NOT delay CPR.

Masks should be used only once and changed if wet (because masks become ineffective when moist); Masks should cover both the nose and the mouth; Avoid touching the mask while it is being worn; Discard all masks into an appropriate receptacle; Masks must not be allowed to dangle around the neck; and Wash hands after removing the mask.



City of Ottawa, Public Health and Long Term Care Branch, Health Protection Division, Communicable Disease Program (2000). A Health Education Resource for Designated Officers of Emergency Services. (2nd Edition). Ottawa, ON: City of Ottawa, Communicable Disease Program.



CLEANING, DISINFECTING CLIENT CARE EQUIPMENTAppropriate cleaning and disinfecting of client-care equipment is important in limiting the transmission of organisms. Cleaning is always essential prior to disinfection. An item that has not been cleaned cannot be assuredly disinfected. The manufacturer of the chemical product provides instructions for proper use of the product.

Cleaning and disinfecting of medical equipment is divided into these three categories based on the potential risk of infection involved in their use:

1) Non-Critical: items that either touch only intact skin but not mucous membranes, or do not directly touch the client, involves cleaning and low-level disinfection.

2) Semi-Critical: items that come in contact with mucous membranes but do not penetrate them, requires cleaning followed by high-level disinfection. Intermediate-level disinfection maybe acceptable. (See Table 4)

3) Critical: items such as instruments or devices that enter sterile tissue must be cleaned, followed by sterilization.

Sterilization: there is no sterilization available for equipment onsite at the shelters. Therefore, it is the responsibility of the individual health care worker to ensure equipment is sterilized.

RECOMMENDATIONS FOR CLIENT CARE EQUIPMENT:

1) Where possible, client-care equipment should not be shared.

2) Reusable equipment that has been in direct contact with the client should be cleaned before use in the care of another client. Items that are routinely shared should be cleaned between clients.A routine cleaning schedule should be established and monitored for items that are in contact only with intact skin, if cleaning between clients is not feasible.

3) Equipment that is visibly soiled should be cleaned.

4) Commodes, like toilets, should be cleaned regularly, and when soiled. Bedpans should be reserved for use by a single client and labeled appropriately.

5) Procedures should be established for assigning responsibility and accountability for routine cleaning of all client-care equipment.

6) Soiled health care equipment, e.g. bedpans, should be handled in a manner that prevents exposures to skin and mucous membranes and contamination of clothing and the environment.





CLEANING, DISINFECTING CLIENT CARE EQUIPMENT

PRODUCT LABELING (CHEMICAL DISINFECTANTS) The product label must have a Drug Identification Number (DIN). The presence of a DIN indicates

that, upon review, it has been established that the product is safe and effective for its intended use. The product label must be read carefully for instructions on use. Failure to do so often leads to

inappropriate use, storage or disposal of the product and may expose the client as well as the health care worker to an increased risk of infections or toxic chemical effects. Inappropriate storage of chemical disinfectants may reduce their shelf life, and if they become contaminated, may also lead to bacterial growth.

The product label should include mixing instructions, including concentrations for dilution, and length of disinfection time.

The product label needs to be read for factors that may influence the activity of the disinfectant, such as temperature, ph, relative humidity and water hardness.

TABLE 4: CLEANING AND DISINFECTING COMMONLY-USED EQUIPMENTManufacturers’ Recommendations for Concentration and Exposure Time Must be followed.

Process Equipment Examples of Items* Products or MethodsCleaning some items may require low level disinfection‡

All reusable equipment

All reusable equipment, since such equipment requires cleaning after use and before further disinfection processes are initiated

Bedpans, urinals, commodes

Stethoscopes Blood pressure cuffs Ear specula

Physical removal of soil, dust or foreign material

Chemical, thermal or mechanical aids may be used

Cleaning usually involves soap and water, detergents or enzymatic agents

Quaternary ammonium compounds

Phenolics Some iodophors 3% hydrogen peroxide

Cleaning followed by intermediate level disinfection‡

Some semicritical items

After large environmental blood spills

Glass thermometers Electronic thermometers Hydrotherapy tanks /

bathtubs used for client whose skin is not intact‡

Alcohols Hypochlorite solutions Iodophors Phenolics

Cleaning followed by high level disinfection‡

Semicritical items

Respiratory therapy equipment‡

Nebulizer cups‡ Ear syringe nozzles

2% glutaraldehyde 6% hydrogen peroxide Peracetic acid Chlorine or chlorine compounds

*For products that appear in two categories, manufacturers’ directions differ for length of exposure time and concentration.‡ For guidelines regarding disinfection, refer to comprehensive discussion of disinfection issues.


(adapted for use by shelters June 2001)



CLEANING, DISINFECTING CLIENT CARE EQUIPMENT

TABLE 5: MAJOR CLASSES OF CHEMICAL DISINFECTANTS AND THEIR RELATIVE ADVANTAGES AND DISADVANTAGES

Manufacturers’ recommendations for concentration and exposure time must be followed.

Disinfectant Uses Advantages DisadvantagesAlcohols Intermediate level disinfectant

Disinfect thermometers, external surfaces of some equipment(e.g., stethoscopes)

Equipment used for home health care

Used as a skin antiseptic

Fast acting No residue Non staining

Volatile Evaporation may

diminish concentration. Inactivated by organic

material May harden rubber or

cause deterioration of glues

Chlorines Intermediate level disinfectant Disinfect hydrotherapy tanks,

bathtubs, environmental surfaces Effective disinfectant following

blood spills Equipment used for home health

care See Table 6 for uses and dilution

of chlorines

Low cost Fast acting Readily

available in non-hospital settings

Corrosive to metals Inactivated by organic

material Irritant to skin and

mucous membranes The length of time

bleach solutions can be used: dilution of bleach

1:10 prepared fresh and used within24-hours;

dilution of bleach 1:50 prepared fresh and used within1-30 days—this solution must be kept in an enclosed brown, opaque bottle.

Use in well-ventilated areas

Hydrogen peroxide

3% solution (low-level disinfectant)

Equipment used for home health care

Cleans floors, walls and furnishings

BP cuffs & stethoscopes, bedpans, urinals, commodes, ear specula

Strong oxidant

Fast acting Breaks down

into water and oxygen

Can be corrosive to aluminum, copper, brass or zinc



TABLE 5: MAJOR CLASSES OF CHEMICAL DISINFECTANTS AND THEIR RELATIVE ADVANTAGES AND DISADVANTAGES

Manufacturers’ recommendations for concentration and exposure time must be followed.

Health Canada (1998). Infection Control Guidelines: Hand Washing, Cleaning, Disinfection and Sterilization in Health Care.Canadian Communicable Disease Report. Ottawa, ON: Health Canada, 1-58. (adapted for use by shelters June 2001)

Rutala, William A (1996). APIC (Association for Professional in Infection Control and Epidemiology) Guidelines for Selection and Use of Disinfectants.AJIC Am J Infect Control 24:313-42.

Disinfectant Uses Advantages DisadvantagesIodophors Intermediate level

disinfectant for some equipment (hydrotherapy tanks, thermometers)

Low level disinfectant for hard surfaces and equipment that does not touch mucous membranes (e.g., IV poles, wheelchairs, beds, thermometers, BP cuffs & stethoscopes, bedpans, urinals, commodes, ear specula)

Rapid action Relatively free of

toxicity and irritancy

Note: Antiseptic iodophors are NOT suitable for use as hard surface disinfectant

Corrosive to metal unless combined with inhibitors

Disinfectant may burn tissue

Inactivated by organic materials

May stain fabrics and synthetic materials

Phenolics Low/intermediate level disinfectants

Clean floors, walls and furnishings

Clean hard surfaces and equipment that does not touch mucous membranes (e.g., IV poles, wheelchairs, beds)

Leaves residual film on environmental surfaces

Commercially available with added detergents to provide one-step cleaning and disinfecting

Not recommended for use on food contact surfaces

May be absorbed through skin or by rubber

Some synthetic flooring may become sticky with repetitive use

Quaternary ammonium compounds

Low level disinfectant Cleans floors, walls and

furnishings Clean blood spills, BP

cuffs & stethoscopes, bedpans, urinals, commodes, ear specula

Generally non-irritating to hands

Usually have detergent properties

DO NOT use to disinfect instruments

Non-corrosive Limited use as

disinfectant because of narrow microbicidal spectrum





TABLE 6: DIRECTIONS FOR HOUSEHOLD BLEACH PREPARATION

Product Intended Use Recommended DilutionHousehold Bleach(5% sodium hypochlorite solution with 50,000 ppm* available chlorine)

Cleanup of blood spills

Use concentrations of 1 part bleach(e.g. 8-ounce cup/250ml to be mixed with 9 cups of tap water—1:10)

To add to laundry water

One part (one 8-ounce cup/250ml) of bleach to be mixed with 500 parts (28 gallons†) of tap water

Surface cleaning Soaking of

glassware or plastic items

One part (one 8-ounce cup/250ml) to be mixed with 50 parts (2.8 gallons†/12.6 litres) of tap water

NaDCC (Sodium dichloroisocyanurate) powder with 60% available chlorine


Dissolve 8.5g in one litre of tap water

Chloramine-T powder with 25% available chlorine


Dissolve 20 g in one litre of tap water

* Parts per million † Imperial gallon (4.5 litres)

The length of time bleach solutions can be used:— dilution of bleach 1:10 prepared fresh and used within 24 hours; and— dilution of bleach 1:50 prepared fresh and used within 1-30 days—this solution must be kept in an enclosed brown, opaque bottle.

Health Canada (1998). Infection Control Guidelines: Hand Washing, Cleaning, Disinfection and Sterilization in Health Care.Canadian Communicable Disease Report. Ottawa, ON: Health Canada, 1-58. (adapted for use by shelters June 2001)

Rutala, William A (1996). APIC (Association for Professional in Infection Control and Epidemiology)Guidelines for Selection and Use of Disinfectants. AJIC Am J Infect Control 24:313-42.



HOUSEKEEPINGThe aim of cleaning is to achieve a clean environment with regular and conscientious general housekeeping. Visible dust and dirt should be removed routinely with water and detergent and/or vacuuming. The environment should be kept free of clutter to facilitate housekeeping.

RECOMMENDATIONS FOR ROUTINE HOUSEKEEPING

1) Housekeeping protocols should include careful cleaning of wet surfaces and equipment to prevent the build-up of biofilms. Environmental water reservoirs have been associated with numerous infections and outbreaks. Examples include faucet aerators, showerheads, sinks, drains, ice machines, water carafes and bathtubs.

2) Facilities should determine a schedule for cleaning and maintaining ducts, fans, and air conditioning systems.

3) During wet cleaning, cleaning solutions and the tools with which they are applied soon become contaminated. Therefore, a routine should be adopted that does not redistribute microorganisms. Cleaning less heavily contaminated areas first, and changing cleaning solutions and cloths/mops frequently, may accomplish this.

4) Wet mopping is most commonly done with a double-bucket technique, which extends the life of the solution because fewer changes are required. When a single bucket is used, the solution must be changed more frequently because of increased bioload.

5) Tools used for cleaning and disinfecting must be cleaned and dried between uses.

6) Mop heads should be laundered daily in areas of great activity and at a set interval for areas of lesser contamination. All washed mop heads must be dried thoroughly before storage.

7) Facilities should develop policies for cleaning schedules and methods, which should include the name of the person who is responsible for housekeeping.




HOUSEKEEPING

TABLE 7: CLEANING PROCEDURES FOR COMMON ITEMS

Surface / Object

Procedure / Frequency Special Considerations

Horizontal surfaces such as over-head tables, work counters, beds, mattresses, bedrails

Thorough cleaning Cleaning when soiled Cleaning between clients

and after discharge

Walls, blinds, curtains

Should be cleaned regularly with a detergent and as splashes/visible soil occur

Floors Thorough regular cleaning Cleaning between clients

and after discharge Damp-mopping preferered

Detergent is adequate in most areas. Blood/body fluid spills should be cleaned up

with disposable cloths, followed by disinfection

Carpets / Upholstery

Should be vacuumed regularly and shampooed as necessary

Toilets and Commodes

Thorough cleaning Cleaning when soiled Cleaning between clients

and after discharge

These may be the source of enteric pathogens such as hepatitis A, salmonella, and E. Coli





TABLE 7: CLEANING PROCEDURES FOR COMMON ITEMS

Surface / Object

Procedure / Frequency Special Considerations

Toys Should be regularly cleaned, disinfected with a low-level disinfectant, thoroughly rinsed, and air-dried

Toys should be constructed of smooth, nonporous (i.e., not plush) materials to facilitate cleaning and decontamination:1. Clean to remove visible dirt. Use detergent and

hot water;2. Sanitize by soaking in a 1/100 bleach in water

solution (10 ml bleach in 1 L water) for 30 seconds and then allow to air-dry. Sanitizing solution should be made at the time of use;

3. Mouthing toys should be avoided as it is impractical to clean and disinfect after each use;

4. All toys that have not been mouthed can be cleaned and sanitized once a week as follows: Small toys: clean and sanitize as indicated

above; Soft washable, cuddly toys should be

avoided. When they are essential, they should be machine-washed in hot water with normal detergent and dried on the hottest cycle of your dryer on a weekly basis;

Non machine-washable or large toys, (e.g. books, puzzles, activity centres, riding toys): wipe with a clean cloth soaked in hot water with detergent, then wipe with a clean cloth soaked in a sanitizing solution of 1/50 bleach in water solution, (20 ml bleach in 1L water) and let air dry. 1/50 bleach in water is used here for items which cannot be soaked in sanitizing solution.

Consider the use of gloves when disinfecting to prevent skin irritation. Wash hands after disinfecting toys.

Do not use phenolics



City of Ottawa, Public Health and Long Term Care Branch (November, 2000). Communicable Disease Report. Ottawa, ON: City of Ottawa.



CLEANING BLOOD SPILLS

RECOMMENDATIONS FOR CLEANING BLOOD SPILLS

1) Appropriate personal protective equipment should be worn for cleaning up a blood spill.Gloves should be worn during the cleaning and disinfecting procedures. If the possibility of splashing exists, the worker should wear a facemask and gown. Personal protective equipment should be changed if torn or soiled and always removed before leaving the location of the spill, and hands washed.

2) The blood spill area must be cleaned of obvious organic material before applying a disinfectant, as hypochlorites and other disinfectants are substantially inactivated by blood and other materials

3) Excess blood and fluid capable of transmitting infection should be removed with disposable towels. Discard the towels in a plastic-lined waste receptacle.

4) After cleaning, the area should be disinfected with a low - intermediate chemical disinfectant such as quaternary ammonium compounds or household bleach. Concentration of household bleach—1:10 dilution: mix 1 part bleach to 9 parts water—i.e., 1 cup bleach to 9 cups water.See Table 6 for directions on the preparation and use of chlorine-based disinfectants.

5) Household bleach or chemical germicide should be left on the surface for 10 minutes.

6) The treated area should then be wiped with paper towels soaked in tap water. Allow the area to dry.

7) The towels should be discarded in a plastic lined waste receptacle.

8) Care must be taken to avoid splashing or generating aerosols during the clean up.

9) Hands must be thoroughly washed after gloves are removed.

10) For carpet or upholstered surfaces, a common supermarket disinfectant may be used.

11) Counter tops and surfaces that have been contaminated with blood or body fluids should be cleaned with disposable toweling, using an appropriate cleaning agent and water as necessary, (e.g., after each procedure, after treatment of each client, at the completion of daily work activities, and after any spill). Surfaces should then be disinfected with a low-level chemical disinfectant or sodium hypochlorite (household bleach dilution).




LAUNDRYAll linen that is soiled with blood, body fluids, secretions or excretions, or contaminated with lice or scabies, should be handled using the following list of recommendations—regardless of source, or care setting:

RECOMMENDATIONS FOR HANDLING LAUNDRY

1) Collection and Handling Linen should be handled with a minimum of agitation and shaking. Heavily soiled linen should be rolled or folded to contain the heaviest soil in the center of the

bundle. Large amounts of solid soil, feces or blood clots should be removed from linen with a gloved hand and toilet tissue and placed into a bedpan or toilet for flushing. Excrement should not be removed by spraying with water (e.g., from clothing, reusable incontinence pads).

2) Bagging and Containment Soiled linen should be bagged at the site of collection. To prevent contamination or soaking through, a single, leakproof bag or a single cloth bag

can be used. Laundry carts or hampers should be used to collect or transport soiled linen and need not be

covered. The practice of placing lids on soiled linen carts is not necessary from an infection control perspective.

Linen bags should be washed after each use and can be washed in the same cycle as the linen contained in them.

3) Washing and Drying Microbial counts on soiled linens are significantly reduced during the mechanical action and

dilution of washing and rinsing. With the high cost of energy and use of cold water detergents (which do not require heat to catalyze their actions) hot water washes (>71.1º C for 25 minutes) may not be necessary. Several studies show that low temperature laundering will effectively eliminate residual bacteria to a level comparable with high temperature laundering. When low temperature washes are combined with the addition of bleach (with a total available residual chlorine of 50-150 ppm), residual bacteria on laundry are reduced to below levels found on laundry washed at high temperatures. See Table 6 for directions on preparing and using chlorine-based disinfectants. Machine drying of linen contributes to a further reduction of residual bacteria.




4) Protection of Laundry Workers Reusable gloves should be washed after use, allowed to hang dry, and discarded if punctured

or torn. Hand washing facilities should be readily available. Personnel should wash their hands whenever gloves are changed or removed. Staff in care areas, need to be aware of sharps when placing soiled linen in bags. Workers are

at risk from contaminated sharps, instruments or broken glass that may be contained with linen in the laundry bags.

All care givers and laundry workers should be trained in procedures for handling of soiled linen.

Laundry workers, should be offered immunization against hepatitis B—needles may be occasionally found in soiled linen.




MANAGING UNTREATED WASTE

RECOMMENDATIONS FOR MANAGING UNTREATED WASTE

1) Blood and body fluid waste, drainage-collection units, and suction containers with blood— should be sealed in impervious containers and disposed of in the sanitary sewer if permitted by local regulatory authorities, or incinerated.

2) Waste such as gloves, dressings, or materials soaked with blood or secretions—should be put in leak-proof garbage bags and disposed of in normal landfill sites.

3) Sharps such as needles, blood syringes, lancets, or clinical glass—should be disposed of in a biohazard container and disposed using Medical Waste Management Inc., telephone:(905) 789-6660, or Med-Tech Environmental Ltd., (877) 791-3545. Sharps must not be put in regular garbage collection and compaction to become a risk to solid waste workers.

“What To Do With Used Needles” (City Of Ottawa, February 19, 2001): Call the City of Ottawa, 580-2400 (this applies to households and institutions.)

Agencies should use a licensed disposal company. See pamphlet in the Additional Resources section of this resource.

“Be Careful With Needles!” (City Of Ottawa, March, 2001): see fact sheet in the Additional Resources section of this resource.

SAFE HANDLING OF SHARP OBJECTS

How to minimize the risk of sharps injuries and reduce the potential for transmission of infection: do not recap, bend, or break used needles; do not remove used, uncapped needles from syringes; do not leave unattended used sharps; immediately after use, place in an approved, biohazard container all used disposable syringes,

needles and other sharp items; place biohazard container as close to area of use as possible; fill sharps container only 2/3 full; follow safe procedures when performing needle exchange; and postpone certain procedures if possible i.e., if the client’s behavior is inappropriate.

College of Nurses of Ontario (2000). Infection Control Guidelines. Toronto, ON, College of Nurses of Ontario, 3-10.




Guidelinesfor

Communicable Disease and

Other Health Issuesin Shelters

andDrop-In Centres

— —

35

GUIDELINES FOR COMMUNICABLE DISEASE & OTHERGUIDELINES FOR COMMUNICABLE DISEASE & OTHERHEALTH ISSUES IN SHELTERS AND DROP-IN CENTRESHEALTH ISSUES IN SHELTERS AND DROP-IN CENTRES

METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA)…WHAT IS IT?Staphylococcus aureus (S. aureus), is a bacteria commonly found on people and in the environment. MRSA is a type of S. aureus that has become resistant to the antibiotic methicillin, and other antibiotics.

MRSA COLONIZATION Colonization occurs when the bacteria live on or in the body with no sign or symptom of illness.

Twenty-five percent of people carry the more common S. aureus on the skin and in the nose, and do not get sick with it. Colonization must be present for infection to occur.

MRSA INFECTION Infection occurs when the bacteria gets past the person’s normal defenses and the person becomes ill

—e.g., respiratory infection, blood infection, or open-sore infection.

HOW IS MRSA TRANSMITTED? MRSA is spread from person-to-person, when a person’s contaminated unwashed hands or gloves

come into contact with the eyes, nose, mouth or open sores of another person. MRSA is more commonly spread in health care settings by workers who do not wash their hands between clients, or by unclean, shared equipment.

WHO IS AT INCREASED RISK OF COLONIZATION OR INFECTION OF MRSA? People with a severely weakened immune system with underlying chronic disease—

e.g., alcoholism, malnutrition, diabetes, peripheral vascular disease, cancer (receiving chemotherapy), and AIDS;

People undergoing invasive medical procedures with the presence of invasive devices; People with ongoing multiple antibiotic therapy; and People who have multiple hospital admissions or prolonged hospitalization.


Ontario Ministry of Health (1996). Guidelines for the Management of Methicillin Resistant Staphylococcus Aureus in Long Term Care Facilities. Toronto, ON: Queens Printer for Ontario, 1-22.

(The) Ottawa Organization for Practitioners in Infection Prevention and Control. A Chapter of the Community and Hospital Infection Control Association-Canada (November 1999). Infection Prevention and Control Guidelines for Housekeeping Practices Related to Multi-Drug Resistant Organisms (MDRO).Ottawa, ON, the

Ottawa Organization for Practitioners in Infection Prevention and Control. A Chapter of the Community and Hospital Infection Control Association-Canada.



PRECAUTIONS TO TAKE FOR CLIENTS WITH COLONIZED OR INFECTED WITH MRSA

Accommodation Single rooms may reduce opportunities for direct and indirect contact, and droplet transmission when

the source client has poor hygiene, contaminates the environment, or cannot be expected to comply with infection-control measures because of age or altered mental status.

Handwashing Handwashing is the main method of prevention; All staff should wash their hands before and after every client contact. Regular soap and water should

be used with friction for 10 seconds; Alcohol handwash should be used if washing stations are not readily available; and Hands must be washed after glove use, and after all skin-to-skin contact.

Barriers Non-sterile gloves are required when providing all personal care within the client’s room—including

toileting and bathing; Change gloves after having contact with infective material that may contain high concentrations of

microorganisms (i.e. wound drainage). Remove gloves before leaving client’s room. Handwashing after wearing gloves is essential;

Gowns are only required during care if gross contamination or soiling of clothing is likely (i.e. bed bath). Gowns are not necessary for walking into the client’s room to deliver items or to check on the client; and

The use of masks is not required, even with clients with MRSA pneumonia (there is little evidence that MRSA can be spread by droplet transmission from a person with MRSA pneumonia).

Equipment A supply of care items/equipment (e.g., gowns, gloves) should be kept in the client’s room; and Skin care items (e.g., soaps, solutions, creams) should not be shared with other clients and they

should be kept in the client’s room.








Housekeeping As contaminated environmental surfaces are not a significant reservoir for MRSA, special

housekeeping practices are not warranted. (reminder: all hydrotherapy equipment should be cleaned and disinfected following facility and manufacturer’s protocol after each client’s use, regardless of MRSA culture status.): daily cleaning of all horizontal surfaces and frequently touched surfaces/items is the minimal

requirement, e.g., bedrails, bedside tables, commodes and bathroom, door handles, faucet handles, light switches, call bell, telephone, etc. Any other surfaces or items that are visibly soiled must be cleaned;

terminal cleaning should also include disinfection of less frequently touched surfaces, e.g., wash wall areas likely to be touched, change bedside curtain, etc. all supplies and patient care equipment must be thoroughly cleaned, e.g., blood pressure cuff, IV pole, IV pump, respiratory equipment, etc. items which cannot be cleaned must be discarded, e.g., dressings;

a process should be in place to ensure that compliance to these cleaning procedures is maintained, e.g. signed checklist; and

refer to Routine Practices—Cleaning, disinfecting client-care equipment, Table 4 (pg. 24); It is unnecessary to label or take special precautions with garbage (e.g., double-bagging is not

needed). Secure the garbage bag before it leaves the room.

Laundry Normal wash and dry cycles for clothing and gowns are sufficient to destroy the MRSA; Soiled linens should be bagged in each client’s room; and Laundry staff do not need to take special precautions.

Dietary Use of disposable dishes is not required. Regular dishwashing cycles will clean dishes sufficiently.

Client Activities There is no need to restrict the client’s participation in facility activities; Cover open wounds; and Assist client with handwashing technique. If the resident cannot reliably follow basic hygienic

measures, be sure client is supervised during toileting and handwashing activities.

Notification / Transfer of Client Before transferring client, notify all receiving facilities of client’s MRSA status.








Visitors There is no need to restrict visitors; Visitors do not need to wear gowns or gloves; and Teach visitors good handwashing technique.

Criteria for Discontinuing MRSA Precautions The client must remain on precautions until three sets of negative colonization and site specific

swabs, taken one week apart, have been obtained; Once the client has been removed from precautions, he/she will be monitored once per month for

three months, by obtaining swabs of nose, axilla, groin/perineum, dry skin lesions and/or any cultured exit sites; and

Should the client become positive again after negative cultures are obtained, this protocol must be followed again.







VANCOMYCIN-RESISTANT ENTEROCOCCUS (VRE)… WHAT IS IT?Enterococcus is a bacteria that usually lives in people’s bowels; however, it can also live on skin or in the environment. VRE is a type of enterococcus (a bacteria), that has become resistant to the antibiotic vancomycin, and other antibiotics.

VRE COLONIZATION Colonization occurs when the bacteria lives on or in the body with no sign or symptom of illness.

VRE behaves the same way as all other enterecocci bacteria.

VRE INFECTION Infection occurs when the bacteria get past the person’s normal defenses and the person becomes ill

— e.g., blood infection, gastrointestinal infection or open-sore infection.

HOW IS VRE TRANSMITTED? VRE is spread from person-to-person when one person’s contaminated, unwashed hands or gloves

come into contact with the eyes, nose, mouth or open sores of another person. VRE is spread more commonly in health care settings by workers who do not wash their hands between clients, or by unclean, shared equipment.

WHO IS AT INCREASED RISK OF COLONIZATION OR INFECTION OF VRE? People with a severely weakened immune system with underlying chronic disease—e.g., alcoholism,

malnutrition, diabetes, peripheral vascular disease, cancer (receiving chemotherapy), and AIDS; People undergoing invasive medical procedures with the presence of invasive devices; People with ongoing multiple antibiotic therapy/or vancomycin therapy; and People who have multiple hospital admissions or prolonged hospitalization.


Ontario Ministry of Health (1996). Guidelines for the Management of Residents With Vancomycin Resistant Enterococci in Long Term Care Facilities. Toronto, ON: Queens Printer for Ontario, 1-23.





PRECAUTIONS TO TAKE FOR CLIENTS WITH COLONIZED OR INFECTED WITH VRE

Accommodation The optimal placement is a private room. If this is not possible, avoid placing the client who has

VRE in a room with clients who have poor personal hygiene, open skin lesions, invasive devices, or who require frequent hospital admissions.

Handwashing Handwashing is the main method of prevention; Before and after every contact with the VRE-positive client or his/her environment, all staff must

wash their hands using an antibacterial soap; Upon leaving the client’s room, all persons (staff, clients, visitors) must wash their hands with an

antibacterial soap or alcohol handwash; and After removing gloves hands must be washed.

Barriers Wear gloves when providing all personal care or cleaning the environment. Change gloves after

contact with sites/bodily fluids soiled with stool or after toileting. Use non-sterile gloves; Wear a clean gown when providing all personal care. Discard gown after each use; As VRE is not spread through the air, masks are not required.

Procedures For All Service Providers Before Leaving Client’s Room Remove gloves and place in the garbage receptacle for general waste; Remove gown, making sure to turn contaminated side inwards, and place in laundry if washable, or

in garbage receptacle if disposable; Using sink in client’s room or bathroom, wash hands with antibacterial soap. Dry hands with paper

towels and use paper towels to turn off taps. Dispose of paper towel in garbage container; Use alcohol handwash while in client’s room if handwashing sinks are not available. Ideally, staff

should carry their own supply of alcohol handwash on their person; and Once gown and gloves are removed, ensure that clothing and hands do not come in contact with

environmental surfaces (e.g. curtains, door handles, light switches). Use new paper towels to handle these objects.








Supplies and Equipment The following supplies are required:

Gowns and gloves; Bags for linens; Plastic bags for heavily soiled linen and for garbage containers; Extra bedpans and urinals; and Garbage container, lined with plastic bag for general waste, which is to be placed inside the

client’s room. Dispose of all contaminated garbage and linen inside room. Dedicate equipment (e.g. stethoscope, BP cuff, dressing supplies, creams/lotions etc.) to the VRE-

colonized client. Label and use only one wheelchair or walker for the client, and keep the equipment in the client’s room until no longer needed. Place a sign on the door to remind visiting physicians to not take their own equipment into the room. Clean all equipment removed from the client’s room with an approved disinfectant and bleach.

Clean the client’s wheelchair daily with an approved disinfectant while the wheelchair is in the client’s room. Put gloves on the handles and brakes after the cleaning. When the wheelchair leaves the room, remove the gloves. It is recommended that wheelchairs with foam grips not be used because the grips are very difficult to keep clean. The wheelchair should stay in the client’s room when not in use. The wheelchair should be treated as being clean.

Any equipment shared between clients (e.g. shower chair, bathtub, non-disposable therapy equipment), must be cleaned after each use. Cleaning includes the use of approved disinfectant, then bleach at a 1:10 concentration.

Client’s Use of Toileting Facilities The options for toileting are listed in order from the most preferable to least preferable:

Client has own private washroom. Client has designated toilet/stall that no other client uses (service providers could use tape on the

toilet seat or stall door to discourage other clients from accessing). Client-shared toilets must be cleaned after each use; or client has own dedicated commode, which

is cleaned daily. Transmission of VRE from toilets being used by more than the VRE-client is an issue. Each client with VRE will need to be assessed to determine the best approach to toileting and subsequent cleaning.

Clean the toilet surfaces (seat, grab bar, toilet paper dispenser, flusher handle) after each use if client shares washroom. Cleaning includes the use of an approved disinfectant, then bleach at a 1:10 concentration. Management will need to plan for this to ensure staff’s compliance with the cleaning requirements.

City of Ottawa, Public Health and Long Term Care Branch, Health Protection Division, Communicable Disease Program (2000).

A Health Education Resource for Designated Officers of Emergency Services. (2nd Edition). Ottawa, ON: City of Ottawa, Communicable Disease Program.

Ontario Ministry of Health (1996). Guidelines for the Management of Residents With Vancomycin Resistant Enterococci in Long Term Care Facilities.Toronto, ON: Queens Printer for Ontario, 1-23.






Day-to-Day Cleaning of a Client’s Room Gloves should be worn while cleaning the client’s room or washroom. Discard gloves after each use.

Daily cleaning of all horizontal surfaces and frequently touched surfaces/items is the minimal requirement, e.g., bedrails, bedside tables, commodes and bathroom, door handles, faucet handles, light switches, call bell, telephone, etc. Any other surfaces or items that are visibly soiled must be cleaned.

A process should be in place to ensure that compliance to these cleaning procedures is maintained, e.g. signed checklist.

Terminal cleaning should also include disinfection of less frequently touched surfaces, e.g., wash wall areas likely to be touched, change bedside curtain, etc. all supplies and patient care equipment must be thoroughly cleaned, e.g., blood pressure cuff, IV pole, IV pump, respiratory equipment, etc. items which cannot be cleaned must be discarded, e.g., dressings.

Laundry Deposit bed linen and clothing in the regular laundry hamper, kept in the client’s room. If heavily

soiled or very wet, place the items in a plastic bag before depositing in the laundry hamper; and Use normal procedures for handling and cleaning laundry of the VRE-affected client.

Allow a Client who is still positive for VRE out of their room if: Continent of bowel and bladder; or Incontinent but wearing a leak proof brief; or If VRE is colonizing a wound or stoma which is covered with a dressing with no risk of drainage

soaking through the dressing; or Client’s personal hygiene is adequate and contamination of the environment is unlikely; Client washes hands well prior to leaving the room; and/or For clients who are confused, a system of regular assisted hand washing may need to be

implemented.

City of Ottawa, Public Health and Long Term Care Branch, Health Protection Division, Communicable Disease Program (2000).A Health Education Resource for Designated Officers of Emergency Services. (2nd Edition). Ottawa, ON: City of Ottawa, Communicable Disease Program.







Meals Client must wash hands before going to dining area. Have client sit in the same place using the same

seat at each meal; Use regular dishes and cutlery. Use of disposable dishes is not required. Regular dishwashing cycles

will clean dishes sufficiently; Clean the table and chair after each meal; If the client has very poor personal hygiene, or requires extensive personal contact during feeding,

tray service to the client’s room may be considered.

Visitors Visitors should wear gloves if the are visiting the client within his/her room; Visitors should wash their hands when leaving the client’s room; Visitors should wear a gown if they are going to have direct contact with the client (i.e., assistance

with personal care).

Notification / Transfer of Client Prepare the client for transfer by washing their hands and cleaning their wheelchair/assistive devices

if they are being transferred with the device(s); Notify the transferring ambulance and the receiving facility of the VRE status before the transfer

occurs (i.e., emergency department or admission unit and infection control practitioner).

Criteria for Discontinuing VRE Precautions VRE-infected or colonized clients may be removed from precautions when VRE-negative results

have been obtained on at least three consecutive cultures, one or more weeks apart. Appropriate specimens for VRE culture include stool or rectal swab;

Once the client has been removed from precautions, he/she should be monitored, by obtaining a rectal swab/stool specimen once per month, for four months.

Client attending Medical appointments Physicians should visit the client within the facility whenever possible. If this is not possible, the

client may attend medical appointments if necessary. Inform the physician’s office ahead of time of the required precautions.

Follow-up/Evaluation After 3 weeks, rescreen the clients within the geographic area of the client(s) carrying VRE to check

for further transmission of VRE. Consideration should be given to rescreening when all residents have become negative or a resident remains colonized after two months.

City of Ottawa, Public Health and Long Term Care Branch, Health Protection Division, Communicable Disease Program (2000).A Health Education Resource for Designated Officers of Emergency Services. (2nd Edition). Ottawa, ON: City of Ottawa, Communicable Disease Program.





These guidelines are intended to provide service providers and other professionals with guidance on communicable disease control in shelters and drop-in centres.

City of Ottawa, Public Health and Long Term Care BranchHealth Protection Division

COMMUNICABLE DISEASE PROGRAM(613) 724-4224

February 2002

Disease Cause/Symptoms Transmission Incubation Period of Communicability

Reporting of Individual Cases

Amebiasis Parasite.

Abdominal distention and cramps, diarrhea or constipation, and rarely fever or chills.

May be symptom free.

Fecal-oral route.

Food and water contaminated by infected food handler or sewage.

Few days to several months, commonly 2 to 4 weeks.

Until treated. Report within one working day to 724-4224.

Beaver Fever See Giardia.

Bite(Animal)

There is risk of rabies from the bites of bats, cats, dogs, ferrets, groundhogs, muskrats, racoons, skunks and other wild mammals. Bites of gerbils, hamsters, mice, moles, rabbits and squirrels do not have to be reported unless the animal’s behaviour was very abnormal. Feeding squirrels is a form of provocation.

Animal saliva introduced by a bite or scratch.

Depends on the cause.


Report immediately to 722-2200

(580-2400 after hours) in order to begin rabies immunization if needed and/or quarantine the biting animal if available.

Bite(Human)

If the skin is broken, there is a risk of transmission of hepatitis B, hepatitis C, and HIV from an infected person.

Contact of contaminated blood with a break in the skin or blood inside of the mouth.



Report immediately to 724-4224 if a bite breaks the skin

(580-2400after hours).



Campylobacter Bacteria.

Diarrhea, abdominal pain, fever, nausea and vomiting. Stools may contain blood.

Fecal-oral route. Food and water contaminated by infected food handler or sewage. Undercooked meats (all kinds).

Unpasteurized milk. Contact with animals (often kittens and puppies).

1 to 10 days. Up to several weeks after beginning of symptoms, or until treated.

Report within one working day to 724-4224.

Candidiasis

(Thrush, Diaper Rash)

Fungus.

Thrush: Thin white layer on tongue and inside of cheeks. May cause difficulty in feeding, or may be symptom-free.

Diaper rash or other skin rash: Well demarcated, beefy red rash with white flaky border, usually in skin folds. Painful when comes in contact with urine.

Person-to-person by direct contact.

Candida organism normally present on skin, so can be auto-infected.

Variable, 2-5 days for thrush in infants.

White lesions are present.

Not needed.

Chickenpox

(Varicella)

Virus.

Fever. Blister-like rash occurs in successive crops. Scabs form after the blister stage. "Spots" usually appear first on the body, face and scalp, then later spread to the arms and legs.

Person-to-person by:

a) respiratory secretions, or

b) direct skin contact with fluid from blisters or objects and surfaces contaminated by the fluid from the blisters.

2 to 3 weeks; commonly 13 to 17 days.

1-4 days before to 5 days after onset of rash.

Low infectiousness after 1 or 2 days of rash.

Report number of cases and age of client, by mail or fax to 724-4130 on a weekly basis. See form.



Cold Sores

(Herpes)

Virus.

Small blisters appear and then burst to form a crust. Sores are usually around the mouth but can be around the nose and eyes area.

With the first infection, sores may be accompanied by fever, flu-like illness, and painful irritation.

Person-to-person by saliva.

Hand washing is important in preventing transmission.

2 to 12 days. While sores are apparent. Virus may be transmitted even when no visible lesions are present.

Not needed.

Conjunctivitis-Bacterial

(Pink Eye)

Purulent conjunctivitis (bacterial): Pink or red conjunctiva (the white of the eye) with thick or crusty white or yellow discharge (pus), occasionally accompanied by fever.

Person-to-person: by direct or indirect contact with eye secretions.


24 to 72 hours. For duration of infection or until 24 hours of antibiotic treatment.

Not needed.

Conjunctivitis-Viral

(Pink Eye)

Non-purulent conjunctivitis (viral or allergic): Pink conjunctiva (the white of the eye) with a clear, watery eye discharge often accompanied by a cold.

Person-to-person: by direct or indirect contact with eye secretions.


12 hours to 12 days.

For duration of infection.

Not needed.

Cough See Influenza, Pertussis, Respiratory Syncytial Virus, or Tuberculosis.



Coxsackie Virus

(Hand, Foot and Mouth Disease)

Sudden onset of fever, sore throat.

Rash on the palms of the hands, the fingers, and on the soles of the feet, and sores inside the mouth

Acute self-limited viral infection. Usually in children, particularly in the summer months.

Person-to-person by respiratory secretions and fecal-oral route.

Lesions themselves do not spread infection.

Usually 3 to 6 days.

During the acute stage of the illness.

Transmission via stools persists for several weeks.

Not needed

Crabs

(Genital lice)

Small grey-brown insects and white eggs (nits) attached to pubic hairs. May spread to other areas where there are hairs: head, eyebrows, underarms, etc. Cause intense itching and skin redness.

Person-to-person by direct skin-to-skin contact (sexually) or indirect contact through bedding, clothing, and towels.

6 to 10 days. As long as lice or eggs remain alive on hair (until treatment).

Not needed.

Diarrhea See Gastroenteritis. Not needed unless part of an outbreak, call 724-4224

(580-2400 after hours).

Eschericha coli 0.157:H7

Bacteria.

Severe abdominal cramps, watery, possibly bloody diarrhea, and fever.

Fecal-oral route.

Contaminated food and water: undercooked meat, unpasteurised milk, vegetables.

1 to 8 days 3 weeks in a third of children.

1 week or less in adults.



Eye infection See Conjunctivitis.



Fever If accompanied by diarrhea or vomiting, see Gastroenteritis, Hepatitis, Meningitis.

If accompanied by rash, see Chickenpox, Coxsackie, Impetigo, Measles, Parvovirus, Roseola, Rubella, or Streptococcal Infection.

If accompanied by cough, sore throat or runny nose, see Influenza, Mononucleosis, Pertussis, Strep throat, or Tuberculosis.

Fifth Disease See Parvovirus B19

Gastroenteritis:

Outbreaks at shelters & drop-

in centres

Bacteria, viruses or parasites.

See Amebiasis, Campylobacter, E. Coli, Giardiasis, Salmonella, Shigella, Yersinia

Vomiting, diarrhea, abdominal pain, headache, fever.

Depends on cause. Usually fecal-oral route or through food and water contaminated with causing germs.

Depends on cause.

Depends on cause. Early recognition of an outbreak is important

For shelters & drop-in centres— an outbreak will be defined as 3 or more cases within 48 hours of each other

Report immediately to 724-4224 or(580-2400 after hours)

Gastroenteritis

(single case)

Bacteria, viruses or parasites.

See Amebiasis, Campylobacter, Eschericha coli, Giardiasis, Salmonella, Shigella, or Yersinia.

Vomiting, diarrhea, abdominal pain, headache, fever.

Depends on cause.

Usually fecal-oral route or through food and water contaminated with causing germs.

Depends on cause.

Depends on cause. Not needed unless part of an outbreak (see above).



Genital herpes Virus.

Painful sores on the skin around genitalia. With the first infection, sores may be accompanied by fever, flu-like symptoms and painful irritation.

Sexually (skin-to-skin). 2 to 12 days. Usually while sores are apparent but virus may be transmitted even when no visible lesions are present.

Not required.

German Measles

See Rubella.

Giardiasis

(Beaver Fever)

Parasite.

Diarrhea, abdominal cramps, bloating, weight loss. May be symptom free.

Fecal-oral route.

Water and food contaminated by infected food handler or sewage. Lake and river water.

3 to 28 days or longer, usually 7 to 10 days.

Entire period of infection, often months, or until treated.


Hand Foot and Mouth Disease

See Coxsackie Virus.

Head lice

(Pediculosis)

Itching of the scalp

Nits found attached to the hair

Lice seen in the hair

(see fact sheet in the “additional resources” section at the back of this manual)

Direct head-to-head contact

The egg to egg cycle coverage about 3 weeks.

The louse life cycle extends over 18 days.

As long as lice or eggs remain alive on the infested person or until treated

Not needed

Hepatitis A Virus.

Fever, tiredness, nausea, jaundice, (yellowing of skin), abdominal discomfort, dark urine, clay coloured stools.

May be symptom free.

Fecal-oral route. Food and water contaminated by infected food handler or sewage.

15 to 50 days, average 28-30 days.

1-2 weeks prior to symptoms to 1 week after the onset of symptoms.





Hepatitis B Virus.

Same symptoms as hepatitis A.


Through contact with blood and bloody fluids, semen, vaginal fluid and saliva with non-intact skin or mucous membrane (eyes, nose and mouth).

For example: unprotected sexual intercourse, sharing of needles in injection drug use, bites that break the skin.

45 to 180 days, average 2-4 months.

From weeks before onset of symptoms to months or years after end of symptoms. Some become carriers and remain contagious for life.

Report to

560-6099 within one working day.

Hepatitis C Virus.

Same symptoms as hepatitis A and B.


Through contact with blood (bites that break the skin, needle sharing in injection drug users, unsterile tattooing or body piercing, sharing contaminated razors or toothbrushes, receiving blood products prior to 1990.

There is no evidence of transmission through sharing of eating and drinking utensils or through blood touching intact skin.

2 weeks - 6 months, most common 6-9 weeks.

From one or more weeks before onset of first symptoms to the end of symptoms; persists indefinitely in carriers (90% of those infected).

Report to 560-6099 within one working day.



HIV (Human Immunodeficie

ncy Virus) / AIDS

Many will develop a short-term flu-like illness several weeks to months after infection; after several years, damage to the immune and other systems lead to severe infections and death.

(see HIV fact sheet in the “additional resources” section at the back of this manual)

Through contact with blood (needle sharing in injection drug users, unsterile tattooing or body piercing), unprotected sexual intercourse, or from mother to fetus.

Generally 4-12 weeks until HIV blood test is positive.

Generally begins early after onset of infection and extends throughout life.

Report to 560-6099 within one working day.

Impetigo Infection of the skin caused by Streptococcus or Staphylococcus bacteria. It often follows a scrape or insect bite. It usually appears on the face or exposed skin as a rash with a cluster of red bumps or blisters, which may ooze or be covered by a honey-coloured crust.

It is very contagious and should be treated at once.

Person-to-person by direct contact with sores or from asymptomatic carriers.


Variable.

Commonly 1-10 days.

From onset of rash until 24 hours of treatment with oral or topical antibiotics if lesions are few and small.

Not needed.

Influenza Infection of the airways caused by the viruses influenza, A, B, or C leading to fever headache, muscle soreness, runny nose, sore throat, and cough.

Person to person by respiratory secretions or direct contact with secretions.

1-5 days. From onset of symptoms up to 7 days.

Not required unless part of an outbreak.If = 15% of adults ill, report within one working day to724-4224.

Lice

(Pediculosis)

See head lice.



Measles

(Rubeola)

Virus.

Fever (=38.3°C), cough, pink eyes sensitive to light, runny nose (symptoms of a cold), dusky-red blotchy rash on 3rd to 4th day after onset of symptoms spreading downwards from face, and sometimes white spots in mouth.

Person-to-person by respiratory secretions or direct contact with secretions.

Very contagious.

10 days (range of 7-18) for fever and 14 for rash.

2 days before the fever and cough until 4 days after beginning of rash.



Meningitis

(any kind)

Bacteria or virus.

Young children may show a cluster of symptoms such as irritability, poor feeding, vomiting, fever and excessive high-pitched crying. Older children and adults may experience severe persistent headache, vomiting and neck rigidity.

Varies depending on cause of meningitis.

Often is person-to-person by respiratory secretions.





Molluscum contagiosum

(Non-plantar warts)

Virus.

Skin infection with small flesh-coloured or translucent bumps with sunken centre, most often on face, trunk, or limbs of children. Can be found on genitalia. Usually symptom-free, but may cause itchiness.

Person-to-person through direct skin-to-skin contact or indirect contact (by sharing clothes or at swimming pools), or sexually.

Handwashing is important to prevent transmission.

1-7 weeks, but can be as long as 6 months.

Unknown, but probably as long as lesions persist.

Not needed.

Mononucleosis Virus.

Fever, sore throat, swelling of glands around neck area, fatigue.

Person-to-person by respiratory secretions.

4-6 weeks. Up to 1 year or more.

Not needed.



Mumps Virus.

Fever, swelling and tenderness of salivary glands slightly above the angle of the jaw.

Person-to-person by respiratory secretions or contact with saliva.

12-25 days; usually 18 days.

7 days before, to 9 days after swelling; most contagious 48 hours before onset of illness.


If more than 1 case, report immediately to 724-4224(580-2400 after hours).

Nausea See Gastroenteritis.

Outbreaks(any kind, except for

gastroenteritis or diarrhea)

15% or more people sick with similar symptoms or absent at the same time.

For gastroenteritis or diarrhea: 3 or more cases, within 48 hours of each other in the same shelter or drop-in centre.

For mumps, measles, parvovirus, pertussis, and rubella: see specific reporting criteria.

Varies. Varies. Varies. Report immediately to 724-4224(580-2400 after hours).

Parvovirus B19 Virus

Mild fever and distinctive “slapped cheeks” facial rash. After 1-4 days, a red, lace-like rash appears on the arms and body and can last 1-3 weeks. May be symptom-free.

Person-to-person by respiratory secretions and mother-to-fetus

4-14 days (can be as long as 21 days)

One week before onset of rash until onset of rash. Children with chronic anemia maybe contagious for up to one week after onset of rash.

Report immediately if 2 cases (diagnosed by a physician)

Call 724-4224 or 560-2400 after hours

Pediculosis See head lice.



Pertussis

(Whooping cough)

Bacteria.

Repeated bouts of violent coughs which may end with a crowing or high pitched whoop and vomiting. Last 6 - 10 weeks.

Occurs mainly in pre-school children.


7 to 10 days, up to 20 days.

From the onset of the cough until:

a) 3 weeks after onset of paroxysms or whooping; or

b) 5 days after starting proper antibiotic treatment.


If part of an outbreak,

(more than 1 case) call immediately to 724-4224.

Pink Eye See Conjunctivitis.

Pinworms Worm.

Itching around the anal area. Irritability.

Pinworm eggs transmit to others by fecal-oral route or contaminated bedding, food or clothing.

2 to 8 weeks. During incubation period, until treatment is initiated.

Not needed.

Poison Ivy Plant toxin.

Not contagious.

Redness and blisters in linear pattern, where skin was exposed. Very itchy.

Direct skin contact with any part of the plant.

Washing any exposed skin and clothing to remove toxin ensures that no one else comes into contact with the toxin.

Symptoms appear after a few minutes to several days. Washing the exposed area immediately decreases the severity of symptoms.

Not contagious after the toxin has been washed off from the skin or clothing. The blister liquid is not contagious.

Not needed.

Rash See Candidiasis, Chickenpox, Coxsackie, Impetigo, Measles, Parvovirus, Poison Ivy, Ringworm, Roseola, Rubella, Scabies, or Streptococcal Infection.



Respiratory Syncytial Virus

Virus.

Can cause colds, bronchiolitis, bronchitis, croup, pneumonia, and ear infections. Most common in 0-2 years old.

Person-to-person through respiratory droplets or contact with secretions. Can be spread by contaminated toys and other surfaces.

2 to 8 days. From a few days before the appearance of symptoms for up to 4 weeks.

Not needed.

Ringworm

(Tinea)

Fungus. Flat, well demarcated, red, circular patches with scaly or crusted border on the skin or scalp. The patches are often itchy.

Person-to-person by direct contact: skin-to-skin.

Indirect spread by contaminated hands, objects and surfaces.

4 to 10 days. For duration of illness or until treatment is initiated.

Not needed

Roseola Virus.

Sudden onset of fever lasting 3-5 days. Following break of fever, fine, pink rash appears on trunk and body.

Person-to-person. Not well understood.

10 days. Unknown. Not needed.

Rubella

(German measles)

Virus.

Mild fever, runny nose, enlarged tender neck nodes, fine pale red rash spreading from behind the ears to the face, then downward. May have tender joints. Often difficult to diagnose.


Very contagious.

From 14 to 23 days, usually 16-18 days.

For about 1 week before until 7 days after the onset of the rash.

Report by next working day to724-4224.

If part of an outbreak, (more than 1 case) call immediately to724-4224(580-2400 after hours).



Salmonella Bacteria.

Diarrhea, nausea, vomiting, headache, abdominal pain, fever, lack of appetite. May be symptom-free.

Fecal-oral route.


Undercooked meats (any kind).

Undercooked eggs.

Unpasteurized milk.

Animal contact, e.g., turtles, chicks.

6-72 hours, usually 12-36 hours.

Several weeks to months after beginning of symptoms.

Report within one working day at 724-4224.

Scabies Caused by a mite burrowing under the skin.

Rash appears as bumps, patches or tiny red lines, usually between fingers and toes and in skin folds.

Intense itching, especially at night.

See fact sheet in “additional resources” section at the back of this manual

Person-to-person by direct skin-to-skin contact or indirectly by sharing of clothes or towels.

2 to 6 weeks.

1-4 days in persons previously infested.

From beginning of the incubation period until treated.

Scarlet Fever See Streptococcal Infection.

Shigella Bacteria.

Watery diarrhea which may contain blood, fever, nausea, vomiting, abdominal cramps. May be symptom free.


Fecal-oral route.

1 to 7 days, usually 1-3 days.

As long as present in the stool: 1 week if treated, up to 4 weeks if not.




Stomach Ache See Gastroenteritis or Hepatitis.

"Strep Throat" See Streptococcal Infection.

Streptococcal Infection

(Strep Throat)

(Scarlet Fever)

Bacteria.

Strep Throat:Very sore and red throat, fever.

Scarlet Fever:High fever, vomiting, "sandpaper" skin rash, "strawberry tongue", red cheeks and whiteness around mouth.

During convalescence, skin on hands and feet may peel.


1 to 5 days. From onset of symptoms until 24 hours after beginning of treatment.

Up to 10-21 days if untreated.

Not needed.

If in an outbreak situation (refer to "outbreak")

report, report immediately to724-4224(580-2400 after hours).

Streptococcal Infection

(Invasive Group A Strep)

Necrotizing fasciitis:Fever, localised redness, swelling, blister formation, and intense pain. Redness spreads very quickly (up to 3 cm/hour). Can arise from infected chickenpox lesions.

Toxic Shock Syndrome:Sudden onset of high fever, vomiting, diarrhea, rash, muscle pains, and shock. Can be fatal.

Person-to-person by respiratory secretions, through direct and indirect contact.

Up to 10 days. Unknown. Report immediately to 724-4224(580-2400 after hours).

Tinea See Ringworm



Tuberculosis Mycobacterium.

In the lungs or airways (pharynx, larynx):

Cough producing sputum, lasting over 2 weeks.

Loss of weight, fever, night sweats, tiredness.

Outside of the lungs or airways:It varies depending on where the disease is located (lymph nodes, larynx, bones, kidneys meningitis).

See fact sheet in “additional resources” section at the back of this manual

In the lungs or airways:Person-to-person by respiratory secretions.

Outside of the lungs or airways:If tuberculosis is anywhere else in the body, it is not contagious.

2 to 12 weeks for the Mantoux skin test to show exposure to the tuberculosis.

Several weeks to years for someone to show symptoms of illness.

In children 18 years of age and under, the incubation period tends to be shortest and the complications greatest.

Tuberculosis can be contagious only if it is in the lungs or airways.

Laboratory tests are needed to identify if or how contagious someone is.

Report within one working day to724-4224.

Typhoid fever See Salmonella.

Varicella See Chickenpox.

Vomiting See Gastroenteritis.

Whooping Cough

See Pertussis.



Yersinia Bacteria.

Watery diarrhea, fever, headache.

Raw pork and beef. Food and water contaminated by infected food handler or sewage. Contact with infected pets, e.g.: dogs, cats, rodents, birds.

3 to 7 days, usually under 10 days.

For 2 to 3 months or until treated with antibiotics.

Report within one working day 724-4224.

CITY OF OTTAWA PUBLIC HEALTH AND LONG TERM CARE BRANCH

REPORT OF DESIGNATED COMMUNICABLE DISEASESTO THE MEDICAL OFFICER OF HEALTH (MOH)

Under the Ontario Health Protection and Promotion Act, physicians, hospital operators, laboratory operators, school principals and child care facilities must report to the local MOH any person who, in his or her opinion, is or may be infected with an agent of one of the communicable diseases listed below. Your co-operation in reporting will help to ensure prompt and complete follow-up of cases.Please report according to the schedule outlined below.

Category 1: Diseases requiring IMMEDIATE public health follow up: Report immediately by telephone at 724-4224 during office hours. During evenings and week-ends report to the MOH on call at 580-2400.

Category 2: Diseases requiring prompt follow-up. Please ensure delivery by mail the next working day or telephone 724-4224.Any known or suspected outbreaks should be reported immediately as per category 1.

Category 3: Sexually Transmitted Diseases. These diseases should be reported to the SEXUAL HEALTH CENTRE on the next working day at 560-6099.

Category 4: No immediate action - may be delivered weekly by mail, in batches. Schools, day cares and nurseries may also report by calling 724-4224. Specific forms are available for chickenpox reporting and these may be sent in on a monthly basis.

CAT. DISEASE CAT. DISEASE

3- AIDS 2- Amebiasis 1- Anthrax 1- Bites of dogs, cats & suspected rabid animals 1 - Botulism 4 - Brucellosis 2 - Campylobacter enteritis 3 - Chancroid 4 - Chickenpox (Varicella) 3 - Chlamydia trachomatis infections 1 - Cholera 2 - Cryptosporidiosis 4 - Cytomegalovirus infection, congenital 1 - Diphtheria 4 - Encephalitis, including: i. Primary, viral ii. Post-infectious iii. Vaccine-related iv. Subacute sclerosing panencephalitis v. Unspecified 1 - Food poisoning, all causes 1 - Gastroenteritis, institutional outbreaks 2 - Giardiasis, except asymptomatic cases 3 - Gonorrhoea 1 - Group A Streptococcal infections, invasive 4 - Group B Streptococcal infections, neonatal 1 - Haemophilus influenzae b, invasive 1 - Hemorrhagic fevers, including: I. Ebola virus disease ii. Marburg virus disease iii. Other viral causes 1 - Hepatitis A 3 - Hepatitis B 3 - Hepatitis C 4 - Hepatitis D (Delta hepatitis) 3 - Herpes, neonatal 3 - HIV infection

4 - Influenza, Types A, B, & C 1 - Lassa Fever 4 - Legionellosis 4 - Leprosy 2 - Listeriosis 4 - Lyme Disease 4 - Malaria 1 - Measles 1 - Meningitis, bacterial 4 - Meningitis, viral 1 - Meningococcal disease, invasive 2 - Mumps 3 - Ophthalmia neonatorum 1 - Paratyphoid Fever 2 - Pertussis (Whooping Cough) 1 - Plague 1 - Poliomyelitis, acute 2 - Psittacosis/Ornithosis 2 - Q Fever 1 - Rabies 2 - Rubella 4 - Rubella, congenital syndrome 2 - Salmonellosis 1 - Shigellosis 3 - Syphilis 4 - Tetanus 2 - Trichinosis 2 - Tuberculosis 2 - Tularemia 1 - Typhoid Fever 1 - Verotoxin-producing E. coli infections and indicator conditions including Hemolytic Uremic Syndrome (HUS) 1 - Yellow Fever 2 - Yersiniosis

62

63

REPORTING FORM

Please complete all applicable areas and return form to:Medical Officer of HealthCity of OttawaPublic Health and Long Care BranchCommunicable Disease495 Richmond RoadOttawa, Ontario, K2A 4A4

FAX: (613) 724-4130

REPORTING AGENCY:

PATIENT INFORMATION:

SURNAME: FIRST NAME:

DATE OF BIRTH: AGE: SEX:

ADDRESS:

CITY: POSTAL CODE:

HOME PHONE: WORK PHONE:

OCCUPATION:

NAME OF SCHOOL/DAYCARE:

DISEASE INFORMATION:

DISEASE: ORGANISM/SITE: ONSET DATE: SPECIMEN TYPE:

TREATMENT HISTORY:

TREATMENT: TREATMENT DATE:

HOSPITALIZED?: YES NO HOSPITAL NAME:

ADMISSION DATE: DISCHARGE DATE: COMMENTS:

PHYSICIAN INFORMATION:

NAME: SPECIALTY: ADDRESS: CITY:

POSTAL CODE: PHONE:

DATE OF NOTIFICATION: SIGNATURE OF PERSON REPORTING:

64

Personal information on this form is collected under the authority of the Health Protection and Promotion Act, Sections 22 and 24, and will be used for Public Health follow-up. Any questions should be directed to the Communicable Diseases Manager at 722-2328.

65


Additional Information

— —

66


Resources

Hepatitis B, Hepatitis C

HIV

Head Lice

Scabies

Tuberculosis Health Facts

Positive Skin Test

TB Booklet – What I Need to Know

What to Do With Used Needles

Be Careful With Needles!

— —

67


AppendicesAppendix I

Table 6:Transmission Characteristics and Empiric Precautions by Clinical Presentations: Recommendations for Acute Care Centres.

Appendix IITable 7:Transmission Characteristics and Precautions by Specific Etiology: Recommendations for Acute Care Centres

Health Canada (1999). Infection Control Guidelines: Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Health Care.Canadian Communicable Disease Report. Ottawa, ON: Health Canada

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68


Glossary of Terms

— —

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GLOSSARY OF TERMS

Antimicrobial Agent: A product that kills or suppresses the growth of microorganisms.

Antimicrobial-Resistant Organism: A microorganism that has developed resistance to the action of several antimicrobial agents and that is of special clinical or epidemiologic significance. Organisms included in this group are MRSA, VRE, penicillin-resistant pneumococcus, certain Gram negative bacilli resistant to all penicillins and cephalosporins, and multi-drug resistant Mycobacterium tuberculosis. Other microorganisms may be added to this list if antibiotic resistance is judged to be significant in a specific health care facility or patient population, at the discretion of the infection control program or local, regional or national authorities.

Antiseptics: chemicals that kill microorganisms on living skin or mucous membranes. Antiseptics should not be used in housekeeping.

Barrier Techniques: Use of single rooms, gloves, masks, or gowns in health care settings to prevent transmission of microorganisms.

Carrier: An individual who is found to be persistently colonized (culture-positive) for a particular organism, at one or more body sites, but has no signs or symptoms of infection.

Cleaning: the physical removal of foreign material, e.g., dust, soil, organic material such as blood, secretions, excretions and microorganisms. Cleaning physically removes rather than kills microorganisms. It is accomplished with water, detergents and mechanical action. The terms “decontamination” and “sanitation” may be used for this process in certain settings, e.g., central service or dietetics. Cleaning reduces or eliminates the reservoirs of potential pathogenic organisms. Cleaning agents are the most common chemicals used in housekeeping activity.

Colonization: Presence of microorganisms in or on a host with growth and multiplication but without tissue invasion or cellular injury.

Communicable: Capable of being transmitted from one person to another; synonymous with “infectious” and “contagious”.

Contagious: Capable of being transmitted from one person to another; synonymous with “infectious” and “communicable”.

Contamination: The presence of microorganisms on inanimate objects (e.g. clothing, surgical instruments) or microorganisms transported transiently on body surfaces such as hands, or in substances (e.g. water, food, milk).

Critical items: instruments and devices that enter sterile tissues, including the vascular system. Critical items present a high risk of infection if the item is contaminated with any microorganisms, including bacterial spores. Reprocessing critical items involves meticulous cleaning followed by sterilization.

Disease: Clinical expression of infection; signs and/or symptoms are produced.

Health Canada (1999). Infection Control Guidelines: Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Health Care. Canadian Communicable Disease Report. Ottawa, ON: Health Canada

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GLOSSARY OF TERMS

Disinfection: the inactivation of disease-producing microorganisms. Disinfection does not destroy bacterial spores. Disinfectants are used on inanimate objects; antiseptics are used on living tissue. Disinfection usually involves chemicals, heat or ultraviolet light. Levels of chemical disinfection vary with the type of product used.

Fomites: those objects in the inanimate environment that may become contaminated with microorganisms and serve as a vehicle of transmission.

Germicide: an agent that destroys microorganisms, especially pathogenic organisms.

Hand antisepsis: a process for the removal or destruction of resident and transient microorganisms on hands.

Hand wash(ing): a process for the removal of soil and transient microorganisms from the hands.

Heavy microbial soiling: the presence of infection or high levels of contamination with organic material, e.g., infected wounds, feces.

High level disinfection: level of disinfection required when processing semicritical items. High level disinfection processes destroy vegetative bacteria, mycobacteria, fungi and enveloped (lipid) and non enveloped (non lipid) viruses, but not necessarily bacterial spores. High level disinfectant chemicals (also called chemisterilants) must be capable of sterilization when contact time is extended. Items must be thoroughly cleaned prior to high level disinfection.

Immunocompromised: Increased susceptibility to infection. In this document the term refers to patients with congenital or acquired immunodeficiency or immunodeficiency due to chemotherapeutic agents or hematologic malignancies.

Infection: The entry and multiplication of an infectious agent in the tissues of the host

a) Inapparent (asymptomatic, subclinical) infection: an infectious process running a course similar to that of clinical disease but below the threshold of clinical symptoms

b) Apparent (symptomatic, clinical) infection: one resulting in clinical signs and symptoms (disease).

Infectious: Caused by infection or capable of being transmitted.

Infectious tuberculosis: Factors related to the patient that enhance transmission and determine the patient’s level of infectivity include:

• disease involving the lungs, airways or larynx• presence of acid-fast bacilli on microscopic direct smear examination of the sputum• presence of cavitation, extensive disease, or pneumonic infiltrates on x-ray• undergoing a procedure that can induce coughing or cause aerosolization of tubercle bacilli• presence of cough, sneeze or other forceful expiratory procedure in a patient with pulmonary TB.



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GLOSSARY OF TERMS

Infectious waste: that portion of biomedical waste that is capable of producing infectious disease (219)

Intermediate level disinfection: level of disinfection required for some semicritical items. Intermediate level disinfectants kill vegetative bacteria, most viruses and most fungi but not resistant bacterial spores.

Isolation The physical separation of infected individuals from those uninfected for the period of communicability of a particular disease.

Low level disinfection: level of disinfection required when processing noncritical items or some environmental surfaces. Low level disinfectants kill most vegetative bacteria and some fungi as well as enveloped (lipid) viruses (e.g., hepatitis B, C, Hantavirus, and HIV). Low level disinfectants do not kill mycobacteria or bacterial spores. Low level disinfectants-detergents are used to clean environmental surfaces.

Noncritical items: those that either touch only intact skin but not mucous membranes or do not directly touch the patient. Reprocessing of noncritical items involves cleaning and/or low level disinfection.

Outbreak: An excess over the expected incidence of disease within a geographic area during a specified time period, synonymous with epidemic.

Plain or nonantimicrobial soap: detergent-based cleansers in any form (bar, liquid, leaflet, or powder) used for the primary purpose of physical removal of soil and contaminating microorganisms. Such soaps work principally by mechanical action and have weak or no bactericidal activity. Although some soaps contain low concentrations of antimicrobial ingredients, these are used as preservatives and have minimal effect on colonizing flora.

Precautions: Interventions implemented to reduce the risk of transmission of microorganisms from patient to patient, patient to health care worker, and health care worker to patient.

Sanitation: a process that reduces microorganisms on an inanimate object to a safe level (e.g., dishes and eating utensils are sanitized).

Semicritical items: devices that come in contact with nonintact skin or mucous membranes but ordinarily do not penetrate them. Reprocessing semicritical items involves meticulous cleaning followed preferably by high-level disinfection (level of disinfection required is dependent on the item, see Table 5). Depending on the type of item and its intended use, intermediate level disinfection may be acceptable (see Table 5 for examples).

Sharps: needles, syringes, blades, laboratory glass or other objects capable of causing punctures or cuts.

Sterilization: the destruction of all forms of microbial life including bacteria, viruses, spores and fungi. Items must be cleaned thoroughly before effective sterilization can take place.


(adapted for use by shelters June 2001

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References

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REFERENCESBlock, Seymour S (1991). Disinfection, Sterilizaton, and Preservation. (4th Edition). Philadelphia:Lea & Febiger.

City of Ottawa, Public Health and Long Term Care Branch, Health Protection Division, Communicable Disease Program (1997). Tuberculosis Screening and Contact Management: Recommendations and Notes. Ottawa, ON, City of Ottawa, Communicable Disease Program.


City of Ottawa, Public Health and Long Term Care Branch, Health Protection Division, Communicable Disease Program (2001). Policy for Tuberculosis Screening in Shelters and Drop-In Centres. Ottawa, ON: City of Ottawa, Communicable Disease Program.

City of Ottawa, Public Health and Long Term Care Branch. Health Protection Division, Communicable Disease Program (2001). Guidelines for Communicable Disease and Other Health Issues in Shelters and Drop-In Centres. Ottawa, ON: City of Ottawa, Communicable Disease Program.

City of Ottawa. Public Health and Long Term Care Branch. Health Protection Division. Communicable Disease Program (2001). Needlestick Injury/Accidental Exposure Protocol Chart for use in Shelters and Drop-In Centres. Ottawa, ON: City of Ottawa, Communicable Disease Program.

City of Ottawa, Public Health and Long Term Care Branch (November, 2000). Communicable Disease Report. Ottawa, ON: City of Ottawa

City of Ottawa, Public Health and Long Term Care Branch. Health Protection Division. Environmental Health Program (Date Unknown). Correct Handwashing Procedures: Fact Sheet. Ottawa, ON: City of Ottawa, Environmental Health Program.

City of Ottawa, Public Health and Long Term Care Branch, Health Protection Division, Environmental Health Program (2001). What to Do With Used Needles. Ottawa, ON: City of Ottawa, Environmental Health Program

City of Ottawa, Public Health and Long Term Care Branch. Sexual Health Centre (2001). Be Careful With Needles! Ottawa, ON: City of Ottawa, Sexual Health Centre.

City of Ottawa, Public Health and Long Term Care Branch. Sexual Health Centre (2000).Hepatitis B: Fact sheet. Ottawa, ON: City of Ottawa, Sexual Health Centre.

City of Ottawa, Public Health and Long Term Care Branch, Sexual Health Centre. (2000).Hepatitis C: Fact sheet. Ottawa, ON: City of Ottawa, Sexual Health Centre.

City of Ottawa, Public Health and Long Term Care Branch, Sexual Health Centre. (2000).HIV: Fact sheet. Ottawa, ON: City of Ottawa, Sexual Health Centre.

City of Toronto Public Health and Lung Association (Date Unknown). Positive Skin Test. Toronto, ON, City of Toronto, Public Health Department.

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REFERENCESCollege of Nurses of Ontario (2000). Infection Control Guidelines. Toronto, ON, College of Nurses of Ontario, 3-10.

(The) College of Physicians and Surgeons of Ontario (1999). Infection Control in the Physicians’ Office. Toronto, ON. the College of Physicians and Surgeons of Ontario, 1-41.

Health Canada (1998). Canadian Immunization Guide. (5th Edition). Ottawa, ON: Canadian Medical Association, 54-57.

Health Canada (1998). Infection Control Guidelines: Hand Washing, Cleaning, Disinfection and Sterilization in Health Care. Canadian Communicable Disease Report. Ottawa, ON: Health Canada, 1-58.

Health Canada (1997). Infection Control Guidelines: Preventing the Transmission of Bloodborne Pathogens in Health Care and Public Services Settings. Canada Communicable Disease Report 23S3. Ottawa, ON: Health Canada, 1-42.


Ontario Ministry of Health (1998). Tuberculosis Control Protocol, Ministry of Health, Public Health Branch, Mandatory Health Programs Service Guidelines. Toronto, ON: Queens Printer for Ontario.



Ontario Ministry of Health (1995). Health Facts TB Infection /TB Disease. 100M/12/95 CAT# 4129492, Toronto, ON: Queens Printer for Ontario.

Ontario Ministry of Health (1993). Communicable Disease Control Outbreak Control: A Guide to the Control of Enteric Disease Outbreaks in Health Care Facilities. Toronto, ON: Queens Printer for Ontario.

(The) Ottawa Organization for Practitioners in Infection Prevention and Control. A Chapter of the Community and Hospital Infection Control Association-Canada (November 1999). Infection Prevention and Control Guidelines for Housekeeping Practices Related to Multi-Drug Resistant Organisms (MDRO).Ottawa, ON, the Ottawa Organization for Practitioners in Infection Prevention and Control.A Chapter of the Community and Hospital Infection Control Association-Canada.

Rutala, William A (1996). APIC (Association for Professional in Infection Control and Epidemiology) Guidelines for Selection and Use of Disinfectants. AJIC Am J Infect Control 24:313-42

Rutala, William A. (1998). Stability and Bactericidal Activity of Chlorine Solutions.Infection Control and Hospital Epidemiology vol. 19: No 5 323-610

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Documents

TABLE OF CONTENTS - Ottawa Inner City Health · Web viewSharps such as needles, blood syringes, lancets, or clinical glass—should be disposed of in a biohazard container and disposed