Infection Control
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Infection Control Dr Khansa Ababneh
Specialties
Dentists
Dental hygienists
Dental Assistants
Dental technicians
Radiographic technicians
A High Risk Profession
Need For Protection
Protection From What?
Blood (saliva)-borne pathogens
Air-borne pathogens
Pathogens transmitted by skin contact
Protecting Whom?
Protecting:
Ourselves
Patient
Other patients
Other staff
Our families
Infectious diseases Viral Bacterial Parasitic
Viral infections
HIV (AIDS)
Hepatitis Viruses
Papilloma viruses (HPV)
Measles, Rubella, Mumps
Hepatitis
A, B, C, E, G, H
Only
vaccination against HBv is available !!
Protect Yourself!
Herpes viruses
Herpes simplex (HS type 1 & 2) Varicella & zoster (human HV 3) Epstein-Barr virus (human HV 4)
Infectious mononucleosis
Cytomegalovirus CMV (human HV 5)
AIDS
Bacterial Infections
Tuberculosis (TB) Legionnaire’s disease Infected
aerosols!
Cross-Infection
Patient
Operator
Other personnel
During surgical procedures
Pathogenic MO introduced into wounds
Bloodstream Wound Breakdown Delayed Healing
In UK
Working Groups:
EAGA (Expert Advisory Group on AIDS)
ACDP (Advisory Committee on dangerous pathogens)
Advisory Group on Hepatitis
Microbiology Advisory Committee
Health Services Advisory Committee (HSAC) Joint Committee on Vaccination & Immunisation (JCVI) Control of Substances Hazardous to Health (COSHH)
Whose Responsibility?
Health authorities must draw their own detailed local guidelines to prevent spread of Hepatitis and AIDS viruses.
All employers have a legal obligation to ensure that all their employees are appropriately trained and proficient in the procedures necessary for working safety.
Every member of the dental/medical staff has a legal and moral duty to ensure that all necessary steps are taken to prevent cross-infection to protect the patient, colleagues and themselves
“Getting Rid” of Microorganisms
Definitions
Sterilization
Disinfection
Asepsis
Sterilization Removal/destruction of all microorganisms
Disinfection Destruction of the pathogenic MO in their non-sporing state
Asepsis A method of surgery which is designed to prevent the introduction of infection into a wound during surgery or wound dressing
Mouth cannot be sterilized but the number of MO can be reduced by scaling one week before surgery + CHX mw. Local defence mechanisms can cope with endogenous infection, but not exogenous infections
Cannot autoclave patients
General Guidelines Before procedures: Hands must be cleansed: (soap + water)/(surgical scrub) & wear clean/sterile gloves
Instruments must be sterilized Before sterilization, instruments must be CLEANED from debris and blood deposits
Sterilization of Disposable Items
Gamma irradiated
Reliable manufacturer and unbroken rapping
Suitable for scalpel blades and sutures
Autoclaving (moist heat) sterilization
Boiling water alone is INSUFFICIENT to kill spores and viruses Effective autoclaving: Temperature = 134ºC, Pressure= 32 lb/sq (Psi), Time =3.5 minutes If instrument will not be used immediately, must have a drying phase Autoclaving may reduce sharpness of instruments and promote rusting
Dry heat sterilization
Takes place in a “Hot Air Oven”
Suitable for instruments with a sharp cutting edge
For effective heat sterilization: Temperature = 160º C, Time = 60 minutes
Chemical disinfection
Suitable for working surfaces & instruments
Limitations:
The object to be disinfected must be thoroughly cleaned
Efficient at certain Concentration & Temperature
Each agent needs a certain minimum exposure time
Certain chemicals may damage certain surfaces
Shelf-life
Chemical Disinfectants
Alcohols, Aldehydes, Biguanides, Halogens, Phenolics, Quaternary Ammonium Compounds
Alcohols
Isopropyl alcohol & 70% ethyl alcohol
Effective against Gram negative (G-ve) bacteria on clean surfaces Not active against fungi Suitable for skin preparation before venepuncture
Aldehydes
Glutaraldehyde (Cidex), & Formaldehyde (formalin)
Active against G-ve bact., spores, viruses (HB, HIV) & fungi Require 3 hours of exposure Suitable for nonautoclavable instruments Blood/saliva spillages
Biguanides
Chlorhexidine
Active against Staph. aureus & some G-Ve bacteria
Active against fungi & viruses ONLY at very high conc
Inactivated by soap and pus
Antiseptic: Used for disinfecting skin and mucous membranes e.g.:
Savlon®: 0.5%CHX + cetrimide Hibiscrub®: 4%CHX + detergent Hexana®, Corsodyl® mw =0.2% CHX
Halogens I Sodium
hypochlorite, 10000 ppm of available chlorine Active
against bacteria, spores, fungi and viruses (HB, HIV)
At
least 20 minutes of exposure time
Inactivated
by blood, pus and dilution
Halogens II
Iodophors & iodine
Active against bacteria, spores & some viruses & fungi Can be inactivated by pus and blood
Suitable for skin preparation, mouthwash & as a surgical scrub (7.5% Povidone-iodine= Betadine)
Phenolics
Hexachloraphane Active against staph aureus, limited activity against G-ve bacilli Used as a surgical scrub (Phisomed®)
Quaternary Ammonium Compounds Cetrimide Active Easily Can
(+0.5%CHX= Savlon®)
against staph aureus
inactivated by water and soap
be contaminated by pseudomonas
Hand disinfection
Jewellery removed & nails short Hibiscrub, Phisomed or Betadine If above is not available: Soap with hexachloraphane for 5 min in running water followed by 70% alcohol or Hibisol® (2.5%CHX+70% alcohol)
Preparation of operation site
Circumoral skin with same agent used for hand disinfection Oral mucosa disinfection with 0.2-0.5% CHX mw, or iodine mw Needle puncture site: CHX mw & dry area
Key Points in Infection Control UNIVERSAL PRECAUTIONS
Universal Precautions
CDC (Centers for Disease Control) in 1987:
All patients be regarded as potentially infective (HIV & Hepatitis…)
“All health care workers should routinely use appropriate barrier precautions to prevent skin and mucous membrane exposure when contact with blood or other body fluids of any patient is anticipated”
Universal Precautions Staff
members & patients should be protected from blood-borne (and all) infections
Equipment
All working surfaces should be covered with disposable material Disposable instruments should be used wherever possible Anaesthetic cartridges and needles must not be reused for any other patient Used equipment should be identified as infected and handled with gloves before discarding into an impervious container, or washing and autoclaving.
Sterilization
Instruments must be placed in impervious container before sterilization
Disposable instruments, dressings etc. should be incinerated
Heavy domestic rubber gloves should be worn during instrument cleaning Non-disposable instruments should be rinsed in an effective disinfectant
Sterilization
Non-disposable instruments and dental impressions that cannot be sterilized by heat should be disinfected by immersion for at least 1 hr (preferably overnight) in a suitable disinfectant such as 10 % hypochlorite Working areas are disinfected with hypochlorite (1 per cent available chlorine) Since some viruses remain stable in blood stains for up to 6 months at room temperature, spillage of blood should be disinfected by dropping a napkin on the area and flooding it with hypochlorite
Protection of dental staff
All staff must be educated about the possible dangers of hepatitis, HIV and other infections, their modes of transmission and the precautions necessary to prevent cross-infection, particularly vaccination against HBV. All members of the dental team should be fully immunized against HBV Immunocompromised staff should be absolved from the responsibility of treating infected patients
Should the skin be punctured by an instrument that has been used on a patient, the area of skin should be liberally rinsed in water and the advice of the nearest Public Health Laboratory or hospital microbiologist sought. Where appropriate, blood from the patient on whom the instrument was used, and from the wounded person, should be tested for HBeAg, and HIV antibodies to determine the possible risks.
Routine safe working practice
Always cover cuts and grazes with waterproof dressings
Wear gloves if there is any chance of contact with blood or body fluids
Gloves must always be worn when touching blood, saliva, teeth or mucous membranes or items that have been in contact with them.
Between patients the gloves are removed, hands washed and a new pair of gloves put on before proceeding When wearing gloves contact with inanimate objects should be avoided as far as possible When gloves are torn, cut or punctured, they must be removed immediately, hands thoroughly washed and regloving accomplished before completion of the procedure.
Aerosol and Splashes
If there is a risk of splashes of blood or body fluid, also wear masks and protective spectacles or goggles
Masks should be worn whenever dental aerosol or tooth fragments are generated Eye protection should be worn by staff treating patients Eye protection for patients
Sharps
Dispose of needles immediately into sharps containers ; only re-sheath local anaesthetic syringe needles using an appropriate sheath-holding device.
Dispose carefully of all surgical sharps, glass items, burs, wire etc., into a sharpsafe box
Take extreme care with sharp instruments.
You
Make sure working clothing is clean. Contaminated clothing (e.g. blood-stained) must be changed immediately. Hands should be washed thoroughly when entering or leaving clinical areas and before eating or drinking. Soap dispensers and taps should be operated by the elbows or wrists not gloves or hands. All specimens for laboratory tests should be placed in appropriate containers and sealed into plastic bags separate from the request form Do not eat, drink, comb hair, brush teeth or apply cosmetics in clinical areas
Smoking
Specific Precautions
Before a session 4.
Run water through each water system Clean and disinfect with detergent: Working surfaces 2. Dental equipment Reduce to a minimum the number of equipment laid out ready for use. Wherever possible, instruments should be sterilizable or disposable Cling-film should be placed across the chair buttons, light handles, ultrasonic scaler handpiece and 3-in-1 syringe. The film is changed after every patient.
During a clinical session
In a small area around the patient (includes the dental unit and extends to include the waste disposal bag), only essential equipment, instrument, materials and personnel should be in this area of potential high contamination. The contents of the remainder of the treatment should be kept to a minimum Open cuts and fresh abrasions to the skin should be covered with a waterproof dressing Touching anything other than “essential items” with gloves/hands should be avoided.
A good working posture should be maintained to reduce facial contamination from the patient's mouth
High volume suction should be used to reduce dental aerosols
Blood or body fluid spillage must be dealt with as soon as it happens: Hypochlorite granules can be sprinkled over the spillage. Alternatively, disposable tissues can be placed over the spillage and then strong hypochlorite poured on to paper towels which are placed over the spill and left for 30 minutes.
Clearing up and cleaning after each patient
It is during the clean up and disposal stage that the greatest risk of injury or infection occurs It is advisable to wear heavy-duty rubber gloves and to wash them during clean-up procedures to reduce the spread of infection Remove sharps first and place in a sharp-safe box
Sterilize detachable handpieces, ultrasonic scalers, aspiration tips and 3-in-1 tip.
Disinfect the chair, bracket table, including body of the 3-in-1 syringe, slow speed motor and the holder, operating light and spittoon Wipe all surfaces with detergent or hypochlorite Remove any residual cement or impression material from handles etc., and wipe area with detergent chloros Anything likely to be contaminated with blood, wipe thoroughly with strong hypochlorite
All
non-disposable garments can be washed in a conventional automatic washing machine, provided the washing cycle includes a 10 min period of 90°C water temperature.
Immunization Against Hepatitis B virus
Your Responsibility
Specialties
Dentists
Dental hygienists
Dental Assistants
Dental technicians
Radiographic technicians
A High Risk Profession
Need For Protection
Protection From What?
Blood (saliva)-borne pathogens
Air-borne pathogens
Pathogens transmitted by skin contact
Protecting Whom?
Protecting:
Ourselves
Patient
Other patients
Other staff
Our families
Infectious diseases Viral Bacterial Parasitic
Viral infections
HIV (AIDS)
Hepatitis Viruses
Papilloma viruses (HPV)
Measles, Rubella, Mumps
Hepatitis
A, B, C, E, G, H
Only
vaccination against HBv is available !!
Protect Yourself!
Herpes viruses
Herpes simplex (HS type 1 & 2) Varicella & zoster (human HV 3) Epstein-Barr virus (human HV 4)
Infectious mononucleosis
Cytomegalovirus CMV (human HV 5)
AIDS
Bacterial Infections
Tuberculosis (TB) Legionnaire’s disease Infected
aerosols!
Cross-Infection
Patient
Operator
Other personnel
During surgical procedures
Pathogenic MO introduced into wounds
Bloodstream Wound Breakdown Delayed Healing
In UK
Working Groups:
EAGA (Expert Advisory Group on AIDS)
ACDP (Advisory Committee on dangerous pathogens)
Advisory Group on Hepatitis
Microbiology Advisory Committee
Health Services Advisory Committee (HSAC) Joint Committee on Vaccination & Immunisation (JCVI) Control of Substances Hazardous to Health (COSHH)
Whose Responsibility?
Health authorities must draw their own detailed local guidelines to prevent spread of Hepatitis and AIDS viruses.
All employers have a legal obligation to ensure that all their employees are appropriately trained and proficient in the procedures necessary for working safety.
Every member of the dental/medical staff has a legal and moral duty to ensure that all necessary steps are taken to prevent cross-infection to protect the patient, colleagues and themselves
“Getting Rid” of Microorganisms
Definitions
Sterilization
Disinfection
Asepsis
Sterilization Removal/destruction of all microorganisms
Disinfection Destruction of the pathogenic MO in their non-sporing state
Asepsis A method of surgery which is designed to prevent the introduction of infection into a wound during surgery or wound dressing
Mouth cannot be sterilized but the number of MO can be reduced by scaling one week before surgery + CHX mw. Local defence mechanisms can cope with endogenous infection, but not exogenous infections
Cannot autoclave patients
General Guidelines Before procedures: Hands must be cleansed: (soap + water)/(surgical scrub) & wear clean/sterile gloves
Instruments must be sterilized Before sterilization, instruments must be CLEANED from debris and blood deposits
Sterilization of Disposable Items
Gamma irradiated
Reliable manufacturer and unbroken rapping
Suitable for scalpel blades and sutures
Autoclaving (moist heat) sterilization
Boiling water alone is INSUFFICIENT to kill spores and viruses Effective autoclaving: Temperature = 134ºC, Pressure= 32 lb/sq (Psi), Time =3.5 minutes If instrument will not be used immediately, must have a drying phase Autoclaving may reduce sharpness of instruments and promote rusting
Dry heat sterilization
Takes place in a “Hot Air Oven”
Suitable for instruments with a sharp cutting edge
For effective heat sterilization: Temperature = 160º C, Time = 60 minutes
Chemical disinfection
Suitable for working surfaces & instruments
Limitations:
The object to be disinfected must be thoroughly cleaned
Efficient at certain Concentration & Temperature
Each agent needs a certain minimum exposure time
Certain chemicals may damage certain surfaces
Shelf-life
Chemical Disinfectants
Alcohols, Aldehydes, Biguanides, Halogens, Phenolics, Quaternary Ammonium Compounds
Alcohols
Isopropyl alcohol & 70% ethyl alcohol
Effective against Gram negative (G-ve) bacteria on clean surfaces Not active against fungi Suitable for skin preparation before venepuncture
Aldehydes
Glutaraldehyde (Cidex), & Formaldehyde (formalin)
Active against G-ve bact., spores, viruses (HB, HIV) & fungi Require 3 hours of exposure Suitable for nonautoclavable instruments Blood/saliva spillages
Biguanides
Chlorhexidine
Active against Staph. aureus & some G-Ve bacteria
Active against fungi & viruses ONLY at very high conc
Inactivated by soap and pus
Antiseptic: Used for disinfecting skin and mucous membranes e.g.:
Savlon®: 0.5%CHX + cetrimide Hibiscrub®: 4%CHX + detergent Hexana®, Corsodyl® mw =0.2% CHX
Halogens I Sodium
hypochlorite, 10000 ppm of available chlorine Active
against bacteria, spores, fungi and viruses (HB, HIV)
At
least 20 minutes of exposure time
Inactivated
by blood, pus and dilution
Halogens II
Iodophors & iodine
Active against bacteria, spores & some viruses & fungi Can be inactivated by pus and blood
Suitable for skin preparation, mouthwash & as a surgical scrub (7.5% Povidone-iodine= Betadine)
Phenolics
Hexachloraphane Active against staph aureus, limited activity against G-ve bacilli Used as a surgical scrub (Phisomed®)
Quaternary Ammonium Compounds Cetrimide Active Easily Can
(+0.5%CHX= Savlon®)
against staph aureus
inactivated by water and soap
be contaminated by pseudomonas
Hand disinfection
Jewellery removed & nails short Hibiscrub, Phisomed or Betadine If above is not available: Soap with hexachloraphane for 5 min in running water followed by 70% alcohol or Hibisol® (2.5%CHX+70% alcohol)
Preparation of operation site
Circumoral skin with same agent used for hand disinfection Oral mucosa disinfection with 0.2-0.5% CHX mw, or iodine mw Needle puncture site: CHX mw & dry area
Key Points in Infection Control UNIVERSAL PRECAUTIONS
Universal Precautions
CDC (Centers for Disease Control) in 1987:
All patients be regarded as potentially infective (HIV & Hepatitis…)
“All health care workers should routinely use appropriate barrier precautions to prevent skin and mucous membrane exposure when contact with blood or other body fluids of any patient is anticipated”
Universal Precautions Staff
members & patients should be protected from blood-borne (and all) infections
Equipment
All working surfaces should be covered with disposable material Disposable instruments should be used wherever possible Anaesthetic cartridges and needles must not be reused for any other patient Used equipment should be identified as infected and handled with gloves before discarding into an impervious container, or washing and autoclaving.
Sterilization
Instruments must be placed in impervious container before sterilization
Disposable instruments, dressings etc. should be incinerated
Heavy domestic rubber gloves should be worn during instrument cleaning Non-disposable instruments should be rinsed in an effective disinfectant
Sterilization
Non-disposable instruments and dental impressions that cannot be sterilized by heat should be disinfected by immersion for at least 1 hr (preferably overnight) in a suitable disinfectant such as 10 % hypochlorite Working areas are disinfected with hypochlorite (1 per cent available chlorine) Since some viruses remain stable in blood stains for up to 6 months at room temperature, spillage of blood should be disinfected by dropping a napkin on the area and flooding it with hypochlorite
Protection of dental staff
All staff must be educated about the possible dangers of hepatitis, HIV and other infections, their modes of transmission and the precautions necessary to prevent cross-infection, particularly vaccination against HBV. All members of the dental team should be fully immunized against HBV Immunocompromised staff should be absolved from the responsibility of treating infected patients
Should the skin be punctured by an instrument that has been used on a patient, the area of skin should be liberally rinsed in water and the advice of the nearest Public Health Laboratory or hospital microbiologist sought. Where appropriate, blood from the patient on whom the instrument was used, and from the wounded person, should be tested for HBeAg, and HIV antibodies to determine the possible risks.
Routine safe working practice
Always cover cuts and grazes with waterproof dressings
Wear gloves if there is any chance of contact with blood or body fluids
Gloves must always be worn when touching blood, saliva, teeth or mucous membranes or items that have been in contact with them.
Between patients the gloves are removed, hands washed and a new pair of gloves put on before proceeding When wearing gloves contact with inanimate objects should be avoided as far as possible When gloves are torn, cut or punctured, they must be removed immediately, hands thoroughly washed and regloving accomplished before completion of the procedure.
Aerosol and Splashes
If there is a risk of splashes of blood or body fluid, also wear masks and protective spectacles or goggles
Masks should be worn whenever dental aerosol or tooth fragments are generated Eye protection should be worn by staff treating patients Eye protection for patients
Sharps
Dispose of needles immediately into sharps containers ; only re-sheath local anaesthetic syringe needles using an appropriate sheath-holding device.
Dispose carefully of all surgical sharps, glass items, burs, wire etc., into a sharpsafe box
Take extreme care with sharp instruments.
You
Make sure working clothing is clean. Contaminated clothing (e.g. blood-stained) must be changed immediately. Hands should be washed thoroughly when entering or leaving clinical areas and before eating or drinking. Soap dispensers and taps should be operated by the elbows or wrists not gloves or hands. All specimens for laboratory tests should be placed in appropriate containers and sealed into plastic bags separate from the request form Do not eat, drink, comb hair, brush teeth or apply cosmetics in clinical areas
Smoking
Specific Precautions
Before a session 4.
Run water through each water system Clean and disinfect with detergent: Working surfaces 2. Dental equipment Reduce to a minimum the number of equipment laid out ready for use. Wherever possible, instruments should be sterilizable or disposable Cling-film should be placed across the chair buttons, light handles, ultrasonic scaler handpiece and 3-in-1 syringe. The film is changed after every patient.
During a clinical session
In a small area around the patient (includes the dental unit and extends to include the waste disposal bag), only essential equipment, instrument, materials and personnel should be in this area of potential high contamination. The contents of the remainder of the treatment should be kept to a minimum Open cuts and fresh abrasions to the skin should be covered with a waterproof dressing Touching anything other than “essential items” with gloves/hands should be avoided.
A good working posture should be maintained to reduce facial contamination from the patient's mouth
High volume suction should be used to reduce dental aerosols
Blood or body fluid spillage must be dealt with as soon as it happens: Hypochlorite granules can be sprinkled over the spillage. Alternatively, disposable tissues can be placed over the spillage and then strong hypochlorite poured on to paper towels which are placed over the spill and left for 30 minutes.
Clearing up and cleaning after each patient
It is during the clean up and disposal stage that the greatest risk of injury or infection occurs It is advisable to wear heavy-duty rubber gloves and to wash them during clean-up procedures to reduce the spread of infection Remove sharps first and place in a sharp-safe box
Sterilize detachable handpieces, ultrasonic scalers, aspiration tips and 3-in-1 tip.
Disinfect the chair, bracket table, including body of the 3-in-1 syringe, slow speed motor and the holder, operating light and spittoon Wipe all surfaces with detergent or hypochlorite Remove any residual cement or impression material from handles etc., and wipe area with detergent chloros Anything likely to be contaminated with blood, wipe thoroughly with strong hypochlorite
All
non-disposable garments can be washed in a conventional automatic washing machine, provided the washing cycle includes a 10 min period of 90°C water temperature.
Immunization Against Hepatitis B virus
Your Responsibility
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