CHAPTER ONE
INTRODUCTION
This chapter reviews in brief, Health Care Associated Infections (HAI), elements required for transmission of infectious agent within a health care setting (chain of infection, sources of infection, susceptible host, mode of transmission, portal of entry and portal of exit), HAI among health-care workers, Universal Precautions (UP), Body Substances Isolation (BSI) and Standard Precautions (SP).
1.1 HEALTH CARE- ASSOCIATED INFECTIONS (HAI):
Health-care associated infection (HAI), also referred to as nosocomial infection and hospital acquired infection, is defined by Center of Disease Control and Prevention (CDC) as an “infection caused by a wide variety of common and unusual bacteria, fungi, and viruses during the course of receiving medical care”(CDC, 2012). It either occurs while patients receive care or may develop after discharge. It also involves occupation infection among staff. HAI can also be defined as an “infection occurring in patients during the process of care in a hospital or health care facility which was not present or incubating at the time of admission. This includes infection acquired in the hospital, but appearing after discharge and also occupational infections among staff or facility” (WHO, 2012).HAI is considered an important public health problem (WHO, 2012). Globally, hundreds of millions of patients are infected by HAI every year in both developed and developing countries. According to WHO, its prevalence in developed countries varied between 3.5% and 12%, while in developing countries it varied between 5.7% and 19.1% (WHO, 2012). The highest occurrence of HAI were in acute surgical, orthopedic wards and Intensive Care Unit (WHO, 2002). The prevalence rate of ICU-acquired infection in high-income countries was 30%, while in middle and low-income countries, it was at least 2-3 times higher than that in high -income countries(WHO, 2009; WHO, 2012).
The consequences of HAI at patients’ level imply more suffering, more complications, more treatments, and increase in hospitalization periods. For example, in Europe duration of hospitalization increased to nearly 16 million extra days (WHO, 2012).This is in itself considered a risk factor for acquiring HAI, and it means an increase in costs (WHO, 2012). In addition, it increases economic burden on the health care systems of countries. For example, in England, the annual financial costs topped 1.3 billion euro’s, while in the United States of America, the costs amounted to approximately 3.5 billion euro’s and 7 billion euro’s in Europe (WHO, 2012; WHO, 2012; Agozzino et al., 2012).
1.2 HEALTH-ASSOCIATED INFECTIONS AMONG HEALTH CARE WORKERS NURSES:
HAI can affect both patients and health-care workers. It involves Occupational infections among nurses. Due to the nature of their occupations, the major occupational hazard is the transmission of blood-borne disease such as hepatitis B and AIDS by being exposed to injuries caused by contaminated sharp objects such as scalpels and broken glass and needle stick (CDC, 2012). Nurses can be infected by HAIs while dealing with patients or providing them with health treatment. They can play a role in the widespread of infections. For example, the nurses played an important role in the amplification of the outbreak of Marburg viral hemorrhage fever in Angola (WHO, 2015). The mode of transmission depends on many factors such as immunity of HCW and amount of blood transferred during injuries (CDC, 2012). According to WHO, nearly three million HCW are exposed to percutaneous blood borne pathogens each year worldwide; 2 million of those were exposed to HBV ,0.9 million to HCV and 170, 000 to HIV. These sharp injuries resulted in 15,000 HCV, 70,000 HBV and 500 HIV infections. About 90% of these events happened in the developing countries (WHO, 2014). The infectious agent is transmitted to nurses mainly via droplet: direct contact or contact with inanimate contaminated objects by infectious material. The risk of transmission of infectious agents would increase if infection control practice and standard precautions were not applied (WHO, 2013).
1.3 SOLUTIONS TO HAI PROBLEM
Solutions of this problem include the following (WHO, 2012):
1. Determination of the local factors of the HAI burden.
2.
Encouragement of the reporting and surveillance system.
3. Improvement of education and training of nurses in applying safety precaution.
4.Implementation and application of standard precaution which is simple and low-cost but helpful in controlling spread of HAI as it saves money and saves life.
1.4 UNIVERSAL PRECAUTIONS (UP):
In 1983, CDC disseminated a document called (Guidelines for Isolation Precautions in Hospitals). This document included a section about precautions that must be taken when dealing with blood and body fluid of suspected patient infected by blood-borne pathogen (CDC, 2001).In 1985, in response to HIV /AIDS epidemic(CDC, 2007), CDC developed precautions to be applied to all patients irrespective of their blood-borne infection status. They were called universal precautions. These precautions are defined as ” a set of precautions devised to prevent, and minimize accidental transmission of all known blood-borne pathogens including HIV, hepatitis B virus, and hepatitis C virus to/from health care personnel when providing first aid or other health care services” (Vaz et al., 2010). These universal precautions can also be defined as an “approach to infection control to treat all human blood and certain human body fluids as if they were known to be infectious for HIV,HBV and other blood borne pathogens” (NIOSH,2016). These precautions apply to blood, body fluid containing visible blood, semen, cerebrospinal, synovial, pleural, peritoneal and amniotic fluid but don’t apply to feces, nasal secretion, sputum, sweat, tears, urine and vomits unless blood appears (Vaz et al., 2010).
1.5 BODY SUBSTANCES ISOLATION (BSI):
BSI appeared in 1987. This precaution supposed that all moist substances except sweat (execrations and secretions) were infectious (not just blood in UP) (Vaz et al., 2012). It depended mainly on using gloves, and it was advised to use clean gloves before dealing with or touching mucous membranes or contact with body fluids or moist substances, but after removing gloves there would be no need for hand washing if there was recommended(CDC, 2007; Vaz et al., 2010). UP and BSI were presented nearly in the same period.Some hospitals adapted UP while others adapted BSI. This problem and other problems required additional precautions to prevent transmission of diseases that are transmitted via airborne and droplet routes. However, there was no agreement on the washing of hands after using gloves. The existence of such problems led to emergence of another system of precautions called Standard Precautions (SP) (Vaz et al., 2012).
1.6 STANDARD PRECAUTIONS (SP)
The main principles of Universal Precautions and Body Substance Isolation practice were mixed by CDC in a new precaution system called Standard Precautions (SP) which now has replaced the “Universal Precautions”. Standard precautions are defined as “group of infection prevention practices that apply to all patients, regardless of suspected or confirmed diagnosis or presumed infection status” (CDC, 2012). These precautions are the basic level of infection control precautions which are to be used, as a level of precautions (CDC, 2012; WHO, 2013). The fact is that “standard precautions” are recommended when delivering the care to all patients,regardless of their presumed infection status. It is also recommended that when handling equipment and devices that are contaminated or suspected of contamination, and in situations of contact risk with blood, body fluids, secretions and excretions except sweat, without considering the presence or absence of visible blood and skin with solution of continuity and mucous tissues. They included precautions against agents that are transmitted by the following routes of transmission: air-borne, droplet and contact routes (CDC, 2007; Vaz et al., 2013).
The aims of standard precautions are the following: prevention and/ or reduction of transmission of HAI, and, at the same time, protection of nurses from sharp injuries. These aims can be achieved by the application of SP measures which consist of the following elements: hand hygiene, personal protective equipment (gloves, gown, gaggle, facemasks, head protection, foot protection and wearing face shields) and prevention of sharp injuries (CDC, 2015; WHO, 2012).
1.6.1 HAND HYGIENE:
Hand washing is the most important element of SP measures. This concept includes hand washing with soap (plain or antiseptic soap) and water or rubbing hands by using alcohol-based products without using water.
Hand hygiene is recommended in following situations (WHO, 2013):
i.After direct contact with patients
ii.Before direct contact with patients.
iii.After exposure to blood, body fluids, secretions, excretions, non-intact skin, and contaminated items.
iv.After contact with patients surrounding
v.Before doing aseptic tasks like using an invasive device.
1.6. 2 PERSONAL PROTECTIVE EQUIPMENTS (PPE):