PREVENTING PREVENTING TRANSMISSION TRANSMISSION OF RESPIRATORY OF RESPIRATORY

INFECTIOUS DISEASESINFECTIOUS DISEASES IN CLINICS AND OFFICE SETTINGSIN CLINICS AND OFFICE SETTINGS

BRENDA J. ROUP, PhD, RN, CICBRENDA J. ROUP, PhD, RN, CICNURSE CONSULTANT IN INFECTION CONTROLNURSE CONSULTANT IN INFECTION CONTROL

MARYLAND DEPARTMENT OF HEALTH MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENEAND MENTAL HYGIENE

TRANSMISSION OF RESPIRATORY TRANSMISSION OF RESPIRATORY INFECTIOUS DISEASES AND INFECTIOUS DISEASES AND INFLUENZAINFLUENZA MUSHER, D. HOW CONTAGIOUS ARE MUSHER, D. HOW CONTAGIOUS ARE

COMMON RESPIRATORY TRACT COMMON RESPIRATORY TRACT INFECTIONS? NEJM, 348:13, MAR 27, 2003INFECTIONS? NEJM, 348:13, MAR 27, 2003

TELLIER, R. REVIEW OF AEROSOL TELLIER, R. REVIEW OF AEROSOL TRANSMISSION OF INFLUENZA A VIRUS. TRANSMISSION OF INFLUENZA A VIRUS. EMERGING INFECTIOUS DISEASES, 12:11, EMERGING INFECTIOUS DISEASES, 12:11, NOV. 2006NOV. 2006

TRANSMISSION OF INFLUENZATRANSMISSION OF INFLUENZA

DEPT OF HEALTH AND HUMAN SERVICES, DEPT OF HEALTH AND HUMAN SERVICES, PANDEMIC INFLUENZA PLAN, 2005, PANDEMIC INFLUENZA PLAN, 2005, SUPPLEMENT 4, INFECTION CONTROL, SUPPLEMENT 4, INFECTION CONTROL, OUTPATIENT MEDICAL OFFICESOUTPATIENT MEDICAL OFFICES

http://www.hhs.gov/pandemicflu/plan/http://www.hhs.gov/pandemicflu/plan/ http://www.pandemicflu.gov/plan/healthcarhttp://www.pandemicflu.gov/plan/healthcar

e/maskguidancehc.htmle/maskguidancehc.html

TRANSMISSION OF INFLUENZATRANSMISSION OF INFLUENZA

MARYLAND DEPARTMENT OF HEALTH AND MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE, OFFICE OF MENTAL HYGIENE, OFFICE OF PREPAREDNESS AND RESPONSE. PREPAREDNESS AND RESPONSE. MARYLAND PANDEMIC INFLUENZA PLAN, MARYLAND PANDEMIC INFLUENZA PLAN, VERSION 6, DECEMBER 2006.VERSION 6, DECEMBER 2006.

http://flu.maryland.gov/http://flu.maryland.gov/

TOPICSTOPICS

1.1. TRANSMISSIBILITY/COMMUNICABILITYTRANSMISSIBILITY/COMMUNICABILITY OF OF INFLUENZA VIRUSINFLUENZA VIRUS

2.2. TRIAGE/SCREENING IN OFFICE/CLINIC TRIAGE/SCREENING IN OFFICE/CLINIC ENVIRONMENTENVIRONMENT

3.3. CONTAINMENT IN OFFICE/CLINIC CONTAINMENT IN OFFICE/CLINIC ENVIRONMENTENVIRONMENT

4.4. DVD – WHY DON’T WE DO IT IN OUR DVD – WHY DON’T WE DO IT IN OUR SLEEVES? (SLEEVES? (www.coughsafe.comwww.coughsafe.com) )

TRANSMISSIBILITY OF INFLUENZA TRANSMISSIBILITY OF INFLUENZA VIRUSVIRUS REFERS TO THE CAPACITY OF AN REFERS TO THE CAPACITY OF AN

INFECTIOUS AGENT TO SPREAD FROM ONE INFECTIOUS AGENT TO SPREAD FROM ONE PERSON TO ANOTHERPERSON TO ANOTHER

FOR INFLUENZA VIRUS, DEPENDENT UPON:FOR INFLUENZA VIRUS, DEPENDENT UPON: PARTICLE SIZE AND INFECTIVE DOSEPARTICLE SIZE AND INFECTIVE DOSE SUSCEPTIBILITY OF HOSTSUSCEPTIBILITY OF HOST TEMPERATURE, HUMIDITY, AIR TEMPERATURE, HUMIDITY, AIR

CURRENTS, VENTILATIONCURRENTS, VENTILATION DOWNWIND OR UPWINDDOWNWIND OR UPWIND

INFLUENZA VIRUSINFLUENZA VIRUS

INFLUENZA VIRUS H & NINFLUENZA VIRUS H & N

PANDEMIC INFLUENZAPANDEMIC INFLUENZA

VERY SERIOUS FORM OF INFLUENZA VIRUS THAT VERY SERIOUS FORM OF INFLUENZA VIRUS THAT MAY CAUSE GLOBAL OUTBREAKMAY CAUSE GLOBAL OUTBREAK

AN INFLUENZA VIRUS MUST MEET THESE THREE AN INFLUENZA VIRUS MUST MEET THESE THREE CONDITIONS IN ORDER TO BECOME A PANDEMIC:CONDITIONS IN ORDER TO BECOME A PANDEMIC:

1.1. BE A NEW SUBTYPE OF INFLUENZA VIRUS THAT BE A NEW SUBTYPE OF INFLUENZA VIRUS THAT HAS NOT PREVIOUSLY OR RECENTLY HAS NOT PREVIOUSLY OR RECENTLY CIRCULATED IN HUMANSCIRCULATED IN HUMANS

2.2. CAUSES DISEASE IN HUMANSCAUSES DISEASE IN HUMANS

3.3. SUSTAINS HUMAN TO HUMAN TRANSMISSIONSUSTAINS HUMAN TO HUMAN TRANSMISSION

SNEEZINGSNEEZING

SNEEZINGSNEEZING

PARTICLE SIZE OFPARTICLE SIZE OF INFLUENZA INFLUENZA VIRUSVIRUS LARGE DROPLETS (50-100 LARGE DROPLETS (50-100 μμm diameter)m diameter) DO NOT REMAIN SUSPENDED IN AIRDO NOT REMAIN SUSPENDED IN AIR BALLISTIC TRAJECTORY OF A FEW FEETBALLISTIC TRAJECTORY OF A FEW FEET INFECT BY DIRECT CONTACT WITH INFECT BY DIRECT CONTACT WITH

MUCOUS MEMBRANES OF MOUTH, EYES, MUCOUS MEMBRANES OF MOUTH, EYES, UPPER NASAL PASSAGESUPPER NASAL PASSAGES

PARTICLE SIZE OFPARTICLE SIZE OF INFLUENZA INFLUENZA VIRUSVIRUS

INTERMEDIATE SIZE PARTICLES (10-50 INTERMEDIATE SIZE PARTICLES (10-50 μμm)m) TRANSMISSION OF THESE PARTICLES TRANSMISSION OF THESE PARTICLES

INFLUENCED BY:INFLUENCED BY: TEMPERATURE OF AIR IN YOUR OFFICETEMPERATURE OF AIR IN YOUR OFFICE HUMIDITYHUMIDITY AIR CURRENTSAIR CURRENTS AIR VELOCITYAIR VELOCITY

REACH UPPER RESPIRATORY TRACTREACH UPPER RESPIRATORY TRACT

PARTICLE SIZE OFPARTICLE SIZE OF INFLUENZA INFLUENZA VIRUSVIRUS

INCLUDES SMALL PARTICLE AEROSOLS INCLUDES SMALL PARTICLE AEROSOLS AND DROPLET NUCLEI (<10 AND DROPLET NUCLEI (<10 μμM)M)

DROPLET NUCLEI = INTERMEDIATE SIZE DROPLET NUCLEI = INTERMEDIATE SIZE PARTICLES THAT HAVE DESICATED AND PARTICLES THAT HAVE DESICATED AND SHRUNKSHRUNK

TRANSMISSION PRIMARILY INFLUENCED TRANSMISSION PRIMARILY INFLUENCED BY AIR CURRENTSBY AIR CURRENTS

REACH LOWER RESPIRATORY TRACTREACH LOWER RESPIRATORY TRACT

SURVIVAL OF VIRUS SURVIVAL OF VIRUS ON ENVIRONMENTAL SURFACESON ENVIRONMENTAL SURFACES ON CLOTH OR PAPER = 8 - 10 HOURSON CLOTH OR PAPER = 8 - 10 HOURS ON NON-POROUS SURFACES ON NON-POROUS SURFACES

(STAINLESS STEEL) = 24 - 48 HOURS(STAINLESS STEEL) = 24 - 48 HOURS ON POROUS SURFACES = ??ON POROUS SURFACES = ??

MUSHER, NEJM

TRANSMISSIONTRANSMISSION OF INFLUENZA AOF INFLUENZA A

VIRUS INTRODUCED INTO AVIRUS INTRODUCED INTO A HOME – 50% CLINICAL SYMPTOMSHOME – 50% CLINICAL SYMPTOMS ENCLOSED SPACE OUTSIDE HOME – 50% ENCLOSED SPACE OUTSIDE HOME – 50%

CLINICAL SYMPTOMSCLINICAL SYMPTOMS NAVAL CRUISER – 42% CLINICAL NAVAL CRUISER – 42% CLINICAL

SYMPTOMSSYMPTOMS AIRPLANE WITH FAILED AIR AIRPLANE WITH FAILED AIR

CIRCULATION SYSTEM – 73% CLINICAL CIRCULATION SYSTEM – 73% CLINICAL SYMPTOMSSYMPTOMS

TOPICSTOPICS1.1. TRANSMISSIBILITY/ COMMUNICABILITY OF TRANSMISSIBILITY/ COMMUNICABILITY OF

INFLUENZA VIRUSINFLUENZA VIRUS2.2. TRIAGE/SCREENING IN OFFICE/CLINIC TRIAGE/SCREENING IN OFFICE/CLINIC

ENVIRONMENTENVIRONMENT3.3. CONTAINMENT IN OFFICE/CLINIC CONTAINMENT IN OFFICE/CLINIC

ENVIRONMENTENVIRONMENT4.4. DVD – WHY DON’T WE DO IT IN OUR DVD – WHY DON’T WE DO IT IN OUR

SLEEVES?SLEEVES?

TRIAGE/SCREENINGTRIAGE/SCREENING

1.1. KEEP YOUR WAITING ROOM AS EMPTY AS KEEP YOUR WAITING ROOM AS EMPTY AS POSSIBLEPOSSIBLE

2.2. CANCEL NON-ESSENTIAL PATIENT APPTSCANCEL NON-ESSENTIAL PATIENT APPTS (EXAMPLE: CHRONIC DISEASE FOLLOW (EXAMPLE: CHRONIC DISEASE FOLLOW UP)UP)

3.3. TRAIN FRONT DESK WORKERS IN TRAIN FRONT DESK WORKERS IN SCREENING FOR INFLUENZA SYMPTOMSSCREENING FOR INFLUENZA SYMPTOMS

4.4. MAXIMUM USE OF TELEPHONE MAXIMUM USE OF TELEPHONE TRIAGE/SCREENINGTRIAGE/SCREENING

TRIAGE/SCREENINGTRIAGE/SCREENING

1.1. DISCOURAGE VISITS TO OFFICEDISCOURAGE VISITS TO OFFICE

2.2. SEE RESPIRATORY INFECTION PATIENTS AT SEE RESPIRATORY INFECTION PATIENTS AT END OF DAYEND OF DAY

3.3. ““FRONT DOOR” ALERT TO PATIENTS:FRONT DOOR” ALERT TO PATIENTS:1.1. Please cough or sneeze into your upper sleeve or tissue-Please cough or sneeze into your upper sleeve or tissue-

throw the tissue into the trash can & wash your hands!throw the tissue into the trash can & wash your hands!

2.2. If you are coughing & sneezing, please inform the front If you are coughing & sneezing, please inform the front desk staff!desk staff!

4.4. MOVE SYMPTOMATIC PATIENTS INTO EXAM MOVE SYMPTOMATIC PATIENTS INTO EXAM ROOMS AS QUICKLY AS POSSIBLEROOMS AS QUICKLY AS POSSIBLE

TOPICSTOPICS1.1. TRANSMISSIBILITY/ COMMUNICABILITY OF TRANSMISSIBILITY/ COMMUNICABILITY OF

INFLUENZA VIRUSINFLUENZA VIRUS2.2. TRIAGE/SCREENING IN OFFICE/CLINIC TRIAGE/SCREENING IN OFFICE/CLINIC

ENVIRONMENTENVIRONMENT3.3. CONTAINMENT IN OFFICE/CLINIC CONTAINMENT IN OFFICE/CLINIC

ENVIRONMENTENVIRONMENT4.4. DVD – WHY DON’T WE DO IT IN OUR DVD – WHY DON’T WE DO IT IN OUR

SLEEVES?SLEEVES?

RESPIRATORYRESPIRATORY HYGIENE/COUGH HYGIENE/COUGH ETIQUETTEETIQUETTE http://www.cdc.gov/flu/professionals/infectioncontrolhttp://www.cdc.gov/flu/professionals/infectioncontrol

/resphygiene.htm/resphygiene.htm EMPHASIZES COUGHS AND SNEEZES AND EMPHASIZES COUGHS AND SNEEZES AND

CLEANING OF HANDSCLEANING OF HANDS POSTERS IN WAITING AREASPOSTERS IN WAITING AREAS CONSIDER PAMPHLETS HANDED OUT BY CONSIDER PAMPHLETS HANDED OUT BY

RECEPTIONIST (FREE FROM CDC)RECEPTIONIST (FREE FROM CDC) IF PATIENT IS ACTIVELY COUGHING, HAND A IF PATIENT IS ACTIVELY COUGHING, HAND A

PROCEDURE MASK (EAR LOOPS) AND MAKE PROCEDURE MASK (EAR LOOPS) AND MAKE SURE THEY PUT ONSURE THEY PUT ON

MASK WITH EAR LOOPSMASK WITH EAR LOOPS

CONTAINMENTCONTAINMENT1.1. IF PATIENT HAS TO COME TO OFFICE, ONLY IF PATIENT HAS TO COME TO OFFICE, ONLY

ONE PERSON MAY ACCOMPANY THAT ONE PERSON MAY ACCOMPANY THAT PERSON IN THE WAITING ROOMPERSON IN THE WAITING ROOM

2.2. PROVIDE BOXES OF DISPOSABLE TISSUES IN PROVIDE BOXES OF DISPOSABLE TISSUES IN WAITING ROOM, NOT JUST AT RECEPTION WAITING ROOM, NOT JUST AT RECEPTION WINDOWWINDOW

3.3. PLACE LARGE JUGS OF ALCOHOL-BASED PLACE LARGE JUGS OF ALCOHOL-BASED HAND CLEANER (60 – 70% ISOPROPYL OR HAND CLEANER (60 – 70% ISOPROPYL OR ETHYL ALCOHOL) IN WAITING ROOMETHYL ALCOHOL) IN WAITING ROOM

4.4. PROVIDE AT LEAST ONE CLOSED TRASH CAN PROVIDE AT LEAST ONE CLOSED TRASH CAN WITH FOOT-OPERATED PEDALWITH FOOT-OPERATED PEDAL

CONTAINMENTCONTAINMENT5.5. REMOVE ALL MAGAZINES AND TOYS FROM REMOVE ALL MAGAZINES AND TOYS FROM

WAITING ROOM (FOMITES)WAITING ROOM (FOMITES)6.6. ASSIGN SOMEONE TO CLEAN HIGH-TOUCH ASSIGN SOMEONE TO CLEAN HIGH-TOUCH

SURFACES EVERY 1-2 HOURSSURFACES EVERY 1-2 HOURS WITH A WITH A DISINFECTANTDISINFECTANT

DOOR KNOBSDOOR KNOBS LIGHT SWITCHESLIGHT SWITCHES PENSPENS COMPUTER KEYBOARDSCOMPUTER KEYBOARDS TELEPHONESTELEPHONES CHAIR ARMSCHAIR ARMS

OFFICE ARRANGEMENT 1OFFICE ARRANGEMENT 1

OFFICE ARRANGEMENT 2OFFICE ARRANGEMENT 2

OFFICE ARRANGEMENT 3OFFICE ARRANGEMENT 3

OTHER CONTAINMENT OTHER CONTAINMENT STRATEGIESSTRATEGIES CHECK WITH BUILDING MANAGER RE: CHECK WITH BUILDING MANAGER RE:

NUMBER OF AIR EXCHANGES IN OFFICE (12 NUMBER OF AIR EXCHANGES IN OFFICE (12 OR MORE BEST) AND HUMIDITY LEVELSOR MORE BEST) AND HUMIDITY LEVELS

HIGH AIR FLOW WILL DILUTE INFLUENZA HIGH AIR FLOW WILL DILUTE INFLUENZA VIRUS AND DESSICATEVIRUS AND DESSICATE

INCREASED HUMIDITY (>40%) WILL INCREASED HUMIDITY (>40%) WILL DECREASE VIRUS INFECTIVITYDECREASE VIRUS INFECTIVITY

N95 RESPIRATORSN95 RESPIRATORS THERE IS NO RECOMMENDED ROLE FOR THERE IS NO RECOMMENDED ROLE FOR

THE USE OF N95 RESPIRATORS IN THE THE USE OF N95 RESPIRATORS IN THE OFFICE/CLINIC SETTINGOFFICE/CLINIC SETTING

USE THESE OTHER STRATEGIES, USE THESE OTHER STRATEGIES, ESPECIALLY:ESPECIALLY: TELEPHONE TRIAGETELEPHONE TRIAGE KEEP WAITING ROOM EMPTYKEEP WAITING ROOM EMPTY GET COUGHING PATIENTS INTO EXAM GET COUGHING PATIENTS INTO EXAM

ROOMS QUICKLYROOMS QUICKLY MASK COUGHING PATIENTSMASK COUGHING PATIENTS

TOPICSTOPICS1.1. TRANSMISSIBILITY/ COMMUNICABILITY OF TRANSMISSIBILITY/ COMMUNICABILITY OF

INFLUENZA VIRUSINFLUENZA VIRUS2.2. TRIAGE/SCREENING IN OFFICE/CLINIC TRIAGE/SCREENING IN OFFICE/CLINIC

ENVIRONMENTENVIRONMENT3.3. CONTAINMENT IN OFFICE/CLINIC CONTAINMENT IN OFFICE/CLINIC

ENVIRONMENTENVIRONMENT4.4. DVD – WHY DON’T WE DO IT IN OUR SLEEVEDVD – WHY DON’T WE DO IT IN OUR SLEEVE

SS? (? (www.coughsafe.comwww.coughsafe.com) )

WEBSITESWEBSITES

www.cdc.govwww.cdc.gov www.panflu.govwww.panflu.gov www.montgomerycountymd.gov/www.montgomerycountymd.gov/

apcapc

QUESTIONSQUESTIONS

www.montgomerycountymd.gov/www.montgomerycountymd.gov/apcapc

STOPTHE SPREAD!STOPTHE SPREAD!

This publication was supported by Cooperative Agreement Number U50/CCU302718 This publication was supported by Cooperative Agreement Number U50/CCU302718

from the CDC to NACCHO.from the CDC to NACCHO. Its contents are solely the responsibility of the Its contents are solely the responsibility of the

Montgomery County,Montgomery County, Maryland Advanced Practice Center for Public Health Maryland Advanced Practice Center for Public Health Emergency Preparedness and Response and do not necessarily represent the Emergency Preparedness and Response and do not necessarily represent the official views of CDC or NACCHO.official views of CDC or NACCHO.

This publication is in the public domain. It may be reproduced in whole or in part by This publication is in the public domain. It may be reproduced in whole or in part by any individual or organization without permission, as long as the following citation any individual or organization without permission, as long as the following citation is given: Montgomery County, Maryland Advanced Practice Center for Emergency is given: Montgomery County, Maryland Advanced Practice Center for Emergency Preparedness and Response “Stop the Spread! A Toolkit for Preventing the Spread Preparedness and Response “Stop the Spread! A Toolkit for Preventing the Spread of Germs in Clinics and Office Settings”. If a part or all of the publication is of Germs in Clinics and Office Settings”. If a part or all of the publication is reproduced, the Montgomery County APC would appreciate knowing how it is used. reproduced, the Montgomery County APC would appreciate knowing how it is used. Please use the form at our website, http://www.montgomerycountymd.gov/apc.Please use the form at our website, http://www.montgomerycountymd.gov/apc.