Abkhazia Institute for Social and Economic Research

• Infectious diseases can be spread from patient to patient, patient to healthcare worker, and from healthcare worker to patient.
• Microorganisms that may cause infections include bacteria, viruses, and parasites.
• Microorganisms may be present in blood, urine, feces, tissue, body fluids, and other secretions/excretions.
• Safety precautions must be used to protect patients, our coworkers, and us.

INFECTIOUS DISEASES THAT MAY BE TRANSMITTED OR ACQUIRED IN ABKHAZIA (Break-away province of Georgia) HEALTH CARE SETTINGS
NOTE: Infectious diseases acquired by patients while in the hospital are often referred to as “noscomial” infections.
Acinetobacter infection
Group of bacteria commonly found in soil and water. It can also be found on the skin of healthy people, especially healthcare personnel. Outbreaks typically occur in intensive care units and healthcare settings housing very ill patients.
Bloodborne pathogens
Pathogens found in blood and body fluids. Hepatitis B, hepatitis C, and HIV are of most concern in the Abkhazia
Chickenpox (Varicella)
Primary infection results in varicella (chickenpox); recurrent infection results in herpes zoster (shingles). Live virus is shed in both primary and recurrent infection.
Clostridium difficile
Bacteria that causes diarrhea and more serious intestinal conditions such as colitis.
Creutzfeldt-Jakob Disease
Rapidly progressive, invariably fatal neurodegenerative disorder believed to be caused by a prion.
Ebola
One of a group of viruses that cause severe multisystem failure syndrome; often accompanied by hemorrhage.
Gastrointestinal (GI) infections
Acute diarrhea/GI distress caused by a variety of microorganisms including bacteria, viruses, and protozoa.
Hantavirus
Deadly viral respiratory disease.
Hepatitis A, B, C
Group of viruses that cause liver disease. Hepatitis A is spread via “fecal-oral” route; hepatitis B and C are bloodborne pathogens.
HIV
Human immunodeficiency virus; infection usually results in the development of Acquired Immunodeficiency Syndrome (AIDS).
Influenza
Numerous virus strains that cause respiratory disease.
Methicillin-resistant Staphlococcus aureus
(MRSA)
A type of bacteria that is resistant to methicillin. Infections occur most frequently among persons who have weakened immune systems. Antibiotic-resistant bacteria are of great concern to the healthcare community.
Parvovirus
Cause of erythema infectiosum (fifth disease), a common rash illness that is usually acquired in childhood.
Poliovirus
Since 1979, all cases of endemic poliomyelitis reported in the United States (5 to 10 endemic cases/year) have been related to the administration of oral polio vaccine. Poliovirus is transmitted through contact with feces or urine of infected persons but can be spread by contact with respiratory secretions and, in rare instances, through items contaminated with feces.
Pneumonia
In a healthcare setting, bacterial pneumonia may be associated with mechanical ventilation (Gram negative bacteria, S. aureus, Hemophilus influenzae, and Streptococcus pneumoniae). S. pneumoniae can also be transmitted person-to-person.
Rubella
Rubella is usually a mild febrile rash illness in adults and children. Outbreaks of rubella continue to occur in the United States despite widespread use of the measles-mumps-rubella (MMR) vaccine. Throughout the mid- to late-1990s, rubella outbreaks were characterized by increased numbers of cases among adults born in countries that do not have or have only recently instituted a national rubella vaccination program.
SARS
Severe acute respiratory syndrome (SARS) is a viral respiratory illness caused by a coronavirus; SARS was first reported in Asia in February 2003. Over the next few months, the illness spread to more than two dozen countries in North America, South America, Europe, and Asia before the SARS global outbreak of 2003 was contained.
Tuberculosis
Caused by Mycobacterium tuberculosis (TB). TB, a potentially fatal disease, usually affects the lungs, but it can affect other parts of the body. For more information, refer to Tuberculosis: From Consumption to Molecular Diagnosis.
Vancomycin intermediate Staphylococcus aureus
(VISA)
and Vancomycin resistant Staphylococus aureus
(VRSA)
Often referred to as “staph”; S. aureus is commonly found on the skin and in the noses of healthy people. In the past several years, treatment of these infections has become more difficult because staph bacteria have become resistant to various antimicrobial agents, including the commonly used penicillin-related antibiotics. Antibiotic-resistant bacteria are of great concern in the healthcare community.
Vancomycin resistant enterococci (VRE)
Enterococci, leading causes of nosocomial bacteremia, surgical wound infection, and urinary tract infection, that are resistant to many and sometimes all standard therapies. Antibiotic-resistant bacteria are of great concern in the healthcare community.

THE CHAIN OF INFECTION
Infectious diseases are spread through a series of steps known as the “chain of infection”.

For an infection to occur and spread, each of the six links of the chain must take place.
Removing any link in the chain will stop the cycle. Therefore, identifying and instituting appropriate actions at different steps in the cycle will halt the spread of the infection.
1. Infectious Agent
Infectious agents can be:
Bacteria (one-celled microorganisms), examples of disease: gonorrhea, tuberculosis, strep throat;
Viruses (one-celled microorganisms that contain either DNA or RNA but not both), examples of disease: influenza, measles, hepatitis B;
Parasites (single or multi-celled microorganisms), examples of disease: malaria, pinworm, lice;
Fungi (molds and yeasts), examples of disease: vaginal yeast infections, ringworm, histoplasmosis;
Rickettsia (single or multi-celled microorganisms that occupy a position intermediate between viruses and bacteria), examples of disease: Rocky Mountain Spotted Fever, typhus, Lyme Disease; and
Prions (a small infectious particle composed primarily of protein), example of disease: Creutzfeld-Jakob Disease.
2. Reservoir
A reservoir is a place for microorganisms to live. Reservoirs can be animals, insects, food, water, humans, objects, the air we breathe, etc.
If a human, animal, or insect serves as the reservoir, they often do not have any symptoms of the disease.
3. Portal of Exit
There must be a way for the microorganism to leave the reservoir for transmission of disease. This is known as the portal of exit.
For example, some infectious bacteria may leave the human body in feces.
4. Method/Mode of Infection
Infectious diseases are spread by contact, by vehicle, by vector, and by inhalation.
Transmission by Contact
Direct contact
Some microorganisms are transferred from one individual to another by close or intimate contact such as kissing.
Example: hepatitis A, staph/strep infections, scabies
Indirect contact
Some microorganisms are transferred from one individual to another when the healthy individual comes in contact with items from the infected individual such as eating utensils, Kleenex, contaminated clothing, bed linens, contaminated sharps (needles and instrument probes), and splashes of blood, serum, plasma, body fluids to the eyes, mouth, or nose.
Includes transfer of microorganisms through needle sticks and sharps injuries.
Examples: hepatitis A, hepatitis B, hepatitis C, HIV, influenza, staph/strep infections.
Droplet contact
Microorganisms are present in droplets generated when an infected individual coughs, sneezes, or talks. The healthy individual becomes infected when these droplets come in contact with nose, mouth, or eyes.
Requires close contact (within 3 feet); droplets are > 5 microns in size.
Examples: chickenpox, influenza, respiratory syncytial virus, measles.
Transmission by Vehicle
Infection is transmitted by contaminated food, water, and drugs.
Examples: E. coli 0157-contaminated food/drink, chicken/utensils contaminated with salmonella.
Transmission by Vector
Infection transmitted by an insect, animal, arthropod.
Examples: West Nile virus (mosquito), malaria (mosquito), Lyme disease (tick).
Transmission by Inhalation
Microorganisms are present in droplets generated when an infected individual coughs, sneezes, spits, laughs, or talks.
Infection is transmitted when a healthy individual inhales the droplets.
Droplets, called droplet nuclei, are < 5 microns in size and can remain suspended in air, be widely dispersed by air currents, and remain in air over a long distance.
Close patient contact is not necessary.
Example: tuberculosis.
5. Portal of Entry
Microorganisms must have a means of entering a new reservoir or host.
Microorganisms can enter through breaks in the skin, through the mucous membranes, through the digestive tract, through an insect bite, through the respiratory tract, etc.
6. Susceptible Host
If the host’s immune mechanisms are strong, it may be able to stop the infection. However, factors such as age, genetics, nutritional status, disease state, and overall health, can make a person significantly more susceptible to a microorganism.

THE HUMAN BODY’S DEFENSE MECHANISMS
Humans can deter the infectious microorganism by mounting an immune response. The immune system protects the body from potentially harmful substances by recognizing and responding to antigens.
Antigens are large molecules (usually proteins) on the surface of cells, viruses, fungi, or bacteria.
Substances that contain these antigens are recognized and destroyed by the immune system.
There are two general types of immunity: non-specific and specific.
Non-specific (innate) immunity
Almost all humans are born with innate immunity. Innate immunity includes:
Barriers such as intact skin, stomach acid, mucous membranes, cough, tears, and skin oils can keep microorganisms from entering the body.
Certain blood chemicals and proteins, such as complement and interferon, directly attack and kill microorganisms if they make it through the various barriers.
Chemicals such as histamine, serotonin, and bradykinin are released from tissues and certain white blood cells when they are injured by microorganisms. These chemicals cause blood vessels to leak fluid into the tissues, causing swelling. This helps isolate the foreign substance from further contact with body tissues. This chemical reaction is called inflammation. Inflammation also attracts white blood cells that "eat" microorganisms and dead or damaged cells. The process in which these white blood cells surround, engulf, and destroy foreign substances is called phagocytosis.
Specific (acquired) immunity
Acquired immunity develops when the body is exposed to various antigens and builds a defense that is specific to that antigen. When exposed to an antigen, T cells and B cells (types of lymphocytes) become reactive. Specific B cells and T cells are formed and a few of those cells will multiply and provide "memory". When exposed to the antigen again, the “memory cells” will quickly reactivate and destroy the antigen, thus preventing the development of the disease.
For example, an individual who has had rubella is immune to getting rubella again.
Acquired immunity can occur naturally or via vaccination.
Specific (passive) immunity
Passive immunity involves antibodies that are produced in someone's body other than your own.
Infants have passive immunity because they are born with antibodies that are transferred through the placenta from the mother. These antibodies disappear between 6 and 12 months of age.
Gamma globulin is another form of passive immunity that occurs via an injection. For example, gamma globulin high in antibodies to hepatitis A may be injected into someone who has been exposed to hepatitis A. Its protection is also temporary.

BREAKING THE CHAIN OF INFECTION
INTERVENTION
Infectious Agent
•    Early recognition of signs/symptoms of infectious diseases
•    Accurate and rapid identification of microorganisms
•    Reservoir
•    Employee health exams and screening
•    Environmental sanitization including floors, walls, exam tables, and beds
•    Disinfection/sterilization of equipment and instruments
•    Standard precautions
•    Medical asepsis
•    Proper hygiene
•    Clean gowns, linens, and towels
•    Clean wound dressings
•    Portal of Exit
•    Appropriate hand hygiene
•    Use of personal protective equipment
•    Clean dressings over wounds
•    Medical asepsis
•    Control of excretions/secretions
•    Covering the mouth and nose when coughing/sneezing
•    Proper trash and waste disposal
•    Standard precautions
•    Method/Mode of Transmission
•    Appropriate hand hygiene
•    Standard precautions
•    Rooms with air flow control
•    Safe food handling
•    Transmission-based precautions
•    Sterilization of equipment and supplies
•    Medical and surgical asepsis
•    Use of personal protective equipment
•    Proper disposal of contaminated objects
•    Portal of Entry
•    Aseptic technique
•    Sterile technique or surgical asepsis
•    Medical sepsis
•    Catheter care
•    Wound care
•    Proper disposal of needles/sharps
•    Maintaining skin integrity
•    Standard precautions
•    Susceptible Host
•    Treatment of disease
•    Recognition of patients at risk
•    Immunization
•    Exercise
•    Proper nutrition

ASEPSIS
One of the more important methods for breaking the chain of infection is asepsis. Asepsis is defined as a condition in which pathogens are absent or controlled. Aseptic practices break the chain of infection by preventing the transmission of pathogens. Strict adherence to aseptic practices is the only way to prevent the spread and transmission of infectious diseases. There are three levels of aseptic control: antisepsis or sanitation, disinfection, and sterilization.
Antisepsis or sanitation
This is a method of infection control that includes using soap and water to wash the hands and body as well as the use of antiseptics such as alcohol, iodine, and Betadine® to cleanse the skin for medical procedures.
The level of asepsis may kill or inhibit some bacteria but generally are not effective against viruses or bacterial spores.
Disinfection
This is the process of using chemicals or boiling water to destroy or kill microorganisms.
The process is not always effective against viruses or bacterial spores.
Disinfectants are used on surfaces, equipment, and instruments.
Disinfectants are harsh and cannot be used on the skin.
Sterilization
This is the only level of asepsis that kills all microorganisms.
Sterilization is achieved by the use of gas, chemicals, radiation, and steam under pressure.
It is primarily used on medical instruments and equipment, surgical dressings, and gowns.

MEDICAL ASEPSIS
Medical asepsis, sometimes called clean technique, is based on maintaining cleanliness to prevent the spread of infectious diseases and to assure that the environment is as free of microorganisms as possible. Medical asepsis involves confining microorganisms to specific areas and making objects either clean or dirty. The basic principles of medical asepsis include:
Cleanse hands frequently following CDC’s Hand Hygiene Guidelines.
Keep soiled items and equipment from touching clothing.
Do not place soiled bed linens or other items on the floor.
Avoid having the patient cough, sneeze, or breathe directly on others.
Move equipment away from you when sweeping, dusting, or scrubbing articles.
Clean the least soiled items first then the more soiled ones.
Dispose of soiled or used items directly into the appropriate containers.
Pour liquids that are to be discarded directly into the drain to avoid splattering in the sink and onto you.
Avoid leaning against sinks, supplies, and equipment.
Avoid touching your eyes, face, and mouth.
Use practices of personal grooming that help prevent spreading microorganisms.
Follow your facility’s guidelines for isolation and barrier techniques.

SURGICAL ASEPSIS
Surgical asepsis, also called sterile technique, is used in the operating room, delivery room, during surgical procedures, catheterization, and during dressing changes. Basic principles include:
Only a sterile object can touch another sterile object.
Open sterile packages so that the first edge of the wrapper is directed away from the worker to avoid the possibility of a sterile wrapper touching non-sterile clothing.
Avoid spilling any solution on a cloth or paper used as a field for sterile set up.
Hold sterile objects above the waist level.
Avoid talking, coughing, sneezing, and reaching over a sterile field or object.
Never walk away from or turn your back on a sterile field.
All items brought into contact with broken skin or used to penetrate the skin in order to inject substances into the body, or to enter normally sterile body cavities, should be sterile.
Use dry, sterile forceps when necessary.
Consider the edge (outer 1”) of a sterile field to be contaminated.
Consider an object contaminated if you have any doubt as to its sterility.
HANDWASHING
On October 25, 2002, the Centers for Disease Control and Prevention (CDC), released the Guideline for Hand Hygiene in Healthcare Settings. Among other items, the guideline describes washing hands with soap and water and cleansing hands with alcohol-based hand rubs. Washing hands with soap and water is always acceptable. However, use of alcohol-based hand rubs is not always acceptable.
Soap and Water Required
Alcohol-Based Hand Rub OK
After removing gloves that are visibly contaminated with blood/body fluids.
When bare hands are visibly contaminated with blood/body fluids.
Before eating.
After using a restroom.
After exposure to known or suspected Bacillus anthracis (anthrax).
After removing gloves that are not visibly contaminated.
After bare hands come in contact with blood/body fluids, mucous membranes, nonintact skin if hands are not visibly
contaminated.
Before direct patient contact.
After contact with a patient’s intact skin.
Proper hand hygiene is the single most important thing that
everyone can do to prevent and control the spread of infection!

Recommended Hand Hygiene Procedures
Soap and Water
Alcohol-Based Hand Rub
1. Wet hands with water.
2. Apply the recommended amount of soap to wash hands.
3. Rub hands vigorously for at least 15 seconds, covering all surfaces of the hands and fingers.
4. Rinse hands with water and dry thoroughly with a disposable paper towel.
5. Use another paper towel to turn off the faucet.
NOTE: Avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis.
1. Apply the recommended amount of product to the palm of one hand.
2. Rub hands together, covering all surfaces of the hands and fingers, until the hands are dry.
3. Make sure to rub hands together until your hands are DRY!
Surgical Hand Hygiene/Antisepsis
Remove rings, watches, and bracelets before beginning the surgical hand scrub.
Remove debris from underneath fingernails using a nail cleaner and running water.
Perform surgical hand antisepsis using an antimicrobial soap or an alcohol-based hand rub with persistent activity.
IF
THEN
Using antimicrobial soap
a. Scrub hands and forearms for the length of time recommended by the manufacturer, usually 2 – 6 minutes.
b. Dry hands and forearms thoroughly.
c. Don sterile gloves.
Using alcohol-based surgical hand scrub with persistent activity
a. Pre-wash hands and forearms with a non-antimicrobial soap and dry hands and forearms completely.
b. Apply the alcohol-based surgical hand scrub following manufacturer’s instructions.
c. Allow hands and forearms to dry thoroughly.
d. Don sterile gloves.
For more information on CDC’s Hand Hygiene Guidelines, refer to CE Course 1220206 Hand Hygiene Guideline.

STANDARD PRECAUTIONS
Standard Precautions were developed in 1996 when the CDC joined the major features of Universal Precautions and Body Substance Isolation. Standard Precautions should be used in the care of all patients and eliminates the need for Body Substance Isolation and category-specific blood/body fluids isolation.
Standard Precautions:
Assumes that ALL blood, body fluids (except sweat), non-intact skin, and mucous membranes are capable of transmitting bloodborne pathogens.
Personal Protective Equipment (PPE) such as gloves, gowns, mask, eye protection, etc., should be used to prevent the healthcare worker from direct contact with blood, body fluids, non-intact skin, and mucous membranes.

TRANSMISSION-BASED PRECAUTIONS
The Centers for Disease Control and Prevention (CDC) recommend the use of isolation-based categories to prevent the spread of infection in a hospital setting. These categories are initiated as soon as the patient is suspected to be infected. These precautions are used

IN ADDITION to Standard Precautions.
Contact Precautions
Used for infections that could be spread through direct or indirect contact.
Examples: herpes simplex, hepatitis A, sexually transmitted diseases
Gloves and gowns are worn when handling the patient, body fluids, or items from the patient room. A surgical mask and eyewear should be worn if there is a potential for exposure to body fluids.
Droplet Precautions
Used for a patient known or suspected to be infected with microorganisms transmitted by droplets formed when the patient coughs, sneezes, or talks.
Examples: influenza, whooping cough, rubella.
Droplets can travel approximately three feet.
Regular masks are worn to prevent inhalation of droplets. Gloves and gowns must be worn if being exposed to blood or body fluids.
Airborne Precautions
Used to prevent transmission of organisms that are carried on air currents on dust particles.
Examples: tuberculosis, chickenpox.
Special ventilation in a negative air pressure isolation room is required.
Individuals entering the patient room must wear a particulate respirator (HEPA) mask that has been properly fit. Gowns and gloves must be worn if coming into direct contact with the patient.
CONCLUSION
Infectious diseases are caused by microorganisms and can be spread by human to human contact, animal to human contact, human contact with an infected surface, airborne transmission through tiny droplets of infectious agents suspended in the air, and, finally, by such common vehicles as food or water. Approximately 5% of all hospital patients acquire an infection during a hospital stay. These infections result in increased cost, increased time spent in the hospital and, in some cases, death. Infectious diseases can be spread from patient to healthcare worker, healthcare worker to healthcare worker, and healthcare worker to patient. Knowledge of how microorganisms are transmitted is required before healthcare personnel can establish policies and procedures to minimize the risk or eliminate the spread of infections. To ensure the safety of patients and employees, all healthcare workers should strictly adhere to infection control polices and procedures.
This Course can be used in Abkhazia for CE: