Journal of Hospital and Healthcare Administration (ISSN: 2688-6472)

Article / Review Article

"Healthcare Acquired Respiratory Infections-Considerations and Strategies for Prevention and Control"

Mary Catlin1, Hala Jassim AlMossawi1, Neeraj Kak1* and Anil Kaul2

1University Research Co., LLC, Chevy Chase, Maryland, USA

2Oklahoma State University, Tulsa, Oklahoma, USA

*Corresponding Author: Neeraj Kak, Chief Innovation Officer/Senior Vice President, University Research Co., LLC, 5404 Wisconsin Ave, Chevy Chase, Maryland, USA. Tel: +3019418626; Email: NKAK@URC-CHS.COM

Received Date: 5 August, 2019; Accepted Date: 19 August, 2019; Published Date: 26 August, 2019

Abstract

This paper provides a critical review of existing procedures and practices, including surveillance methods and systems for identifying patients’ risk of acquiring healthcare associated respiratory infections, in different settings. The burden of healthcare associated respiratory infections afflicting patients and healthcare workers is underappreciated. Infection control measures for TB control have been strictly applied in the United States and have decreased rates of disease acquisition below that of the general population. However, in most other countries healthcare workers are greater risk of acquiring TB and other infections. The principles of these TB and general infection control measures can be applied in resource scarce settings and should reduce the transmission of TB in particular but may provide protection from other respiratory infections as well. As facilities vary widely in the complexity of care they provide, a framework of risk assessment should be used to identify and apply engineering controls, work practice controls, administrative controls, personal protective equipment and finally education. Novel and creative solutions, including use of telemedicine and mHealth solutions should be further explored.

As care becomes more complex in resource constrained settings, the necessary infrastructure related to water, energy, medical records, ability to do preventive maintenance and sterilize (reprocess) devices must be put into place so that the benefits of invasive care exceed the risks to the patients. The volume of water available per patient and family in hospitalized patients is a crude indicator of the quality and sophistication of care that can be provided. As we seek improve infection control as much as possible with simple interventions, it is important to realize that once again, limits are reached without a broader system infrastructure strengthening.

Safe care does not harm the patient, the provider or the community. Implementation of safe care requires risk assessments and provision of appropriate ventilation and adequate volumes of water. Because the preconditions for a safe environment of care cannot be assumed in resource scarce settings, there may be limitations in the effective application of US infection control “bundles”. Infection control measures will have to be tested prior to implementation. Unlike in the United States, the impact of infection control measures may have to be extrapolated from studies done at sentinel sites. Measures can then be applied to facilities and evaluated with process control measures. Examples of process control measures include compliance with respiratory symptom screening, available volumes of water, hand hygiene monitoring, employee absenteeism, presence of crowds in areas with low air exchanges, ventilation, and indications for treatment among others.

Keywords: Tuberculosis; Respiratory Infections; Healthcare settings; Infection Control

Introduction

A number of important lessons have been learned from efforts to prevent Healthcare-Associated Respiratory Infections (rHAI) in the United States (US), which may provide examples for application in resource limited settings. Healthcare associated infections are infections that are not present on admission that the patient is exposed to during their healthcare. The infection may manifest while the patients is still present in the hospital or it may occur days, months or years later. For example, a patient who comes to deliver a baby may get infected with influenza from a care worker and become ill in a period of days, a patient may be exposed to tuberculosis while waiting for 6 hours waiting room of a clinic and not develop disease for years, or an elderly women treated for a broken leg may get colonized from Methicillin Resistant Staph Aureus (MRSA) and not have an infection develop for 18 months later.

It is important to note that while developments have been made in the United States to put in place infection control tools to prevent respiratory infections, their use has shown a very limited capability to prevent the transmission of respiratory illnesses in healthcare settings, and therefore the deep concern remains over the potential for an influenza, Severe Acute Respiratory Syndrome (SARS), or polio-like eenteroviral outbreak. Healthcare providers are aware of historic difficulties preventing transmission of any respiratory infection which presents with non-specific symptoms.

Infection control is more challenging for pathogens for which we do not have available diagnostic tests, an effective vaccine, or treatment. While theoretically hand hygiene and avoiding contact with ill children or visitors helps [1], in practice most US healthcare facilities have not strictly implemented restrictions on age of visitors, restricted ill visitors, or been able to enforce strict hand hygiene for patients and visitors. One barrier is the Centers for Medicare and Medicaid (CMS) use of Press Ganey surveys to evaluate care. These patient-reported scores place patient satisfaction above patient safety or disease outcome measures, and work against U.S. facilities who wish to restrict ill visitors or require strict mask use or use of gowns and gloves.

For a variety of reasons, North American hospitals have not been able to prevent transmission of either mild illness such as the common cold, or severe illnesses such as SARS. Even with vaccination, few facilities are able to lower staff absenteeism from respiratory illness during seasonal flu outbreaks [2]. A clear example occurred during the SARS outbreak where in Toronto, despite a declared international emergency, a few SARS imported cases spread to hundreds of patients and staff in healthcare settings. When emergency measures ceased and facilities resumed their usual level of respiratory infection control, a second wave of infection occurred:

These examples underline a primary lesson around the importance of routine, continuous application of existing tools to prevent respiratory infection, which can reduce transmission of disease, if applied. Or at least, in the absence of untested alternatives, existing tools should be fully implemented and their efficacy tested. In the U.S., for example, there was no transmission from the 8 cases of SARS to US healthcare workers [3]; although skeptics would argue there were perhaps fewer high-risk exposures (intubations), or less infectious patients. In the above study, it is notable that authors commented that many infections in Toronto happened not because the tools were ineffective but because they were inconsistently applied.

The same basic and well-known Tuberculosis (TB) Infection Control principles are proposed to control respiratory Healthcare-Acquired Infections (rHAI) but with the following caveat: TB infection control is more consistently applied in all healthcare facilities the United States than in Africa or Asia. National, state and local health departments have been continuously funded to provide statutory oversight to infection control programs in hospitals, schools and workplaces. They ensure that controls are applied and investigate gaps when transmission occurs.

Adaptation of the principles of TB infection control applied to all healthcare facilities may reduce rHAI. In the U.S. these practices have reduced disease transmission in the community and in healthcare facilities, decreased patient deaths and prevented TB disease in healthcare workers.

Not only have TB rates in the general population decreased, but occupational acquisition of TB infection in nurses and medical students, which were 10 to 100-fold higher than the general population in the 1950’s, has decreased to levels below those of the general population [4]. In contrast to the United States, healthcare workers in other settings have excessive occupation disease to TB when compared to the general population (Table 1) [5,6].

While the risk of acquiring TB in healthcare facilities has improved, US healthcare workers remain at risk of contracting other respiratory infections and transmitting them to patients. This problem is twofold; first, employees may get exposed at work and, second, employees, patients and visitors acquire respiratory infections in the community and bring these infections into healthcare settings. One study by Loeb et al. [7]. unintentionally illustrated the problem of acquisition of rHAI. Researchers randomized hospital employees to use respirators or surgical masks and monitored their use. They found masks to be non-inferior to respirators in presenting influenza. However, in the study of about 460 participants, about 23% [8], of both groups developed lab confirmed influenza, a rate that does not indicate safety.

Another study also illustrated the risk of respiratory illness in U.S. healthcare workers [9]. This randomized control trial evaluated the impact of flu immunization on work place absenteeism from influenza and other respiratory illnesses in immunized and unimmunized workers. Vaccinated healthcare workers had 9.9 work absences from influenza per 100 workers compared to 21.1 per 100 unvaccinated workers. However, those vaccinated against influenza still reported 28.7 days of febrile respiratory illness compared to 40.6 days in the control group. While it is both biologically plausible and encouraging that immunization would reduce other respiratory co-morbidities, the significant burden of respiratory infection in healthcare workers in healthcare settings is alarming.

Infection control measures used to reduce respiratory transmission in the U.S. are shown in Table 2. Facilities should first conduct a risk assessment to identify the respiratory hazards in their areas and the procedures that put patients at risk. These should assist to prioritize the engineering controls, work practice controls, Personal Protective Equipment (PPE), vaccination, education, surveillance and evaluation or other measures that will be most effective for the identified hazards. In practice, facilities apply a variety of different measures with variable compliance. In comparison to facilities in less developed settings, though, they are applied in settings with a controlled environment of care. The actions taken by US healthcare workers happen in settings, sometimes with statutory mandates, with unlimited volumes of high grades of water (potable, deionized, distilled, sterile, pyrogen free), unlimited volumes of continuous energy, existence of mechanical ventilation equipment and staff to monitor and maintain air exchanges, humidity and dust. Staff have unlimited access to masks/respirators/powered air purifying respirator cover gowns, disinfectants, and cleaning supplies. High quality sterilization and disinfection of medical equipment is provided. Highly reliable products and medications are available. Medical records exist that can record and communicate patient history, status and risk over time. Laboratory systems have diagnostic tests with rapid turnaround times to identify or exclude treatable pathogens in patients with non-specific symptoms. Means of communication exist to contact patients at remote locations. Medical waste, waste water and solid waste are managed with minimal healthcare worker action. In hospitals, staff dedicate time to supervise infection control. Staff are routinely paid wages and given benefits, including sick leave. In short, a safe environment of care is provided that requires little attention of the immediate clinical staff.

In summary respiratory infection control tools exist, and many of the tools which have been in use for a long time can be very efficacious when consistently applied. But the efficacy of these tools in ideal settings and the effectiveness of these tools when applied to resource scarce settings should not be assumed.

Factors that Increase of the Risk of Acquiring rHAI

Whether a patient acquires rHAI depends largely on their susceptibility and exposure. At the moment of care, facilities can reduce exposure, but not change susceptibility. However, proactive early and routine efforts to identify patients who are susceptible may help to prioritize application of measures to reduce exposure for those patients.

In general, susceptibility can be decreased through immunization, immunity acquired from past infection, having a healthy immune system, having a healthy biome, avoiding unnecessary antibiotics, as well as by maintaining the ability to remove pathogens including by bathing and coughing, by intact lungs and skin and mobility, by managing and reducing comorbidities, and by maintaining blood sugar levels within normal limit.

Exposure can be influenced by a variety of factors and their interaction. The burden of infectious disease in the general population also increases the risk of exposure in hospitals. The effectiveness of interventions may vary in high and low prevalence settings. Fragile patients in very invasive settings such as intensive care units [10], are also highly exposed to respiratory pathogens.

Factors which affect exposure include:

·         The patient’s biome (many nosocomial infections come from the patients’ own organisms)

·         The duration and type of contact in the healthcare setting

·         The duration and type of invasive procedures (shorter surgery versus longer surgery)

·         Use of safe care practices (coughing and deep breathing, head of bed up in ventilated patient, sedation vacations, etc.)

·         Contact with medical equipment or devices that have not be reprocessed between patients

·         Sharing space with infectious patients or staff

·         Air that has low air changes per hour and intakes vents that bring in contaminated air

·         Lack of cleaning surfaces,

·         CContaminated food

·         Contaminated medications (prepared with common Intravenous (IV) bags, nebulizers prepared with surface water)

·         Environmental factors that increase or decrease the survival of pathogens in the environment

·         Level of implementation of control strategies

·         Burden of exposure due to local epidemics

Factors that increase susceptibility and exposure increase the risk of infection. Important patient level factors which impact susceptibility are summarized in Table 3.

The greatest exposure to rHAI is present in patents on a ventilator, whose use may increase the rate of acquisition of Ventilator Associated Pneumonia (VAP) 6 to 21 fold [15].

Surveillance Systems to Identify Patients’ Risk of rHAI

In the United States surveillance systems to detect respiratory epidemics exist at the facility or organizational level and in the public health sector’s regional, national and international levels. Public health surveillance is not exclusively focused on healthcare acquired infections, but aids the identification of rHAI via documentation of the prevalence of infections circulating in the community [16]. Public health laboratories also conduct diagnostic tests for emerging infections of public health importance when commercial tests do not exist. Public health systems may also administer, monitor and standardize systems for tracking rHAI in facilities.

Public Health and Regional, National and International Surveillance systems

Examples of these public health surveillance systems related to rHAI are:

·         Laboratory-based surveillance systems such as the National Respiratory and Enteric Virus Surveillance System of the Centers for Disease Control and Prevention (CDC).

·         Armed Forces Health Surveillance Center, which conducts respiratory surveillance on a variety of populations including military recruits, zoonotic-human interfaces on a variety of common respiratory pathogens.

·         The National Syndromic Surveillance System, which uses electronic data from emergency rooms to detect mass events including epidemics of respiratory infections.

·         Respiratory surveillance systems for influenza from the Council of State and Territorial Epidemiologists (sample CSTE report shown below).

·         U.S. Outpatient Influenza-Like Illness Network (ILINET), which is a sentinel surveillance networks of 1800 outpatient settings in 50 states, the US Virgin Islands, Puerto Rico, and the District of Columbia. The system reports the weekly percentage of outpatient visits for influenza-like illness.

·         The Influenza Hospitalization Surveillance Network (FluSurv-NET), which covers approximately 9% of the US population. This system reports hospitalizations and deaths.

·         The 122 Cities mortality reporting system (CDC), which tracks the portion of mortality associated with pneumonia and influenza.

·         The Influenza-Associated Pediatric Mortality Surveillance System.

·         The public health laboratories and WHO collaborating laboratories in the United States.

·         Reporting occupational acquisition of TB to Occupational Safety and Health Administration (OSHA) on the OSHA log and other healthcare acquired infections through workman’s compensation programs.

·         World Health Organization (WHO), Department of Communicable Disease Surveillance Response, maintains a Disease Outbreak News web site (http://www.who.int/csr/don).

·         National Health Safety Network, the largest US system to report HAI in the United States, with more than 13,000 hospitals and ambulatory surgery centers participating.

Non-Public Health Reporting Systems include ProMED-mail (Program for Monitoring Emerging Diseases), a reporting network which includes news, science, and member reports sponsored by the International Society for Infectious Diseases (http://www.promedmail.org).

Hospitals participate in the National Health Safety Network system to track complications of mechanical ventilation, post-operative infections, and flu immunization status. The complications of ventilation include ventilator associated pneumonia, death, pulmonary edema, sepsis, Acute Respiratory Distress Syndrome (ARDS), pulmonary embolism, and barotrauma. Facilities are motivated to participate through various levers including:

1.       Reporting certain metrics is a condition for participation in Centers for Medicaid and Medicare Services programs and requirement for payment for Medicare and Medicaid patients.

2.       State and local health jurisdictions require participation.

3.       Accrediting bodies, e.g., Det Norske Veritas (DNV), the Joint Commission, or the Accreditation Association for Ambulatory Healthcare (AAAHC), require facilities to report with a standardized system.

4.       Facilities wish to use data to be able to compare the quality of care internally and externally.

Intermediate between facility level and governmental surveillance systems to detect nosocomial respiratory infections are research or quality consortiums that may test interventions and which may have private or government funding. Examples include the Washington State Hospital Association’s “Safe Tables,” the Institute for Healthcare Improvement’s Project Joint, and the multi-organization consortium’s Surgical Care Improvement Project (SCIP). Organizations such as Qualis Health offer consulting services to reduce adverse events including ventilation associated pneumonia.

Facility level surveillance systems

At the facility or organizational level, hospitals adopt a variety of surveillance systems to detect and control the transmission of nosocomial respiratory illnesses. For examples, healthcare facilities use the CDC TB risk assessment to identify occupational clusters of TB infection and level of risk. This practice helps facilities develop strategies appropriate to their level of TB risk for screening employees and identifying transmission from patients: http://www.cdc.gov/tb/publications/guidelines/AppendixB_092706.pdf. In other cases, individual facilities may volunteer to become a site in the influenza sentinel surveillance systems. In the United States, care increasingly includes very short length of stay for almost all patients. Hospitals are largely centers for highly invasive procedures and monitoring, and patients may be discharged in hours or days to other care facilities. This reduces the risk of exposure to respiratory infections but also limits the ability to detect infections that may not develop for 30 or 90 days.

Facilities will employ various levels of screening, employing a number of different tools at different levels or at different points in the process of care. These include:

·                     Screening on first contact or admission to a facility.

Screening may occur in a phone call for an appointment, by computer kiosk, by patient phone app, by secure email, or by receptionist or volunteer. The condition screened for, and the questions to detect it, vary by institutional priority and by existing health alerts. They may screen for temperature, infections present on admission, immunization status, MRSA history or Multi-Drug Resistant Organisms (MDRO) test results. Patient may also be screened for presence of a rash and fever illness, fever of unknown origin, or influenza-like illness. During outbreaks, patients may be screened for additional conditions including travel to impacted areas. In the United States, most facilities screened for travel due to the 2014 Ebola emergency and to a lesser degree for travel to countries with transmission of the Middle Eastern Respiratory Syndrome Corona Virus. Hospitalized patients with respiratory syndrome and Acute Flaccid myelitis or Paralysis (AFP)  in the United States are screened for eEnterovirus D68; elsewhere in the world persons younger than 15 years of age with AFP  M 15 years of age would be screened for polio infection.

·                     Screening on entrance to a unit.

Within a facility, individual departments may conduct additional screening for respiratory conditions when they admit a patient. For example, patients admitted to HIV care wards may be screened for TB; patients admitted to Intensive Care Unit (ICU) may have screening cultures for nasal, rectal, and wound culture for MRSA and or other multiple drug resistant infections. Patients admitted to stem cell or transplant services may be screened for a broad array of conditions. Preoperative patients facing major surgery may have chest X-ray and a history and physical taken that can identify respiratory conditions and be used to defer surgery. Mothers presenting for delivery may have themselves and family in attendance screened for respiratory illnesses.

·                     Active screening for respiratory conditions.

Some facilities screen patients and visitors for respiratory symptoms to identify patients who may need isolation or special precautions. Patients are usually actively screened and visitors are actively questioned or undergo self-screening at a check-in kiosk.

U.S. facilities may screen healthcare workers prior to the first day of work for immunizations, annual flu shot, and by law, for TB infection or disease. By law, health facilities are required to:

1.       Conduct annual symptom surveys for employees with latent TB infection, and

2.       Repeat tuberculin testing (Tuberculin skin testing or Interferon-Gamma Release Assays (IGRAs) for staff in high-risk departments.

·                     Surveillance for ventilator related pneumonia or ventilator related events.

Hospitals report ventilator-associated pneumonia in the National Healthcare Safety Network. While the definition and data requirements are standardized, individual facilities develop their own systems to obtain the required data.

Reporting ventilator-related pneumonia requires tracking all patients put on a ventilator in a given unit and then monitoring the number of ventilator-days, which becomes the denominator. For example, if at 8 AM,  10 patients are on a ventilator in an Intensive Care Unit (ICU), this would be counted as 10 ventilator-days. Obtaining the denominator data (ventilator-days) is almost always a manual process and is done daily, or for a sample of days. Staff review charts to exclude patients with pneumonia present on admission, then track lists of patients on ventilators to see if they develop a reportable event attributable to use of the ventilator.

Different facilities use different systems to do this. Some have data mining software, or program algorithms to help identify possible infections. While these systems reduce the chart review, due to the difficulty of diagnosing pneumonia, patients still need to be reviewed individually to see if they meet the definition for ventilation-related pneumonia.

§     Surveillance of post-operative pneumonia to report rates pneumonia following surgery.

Starting with a list of patients who have undergone a surgical procedure, patients are followed for 30 days. Patients with respiratory infections present on admission are removed, then patients are stratified by ventilated and non-ventilated patients, and patients are then tracked to see if they develop infections meeting the definition in the follow-up period. Systems with active surveillance send letters, texts, phone or e-mail to patients and families asking if they developed infections in the post-op period; those indicating in the affirmative are usually interviewed directly. Alternately, letters may be sent to the surgeons or physicians providing follow-care.

·                     Surveillance in non-surgical settings.

Non-surgical hospitals may determine their highest risk patient population and track pneumonia developing more than 48 hours after admission. For example, hospitals may track the development of respiratory illness in stroke patients, trauma patients, burn patients, in patients with tube feeding, and in patients with tracheostomies on a ventilator.

·                     Tracking infections following exposures to lab confirmed infections of public health importance.

Most hospitals have a system in place to notify patients, staff and public health authorities of infections acquired during their care. During high priority outbreaks, health departments or CDC staff will step in. During the SARS outbreak for example, CDC dedicated more than 800 staff to surveillance and containment efforts. Hospitals try to identify exposures to limit future transmission, to remove infectious staff from duty, and to provide prophylaxis or treatment. An example is shown below illustrating the number of healthcare workers and close contacts who developed infection from SARS.

Existing Tools for identifying rHAI

Standard Comprehensive References: Three organizations, the Curry International Center, CDC and WHO have published very clear, exceptionally well done, evidence-based tools for the control of TB in Healthcare settings. Applying the principles of these guidelines and adapting the procedures to other respiratory diseases would likely contribute to the control of a variety of respiratory infections. Because of that, this review strongly recommends their use as primary references and resources, with additional focus on hand hygiene, and provision of large volumes of water to all facilities doing invasive procedures. All three organizations have developed training material related to these guides that are simple, clear and appropriate for a wide variety of settings:

·         WHO Policy on TB infection control in Health-Care Facilities, Congregate Settings and Households 2009. WHO/HTM/TB/2009.419. http://whqlibdoc.who.int/publications/2009/9789241598323_eng.pdf?ua=1

·         Francis J. Curry National TB Center. TB Infection Control, A Practical Manual for Preventing TB. 2011.

http://www.currytbcenter.ucsf.edu/sites/default/files/ic_book_2011.pdf

·         CDC. Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005 MMWR 2005; 54 (No. RR-17).

In addition, the 225 page HICPAC 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings remains the US standard guiding practice on the use of transmission-based precautions for both respiratory syndromes and pathogen-specific infections. The evidence base and duration of application for many of the isolation precautions remain widely debated in the United States. As better diagnosis tools evolve for viral pathogens, more advocacy is seen for the use of both respiratory (airborne or droplet) and contact precautions (e.g., gowns, gloves and mask and eye protection) [17], for a broader range of diseases [18].

The last classic reference is the 2003 federally appointed Healthcare Infection Control Practices Advisory Committee (HICPAC) guideline (Guideline for Preventing Healthcare-Associated Pneumonia) [19], which remains the most evidence dense reference for preventing healthcare associated pneumonia. It includes guidance for preventing ventilation-associated pneumonia (events), tube feeding risk reduction, and an extensive literature review.

References for outbreak investigations: While the resources needed to conduct an analysis of an outbreak investigation may be outside of the budget, time availability and expertise of many healthcare providers, there are some basic principles which can be applied to detect and define that a problem exists, even if the plan is then request external help. Some countries have WHO sponsored field epidemiology courses which can provide training or assistance in outbreaks. CDC provides assistance for outbreaks with novel or unknown risk factors or the potential for multi-country spread [20]. The CDC Healthcare Associated Infection Outbreak Investigation Toolkit contains outbreak abstraction forms and guidance on contains general information or ‘variables’ that might be collected during HAI outbreak investigations in a variety of different settings. An outline of the steps to take is described in Infection Control in Ambulatory Care [21].

Tools, trainings, forms, program descriptions and best practices: Table 3 provides a list of specialized guides, job aids, and case studies related to the measures discussed in Sections I-III above, for different healthcare settings and disease areas. These include commonly used forms, trainings, signs, calculators, sample legislation, and new approaches that may be useful for control of respiratory infections. These should not be regarded as ‘ready to use’ guides, but as illustrations of principles that could be adapted to reduce the susceptibility and vulnerability of patients to rHAI in other settings.

Implications for Practice in Limited Resource Settings

To be successful in halting transmission, infection control measures need to match the complexity of care provided. The more complex the care that is provided, the more important system-level facility enhancements become. At the lowest level, relatively simple measure like implementation of alcohol hand gel or provision of sterile syringes can have important benefits, since at dispensaries or health posts the most common invasive procedures done may be injections. Even for sterile syringes to be success, it will be necessary to have systems for stock management, medical waste, supervision and cost recovery. As care becomes more complex, however, system wide health strengthening in infection control is necessary or care will not be safe. A dispensary may prevent the spread of blood borne pathogens with the use of single-use syringes. A dialysis facility may implement use of sterile syringes but will still spread Hepatitis C and B unless they institute a variety of measures including water systems, adequate volumes of water, reverse osmosis, cleaning protocols, ability to separate patients, strict reprocessing guidelines for dialysis filters. To prevent respiratory transmission within the healthcare setting, system level changes will most likely be necessary.

As worldwide levels of HIV and HCV rise, attention to blood borne IC is of increased importance as both may be transmitted by unsafe care. HCV can be transmitted in the workplace by exposure to nasal secretions and work surfaces even when sterile injection equipment is used.

Bloodborne pathogen control program in the U.S is mandated by government and has a number of key elements, as outlined below. These elements present a framework which is also similar to that applied for the control of rHAI.

1)                   Conduct a risk assessment to identify where exposure to blood will occur and to whom

2)                   Develop a plan for prevention, control and treatment of bloodborne exposure

3)                   Implement engineering controls:

·         Sterile devices for injections, safety devices where available,

·         Eliminating injections and sharps whenever possible,

·         Use sharps containers,

·         Medical waste systems to remove contaminated devices from healthcare or public use.

4)                   Introduce Personal Protective Equipment (PPE) for staff and patients

These should be made available to employees of greatest exposure rather than highest status (e.g. midwifes and surgeons should have the same level of PPE.)

·         Gloves, gowns, masks and eye protection

·         Closed toe shoes

5)                   Implement work practice controls

·         Remove blood from the environment though effective cleaning

·         Cleaners need water, cleanable buckets, brushes, detergent and disinfectants.

·         Launder textiles in safe ways

·         Biosafety program in the lab to minimize blood contact

·         Reprocessing of instruments between patients appropriate to contact with skin, mucous membranes or parenteral use

·         No recapping of used sharps

·         Supervision of medications with potential for abuse

6)                   Require vaccination for healthcare workers and patients (especially HBV)

7)                   Implement exposure management system for workers including testing and treatment, and compensation for work related illness and injuries

Core Principles of airborne (TB) Control

The principles of TB control can adapted to reduce the nosocomial transmission of other respiratory pathogens. These principles and suggested modifications include:

1)                   Conduct a risk assessment to define hazards and select control measures appropriate to the hazard, risk and location.

2)                   Engineering controls

·         Design of facilities to avoid recirculation of unfiltered or untreated air

·         Design of the patient flow to minimize the time infectious patients spend in public waiting rooms or settings without adequate ventilation

·         Provide Enhanced ventilation for higher risk and cough inducing procedures in areas with enhanced ventilation

·         Placement of waiting rooms outside and in areas that have enhanced ventilation or venting to the outside, never in corridors

·         Lab hoods for microscopy and cultures

·         Use of appropriate diagnostic tests to confirm need for treatment or prophylaxis and ensure prudent use of medications

·         Directional air flow or negative pressure

·         Application of evidence based treatment regimens

·         Use of a combination of mechanical ventilation systems, filters, upper air UV light, fans, and non-recirculating exhaust systems when natural ventilation is not possible

·         Use of diagnostic tests to reduce over treatment

3)                   Administrative Controls

·         Use of the least restrictive setting possible including care at home.

·         Avoid purchase of devices that the setting cannot main or reprocess.

·         Prohibition of program financing from the sale of medications as this can promote inappropriate use of medications.

·         Pre-employment screening of employees for infection and disease, with ongoing monitoring.

·         Select an improvement priority based on regional risks and track progress with process indices.

4)                   Work practice controls

·         Screening for infectious cases in staff, visitors and patients in all settings

·         Screening for respiratory symptoms to mask those upon entry to facility (or provide cloth handkerchiefs)

·         Isolation of infectious cases or removal of them from public areas and shared workplaces

·         Investigation of persons with significant exposure to serious and treatable illnesses to prevent additional transmission (SARS, MDR-TB, CoMERS, ARDS from unknown cause)

·         Use of respiratory hygiene (cover coughs, mask persons with respiratory illness)

·         Therapy matched to drug susceptibility, avoiding broad treatment

5)                   Vaccination

·         Use of vaccinations as appropriate and cost effective including pneumococcal, and Hib

6)                   PPE

·         Staff use of appropriate PPE when working with infectious patients

·         Patient use of masks, facility provided handkerchiefs

7)                   Exposure Management

·         Treatment of latent TB infection

·         Furlough or masking of staff with respiratory syndromes

·         Use of directly observed or monitored therapy to ensure completion

·         Evaluation rates of occupational illness and treatment failures to improve the program

Expectations of lowered efficacy when applying TB control measures to other respiratory pathogens

TB control practices have been effective in the United States to reduce transmissions in healthcare sites. The same approaches can be expected to be less effective for the control of other respiratory infections for a number of reasons, for example the high rate of untreated HIV/TB and MDR TB infections in many countries [22]. HIV increases the progression of TB disease, changes the detection by skin testing or CXR, and increases the reactivation rates of TB. A high prevalence of HIV in the population means many additional infectious TB patients were present in healthcare facilities during childbirth, treatment for emergencies such as car accidents, and all other medical treatments [23]. HIV also increases vulnerability to other respiratory infections.

When applying TB control measures to other rHAIs, there are reasons to expect differences in efficacy. Unlike TB, many respiratory pathogens are infectious before the onset of symptoms. Workers come to work infectious without their knowledge. This limits the sensitivity of screening measures to identify infectious cases. Subclinical infections can also be infectious, whereas for TB, not all clinical infections are infectious.

Second, TB control programs in the United States are often supported by law, externally funded, supervised by external oversight, and have standard measures of proven efficacy [24]. Program evaluation measures have also been standardized. Hospital control programs for other infectious respiratory illnesses are not externally funded, but are sometimes monitored by state or local departments of health.

Research money and interest also exists to test TB control measures, including in resource scarce settings. In contrast, the majority of viral infections transmitted in facilities (e.g., RSV in adults and metapneumovirus) are often ignored as a cause of nosocomial infection. Clinicians do not test for them if there is no targeted therapy; diagnostic tests done for screening are not billable. Diagnosis of VAP and pneumonia is difficult [25,26], variable, and unreliable in both developed and developing country settings, making evaluation of pneumonia control measures more difficult.

In addition, TB control is an identified priority due to the high case fatality rates and burden of disease. National, bilateral organizations and foundations fund consensus strategies. The same is not true for many of the poorly understood respiratory adverse events.

As TB also has a lower attack rate than many pathogens [27], it does not overwhelm healthcare facilities the way RSV or influenza epidemics can. A very high rate of TB would be 280 per 100,000 persons per year, as occurs in Southern Africa (In contrast, the US rate in 2014 was 3/100,000 [28]), whereas during a flu season more than three quarters of children may be infected. It is not uncommon during the peak of a seasonal flu outbreak to have more than 10% absenteeism in the U. S. work place.

Even in the United States, lab diagnosed rHAI can only be verified in funded research or sentinel sites; clinical hospitals monitor process indicators rather than outcome indicators except for VAP. Readily available and affordable diagnostic tests exist for TB, but not for most of the other causes of respiratory pathogens which are predominantly viral. This limits the identification of pathogen specific causes for early triage into isolation.

Finally, except in HIV positive persons, healthcare acquired TB disease may take months to years be become visible. The onset of other healthcare acquired infections may be considered at 48 hours after admission or within the incubation period of known pathogens.

Prioritizing tools for use in limited resource settings

Infection Control practices and experience are underrepresented in the professional literature and some of the comments to follow are based on unpublished data from the author’s experience managing a 38 facility infection control program, a university affiliated trauma hospital serving five states, and community hospitals.

Measure ventilation: air exchanges per hour and airflow

The most effective baseline intervention would be to do a facility review of the indoor and outdoor spaces and how they are used, including identifying the paths of patient flow and where the high hazard procedures are done, and documenting the ventilation air changes per hour, where the intake and exhaust vents are located, the use of fans, bio-safety cabinets, and where cough inducing procedures, and the lab are located. When identifying the air intakes and exhaust locations include the opened space of windows, not the size of the glassed window, which can then be used to identify the areas that need more ventilation, and the locations that have enhanced (> 12 ACH), normal (6 ACH), and poor ventilation rates. A list of areas needing enhanced ventilation are provided in all three of the standard TB references mentioned in Section 4.

The highest priorities would be to eliminate crowded internal waiting rooms, such as outside of an X-ray machine, changing the flow to separate infectious patients from low risk settings, and maximizing natural ventilation. Technical guides are available to help locate intake and exhaust vents and to size them to provide safe air.

Locate high risk services in settings with adequate ventilation (ACH and air exchanges per hour)

Services with a high risk of respiratory transmission should be located in areas with enhanced ventilation. However, all patients presenting for care should be assumed to be possibly infectious with respiratory illnesses. Surgery, autopsies, intensive care units, sputum induction, waiting, bronchoscopy, childbirth, toilets, laundry, laboratory, microscopy, central sterile supply, and pulmonary therapy are among the services that should be conducted in areas with enhanced ventilation and with at least two air exchanges per hour and no recirculated air.

Much disease transmission occurs, however, in patients admitted for non-respiratory conditions. It is the pregnant woman with her persistent cough, the child with a broken leg with influenza like illness, the febrile family caregiver of a malaria patient who, unnoticed by staff, may be a super-spreader of respiratory illness. Adequate ventilation without recirculation in all settings is the only way to provide safe care.

Ensure that adequate volume of suitable water is readily available

A point worth emphasizing is that effective infection control requires the provision of large volumes of water. Hand hygiene, patient bathing, cooking, reprocessing of linen and medical instruments, not to mention cleaning of the environment, all require large volumes of water. Even when alcohol hand rubs have been fully implemented, water remains an essential component for care. Conversely, facilities without water should not implement services that cannot be safely provided without large volumes of water, e.g., hemodialysis, bronchoscopy, endoscopy, and surgery.

Water needs to be prioritized for persons doing instrument reprocessing, including steam sterilization. If water is not available, invasive procedures will not be safe.

Use process monitoring coupled with existing outcomes measures to evaluate compliance with infection control measures

In resource limited settings it may be useable and feasible to track some outcomes that are less specific to rHAI than the US National Health Safety Network (NHSN) measures. For example, departments can track death rates beyond 48 hours of admission, all causes of employee absenteeism, and diagnosis of TB disease in employees (or preferably conversion of latent TB infection). In settings without a system to replace ill staff, it may be useful to do periodic anonymous symptom surveys at work for presence of respiratory symptoms. Patient death-rates by unit and if possible by disease are also useful to detect serious problems. Because most facilities do not have dedicated staff who can compile and present statistics, facilities should only try to track measures that can be acted on to improve quality.

Employees, even those vaccinated with BCG can be screened for latent infection by tuberculin. Those with mm reading > 14 are predictive of TB disease, and the size of the induration is also lessened after 15 years [29]. In high prevalence settings these would need to be compared with community acquisition rates. However, identification of infected employees and provision of prophylactic treatment is important to preserve and protect valued, trained staff as well as to identify units where transmission is greater than expected.

Share data and learn from peers

The International Infection Control Consortium is an ongoing working group that shares data and interventions to improve care in middle-income economies. Settings that are willing to share and discuss what issues and data they have, including discussing problems arising, are better able to develop interventions realistic to their settings. Facilities can also use applicable published work as a benchmark for rates or rHAI. For example, Ndegwa et al. [30], surveyed patients twice a week in several Kenyan hospital wards for hospital onset (>48 hrs) of fever, hypothermia, and signs of respiratory infection such as cough. They then took naso-pharyngeal swabs. They established a base rate of 9 per 10000 patient days with ICU having the greatest rates. While this strategy was 5 fold lower than systems that sampled patients every day, it did verify the problems of viral rHai, the problem in ICU and pediatric wards. Rather than replicating this expensive and labor intensive prevalence study on an ongoing basis, facilities can now focus on monitoring interventions including the onset of influenza-like illnesses in staff, hand hygiene monitoring, cleaning validation, volumes of water used, volumes of hand hygiene gel used, etc., to address a known problem.

ICUs with staff who have administrative time can monitor the bed position of ventilated patients and track the portion of afebrile patients who develop a fever or purulent sputum beyond 48 hours (not specific to rHai), as well as track the duration of ventilation, sedation vacations, and the duration of central line or urinary catheter placement. The goal is to decrease the duration of invasive measures. Most simply, this can be done on paper at the head of the bed (then verified by a checklist) by recording the date of admission and date on and off a ventilator. It can also be done on daily ward rounds for patients on the unit. IHI has a simple run chart tool that can be used to identify when the population based rates are “out of control” or statistically significant.

Additional Means of Preventing rHAI in Resource Scarce Settings

Given the concerns that the ‘easy’ simple measures in infection control have already been applied, and understanding that most off-the-shelf infection control measures cannot necessarily be applied in settings without the same environment of care, several recommendations can nevertheless be made to improve infection control, especially against respiratory infections. These include especially undertaking risk assessment of patients and high risk procedures, and identification of existing ventilation to ensure the setting matches the need. Equally important is the need to provide adequate volumes of water for hand hygiene, instrument reprocessing, facility cleaning, laundry, food preparation, water for patient showering, and patient hand hygiene and laundry. Improving these two elements of care: safe air, safe water will provide broad improvements in patient care. No facility can provide safely invasive procedures without them.

In conjunction with these measures, sites should select a process improvement goal based on regional priorities and use Quality Assurance techniques to track its resolution. Depending on the risk profile for the facility, some process goals might be:

·         Increase the rate of HIV and TB testing in patients with pneumonia who are not improving with antibiotics;

·         Improve the TB screening rate for employees with cough greater than two weeks;

·         Track the rate of fever, cough and increased respiratory rate in patients with nasal gastric feeding tubes,

·         Decrease the number of patients with sinusitis who are treated with antibiotics;

·         Decrease the number of patients presenting with influenza-like illness who are treated with antibiotics etc.

Beyond these measures, additional steps which can be taken include the following:

Antimicrobial Stewardship

In support of overall with infection control, the importance of promoting rationale antimicrobial use is paramount. Worldwide, flu and pneumonia remain among of the 10 top causes of mortality, and preserving antibiotics for treatment is essential.

 It is not uncommon for clinicians to prescribe antibiotics and multiple medications to many patients a day, often without diagnostics tests, detailed history, record review or examination. While patients are satisfied when they receive medications often after expensive and long travel to the clinic, and the clinic benefits from the access fee and sale of medications, it cannot be assumed that this care is better than no car., Such care contributes to drug resistance and may be no better than random distribution of medication. In the US case of prescribing opioids, such care has led to tens of thousands of deaths a year. The CDC, Infectious Disease Society of America (IDSA), the WHO Rational Drug Program and US Agency for International Development (USAID) have well developed programs promoting rationale drug use. The US program guides presume that there is no public ability to purchase antimicrobial medications without a prescription, and that existing medications are not counterfeit. Key challenges relate to developing consensus around a new “post Bamako Initiative” that finances primary care without the sales of antibiotics, restricting large scale public access of antimicrobials (i.e., street vendors), and instituting prescriptive authority over antibiotics while maintaining appropriate access for remote populations. However, facilities should not wait for sweeping programmatic changes. In the meantime, and possibly as part of a regional initiative they can apply the rational drug use work of WHO focused on:

·         Developing treatment criteria for antibiotic that are accepted by clinicians, patients and administration

·         Using the shortest effective therapy

·         Auditing antibiotic prescribing for defined conditions

·         Inculcating a physician attitude of adherence to evidence based practice rather than independent decision making in opposition to evidence

·         Educating providers and the public on treatment of viral conditions including flu, upper respiratory infections, simple diarrhea and sinusitis for which universal antibiotic treatment is considered a medical error.

Develop test and implement better diagnostic tests

Large-scale syndromic treatment programs lead to drug resistance. More specific criteria are needed. For example, Amiriv and others are also reconsidering the use of respiratory rate as the diagnostic criteria for bacteria pneumonia in children, due to the low predictive values that lead to the unnecessary use of antimicrobials. To preserve the effectiveness of antibiotics for future years, and to reduce the harms of unnecessary antibiotic use, diagnostic tests should be implemented when cost effective. This cost, however, should consider not just the current patient’s costs, but the cost to society if there is no effective or affordable treatment in future years. Implementation of diagnostic tests can improve care, and programs should promote the use of rapid diagnostic tests where appropriate for HIV, malaria, TB and possibly in some situations for Strep, syphilis and other conditions, so inappropriate antibiotics use is reduced. New work with small scale multi-organism molecular diagnostics may be able to detect organisms within hours. This development work should be guided by needs in developing countries.

Where possible, facilities can support the design and evaluation of new diagnostic measures that can better diagnose pneumonia including new ultrasound and pulse oximeters or other new technologies. This is important as the community dispensing programs for pneumonia use an algorithm that is insensitive for pneumonia and contributes to drug resistance. While pediatric populations may benefit for the first years from community-based distribution, it remains likely that the rapid drug resistance that is developing for cotrimoxazole will eliminate this as a low cost treatment option.

Vaccinate against respiratory infections

As respiratory pathogens develop drug resistance, the cost-effectives of pneumococcal vaccines and Hib will increase in developing country settings.

Use of cell phone and computer technology to expand virtual access in remote settings

A large proportion of healthcare out of pocket patient costs in resource limited settings are for travel to health sites. Where available, increasing the use of mobile technology to contact telehealth visits, convey lab results, send pictures to monitor wound care, report patient status, promote medication compliance, remind about immunizations etc. and in general improve communication between patient and provider should be explored.

Important programmatic models are developing in the US and elsewhere. In the Northwest US, rural providers cover a five-state area including Alaska. Weekly telemedicine sessions are conducting following the Project ECHOã (Extension for Community Health Care Outcomes) model [31], with expert practitioners who coach group sessions of providers in treatment of HCV, pain, rheumatoid arthritis, mental health and HIV. Provider to Provider sessions allow the rural provider to present their case for expert advice. Providers join from their laptop (requiring no travel costs) and have video sessions. The result is to support both patient treatment and continuous provider education. The U.S. Indian Health services [32], has expanded the use of telehealth services to allow patients to consult with providers via secure video and audio links so providers can be in cities and patients on their rural homes. This type of consultation also reduces the exposure to infection pathogens.

Conclusion

It is an unfortunate truth that Infection Preventionists can more easily prevent Ebola in their facilities than the spread of a typical respiratory infection. However, implementing risk assessments for procedures and populations with high associated risk of infection combined with a critical review of existing control strategies can assist to reduce transmission. Engineering controls (e.g. placing waiting areas outside or with enhanced ventilation, use of safety hoods) will be more effective than those requiring workers and patients to change their behavior. As demonstrated by the experience in the US, the routine application of well-known TB control measures to prevent respiratory disease when applied in non-TB settings can be very efficacious. Screening and isolation persons with respiratory symptoms, improving ventilation and PPE use can likewise reduce transmission. There is no existing solution for provision of enough PPE in resource scarce settings, so this needs innovation. Staff might use cartridge masks rather than N-95 as they last longer and the lifetime cost is lower. Process measures should be applied to evaluate the consistency of the infection control interventions. Hand hygiene and enough water for reprocessing of surgical instruments used on multiple patients, hand washing, cleaning and laundry are important. Pubic and provider education, while popular recommendation, but without these addiction recommendation is not sufficient.

Disclaimer

The views expressed herein are those of the authors and do not necessarily reflect the views of their affiliated organizations.

Acknowledgments

The authors would like to express their gratitude to the entire team at the Center for Innovation and Technology, University Research Co., LLC, Bethesda, Maryland, for their support during the preparation of this manuscript.

Conflict of interest

None

Definitions

Airborne infections: Used by US CDC to refer to disease thought to be transmitted largely by nuclei < 5 microns that can travel more than 1 meter from the source. These include disease such as measles, chickenpox, tuberculosis, and Hanta virus.

Droplet infections: Used by US CDC to refer to disease spread by pathogens on aerosolized particles larger than 5 microns which usually fall out of the air close to the patient emitting them. Historically it was thought that separating patients by 3 feet was enough to prevent the spread of disease transmitted by droplet infections. These include disease such as influenza, common colds, influenza, parainfluenza virus, adenovirus, respiratory syncytial virus, and human metapneumovirus.

Efficacy: Results achieved under research or ideal conditions.

Effectiveness: Results achieved under real world settings.

Healthcare-associated infections: Infections acquired as an unintended consequence of receiving healthcare. Depending on the causative organisms, infections may present from 1 day to 18 months or decades (TB) after the exposure during the healthcare visit.

Respiratory infections: Used in this document to refer to pathogens infecting the respiratory tract that may be transmitted by a variety of routes including fecal-respiratory, droplet, airborne and contact.


Work location

TB incidence rate ratio [5]

(Relative to general population TB incidence rate)

Outpatient facilities

4.2 – 11.6

General medical wards

3.9 – 36.6

Inpatient facilities

14.6 – 99.0

Emergency rooms

26.6 – 31.9

Laboratories

78.9

Table 1: Excess occupational risk of TB among workers in low and middle-income settings.


Notifications and Alerts

Medical records or notifiable illness reports of severe respiratory disease

 

Notifiable case report for severe respiratory disease

 

Case and contact investigations

 

Quarantine of exposed individuals

Restrictions

Isolation of symptomatic and confirmed cases

 

Active screening and restricting children and visitors with

respiratory symptoms from visiting

Engineering controls

Having private rooms

 

Having isolation rooms with negative pressure

 

Mapping ACH and air flow in cubic feet per minute

 

Mapping patient flow to reduce non-essential exposure

 

Ventilation: negative pressures

 

Ventilation: increasing number of ventilation exchanges per hours sto the outside air

 

Ventilation: eliminating indoor waiting areas

 

Building design: including directional airflow

 

Ventilation: Ultra violet lights to decontaminate air and air handling systems . x

Decontamination: Possible use of UV robots to enhance cleaning

Employee protections

Paid sick leave for workers with respiratory symptoms

 

Employee health pre-employment TB screening and treatment of latent infection

 

Evaluation of interventions and reporting back to staff and admin

Transmission control

Transmission-based precautions, e.g., airborne, droplet, contact precautions

 

Staff education about respiratory transmission

 

Glove, mask and gown use to reduce transmission

 

Restrict cough-inducing procedures to negative pressure rooms with at least 12 Air Changes per Hour (ACH)

Vaccinations

Mandatory influenza vaccine programs for staff

 

Influenza and pneumococcal vaccine programs for patients

Sterilization and cleaning

Reprocess devices in contact with respiratory secretions: nasal cannulas, masks, intubation devices, ambu bags, peak flow meters etc.

 

Do not reuse single use devices on multiple patients

 

Formal review of decision and process if single use devices reprocesses for use on multiple patients

 

Humidifier: use sterile water

 

High level disinfection of mist tents and all item used on mucous membranes

Respiratory etiquette

Masking symptomatic persons, hand hygiene

 

Screening for signs of respiratory illness at point of entry to the facility

 

Cover your cough reinforced (can use cloth handkerchiefs if no masks for indoor facilities)

 

Masks available at all entry, use reinforced by staff

Facility Information (signs)

Signage at entry

 

Greetings that avoid handshakes

Clinical care

Oral hygiene and Chlorhexidine Gluconate (CHG) mouth swabbing (ventilated patients)

 

Ventilator care bundle (See Table 3)

 

Large volume nebulizers with sterile solutions

 

Suctioning with sterile or at least clean gloves and sterile water

 

Oral 0.12 % CHG before heart surgery

 

Sink guards (to prevent Acinetobacter on supplies on counters near sink)

 

Separating hand hygiene sink from dirty utility sinks

Laboratory

Laboratory biosafety practices (hoods) especially for microscopy

 

Hand hygiene for patients and staff

Programmatic

Coordination between animal and human health for severe pathogens

 

TB screening and control programs

Table 2: Measures to Prevent Respiratory Healthcare Associated Infections in US.


Note: Factors are not independent and may be synergistic or markers of other underlying causal factors [10,12-14]

General factors

Age (very young and > 50* with increased risk > 70) 

Immunization status (MMR, polio, influenza, HIB, pneumococcus, recent pertussis)

Lack of immunization for flu, pneumococcal, or Hib (children)

Malnutrition status including vitamin A deficiency

Existing or prior conditions

Prior hospitalization 90 days or nursing home placement 

Burn or trauma patient

Neoplastic disease 

Congestive heart failure 

Liver, cerebrovascular disease or renal disease

Other respiratory illness, chronic respiratory condition or lung abnormality

Prior colonization with MRSA                                          

Hemodialysis patient                                           

Pregnancy                              

Alcohol or opioid use disorders [11]

Allergies                                                                  

Diabetes

HIV or immunocompromised                                           

Prior use of antibiotics, especially broad spectrum       

Stroke

Lifestyle or environmental factors

Smoking status

Exposure to secondary smoke and air pollution

Occupational exposure (asbestos, silica, young children)

Factors associated with treatment and care

Healthcare wound care therapy

Therapy with H2 blockers, proton pump inhibitors, antacids

Recent bronchoscopy

Immobility

On steroids 

Post-surgical procedure

Use of general anesthesia

Use of 4 or more units of blood

Altered mental status

Tube feeding 

Other health system factors

Lack of treatment for TB infection

Occupying room whose prior patients had drug resistant or respiratory infections

Contact of lab confirmed case of respiratory illness                     

Duration of intubation 

Duration of hospitalization

Table 3: Factors Increasing Patient Susceptibility for rHAI.

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Citation: Catlin M, AlMossawi HJ, Kak N, Kaul A (2019) Healthcare Acquired Respiratory Infections – Considerations and Strategies for Prevention and Control. J Hosp Health Care Admin 3: 124. DOI: 10.29011/JHHA-124.000024