Infection control

INFECTION CONTROL

1. 
   Standard Precautions
   

All clinical personnel should observe Standard Precautions for all patients as part of a routine strategy for infection control in healthcare settings. Dental hygienists and supportive personnel routinely encounter blood and body fluids during the course of preventive dental services. All body fluids are potentially infected with many different infectious agents such as Human Immunodeficiency Virus (HIV), hepatitis B or hepatitis C. Standard Precautions are used to prevent the transmission of these agents among patients and healthcare personnel.

1. 
   Standard Precautions are implemented when blood and saliva, or other body fluids (excluding sweat) will be encountered regardless if they contain visible blood or not. They are also to be utilized when contact with non-intact skin or mucous membranes are anticipated such as perioral lesions like fever blisters and other skin breaks.
   
2. 
   Personal Protective Equipment (PPE) must be appropriate for the type of service provided and the patient interaction anticipated and may include vinyl gloves, gowns, masks, and protective eyewear.
   

3. Dental hygienist should always wear gloves when…

• 
  Touching blood and body fluids.
  

• 
  Touching mucous membranes (i.e. inside mouth)
  

• 
  Touching any non-intact skin (or when the health care worker’s skin is not intact).
  

• 
  Handling items or surfaces soiled by body fluids.
  

4. 
   Hands will be washed before and after the services, before gloving, and before leaving the service area.
   
5. 
   Gloves must be changed after contact with each patient. Change gloves between tasks and procedures on the same patient after contact with materials that may contain a high concentration of microorganisms. After removing gloves, perform hand hygiene. If hands are visibly dirty, contaminated with proteinaceous material, or visibly soiled with blood or body fluids, wash hands with soap and water. When hands are not visibly dirty, alcohol-based hand rubs can be used for hand decontamination.
   
6. 
   Surgical masks and protective eye wear (e.g. goggles or face shields) should be worn by a dental hygienist during procedures that are likely to generate splashes or sprays of body fluids, in order to prevent exposure of mucous membranes in the mouth, nose, and eyes.
   
7. 
   Gowns or aprons should be worn during procedures that are likely to generate splashes of body fluids.
   
8. 
   Dental hygienists and support staff with exudative skin lesions or weeping dermatitis should refrain from direct patient contact, or handling patient care equipment, until the skin condition resolves.
   

2. 
   Transmission-Based Precautions
   

Transmission-Based precautions are broken up into three categories: Contact Precautions, Droplet Precautions, and Airborne Precautions. They are always used in addition to Standard Precautions when the route of transmission is not interrupted by the use of Standard Precautions alone. At times, based on the routes of transmission, combinations of Transmission-Based precautions may be used. Transmission-Based Precautions must remain in place while test results are pending based on the clinical presentation and likely pathogens.

1. 
   Contact Precautions
   

Contact Precautions consist of:

• 
  Donning Personal Protective Equipment (PPE) as needed (See Standard Precautions above)
  
• 
  Gloves will be worn for all interactions that may involve contact with any patient or contaminated areas for which Contact Precautions apply.
  
• 
  All protective equipment shall be applied prior to entry and discarded before exiting the environment containing a potentially infectious agent.
  

2. 
   Droplet Precautions
   

Droplet Precautions consist of:

• 
  Donning Personal Protective Equipment (PPE) as needed (See Standard Precautions above)
  
• 
  A mask is donned prior to close contact with a patient where Droplet Precautions apply.
  
• 
  Mask shall be applied prior to direct services and discarded after exiting the environment containing a potentially infectious agent
  

3. 
   Airborne Precautions
   

Airborne Precautions consist of:

• 
  Donning Personal Protective Equipment (PPE) as needed (See Standard Precautions above)
  
• 
  Prior to entering room, mask or respirator shall be worn based on disease specific recommendations.
  
• 
  Any person with suspected or confirmed TB disease of the lungs, airway, or larynx shall be isolated from other patients. If available, this person shall be placed in a room that meets the requirements for an Airborne Infection Isolation Room (AIIR). If an AIIR in unavailable, a separate room apart from other patients with the door closed shall be used. Persons with suspected or confirmed TB should wear a surgical or procedure mask, if possible and should observe strict Respiratory Hygiene/Cough Etiquette. In addition, they should be instructed to keep the mask on when not in an AIIR.
  

3. 
   Additional Guidance
   

1. 
   KY DPH Communicable Disease Branch should be contacted, if possible, before a patient suspected of having measles or varicella is brought into a preventive dental service setting.
   
2. 
   KY DPH Communicable Disease Branch should be consulted to help determine how to minimize airborne exposure and as to which potentially exposed persons should receive Post-exposure prophylaxis, Vaccine or Immune Globulin.
   
3. 
   A surveillance system must be established for injuries such as percutaneous injuries, and mucous membrane contamination of the hygienist and/or support staff.
   
4. 
   All workers to whom Standard Precautions apply should be offered Hepatitis B vaccine with appropriate training regarding hepatitis B, hepatitis B vaccination, the efficacy, safety, method of administration, and benefits of vaccination, and that the vaccine and vaccination are provided free of charge to the employee. A written statement of Declination of Hepatitis B vaccination must be signed by an employee who chooses not to accept the vaccine and kept in Local Health Department files, http://www.osha.gov/SLTC/etools/hospital/hazards/bbp/declination.html
   
5. 
   To minimize risk of exposure during emergency mouth-to-mouth resuscitation, mouthpieces, resuscitation bags, or other ventilation devices should be available for use in areas where the need for resuscitation might arise. This includes health department settings where anaphylaxis may develop.
   
6. 
   Disinfection means the use of a chemical procedure that eliminates virtually all recognized pathogenic microorganisms but not necessarily all microbial forms (e.g., bacterial endospores) on inanimate objects. There are three levels of disinfection: high, intermediate, and low:
   

• 
  High-level disinfection kills all organisms, except high levels of bacterial spores, and is effected with a chemical germicide cleared for marketing as a sterilant by the Food and Drug Administration.
  
• 
  Intermediate-level disinfection kills mycobacteria, most viruses, and bacteria with a chemical germicide registered as a "tuberculocide" by the Environmental Protection Agency (EPA).
  
• 
  Low-level disinfection kills some viruses and bacteria with a chemical germicide registered as a hospital disinfectant by the EPA.
  

7. 
   Contaminated surfaces must be disinfected:
   

• 
  Use protective gloves, eye shields, and other PPE appropriate for this task.
  

• 
  Use of an EPA-registered disinfecting product while following manufacturers guidelines is preferred, but if such products are not available, generic sodium hypochlorite solutions (e.g., household chlorine bleach) may be used:
  
  • 
    Use a 1:100 dilution (500--615 ppm available chlorine) to decontaminate nonporous surfaces after cleaning a spill of either blood or body fluids in patient-care settings.
    

8. 
   In general, heat stable reusable dental devices such as dental hygiene instruments and equipment must always be reprocessed using heat-based methods of sterilization (e.g., steam autoclave or dry heat oven).
   
9. 
   If sterilization is unavailable, reusable devices or items that touch mucous membranes should, at a minimum, receive high-level disinfection between patients.
   

• 
  Dental devices that require sterilization or disinfection must be thoroughly cleaned to reduce material/bioburden before being exposed to the germicide and the germicide and device manufacturers' instructions should be closely followed.
  

• 
  Non-heat stable reusable dental equipment and instruments) must receive high-level disinfection after each use.  Follow the manufacturer’s recommendations for appropriate disinfectants and technique.  If manufacturer recommendations are not available, the following guideline is suggested for cleaning and disinfection (e.g., disinfectants to use, dilutions, and techniques; Reproline -2003): 
  

• 
  Use protective gloves, eye shields, and other PPE appropriate for this task
  
• 
  Thoroughly clean the reusable dental equipment or instrument by scrubbing with a liquid detergent and water solution to remove all organic material and then rinse well with water. It is essential to remove organic matter before beginning disinfection or sterilization.
  
• 
  Next, device must be completely immersed in a dental disinfectant at the recommended concentration for the recommended amount of time, then removed with sterile or high-level disinfected grasping device (forceps, pickup, tongs, est.) or gloves.
  
• 
  Rinse equipment or instruments well using a sterile or high-level disinfected grasping instrument (forceps, pickup, tongs, est.) or sterile gloves to hold the device, rinse three times with water.
  
• 
  Allow it to air dry suspended or on a clean, dry, disinfected surface.
  
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  Once disinfected, equipment and instruments should be used promptly or stored in a dry, high-level disinfected, covered container. Stored containers should be located in an area that is well ventilated and provides protection against dust, moisture, as well as temperature and humidity extremes and well-labeled.
  
• 
  Dispose of disinfection solutions down a utility sink drain or into a flushable toilet and rinse or flush with water. Avoid splashing.
  

10. 
    Infectious waste should be incinerated or managed according to OSHA standards and guidelines.
    

4. 
   References
   

1. 
   CDC - Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007, June 2007
   

2. 
   CDC - Healthcare Infection Control Practices Advisory Committee (HICPAC) http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm
   
3. 
   Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005 http://www.cdc.gov/mmwr/PDF/rr/rr5417.pdf
   
4. 
   CDC - Sterilization or Disinfection of Medical Devices
   

5. 
   Reproline - Infection Prevention Guidelines for Healthcare Facilities with Limited Resources: 12 - High-Level Disinfection, 2003
   

6. 
   HICPAC - Guidelines for Environmental Infection Control in Health-Care Facilities
   

7. 
   For additional guidance refer to OSHA compliance in the Policy and Procedure Section of the Administrative Reference.
   
8. 
   Guidance and appropriate procedures for precautions may be found in the federally required OSHA manual, onsite in every facility. Or refer to the Occupational Safety and Health Standards. http://www.osha.gov/pls/oshaweb/owastand.display_standard_group?p_toc_level=1&p_part_number=1910
   
9. 
   Guidance and appropriate procedures for precautions may also be found in the LHDs Bloodborne Pathogens Exposure Control Compliance Plan.
   
10. 
    CDC – Guidelines for Infection Control in Dental Health-Care Setting-2003. December, 2003.