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Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee (HICPAC) Draft Guideline for Environmental Infection Control in Healthcare Facilities, 2001- Airborne Pathogens
Table of Contents I. Background Information: Environmental Infection Control in Healthcare Facilities
1. Modes of Transmission of Airborne Diseases 2. Airborne Infectious Diseases in Healthcare Facilities
3. Heating, Ventilation, and Air Conditioning Systems in Healthcare Facilities
4. Construction, Renovation, Remediation, Repair, and Demolition
5. Environmental Infection Control Measures for Special Healthcare Settings
6. Other Aerosol Hazards in Healthcare Facilities D. Water (Refer to CDC 2001 Water Document) E. Environmental Services (Refer to CDC 2001 - Environmental) II. Recommendations for Environmental Infection Control in Healthcare Facilities
III. References IV Appendices
The Guideline for Environmental Infection Control in Healthcare Facilities, 2001 is a compilation of recommendations for the prevention and control of infectious diseases that are linked to healthcare environments. This document: 1) updates and revises several sections (i.e., cleaning and disinfection of environmental surfaces, environmental sampling, laundry and bedding, and regulated medical waste) from the previous editions of the Centers for Disease Control and Prevention [CDC] document entitled Guideline for Handwashing and Hospital Environmental Control; 1, 2 2) incorporates discussions of air and water environmental issues from the Guideline for the Prevention of Nosocomial Pneumonia;3 3) consolidates relevant environmental infection control measures from several other CDC guidelines;4 - 9 and 4) discusses two topics not addressed in previous CDC guidelines -- infection control issues related to the presence of animals in healthcare facilities, and water quality in hemodialysis settings.Part I, "Background Information: Environmental Infection Control in Healthcare Facilities," summarizes the major issues related to environmental infection control in healthcare facilities based on a comprehensive review of the scientific literature. Major attention is given to engineering and infection control concerns during construction, demolition, renovation, and repairs of healthcare facilities. Infection control measures used to recover from catastrophic events (e.g., flooding, sewage spills, loss of electricity and ventilation, disruption of the water supply) are reviewed. The limited impact of environmental surfaces, laundry, plants, animals, medical wastes, cloth furnishings, and carpeting on disease transmission in healthcare facilities is also explored. Part II, "Recommendations for Environmental Infection Control in Healthcare Facilities," presents control measures for preventing infections associated with air, water, or other environmental concerns within healthcare facilities as appropriate. These recommendations represent the consensus of the Healthcare Infection Control Practices Advisory Committee (HICPAC), a 12-member committee that advises CDC on issues related to the surveillance, prevention, and control of healthcare-associated infections primarily in United States healthcare facilities. 10 As of January 1999, HICPAC expanded its infection control focus from acute-care hospitals to all venues where healthcare is provided (e.g., outpatient surgical centers, urgent care centers, clinics, outpatient dialysis centers, physicians’ offices, skilled nursing facilities). The topics addressed in this guideline are generally applicable to a variety of healthcare venues throughout the United States. This document is intended for use primarily by infection control practitioners, epidemiologists, employee health and safety personnel, engineers, informational system specialists, administrators, environmental service and housekeeping professionals, and architects for these facilities.Whenever possible, the recommendations in Part II are based on data from well-designed scientific studies. Some studies, however, have been conducted in narrowly-defined patient populations or for specific healthcare settings (e.g., hospitals versus long-term care facilities), making generalization of their findings to all situations potentially problematic. Construction standards for hospitals or other healthcare facilities may not apply to residential home care units. Similarly, attempts to implement infection control measures indicated for immunosuppressed patient care are generally not necessary in those facilities where such patients are not present. Many of the recommendations are derived from empiric engineering concepts. Consequently, some of the recommendations may reflect an industry standard rather than an evidence-based conclusion. A few of the infection control measures proposed in this document cannot be rigorously evaluated for ethical or logistical reasons. Thus, some of the recommendations in Part II may be based on a strong theoretical rationale and suggestive evidence in the absence of confirmatory scientific evidence. Finally, some of the recommendations are derived from existing federal regulations. The references and the appendices comprise Parts III and IV, respectively. This guideline also identifies key process measurement elements to assist facilities in monitoring compliance with the evidence-based Category IA or IB recommendations provided in Part II. These include: 1) conducting risk assessment prior to construction, renovation, demolition, or major repair projects; 2) conducting ventilation assessments related to construction barrier installation; 3) establishing and maintaining appropriate pressure differentials for special care areas [e.g., operating rooms, airborne infection isolation, protective environments]; 4) evaluating non-tuberculous mycobacteria culture results for possible environmental sources; and 5) implementing infection control procedures to prevent environmental spread of antibiotic-resistant gram-positive cocci and assuring compliance with these procedures. This document does not discuss: 1) industrial hygiene concerns of a non-infectious nature [e.g., "sick building syndrome" from chemicals and fumes, allergies]; 2) environmental issues in the home; 3) home health care; 4) bioterrorism; and 5) foodborne illness acquired in healthcare facilities. This document includes only limited discussion of: 1) handwashing/hand hygiene; 2) Standard Precautions; 3) infection control measures used to prevent instrument or equipment contamination during patient care [e.g., preventing waterborne contamination of nebulizers or ventilator humidifiers]; and 4) infection control measures used to prevent exposures of patients and staff to potentially infectious substances. These topics are mentioned only if they are important in minimizing the transfer of pathogens to and from persons or equipment and the environment. Although the document discusses principles of cleaning and disinfection as they are applied to maintenance of environmental surfaces, the full discussion of sterilization and disinfection of medical instruments and direct patient-care devices is deferred to a future guideline. Similarly, the full discussion of handwashing/hand hygiene, which was a major section in the Guideline for Handwashing and Hospital Enviromental Control, is deferred to a future guideline devoted to this single topic. This guideline was prepared by CDC staff members from the National Center for Infectious Diseases (NCID) and the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) and the designated HICPAC sponsor. Contributors to this document reviewed mostly English-language manuscripts identified from reference searches using the National Library of Medicine’s MEDLINE, bibliographies of published articles, and infection control textbooks. Working drafts of the guideline were reviewed by CDC scientists, HICPAC committee members, and experts in infection control, engineering, internal medicine, infectious diseases, epidemiology, and microbiology. All the recommendations may not reflect the opinions of all reviewers. I. Background Information: Environmental Infection Control in Healthcare Facilities A. Introduction The healthcare environment contains a diverse population of microorganisms, but only a select few are significant pathogens for susceptible humans. Microorganisms are present in great numbers in moist, organic environments, but some can also persist under dry conditions. Although pathogenic microorganisms can be detected in air and water and on fomites, it is difficult to assess their role in causing infection and disease. 11There are few reports which clearly delineate a "cause and effect" with respect to the environment, in particular for the housekeeping surfaces. Seven levels of proof are used to evaluate the strength of evidence for an environmental source or means of transmission of infectious agents. 11 In the order of their rigor, these are: 1) the organism can survive after inoculation onto the fomite; 2) the organism can be cultured from in-use fomites; 3) the organism can proliferate in or on the fomite; 4) some measure of acquisition of infection cannot be explained by other recognized modes of transmission; 5) retrospective case-control studies show an association between exposure to the fomite and infection; 6) prospective observational studies may be possible when more than one similar type of fomite is in.6 use; and 7) prospective studies allocating exposure to the fomite to a subset of patients show an association between exposure and infection. An additional level of proof is that decontamination of the fomite results in the elimination of disease transmission.12Applying these proofs to disease investigations allows scientists to assess the contribution of the environment to disease transmission. The identification of a pathogen (e.g., vancomycin-resistant enterococci [VRE]) on an environmental surface during an outbreak serves as an illustration of this point. The presence of the pathogen does not automatically establish its causal role; its transmission from source to host could be through indirect means, such as via hand transferral. 11 The surface, therefore, would be considered one of a number of potential reservoirs for the pathogen, but not the "de facto" source of exposure.An understanding of how infection occurs after exposure, based on the principles of the "Chain of Infection," is also important in evaluating the contribution of the environment to healthcare-associated disease. 13 All of the components of the "Chain" must be operational for infection to occur. That is, infection requires: 1) an adequate number of pathogenic organisms [dosage]; 2) pathogenic organisms of sufficient virulence; 3) a susceptible host; 4) an appropriate mode of transmission or transferral of the organism in sufficient number from a source to the host; and 5) the correct portal of entry into the host. The presence of the susceptible host has focused recent attention on the importance of the healthcare environment and opportunistic pathogens in air and water and on fomites. As a result of advances in medical technology and therapies (e.g., intensification of cytotoxic chemotherapy; progress of transplantation medicine), a greater number of patients are becoming increasingly immunocompromised in the course of treatment and are therefore at increased risk of acquiring healthcare-associated opportunistic infections.Trends in healthcare delivery are also changing the distribution of patient populations and increasing the number of immunocompromised persons in healthcare settings other than acute-care hospitals, especially in light of early discharge of patients from care. According to the American Hospital Association (AHA), the number of hospitals in the United States in 1998 totaled 6,021, with 1,013,00 |