7.5 Infection prevention and control in a CTC

Hygiene measures implemented in a CTC are designed to reduce the spread of Vibrio cholerae inside and outside the CTC. The probability of spreading or acquiring cholera through frequenting a CTC is low if these measures are respected.
These measures are, in principle, also valid in CTUs and ORPs, although they need to be adapted to the specific characteristics of the facility concerned.

7.5.1 Isolation

From the start of the outbreak, patients should be isolated to avoid the spread of cholera in hospitals and other general health facilities that usually receive the first cases.

7.5.2 Hand hygiene

Hand hygiene avoids the transmission of Vibrio cholerae and other pathogenic micro-organisms in the CTC.

 

The UNICEF recommends routine hand-washing with 0.05% chlorine solution in cholera treatment facilities [1] Citation 1. UNICEF Cholera Toolkit, 2013. Annex 8E - Establishing cholera treatment sites including infection control (WASH).
https://www.unicef.org/cholera_toolkit/Cholera-Toolkit-2017.pdf#page=216 . Hand-washing with soap and water is an alternative.

 

Visibly soiled hands should be washed with soap and water.

 

Table 7.1 - Critical times for hand-washing

 

Note: only patients without danger signs, conscious and capable of walking without assistance, are asked to wash their hands on entering the CTC.
Guards should not delay the treatment of serious cases (patients that have difficulty standing up or with altered consciousness) because of this systematic hygiene measure that is not a priority in patients in life-threatening condition.

7.5.3 Personal protective equipment (PPE)

Basic PPE

Staff protective clothing should be supplied and washed by the CTC. It should preferably be made or bought locally.

 

All staff must have at least:

• 1 short-sleeved top and 1 pair of trousers (OT scrubs)

AND

• 1 pair of boots: essential for staff in contact with patients, corpses, excreta, waste and chlorine solutions. For staff not exposed to projections (administration, kitchen), rubber clogs are sufficient if the ground is not muddy.

 

It is compulsory to wear protective clothing. Staff change on entering and leaving the CTC. Staff must neither leave the CTC in their protective clothing nor work in the CTC in their personal clothes.

Additional PPE

During certain activities, staff should wear the following extra protection:

 

 

Notes:

• Respiratory protection devices (FFP 1, 2 or 3 respirators) protect against dust (e.g. removing ashes, sweeping the waste storage area) but not against gases or vapours.
• Cholera is not transmitted by the inhalation of droplets. It is pointless to wear a surgical mask or FFP2 respirator to protect oneself against cholera.

7.5.4 Laundry

A CTC laundry room handles 3 categories of laundry:

• Staff PPE (clothing, rubber gloves, boots etc.);
• Hospital laundry (sheets, blankets);
• Patients’/attendants’ laundry.

 

PPE is changed every day and each time it is soiled.
Hospital laundry is changed when soiled and on patient discharge.
Patient and attendant clothing is changed when soiled. Patient/attendant clothing must not be sprayed with chlorine before being taken to the laundry room.

 

Soiled PPE, hospital laundry and patient/attendant laundry are:

• collected by staff wearing plastic aprons and rubber gloves;
• transported in reusable containers, separated by category or if not available, in disposable plastic bags;
• washed separately with soap and water or with detergent available on the local market, rinsed in clear water, soaked in 0.05% chlorine solution for 15 minutes, rinsed in clear water again and hung out in the sun until completely dry.

 

Notes:

• During the first days while setting up the CTC, if the disinfection of laundry has not yet be organised, washing laundry with soap and water and leaving it to dry completely outside in the sun eliminates the vibrio as it cannot survive in dry environments.
• In small peripheral CTUs where there are less patients and staff, patient laundry is often washed by attendants. The CTU provides a laundry washing area with water, basins, soap, and an area to hang out washing to dry.

7.5.5 Soiled materials

Disposable materials

• Disposable materials should be eliminated after use.
• Sharps (i.e. needles, catheter guidewires, lancets, drug ampoules and other objects that may cause injury) must be discarded immediately after use into a sharps container. The container is replaced when it is three quarters full (check the level every day).

Reusable materials

• Immersible material (e.g. tourniquet, tray) should be washed with soap and water, rinsed then disinfected with 0.2% chlorine solution.
• Non-immersible material (e.g. sphygmomanometer) should be wiped or sprayed with 0.2% chlorine solution.

7.5.6 Hygiene of premises and vehicles

The cleaning of premises includes all patient zones, all areas of the “clean” zone (administration, changing rooms, stock rooms, etc.) and the outside areas of the CTC.

Cleaning of floors, surfaces and sanitation facilities (showers, toilets, washing areas)

These must be cleaned at least twice a day with detergent available on the local market, rinsed (change soapy solution and rinse water when saturated) then disinfected with 0.2% chlorine solution. Do not mix detergent and 0.2% chlorine solution.
After applying 0.2% chlorine solution, do not rinse (expect stainless steel surfaces that must imperatively be rinsed), leave to completely dry.

Vehicles

Ambulances should be cleaned with detergent at least once a day and every time they are soiled (e.g. spilt stools or vomit), rinsed, then disinfected with 0.2% chlorine solution, then rinsed again to protect the metal surfaces.

7.5.7 Preparation and storage of ORS [2] Citation 2. NA. Daniels, S. Simons, A. Rodrigues, G. Gunnlaugsson, T. Forster, JG. Wells, L. Hutwagner, RV. Tauxe, ED. Mintz. First do not harm: making oral rehydration solution safer in a cholera epidemic. The American Society of Tropical Medicine and Hygiene. Am. J. Trop. Med. Hyg., 60(6), 1999, pp. 1051–1055.
http://www.ajtmh.org/content/60/6/1051.long

The following precautions must be respected:

• Rinse the containers and utensils to be used with 0.05% chlorine solution and leave to dry.
• Wash hands immediately before preparation.
• Dissolve sachets in potable water.
• Store prepared solution in containers equipped with lids and a tap for distribution.
• Keep prepared solutions 24 hours maximum.

 

Note: drinking water is stored under the same conditions to avoid contamination.

7.5.8 Food hygiene

The following precautions should be respected:

• Access to the kitchen and food stores, as well as the handling of food and distribution of meals, is reserved to kitchen staff only.
• Hand-washing before preparing food and serving meals.
• Use of potable water stored in containers with lids and taps.
• After meals: discard leftovers, do not keep prepared food, do not let food out of the CTC.
• Meals are served hot and well cooked, and fruit and vegetables well washed.
• Surfaces and utensils should be cleaned with detergent, rinsed then disinfected with 0.2% chlorine solution (and rinsed again if stainless steel surfaces).

7.5.9 Chlorine solution preparation

Chlorine solution should be available at all times.
See Appendix 15 for preparation and use.
Display the protocol on the preparation of chlorine solutions in all facilities.

7.5.10 Disinfection of shoes

Interest

Shoe disinfection points are traditionally placed at the entrance and exits of CTCs, and sometimes at the passage between the different sectors within the CTC.

 

The effectiveness of this measure in stopping the spread of vibrio in and outside the CTC has not been demonstrated. Its pertinence in controlling infection has long been contested.

 

Shoe disinfection points can serve to raise awareness among patients/attendants on the need for exceptional measures related to the contagious nature of cholera. However they are not considered essential if the CTC implements effective control measures [1] Citation 1. UNICEF Cholera Toolkit, 2013. Annex 8E - Establishing cholera treatment sites including infection control (WASH).
https://www.unicef.org/cholera_toolkit/Cholera-Toolkit-2017.pdf#page=216 : isolation, hand-washing (including at the entrance and exit of CTC and at the passage between the contaminated and clean zone), patient education, control of waste waters, etc.

Methods

If shoe disinfection points are set up, there are 2 methods. Spraying is preferable over foot baths.

 

Spraying with 0.2% chlorine solution
This method requires the presence of a foot sprayer at each disinfection point. The measure should be limited to disinfection points at the entrance and exit of the CTC, as well as the passage between the contaminated and clean zone.
Only the soles of shoes should be disinfected. The feet, body or clothes of patients and attendants must not be sprayed, even if they are soiled.

 

Foot baths containing 0.2% chlorine solution
Foot baths are awkward to maintain (e.g. changing the solution in the baths) and their effectiveness is even more doubtful (rapid deterioration of chlorine due to various mechanisms such as: frequent deposit of mud and other organic matter; prolonged exposure to sun; dilution of chlorine solution with rainwater, etc. They will be bypassed by users if they are not acceptable (dirty, too deep or too small, slippery, etc.).

 

In all events, shoe disinfection must not hinder the circulation of staff and patients/attendants.
Providing treatment to serious cases remains the priority, e.g. patients that need to be carried or who are in shock. Urgent treatment must not be delayed because of a disinfection measure of limited interest.