MERS-CoV infection control classroom manual

MERS-CoV infection control
Classroom session-Clinical
MoH Training Manual – v1.6 20140901

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We are here to stop the spread of MERS-CoV by fixing infection prevention
and control in Saudi hospitals
▪ No vaccine
▪ No treatment
▪ High death rate
▪ Highly contagious
in a hospital setting
▪ Hospital staff at
high risk if not
following infection
control rules
Strict infection control is the only way to stop
MERS-CoV from spreading – everyone of us is
responsible and can help to stop the disease

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Your 10 steps to fight MERS-CoV in your hospital
1. Maintain strict personal hygiene
2. Ensure proper use of PPE by staff and patient
3. Identify and isolate potential MERS-CoV patients early
4. Allocate adequate facilities for MERS-CoV patients
5. Follow appropriate housekeeping practices
6. Monitor staff health – don’t allow sick people at work
7. Implement stricter visitor policy
8. Send for home isolation under supervision, when possible
9. Ensure safe collection and handling of lab samples
10. Take precautions in the mortuary

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1. MAINTAIN STRICT PERSONAL HYGIENE
You already know this, you just need to DO IT EVERY DAY
Cough etiquette
Short nails, no watches, no jewelry
Other basics
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10 2
FRI 16
▪ Avoid touching your face
▪ Avoid touching patient’s items
▪ Do not share personal items
▪ Shower after work
▪ Change uniform daily
▪ Keep home clean and ventilated
▪ If you feel sick, do not come to
work – tell your senior over phone
▪ Avoid contact with sick colleagues
SOURCE: KSA MoH MERS-CoV Infection Prevention and Control Guidelines, May 2014; the Infection Control powerpoint
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TIMEZ
INDIGLO
WR30M
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More on hand hygiene
When to do it?
 5 moments of hand hygiene
 When hands are visibly soiled
 After contact with a source of
microorganisms (body fluids and
substances, mucous membranes, non-intact
skin, surfaces that are likely to be
contaminated)
 After removing gloves and before wearing
them.
 Before and after smoking, eating or
preparing food
 Before leaving the patient’s room
 After bodily functions (e.g., using the toilet,
blowing one’s nose, sneezing)
 When moving from a contaminated body
site to a clean body site during patient care
SOURCE: WHO; Saudi Aramco John Hopkins
How to do it?
Use proper hand hygiene technique to
disinfect all parts of your hands

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Correct technique – how to handrub and handwash (1/3)
Alcohol-based handrub is
more efficient than handwash
when hands are not soiled
SOURCE: WHO; Saudi Aramco John Hopkins

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SOURCE: WHO

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Hand washing Technique

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2. ENSURE PROPER USE OF PPE BY STAFF AND PATIENTS
Droplet and contact precautions required when dealing with potential
MERS-CoV patients; N95 to be worn during aerosol generating procedures
Potential/confirmed MERS-CoV: in patient’s room/close contact –
contact and droplet precautions (for healthcare workers and visitors)
▪ Surgical mask (N95 for aerosol generating procedures)
▪ Eye protection (goggles/face shield)
▪ Gown (clean, non-sterile, long-sleeved)
▪ Gloves (some procedure may require sterile gloves)
▪ Impermeable apron (for procedures with expected splashes)
May be considered if resources permit:
▪ Airborne precautions with all potential/confirmed MERS-CoV patients (N95)
▪ Surgical mask for all fever/respiratory patients at the ER entrance
Safely remove PPE and perform hand hygiene when leaving the
MERS-CoV precautions area (e.g., isolation or procedure room)
SOURCE: KSA MoH MERS-CoV Infection Prevention and Control Guidelines, May 2014; CDC pictures

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2. ENSURE PROPER USE OF PPE BY STAFF AND PATIENTS
N95 provides protection only if appropriately used
Do not use N95 with valves
 …When working in a sterile field such as an
operating room
Conduct fit test for your N95
 N-95 mask comes in different sizes and offers
no protection if not properly fitted
 Fit test has to be performed for employees
wearing N95 to ensure proper fit
How to fit test N95 mask:
https://www.youtube.com/watch?v=7IAsoU6h-8g
Never wear a medical mask under the N95 mask as this prevents proper fitting and
sealing of the N95 mask thus decreasing its efficacy.
Source: Saudi Aramco Johns Hopkins
Inspect your N95 every time before wearing
▪ For structural integrity
▪ Ensure that the straps are not cut or damaged
▪ Make sure the metal nose clip is in place and
functions properly
▪ Determine if it is physically damaged or soiled
How to wear N95 mask:
http://www.youtube.com/watch?v=bo-PEzHE7iw

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Extended Use of N95 Filtering, face piece, respirators in healthcare settings:
Extended use refers to the practice of wearing the same N95 respirator for
repeated close contact encounters with several patients, without removing the
respirator between patient encounters.
Extended use may be implemented when multiple patients are infected with the same
respiratory pathogen and patients are placed together in dedicated waiting rooms or
hospital wards.
* Discard N95 respirators following use during aerosol generating procedures.
* Discard N95 respirators contaminated with blood, respiratory or nasal secretions, or
other bodily fluids from patients.
* Perform hand hygiene with soap and water or an alcohol-based hand sanitizer
before and after touching or adjusting the respirator (if necessary for comfort or to
maintain fit).

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Reuse of N95 filtering, face piece, respirators in Health care settings
Reuse refers to the practice of using the same N95 respirator for multiple encounters
with patients but removing it (“doffing”) after each encounter. The respirator is stored
in between encounters to be put on again (“donned”) prior to the next encounter with
a patient.
• Discard N95 respirators following use during aerosol generating procedures.
• Discard N95 respirators contaminated with blood, respiratory or nasal secretions,
or other bodily fluids from patients.
*Store respirators in a single disposable paper container with identification.
•Clean hands with soap and water or an alcohol-based sanitizer before and after
touching or adjusting the respirator (if necessary for comfort or to maintain fit).

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Reuse continued:
•Clean hands with soap and water or an alcohol-based sanitizer before and after
touching or adjusting the respirator (if necessary for comfort or to maintain fit).
Clean hands with soap and water or an alcohol-based sanitizer after donning a used
N95 respirator and performing a user seal check.
• Follow the manufacturer’s user instructions, including conducting a user seal
check.
• Maximum number of donning up to five times if the manufacturer does not
provide a recommendation.
• Discard any respirator that is obviously damaged or becomes hard to breathe
through.
*Pack or store respirators between uses so that they do not become damaged or
deformed.

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Veil and beard with the N95 mask
VEIL
For female staff who wear veils, the medical or N95 mask should always be
placed directly on the face behind the veil and not over the veil. In this instance a
face shield should also be used along with the mask.
BEARD
N95 does not provide full protection for people with beards – use alternative
respirator such as powered air purifying respirator, should be used.

SEQUENCE FOR DONNING PERSONAL PROTECTIVE EQUIPMENT ( PPE )
The type of PPE used will vary based on the level of precautions required: e.g., Standard and
Contact, Droplet or Airborne Infection Isolation.
1. GOWN
• Fully cover torso from neck to knees, arms to end of wrists
• , and wrap around the back
• Fasten in back of neck and waist
2. MASK OR RESPIRATOR
• Secure ties or elastic bands at middle of head and neck
• Fit flexible band to nose bridge
• Fit snug to face and below chin
• Fit-check respirator
3. GOGGLES OR FACE SHIELD
• Place over face and eyes and adjust to fit
4. GLOVES
• Extend to cover wrist of isolation gown
USE SAFE WORK PRACTICES TO PROTECT YOURSELF AND LIMIT THE SPREAD
OF CONTAMINATION
■ Keep hands away from face
■ Limit surfaces touched
■ Change gloves when torn or heavily contaminated
■ Perform hand hygiene
Putting on PPE: http://www.youtube.com/watch?v=HIR88sJEI2s
SOURCE: CDC (http://www.cdc.gov/HAI/pdfs/ppe/ppeposter1322.pdf)

SEQUENCE FOR DOFFING ( removing ) PERSONAL PROTECTIVE EQUIPMENT ( PPE )
Except for respirator, remove PPE at doorway or inside the patient’s room.
Remove respirator after leaving patient room and closing door (anteroom).
1. GLOVES
• Outside of gloves is contaminated!
• Grasp outside of glove with opposite gloved hand; peel off
• Hold removed glove in gloved hand
• Slide fingers of ungloved hand under remaining glove at wrist
• Peel glove off over first glove
• Discard gloves in waste container
*Perform Hand Hygiene* WHO STATES HAND HYGIENE BEFORE PUTTING ON GLOVES AND IMMEDIATELY AFTER REMOVING GLOVES
2. GOGGLES OR FACE SHIELD
• Outside of goggles or face shield is contaminated!
• To remove, handle by head band or ear pieces
• Place in designated receptacle for reprocessing or in waste container
3. GOWN
• Gown front and sleeves are contaminated!
• Unfasten ties
• Pull away from neck and shoulders, touching
• inside of gown only
• Turn gown inside out
• Fold or roll into a bundle and discard
*Perform Hand Hygiene*
4. MASK OR RESPIRATOR ( done outside of the room )
• Front of mask/respirator is contaminated —
• DO NOT TOUCH!
• Grasp bottom, then top ties or elastics and remove
• Discard in waste container
HAND HYGIENE COULD BE PERFORMED AFTER EVERY STEP OF REMOVAL OF SUSPECTED CONTAMINATED PPE
SOURCE: CDC (http://www.cdc.gov/HAI/pdfs/ppe/ppeposter1322.pdf)
Taking off PPE: http://www.youtube.com/watch?v=vYMWTWE4xqU

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3. IDENTIFY POTENTIAL MERS-CoV PATIENTS EARLY AND TAKE PRECAUTIONS
Promptly identify symptomatic patients at the hospital entry and take
MERS-CoV precautions until recovery, regardless of test results
Patients with fever, ARI1, diarrhea and other
Take precautions for MERS-CoV
▪ PPE for staff and source control for patient
▪ Isolation2
Test for other pathogens. If patient meets
MERS-CoV case definition, also test for MERS-CoV
MERS-CoV positive MERS-CoV negative3
Take precautions for MERS-CoV until symptoms resolve
▪ PPE for staff and source control for patient
▪ Isolation2
1 Acute respiratory infections – symptoms including runny nose, sneezing, coughing, shortness of breath 2 In hospital or home
3 And no alternative confirmed diagnosis / still suspicion for MERS – for multiple reasons, negative tests do not fully rule out possibility of MERS-CoV
SOURCE: KSA MoH MERS-CoV Infection Prevention and Control Guidelines, May 2014
When possible
▪ Identify symptomatic
patients at the hospital
entrance
▪ Allocate a separate
room/area in ER for
symptomatic patients
▪ Allocate separate
procedure rooms for
symptomatic patients
▪ Restrict visitors and do
not rotate personnel in
high risk MERS-CoV area

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MERS-CoV case definition has to be followed when testing for MERS-CoV
Suspect case (patients who should be tested for MERS-CoV)
I. A person with fever and community-acquired pneumonia or acute
respiratory distress syndrome based on clinical or radiological
evidence
OR
II. A hospitalized patient with healthcare associated pneumonia based
on clinical and radiological evidence
OR
III. A person with 1) Acute febrile (≥38°C) illness
AND
2) Body aches, headache, diarrhea, or nausea/
vomiting, with or without respiratory symptoms
AND
3) Unexplained leucopenia (WBC<3.5x10/L) and
thrombocytopenia (platelets<150x10/L)
OR
IV. A person (including health care workers) who had protected or
unprotected exposure to a confirmed or probable case of MERS-CoV
infection and who presents with upper or lower respiratory illness
within 2 weeks after exposure
▪ A probable case is a
patient in category I or II
with absent or
inconclusive laboratory
results for MERS-CoV
and other possible
pathogens who is a
close contact of a
laboratory-confirmed
MERS-CoV case or
who works in a
hospital where MERS-CoV
cases are cared for
▪ A confirmed case is a
person with laboratory
confirmation of MERS-CoV
infection

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Triage and screening for MERS-CoV
PATIENTS
COMING TO THE
EMERGENCY
ROOM
SCREENING FOR MERS SYMPTOMS
There should be a separate desk or room outside the ER
patient care area, where new patients are screened.
Posters for patient to self-triage must be visible here.
Visitors must be strictly controlled. The doctor & nurse
here should wear surgical masks or N95 and follow
general precautions.
Send patient to the
regular ER triage
and waiting area.
1. Put regular mask on patient
2. Shift to isolation room / area
3. Give emergency treatment
4. Test for MERS-CoV
5. Based on clinical assessment,
Admit to MERS unit or send
home with advice on hand
washing, cough etiquette &
home isolation
MERS SYMPTOMS NO SYMPTOMS
Follow MERS case definition
criteria to identify cases
MERS MANAGEMENT

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Decision 1 – Is it an ARI patient (potential MERS)?
YES
Patient ER reception
▪ Apply standard precautions
▪ Provide the patient with a medical mask
▪ Lead the patient into designated waiting
area for ARI patients
NO
▪ Apply standard precautions
▪ Lead the patient into general ER
waiting area
Do you have any of these:
I feel sick.
Help me!
Practical tips
▪ Allocate a separate isolated area for ARI patients in your ER
▪ Ensure ER receptionist wears PPE (mask) and performs hand hygiene
▪ Ensure everybody in ARI part of ER wears PPE (masks) and performs hand hygiene
▪ Have signage and displays for patients, provide masks
SOURCE: KSA MoH MERS Infection Prevention and Control Guidelines, May 2014

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Decision 2 – Should we test for MERS?
Patient
CASE DEFINITION CONFIRMED
NO CASE DEFINITION
Physician
▪ Take nasopharyngeal
swab for MERS-CoV
test
▪ Place patient into
isolated single room
▪ Treat the patient based
on his/her healthcare
needs
▪ Keep applying basic
precautions (PPE etc.)
 Acquire clinical or
radiological
evidence
necessary
to confirm MERS
case definition
Practical tips
▪ All radiological procedure should be done on site as long as possible

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Decision 3 – Isolate in the hospital or at home?
Test results
Physician
 Take decision
about further patient
treatment based on
test results, pre-sence
of symptoms
and patient’s living
conditions
MERS POSITIVE
▪ Continue hospital
isolation if
– Patient has MERS
symptoms
▪ Isolate at home1 if
– Patient has no
MERS symptoms
MERS NEGATIVE
▪ Continue hospital
isolation if
– CD I or II, or
– CD III or IV with
pneumonia
▪ Isolate at home1 if
– CD III or IV without
pneumonia
1 Home should be suitable for isolation based on Home Isolation Guidelines – if not suitable, keep in isolation in the hospital

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Decision 4 – When to discharge the patient?
Hospital
isolation
Home
isolation
Patient discharge criteria
▪ Patient is clinically well for 24 hours, and
– No clinical concern for viral shedding, or
– Repeated MERS CoV test is negative
▪ Repeated weekly test is negative

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4. ALLOCATE ADEQUATE FACILITIES FOR MERS-CoV PATIENTS1
Place patient in isolation –
Patient placement requirement
▪ Place patients with suspected, probable or confirmed MERS-CoV infection who are
not critically ill in adequately ventilated single room.
▪ Place patients with suspected, probable or confirmed MERS-CoV infection who are
critically ill in a negative pressure room. If not available then single room with
HEPA filter.
▪ The rooms used for isolation should be situated in an area that is clearly segregated
from other patient-care areas
▪ When single rooms are not available, cohort – put patients with the same lab
confirmed diagnosis together (i.e., taking into consideration positive MERS-CoV
and other contagious diseases )
▪ Use HEPA-filters when negative pressure rooms not available
▪ Standard, contact & droplet precautions should be used for all suspected and
confirmed patients.
▪ When an AGP is being anticipated air borne precautions should be added
MERS-CoV
More information: GCC Infection Control Manual GCC-ICM-III-03, 04, 05
1 Both, potential and confirmed

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5. FOLLOW APPROPRIATE HOUSEKEEPING PRACTICES
Housekeeping standards and rules should be followed
Item
sharing
Requirements
▪ Use disposable or dedicated equipment when possible
▪ Clean and disinfect shared equipment between patients
▪ Discard single-use devices in a hands-free waste bin
House-keeping
standards
▪ Comply with the hospital’s standards and GCC Infection Control
Manual on all procedures (cleaning, waste etc.)
▪ Follow PPE requirements for MERS-CoV or higher
▪ Use hospital approved disinfectants with approved dilution
Areas
▪ Clean all horizontal and frequently touched surfaces (incl. medical
equipment) at least twice daily/once a shift
▪ Clean isolation areas last; when possible, change mop head after
each isolation room, disinfect after each use
▪ Follow hospital’s terminal cleaning protocol for patient’s room when
vacated by the previous patient. Replace curtains when terminal
cleaning.

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6. MONITOR STAFF HEALTH – DON’T ALLOW SICK PEOPLE AT WORK
Monitor staff health – identify and exclude symptomatic staff from work
Recommendations
Healthcare
facility
▪ Implement flexible non-punitive sick leave policies for staff
▪ Provide staff with quick access to medical consultation and treatment
▪ Screen all staff for MERS-CoV symptoms at the beginning of the shift
▪ Exclude symptomatic staff from work
▪ Dedicate the same staff to MERS-CoV patients
▪ Track staff exposure to MERS-CoV patients
▪ If resources permit, provide separate accommodation for staff with
regular exposure to potential/confirmed MERS-CoV patients
Staff
▪ In general:
– Monitor MERS-CoV symptoms
– Report to supervisor if symptomatic
▪ If symptomatic
– Do not come to work/stop working immediately
– Notify supervisor
– Wear surgical mask for source control
– Seek prompt medical evaluation
– Stay on leave until no longer infectious
▪ If asymptomatic but had unprotected close MERS-CoV exposure
– Monitor symptoms
– Wear surgical mask for source control (when not wearing N95)
– Consider exclusion from work until found non-infectious
SOURCE: CDC MERS-CoV recommendations

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7. IMPLEMENT STRICTER VISITOR POLICY
Limit the number of visitors and train them to comply with precautions
Visitor management requirement
▪ Limit the number of visitors and family members to those
essential for patient support
Additional practices if resources permit
▪ Screen visitors for ARI symptoms at the hospital entrance
▪ Evaluate risk to visitors’ health (e.g., due to underlying illness) and ability to
comply with precautions
▪ Instruct visitors on hand hygiene, potentially contaminated surfaces, and use of
PPE, before entry into the patient care area and supply necessary equipment (e.g.,
surgical masks)
▪ Track (e.g., via logbook) all visitors to MERS-CoV patient rooms
▪ Allow no visitors during aerosol-generating procedures (and if possible, for one
hour after)
▪ Limit visitor movement within the facility (e.g., visitors to MERS-CoV patient rooms
should not visit other areas). A security personnel should be assigned outside
any unit with suspected or confirmed cases to limit access to isolated patients.
1 Acute respiratory infections
SOURCE: KSA MoH MERS-CoV Infection Prevention and Control Guidelines, May 2014; CDC MERS-CoV recommendations

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8. SEND FOR HOME ISOLATION UNDER SUPERVISION, WHEN POSSIBLE
Patients with no shortness of breath, hypoxemia or pneumonia can be
isolated at home, provided home facilities meet the requirements
Assess (by phone or direct observation) whether the home is
appropriate for isolating the ill person
 The home should have a functioning bathroom – ideally,
one bathroom should be designated solely for the ill
person
 The ill person should have his or her own bed and
preferably a private room for sleeping
 Basic amenities, such as AC, electricity, potable and hot
water, sewer, and telephone access, should be available
 There should be a primary caregiver who can
- Follow doctor’s instructions for medications and care
- Help the ill person with basic needs
Follow MERS-CoV Home Isolation
Guidelines for patient home care requirements
SOURCE: KSA MoH MERS-CoV Home Isolation Guidelines, May 2014

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Home isolated patient needs to follow
Separate
oneself from
other people in
the house
Call ahead
before visiting
doctor
Wear a
medical mask
Patient must…
Cover coughs
and sneezes
Avoid sharing
household
items
Wash hands

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Family and caregivers have to take precautions
Health Care Providers
Instructions
Limit the number of
people at home
Be aware of them and help the ill person follow them
To only essential for providing care for the ill person
Other household members should stay in another place of residence.
If this is not possible, stay separated from the ill person as much as
possible and use separate utilities and household items
Who do not have an essential need to be at home
Elderly people and people with medical conditions should
stay away from the ill person
Make sure that shared spaces at home have good air
flow, such as air conditioning and open windows
Wear appropriate PPE when in contact with the ill person’s body
fluids. Dispose all PPE’s and contaminated items appropriately
Clean all “high-touch” surfaces (counters, tabletops, toilets,
etc.) while wearing appropriate PPE daily
Stay Separated
Restrict Visitors
Elderly People and
Medical Conditions
Ventilation
PPE
Surfaces
Laundry and
Household Items
Wash laundry and household items thoroughly and use
detergents
Wash Your Hands
Wash your hands immediately after removing your medical mask,
gown, gloves and at all times

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9. ENSURE SAFE COLLECTION AND HANDLING OF LAB SAMPLES
MERS-CoV testing practices and lab procedures should follow strict PPE
Responsibilities
▪ Swabbing should be done based on MERS-CoV case definition
▪ Swabbing personnel1 should be properly trained on the technique
and wear PPE appropriate for aerosol generating procedures
▪ Use well-ventilated2 (min 6-12 air changes/hour) separate room
in line with aerosol generating procedures requirements
▪ Fill the test form completely
▪ Ensure that healthcare facility laboratories adhere to appropriate
biosafety practices and transport requirements
Swabbing3
Transport
▪ Personnel who transports specimens should be trained in safe
handling practices and spill decontamination
▪ Use leak-proof plastic biohazard specimen bags that have a
separate sealable pocket for the specimen
▪ Maintain the temperature requirement (+4 degrees Celsius) for
keeping the sample valid from collection till processing
▪ Notify the lab that the specimen is being transported
All samples should be sent for testing to one of the 5 regional MoH labs4 unless otherwise specified
(e.g., unless your hospital lab has acknowledged capabilities to run the PCR test for MERS-CoV)
1 Physicians or nurses, based on the hospital policy 2 When resources permit, negative pressure
3 Video on how to take nasopharyngeal swab: https://www.youtube.com/watch?v=hXohAo1d6tk 4 Jeddah, Riyadh, Dammam, Makkah, Medina

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10. TAKE PRECAUTIONS IN THE MORTUARY
Ensure adequate level of PPE in the morgue and follow strict visitor policy
Deceased bodies pose a potential MERS-CoV infection risk
General requirements
 Body should be placed in impervious appropriately sized plastic body
bag
 Body washing must be done at the hospital morgue
 If the family members wish to perform the body washing, they must
adhere to the same precautions as body washers
 Inform the family members about the risks associated with removing the
body from the body bag
Morgue staff PPE
 Hand hygiene
 Gloves
 N95 respirator
 Impermeable/water resistant protective gown
 Boots/shoe covers
 Eye protection (if the body needs to be embalmed)
More information: GCC Infection Control Manual GCC-ICM-VIII-10

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Relevant videos
How to properly do hand hygiene?
http://www.youtube.com/watch?v=uGmMDC-4IMY
Disclaimer: Refer to WHO standards of hand hygiene for more information
How to put on personal protective equipment (PPE)?
http://www.youtube.com/watch?v=HIR88sJEI2s
Disclaimer: Refer to the KSA MERS-CoV Infection Control Guidelines for exact protective
equipment required while caring for suspected/confirmed MERS-CoV patients
How to take off personal protective equipment (PPE)?
http://www.youtube.com/watch?v=vYMWTWE4xqU
Disclaimer: Refer to the KSA MERS-CoV Infection Control Guidelines for exact protective
equipment required while caring for suspected/confirmed MERS-CoV patients
How to wear the N95 mask?
http://www.youtube.com/watch?v=bo-PEzHE7iw
Disclaimer: There might be differences in mask design for different brands
How to fit test the N95 mask?
https://www.youtube.com/watch?v=7IAsoU6h-8g
Disclaimer: There might be differences in mask design for different brands
How to take nasopharyngeal swab for MERS-CoV?
https://www.youtube.com/watch?v=hXohAo1d6tk
Disclaimer: Healthcare worker swabbing the patients, needs to comply to PPE requirements
of aerosol generating procedures as per the KSA MERS-CoV Infection Control Guidelines

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More information sources
KSA MoH website about MERS-CoV
http://www.moh.gov.sa/en/CoronaNew
KSA General Directorate for Infection Prevention and Control
http://www.gdipc.org/
GCC Infection Prevention and Control Manual
http://www.gdipc.org/ic-manual.html
CDC on MERS-CoV
http://www.cdc.gov/CORONAVIRUS/MERS/INDEX.HTML
WHO on MERS-CoV
http://www.who.int/csr/disease/coronavirus_infections/en/
KSA MoH call center
8002494444 or 937 (toll free)
E-mail suggestions about this presentation to
corona@mohfeedback.com

MERS-CoV infection control classroom manual

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