Infection control in paediatric office settings

Question 1

Which children are likely to be sources of infection?

Answer 1

1. Unable to appropriately handle respiratory secretions
2. Diarrhea who are in diapers or incontinent
3. Infected open wounds or skin lesions

Question 2

Which children are at increased risk for disease?

Answer 2

1. Lack immunity
2. Ill
   3 Debilitated
3. Immunocompromised

Question 3

What are the current principles of infection control?

Answer 3

1. Routine Practices
2. Additional Practices
3. Respiratory Etiquette

Question 4

Which illnesses require additional contact precautions?

Answer 4

Antibiotic-resistant organisms

Enteroviral infection for duration of illness

Gastroenteritis for duration of symptoms or until infectious cause r/o

Hepatitis until viral infection r/o or for 7d after onset of hepatitis A

Viral meningitis for duration of illness

Scabies until initial therapy applied

Skin infection until drainage stopped or lesion healed

GAS impetigo until 24h of appropriate antibiotics

Question 5

Which illnesses require additional droplet precautions?

Answer 5

Bacterial meningitis until 24h of appropriate antibiotics

Mumps for 9d after onset of swelling

Non-immune mumps contact from 10d after first exposure to 26d after last day of exposure

Pertussis until 5d of appropriate antibiotics received

Petechial or ecchymotic rash with fever until 24h of appropriate antibiotics or meningococcus r/o

Rubella until 7d after onset of rash

Rubella non-immune contact from 7d after first exposure to 21d after last day of exposure

GAS invasive disease until 24h of appropriate antibiotic

Question 6

Which illnesses require additional airborne precautions?

Answer 6

Measles for 4d after onset of rash of for duration of illness if immunocompromised

Measles non-immune contact from 5d of first day of exposure to 21d after last day of exposure

TB until assesses as not infectious

Varicella non-immune contact from 8d after first day of exposure to 21d after last day of exposure or to 28d if varicella zoster Ig given

Question 7

Which illnesses require additional droplet and contact precautions?

Answer 7

Avian influenza to 14d from onset

Influenza for duration of illness

SARS (plus N95 mask) until 10d after resolution of fever

Viral respiratory tract infection i.e. bronchiolitis, cold, croup, pneumonia, pharyngiits, for duration of illness or until viral infection r/o

Question 8

Which illnesses require additional airborne and contact precautions?

Answer 8

Varicella until lesions crusted or varicella r/o

Zoster until lesion crusted or zoster r/o

Question 9

What are the routes of transmission of infection?

Answer 9

1. Contact
2. Droplet
3. Airborne

Question 10

What are sterilization and disinfection requirements?

Answer 10

1. Critical items (that enter sterile tissue)–> sterilization
2. Semicritical items (that contact mucus membranes or non-intact skin) –> sterilization or high-level disinfection
3. Non-critical items (only touch intact skin) –> intermediate or low-level disinfection, detergent and water maybe sufficient
4. Environmental surfaces –> low-level disinfection OR detergent and water

Question 11

What is the recommendation regarding toys in doctor’s office?

Answer 11

Soft toys are unsuitable for doctors’ offices

Hard toys should be regularly cleaned q1-2 weeks (soak 1h in bleach)

Question 12

What are recommendations regarding administrative policies?

Answer 12

1. Policies and procedures for infection control and prevention should be developed and implemented.
2. Policies should be reviewed at least every two years.
3. Ongoing education should be provided for all office personnel and should include how infections are transmitted, infection control measures, recognition of symptom complexes, prevention and management of potential exposures to blood-borne viruses, and cleaning and disinfection of equipment, toys and surfaces.
4. A system of communication with local public health authorities should be established and maintained to facilitate systematic reporting of reportable diseases and exchange of information about suspected outbreaks

Question 13

What are the recommendations regarding office design?

Answer 13

1. Infection control needs should be considered in office planning (eg, layout, sinks and materials used).
2. Handwashing sinks with adjacent soap and disposable towel dispensers, as well as waterless hand hygiene products should be available in all patient care areas.
3. Plans should include specific spaces to display signs and place materials for Respiratory Etiquette.
4. Carpeting should be avoided in examination and waiting rooms.
5. Ventilation for new or renovated medical offices should provide a minimum of six air exchanges per hour.

Question 14

What are the recommendations regarding triage in the office setting (either over the phone at the time of the appointment or as soon as possible after arrival)?

Answer 14

1. Immunocompromised children need protection from exposure to patients with transmissible infections, especially respiratory viral infections. They should not wait in a waiting room but should be placed into an examination room on arrival.
2. Children with transmissible infections:
   a) Parents should be advised to inform the receptionist immediately on arrival if they suspect their child has a contagious illness.
   b) Signs should be posted in appropriate locations reminding parents and patients to do this.
   c) Children with symptomatic infections should be segregated from well children as quickly as possible. Ideally, those with any contagious illness should not wait in a waiting room but should go to an examination room immediately. As a minimum, children with suspected or diagnosed airborne infections (eg, varicella and measles) should be quickly removed from a common waiting area.
   d) in the event of a travel alert concerning a respiratory pathogen, children with respiratory infections should be assessed for possible imported infection by:
3. Asking about travel outside Canada in the 10 to 14 days before onset of symptoms (time interval may vary depending on the presumed incubation period of the infection).
4. Asking whether there are any persons in the same household who have a respiratory illness and have travelled in the 10 to 14 days before onset of their illness.
5. If so, the family should be placed in an examining room immediately

Question 15

What are the recommendations regarding waiting rooms?

Answer 15

1. Patient visits should be scheduled so as to minimize crowding and shorten waiting time.
2. Facilities for hand hygiene (eg, waterless hand hygiene products, or sinks with soap and disposable towels) should be available in the waiting room.
3. Sharing of toys by infants and young children should be minimized. Options include:
   a) Consider removing toys from waiting rooms unless use can be supervised and appropriate cleaning is feasible.
   b) Ask parents to bring the child’s personal toys designed for individual play and avoid sharing these with other children.
   c) If toys are provided for infants and young children, they should be easily cleaned. Choose toys with smooth solid surfaces and avoid toys with small pieces and crevices, stuffed toys and toys made of fabric or plush.
   d) Ask parents to supervise their child’s use of office toys, not to permit toy sharing and to place toys in a designated used toy container when finished. Used toys should be removed from circulation until cleaned.
   e) Consider the use of disposable books and disposable toys designed for individual child play.
4. Older children who are mature enough to have appropriate hygienic practices (eg, hand hygiene and handling of respiratory secretions) may share toys, books, puzzles and computer games.
5. Contact between children with contagious illnesses and other children should be minimized.
   a) Visits should be scheduled for different times of the day, or separate time periods reserved for drop-in visits and for routine appointments.
   b) Children with vomiting, diarrhea, fever, cough or open skin lesions should remain in the waiting room for as short a time as possible and should not be allowed in common play areas or to handle toys or other shared items.

Question 16

What are the routine practices for care of all patients regarding hand hygiene?

Answer 16

1. All health care personnel should perform hand hygiene with alcohol-based waterless hand rinses or with soap and water.
   a) Before and after contact with each patient.
   b) After contact with blood, body fluids, secretions, excretions or objects contaminated with these.
   c) Before invasive procedures (use antiseptic soap or antiseptic hand rinse).
   d) Before preparing or handling sterile medications or other sterile products.
   e) After removing gloves.
2. Alcohol-based hand rinses should contain 60% to 90% isopropyl or ethyl alcohol.
3. Soap and water should be used if hands are visibly soiled.
4. Parents and children should be taught the importance of hand hygiene.
5. Alcohol-based hand rinses for patient use should be placed out of reach of children, and parents should be advised to supervise their children to avoid accidental ingestion or splashes into the eyes.
6. Hand cleansing towelettes are an alternative to soap and water

Question 17

What are the routine practices for care of all patients regarding PPE?

Answer 17

1. Gloves should be worn:
   a) If anticipating direct hand contact with blood, body fluids, secretions or excretions, or items contaminated with these substances.
   b) For direct hand contact with mucous membranes or nonintact skin.
   c) For direct hand contact with the patient when the health care worker has open lesions on the hands.
2. Gloves are not needed for routine child care such as wiping a nose or changing a diaper, if these can be done without direct hand contamination.
3. Gloves are not routinely required for administering vaccines.
4. A surgical mask and eye protection (eg, goggles or face shield) should be worn during procedures in which splashing of blood, body fluids, respiratory secretions, or other secretions or excretions into the face is anticipated. A mask should be used only once and changed when wet or soiled.
5. A gown should be worn to protect clothing during procedures likely to generate splashes of blood, body fluids, secretions or excretions

Question 18

What are the policies regarding blood-borne pathogens?

Answer 18

1. Needles and other sharp instruments should be handled with care during use and disposal. Puncture-proof, impermeable, approved sharps disposal containers should be available at the point-of-use where injections or venipunctures are performed. The containers should be kept out of the reach of young children and should not be overfilled.
2. Spills of blood or bloody body fluids should be contained promptly and cleaned with detergent followed by bleach (1:10 to 1:100 dilution of household bleach using the higher concentration for larger spills). Gloves should be worn during cleaning of blood spills.
3. Mouthpieces, resuscitation bags or other ventilation devices should be provided for use in areas where the need to resuscitate may be required.
4. Personnel with potential exposure to body fluids should receive hepatitis B vaccine, be tested for antihepatitis B antibody after vaccination and be informed of their hepatitis B immune status.
5. Policies and protocols for management of injuries with used needles or other sharp objects, or other potential exposure to blood-borne viruses, should be available and implemented. These should include procedures for injured personnel to obtain immediate advice, clinical assessment and access to postexposure prophylaxis including hepatitis B vaccine, hepatitis B immune globulin, antiretroviral medications and laboratory testing if indicated

Question 19

What are the recommendations for disinfection, sterilization and cleaning of equipment and surfaces?

Answer 19

1. Written policies and protocols for disinfection, sterilization and cleaning should be in place and followed.
2. Disinfectants approved for health care should be used.
3. Level of disinfection required for medical equipment:
   a) Items entering sterile body spaces should be disposable or sterilized before re-use.
   b) Items in contact with mucous membranes or non-intact skin should be disposable or undergo high-level disinfection or sterilization before re-use.
   c) Items in contact with intact skin only should undergo low-level disinfection or cleaning with detergent and water. Items contaminated with blood or body fluids should undergo disinfection.
4. Recommendations re: cleaning objects:
   a) Optimally, these should be cleaned after each use. If this is not feasible, clean daily and if soiled.
   b) Clean bell and diaphragm of stethoscopes, handle and body of otoscopes and ophthalmoscopes, and reusable ear curettes with alcohol or disinfectant wipes or with soap and water. Disinfect if contaminated with blood.
   c) Items designed for single-patient use should not be used for more than one patient.
5. Clean equipment should be stored where it will not become contaminated.
6. Measures should be taken to avoid contamination of the housing of electronic thermometers, pulse oxymetry and tympanometry equipment, and other frequently handled devices with body fluids, excretions or secretions. Clean daily and when soiled.
7. Frequently touched office items which are difficult to clean should be considered as always contaminated; hand hygiene should be performed before patient contact after contact with these items. Computer mice and keyboards should be cleaned daily. Use of covers on computer keyboards may facilitate cleaning.
8. Cleaning of surfaces:
   a) The examining table should be covered with disposable paper or cloth which is changed between patients. Clean the table between patients if soiled. If soiled with body fluids or stool, clean and disinfect with bleach (1:100).
   b) Examination tables, treatment chairs, sinks and other frequently touched surfaces should be cleaned daily.
   c) Washrooms should be cleaned daily and when soiled. Provide a diaper changing area with disposable paper covers and receptacles for used diapers.
   d) Surfaces such as countertops, chairs and floors are usually not an infection risk and should be cleaned weekly or on a routine basis and when soiled.
   e) Other surfaces, including cupboards, walls, windows and air vents, should be cleaned at least annually and as needed to maintain appropriate standard of cleanliness.
   f) Surfaces may be cleaned with a low-level disinfectant/detergent or with a detergent

Question 20

What are the recommendations regarding cleaning of toys?

Answer 20

1. Toys used by infants and young children should optimally be cleaned between use by different patients. If this is not possible, toys should be cleaned at the end of the day.
2. Toys soiled by body fluids should be removed from use until cleaned.
3. Disinfect with 1:100 bleach solution, wash with soap and water and air dry.
4. Alternatively, toys may be cleaned in a dishwasher.
5. Toys, puzzles and computer games which are used by older children should be cleaned or discarded when soiled.
6. Frequently touched surfaces (eg, knobs, buttons, handles and joy-sticks) should be cleaned daily.
7. Large toys which may be considered as part of office furniture and which are frequently touched should be cleaned daily and if soiled.

Question 21

What are the recommendations regarding aseptic technique and injection safety?

Answer 21

1. Antiseptic technique should be maintained for immunization, venipuncture, suturing, incision, or other invasive procedures and for accessing or manipulation of intravascular catheters.
2. Skin should be prepared with an antiseptic. The preferred agent for venipuncture or immunization is 70% alcohol. For insertion of intravascular catheters and other invasive procedures and for obtaining blood cultures, 2% chlorhexidine, chlorhexidine in 70% alcohol, 10% povidone-iodine or alcoholic tincture of iodine should be used. Povidone-iodine should be left to dry for 2 min.
3. Because antiseptics may become contaminated, single-use products are preferable. If multiple-use containers are used, they should be labelled with the date and discarded after 28 days of use.
4. Multidose medication vials should be avoided if possible. If used:
   a) Handle and store with care to maintain sterility of contents and comply with expiry dates.
   b) Restrict use to a centralized medication area.
5. Separate surfaces should be reserved for the assembly of clean equipment (eg, syringes, needles) or preparation of medications and for the handling of contaminated equipment.
6. Equipment contaminated with blood or body fluids should be handled in a way that prevents transfer of organisms to other patients and surfaces.
7. Physical barriers (eg, disposable paper or plastic pads) should be used to prevent surfaces from blood contamination during blood sampling

Question 22

What is respiratory etiquette?

Answer 22

Measures designed to mini­mize the transmission of respiratory pathogens via the droplet route in health care settings, using source contain­ment beginning at the point of initial patient encounter

Question 23

What measures are used for respiratory etiquette?

Answer 23

1. Early identification of all persons (patients, parents and others) with febrile respiratory illness in outpatient areas.
2. Posting signs at the entrance to the facility or at the reception or registration desk with instructions for patients and those accompanying them to:
   a) Inform the receptionist promptly if symptoms of a respiratory infection are present.
   b) Cover the mouth and nose with tissues during coughing and sneezing, or if necessary, sneeze or cough into the elbow rather than the hand.
   c) Dispose of used tissues in a no-touch receptacle promptly.
   d) Perform hand hygiene after hand contact with respiratory secretions.
   e) Place a surgical or procedure mask on the coughing person if tolerated and if the patient is old enough to wear it.
3. Instructing family members with febrile respiratory illnesses to not accompany the patient to the office unless it is essential, in which case they should take the same measures.
4. Provision of tissues, no-touch waste receptacles, masks and hand hygiene products.
5. Where sinks are placed, ensure that supplies of soap and towels are available.
6. Where space permits, place a coughing patient and accompanying persons at least 2 m away from others in common waiting areas.

Question 24

What additional airborne transmission precautions should occur?

Answer 24

1. Physicians should be aware of the airflow patterns in their offices.
2. If feasible, patients with known or suspected airborne infections should be scheduled at a time that minimizes exposure of other patients (eg, at the end of the day).
3. Patients with known or suspected measles, varicella, disseminated zoster or infectious tuberculosis should be placed directly into an examining room.
   a) Ideally, this should be a negative-pressure room with air vented directly outside or filtered through a HEPA filter before recirculation. Because such rooms are usually unavailable in physician’s offices, a single room, as far away as possible from other patients, may be used.
   b) The examination room door should be kept closed.
   c) Offices in which many patients with infectious tuberculosis are seen should consider having a portable HEPA filtration unit.
4. The patient should be examined and discharged as quickly as possible.
5. The patient should wear a surgical or procedure mask if possible when not in a negative-pressure room. For younger infants, the nose and mouth should be covered with a tissue.
6. Masks for personnel:
   a) For measles or varicella – personnel should be immune; nonimmune persons should not enter the examination room unless absolutely necessary, in which case a N95 mask should be worn.
   b) For suspected or known infectious tuberculosis, N95 masks are recommended for all personnel entering the room. In offices in which patients with infectious tuberculosis are likely to be seen, personnel should be fit tested to select the model with the best fit, and should perform a fit check (forceful inspiration to determine whether the mask seals tightly to the face) each time a N95 mask is applied. If tuberculosis is rarely seen and N95 masks are not available, patients with suspected contagious tuberculosis should be referred as quickly as possible to an appropriately equipped clinic or hospital for assessment.
7. After the patient has left, sufficient time should be allowed for the air to be free of aerosolized particles before using the room for any other patient (if infection is tuberculosis) or for a non-immune patient (if infection is measles or varicella). At six air exchanges per hour, the time required is approximately 70 min. If the number of air exchanges is not known, it may be prudent to avoid using the room for non-immune patients for the rest of the day.
8. Determine whether any exposed persons require post-exposure prophylaxis such as immune globulin or vaccine

Question 25

What additional droplet transmission precautions should occur?

Answer 25

1. If feasible, the patient should be placed directly into an examining room, especially if he or she is suspected of having pertussis, rubella, mumps, meningitis or meningococcal infection.
   a) If this is not possible, the patient should be separated from other patients by at least 2 m, and the time spent in the waiting room should be kept to a minimum.
2. If feasible, the patient should wear a surgical or procedure mask when out of the room. For younger infants, cover the nose and mouth with a tissue.
3. Personnel within 2 m of the patient should wear a surgical or procedure mask (unless immune if rubella or mumps).
4. Eye protection (goggles or face shield) should be considered if splashes of respiratory secretions are anticipated.
5. Eye protection should be used if SARS or avian influenza is suspected.
6. For SARS coronavirus or avian influenza, current recommendations are for personnel to wear a N95 mask. For pandemic influenza, a N95 mask is recommended only for personnel performing certain aerosol-generating procedures. These recommendations may be revised as more information becomes available. Local, provincial or federal authorities should be consulted.

Question 26

What additional contact transmission precautions should occur?

Answer 26

1. Contact Precautions should be taken for conditions in which heavy contamination of the environment is anticipated, including:

a) Infectious diarrhea.
b) Extensive skin lesions which are not covered (including varicella and zoster), or wound drainage not contained by dressings.
c) Selected patients colonized with antibiotic-resistant organisms (AROs), such as MRSA and VRE (below).
d) Children with documented or suspected viral respiratory tract infections with inadequate control of respiratory secretions.

2. Patient should be placed in an examining room as soon as possible.
3. Gloves should be worn on entry to the room or for contact with the patient’s intact skin or with surfaces or items in close proximity to the patient.
4. A gown should be worn if clothing will have direct contact with the patient or with potentially contaminated surfaces or items. Remove the gown before leaving the room.
5. Hands should be cleansed with antiseptic soap or antiseptic hand rinse after removing gloves, or after direct hand contact with the patient or with contaminated items.
6. Equipment and surfaces in direct contact with the patient or with infective material (eg, respiratory secretions, stool or skin exudates) should be cleaned before use for another patient.
7. If the patient is likely to cause extensive environmental contamination (eg, diarrhea or fecal incontinence not contained by diapers, copious wound drainage, and copious uncontrolled respiratory secretions or sputum), all horizontal surfaces and frequently touched surfaces should be cleaned before the room is used for another patient

Question 27

What are the recommendations regarding AROs in ambulatory care?

Answer 27

1. There are few data concerning transmission of AROs, such as MRSA and VRE, in ambulatory settings.
2. Systems should be in place to readily identify patients known to be colonized with AROs.
3. Consistent use of Routine Practices, especially hand hygiene, should suffice for management of most patients colonized with ARO.
4. The need for Contact Precautions should be assessed on a case-by-case basis, considering the nature of the interaction with the patient and the potential for environmental contamination.
5. Antibiotics should be used judiciously, to prevent or delay emergence and spread of antimicrobial resistance

Question 28

What are the recommendations regarding health of personnel?

Answer 28

1. Vaccines:
   a) All personnel should receive influenza vaccine annually.
   b) All personnel should be immune to measles, rubella, mumps, varicella, hepatitis B and polio, and should receive at least one adult dose of acellullar pertussis vaccine.
   c) Personnel should also receive tetanus and diphtheria vaccines and any other vaccines indicated by their health status.
   d) Immunization records should be maintained for all personnel.
2. Personnel should undergo pre-employment tuberculin testing and if negative, repeat testing after any significant exposure.
3. Policies should be in place for work restrictions for personnel with communicable diseases and measures to prevent transmission while working with an infection (Table 3).
   a) Colds and other minor respiratory tract infections are not criteria for exclusion from work but personnel should not have direct contact with high-risk patients; should contain coughs and respiratory secretions using surgical or procedure masks and tissues; and should perform hand hygiene after each contact with nasal or other respiratory tract secretions and before every contact with a patient or patient care equipment.
   b) Personnel with blood-borne viral infections should not perform procedures with a high risk for transmission of blood from the health care worker to a patient. Such procedures are mainly surgical and are unlikely to be performed in the routine office setting.

Question 29

What are the recommendations re: work restrictions for health care providers?

Answer 29

1. Blood-borne viruses (Hep B, C, HIV) restrict from performing specific exposure-prone procedures at high risk of transfer of blood as per local health policy (viremia resolved or blood viral load controlled)
2. Colds, other viral URTI: restricted from direct care of high risk patients and should wear surgical or procedure mask during care and perform hand hygiene after any contact with nasal or respiratory secretions and before any patient contact until symptoms resolved
3. Conjunctivitis: restrict from direct patient care until exudate resolved
4. Gastroenteritis restrict from direct patient care until symptoms resolved or illness deemed noncontagious
5. Hepatitis A restrict from direct patient care until one week after onset of jaundice
6. HSV orofacial: restrict from direct care of newborns and nonimmune immunocompromised patients if lesions not covered until lesiins dry
7. Herpetic whitlow restrict from direct patient care until lesions dry
8. Influenza restrict from office until symptoms resolve
9. Measles restrict from office until 4d after onset of rash
10. Mumps restrict from office until nine days after onset of parotitis
11. Pediculosis restrict from direct patient care until one treatment completed (<24h)
12. Pertussis restrict from office until 5d of appropriate antibiotics
13. Rubella restrict from office for 7d after onset of rash
14. Scabies restrict from direct patient care until one treatment completed (<24h)
15. MSSA skin infection restrict from direct patient care if lesions on hand until lesions are healed or if lesions elsewhere with exudates or drainage that cannot be effectively contained by dressing until lesions elsewhere can be covered by dressings
16. MRSA skin infection restrict from direct patient care until lesions healed and assessed for risk of transmission
17. GAS infection restrict from direct patient care until treated for 24h
18. Active pulmonary TB restrict from office until assessed as non-infectious
19. Varicella restrict from office until lesions crusted
20. Zoster restrict from direct patient if not covered until lesions crusted If covered restrict from care of newborn, non-immune and immunocompromised patients and pregnant women

Question 30

What are the recommendations regarding medical waste?

Answer 30

1. Regulated medical waste should be disposed of according to local legislation. Nonanatomical medical waste includes:
   a) Liquid or semiliquid blood and blood products.
   b) Items contaminated with blood that would release liquid or semiliquid blood if compressed.
   c) Personnel Body fluids contaminated with blood, excluding urine and feces.
   d) Sharp objects including needles, needles attached to syringes and blades.
   e) Broken glass of other materials capable of causing punctures or cuts, if these have been in contact with human blood or body fluids.
   f) Full sharps containers.