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Clinical Infectious Diseases (Oxford University Press (OUP))
Jacob L. Kool 2005
2. Kool JL. Risk of person to person transmission of pneumonic plague. Clinical Infectious Diseases, 2005; 40 (8): 1166-1172
207. Kool JL. Risk of person-to-person transmission of pneumonic plague. Clin Infect Dis 2005;40(8):1166-72.
Infection Control & Hospital Epidemiology (Cambridge University Press (CUP))
Julia S. Garner et al. 1996
1. Garner JS. Guideline for isolation precautions in hospitals. The Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1996;17(1):53-80.(s).
Clinical Infectious Diseases (Oxford University Press (OUP))
G. M. Eliopoulos et al. 2004
2. Harris AD, Bradham DD, Baumgarten M, Zuckerman IH, Fink JC, Perencevich EN. The use and interpretation of quasi-experimental studies in infectious diseases. Clin Infect Dis 2004;38(11):1586-91.
3. Morton V, Torgerson DJ. Effect of regression to the mean on decision making in health care. Bmj 2003;326(7398):1083-4.
New England Journal of Medicine (Massachusetts Medical Society)
Stuart J. Pocock et al. 2000
Observational studies remain relevant and have been used to evaluate infection control interventions 4, 5 .
On page 12
4. Pocock SJ, Elbourne DR. Randomized trials or observational tribulations? N Engl J Med 2000;342(25):1907-9.
JAMA (American Medical Association (AMA))
John P. A. Ioannidis 2001
Observational studies remain relevant and have been used to evaluate infection control interventions 4, 5 .
On page 12
5. Ioannidis JP, Haidich AB, Pappa M, et al. Comparison of evidence of treatment effects in randomized and nonrandomized studies. Jama 2001;286(7):821-30.
American Journal of Infection Control (Elsevier BV)
Stephen Bent et al. 2004
Several authors have summarized properties to consider when evaluating studies for the purpose of determining if the results should change practice or in designing new studies 2, 6, 7 .
On page 12
6. Bent S, Shojania KG, Saint S. The use of systematic reviews and metaanalyses in infection control and hospital epidemiology. Am J Infect Control 2004;32(4):246-54.
Clinical Infectious Diseases (Oxford University Press (OUP))
G. M. Eliopoulos et al. 2005
Several authors have summarized properties to consider when evaluating studies for the purpose of determining if the results should change practice or in designing new studies 2, 6, 7 .
On page 12
7. Harris AD, Lautenbach E, Perencevich E. A systematic review of quasiexperimental study designs in the fields of infection control and antibiotic resistance. Clin Infect Dis 2005;41(1):77-82.
Infection Control & Hospital Epidemiology (Cambridge University Press (CUP))
Arjun Srinivasan et al. 2004
This concept has been incorporated into CDC planning documents for SARS and pandemic influenza 9, 10 .
On page 13
Control of SARS requires a coordinated, dynamic response by multiple disciplines in a healthcare setting 9 .
On page 27
facilities were important factors in the response to SARS that have been summarized 9 .
On page 28
Upon identification of a potentially infectious patient, implementation of prevention measures, including prompt separation of potentially infectious patients and implementation of appropriate control measures (e.g., Respiratory Hygiene/Cough Etiquette and Transmission-Based Precautions) can decrease transmission risks 9, 12 .
On page 36
Patients, family members, and visitors can be partners in preventing transmission of infections in healthcare settings 9, 42, 709-711 .
On page 48
preparation for pandemic influenza, healthcare providers working in outpatient settings are urged to implement source containment measures (e.g., asking couging patients to wear a surgical mask or cover their coughs with tissues) to prevent transmission of respiratory infections, beginning at the point of initial patient encounter 9, 262, 828 as described below in section III.A.1.a.
On page 58
Develop and implement systems for early detection and management (e.g., use of appropriate infection control measures, including isolation precautions, PPE) of potentially infectious persons at initial points of patient encounter in outpatient settings (e.g., triage areas, emergency departments, outpatient clinics, physician offices) and at the time of admission to hospitals and long-term care facilities (LTCF) 9, 122, 134, 253, 827 .
On page 76
Provide instructional materials for patients and visitors on recommended hand hygiene and Respiratory Hygiene/Cough Etiquette practices and the application of Transmission-Based Precautions 9, 709, 710, 963 .
On page 77
Instruct patients to follow recommendations for Respiratory Hygiene/Cough Etiquette 447, 448 9, 828 .
On page 87
9. Srinivasan A, McDonald LC, Jernigan D, et al. Foundations of the severe acute respiratory syndrome preparedness and response plan for healthcare facilities. Infect Control Hosp Epidemiol 2004;25(12):1020-5.
The term “Airborne Precautions” has been supplemented with the term “Airborne Infection Isolation Room (AIIR)” for consistency with the Guidelines for Environmental Infection Control in Healthcare Facilities 11 , the Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings 2005 12 and the American Institute of
On page 13
This guideline does not discuss in detail specialized infection control issues in defined populations that are addressed elsewhere, (e.g., Recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients , Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities 2005, Guidelines for Infection Control in Dental Health- Care Settings and Infection Control Recommendations for Patients with Cystic Fibrosis 12, 18-20 .
On page 14
Preventing the spread of pathogens that are transmitted by the airborne route requires the use of special air handling and ventilation systems (e.g., AIIRs) to contain and then safely remove the infectious agent 11, 12 .
On page 18
Upon identification of a potentially infectious patient, implementation of prevention measures, including prompt separation of potentially infectious patients and implementation of appropriate control measures (e.g., Respiratory Hygiene/Cough Etiquette and Transmission-Based Precautions) can decrease transmission risks 9, 12 .
On page 36
MMWR 2005; 54: RR-17 12 ).
On page 54
However, infections transmitted via the airborne route (e.g., M tuberculosis, measles, chickenpox) require additional precautions 12, 125, 829 .
On page 59
For tuberculosis, additional precautions may be needed in a small shared air space such as in an ambulance 12 .
On page 60
tuberculosis) state laws and regulations, and healthcare facility policies, may dictate the duration of precautions 12 ).
On page 72
B.4.a. Provide ventilation systems required for a sufficient number of AIIRs (as determined by a risk assessment) and Protective Environments in healthcare facilities that provide care to patients for whom such rooms are indicated, according to published recommendations 11-13, 15 .
On page 75
D.1. Use Airborne Precautions as recommended in Appendix A for patients known or suspected to be infected with infectious agents transmitted person-to-person by the airborne route (e.g., M tuberculosis 12 , measles 34, 122, 1020 , chickenpox 123, 773, 1021 , disseminated herpes zoster 1022 .
On page 88
g., manometers) 11, 12, 1023, 1024 .
On page 88
D.2.b. When an AIIR is not available, transfer the patient to a facility that has an available AIIR 12 .
On page 88
Discharge air directly to the outside,away from people and air intakes, or direct all the air through HEPA filters before it is introduced to other air spaces 12 Category II
On page 88
Once the patient leaves, the room should remain vacant for the appropriate time, generally one hour, to allow for a full exchange of air 11, 12, 122 .
On page 89
Once in an AIIR, the mask may be removed; the mask should remain on if the patient is not in an AIIR 12, 107, 145, 899 .
On page 89
Infectious pulmonary or laryngeal tuberculosis or when infectious tuberculosis skin lesions are present and procedures that would aerosolize viable organisms (e.g., irrigation, incision and drainage, whirlpool treatments) are performed 12, 1025, 1026 .
On page 89
D.5.b. If transport or movement outside an AIIR is necessary, instruct patients to wear a surgical mask, if possible, and observe Respiratory Hygiene/Cough Etiquette 12 .
On page 90
D.8. Consult CDC’s “Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005” 12 and the “Guideline for Environmental Infection Control in Health-Care Facilities” 11 for additional guidance on environment strategies for preventing transmission of tuberculosis in healthcare settings.
On page 90
s_cid=rr5 417a1_e ) 12 .
12. CDC. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep 2005;54(17):1-141.
Infection Control and Hospital Epidemiology (Cambridge University Press (CUP))
Elizabeth A. Bolyard et al. 1998
guidelines to prevent transmission of infectious agents associated with healthcare delivery are cited; e.g., Guideline for Hand Hygiene, Guideline for Environmental Infection Control, Guideline for Prevention of Healthcare- Associated Pneumonia, and Guideline for Infection Control in Healthcare Personnel 11, 14, 16, 17 .
On page 14
In the ophthalmology setting, adenovirus type 8 epidemic keratoconjunctivitis has been transmitted via incompletely disinfected ophthalmology equipment and/or from healthcare workers to patients, presumably by contaminated hands 17, 446, 448, 459-462 .
On page 36
The selection of glove type for non-surgical use is based on a number of factors, including the task that is to be performed, anticipated contact with chemicals and chemotherapeutic agents, latex sensitivity, sizing, and facility policies for creating a latex-free environment 17, 732-734 .
On page 50
pertussis 17, 863 , N.
On page 63
large and costly outbreaks that include both healthcare personnel and patients 17,
On page 64
Some vaccines are also used for postexposure prophylaxis of susceptible individuals, including varicella 888 , influenza 611 , hepatitis B 778 , and smallpox 225 vaccines 17, 874 .
On page 64
D.3. Personnel restrictions Restrict susceptible healthcare personnel from entering the rooms of patients known or suspected to have measles (rubeola), varicella (chickenpox), disseminated zoster, or smallpox if other immune healthcare personnel are available 17, 775 .
On page 89
Administer measles vaccine to exposed susceptible persons within 72 hours after the exposure or administer immune globulin within six days of the exposure event for high-risk persons in whom vaccine is contraindicated 17, 1032-1035 .
On page 90
from duty from day 5 after first exposure to day 21 after last exposure, regardless of post-exposure vaccine 17 .
Postexposure chemoprophylaxis for household contacts, HCWs exposed to respiratory secretions; postexposure vaccine only to control outbreaks 15, 17 .
Pregnant women who are not immune should not care for these patients 17, 33 .
17. Bolyard EA, Tablan OC, Williams WW, Pearson ML, Shapiro CN, Deitchmann SD. Guideline for infection control in healthcare personnel, 1998. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1998;19(6):407-63.
This guideline does not discuss in detail specialized infection control issues in defined populations that are addressed elsewhere, (e.g., Recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients , Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities 2005, Guidelines for Infection Control in Dental Health- Care Settings and Infection Control Recommendations for Patients with Cystic Fibrosis 12, 18-20 .
On page 14
The need to restrict the wearing of artificial fingernails by all healthcare personnel who provide direct patient care or by healthcare personnel who have contact with other high risk groups (e.g., oncology, cystic fibrosis patients), has not been studied, but has been recommended by some experts 20 .
On page 49
Patients with underlying conditions that increase their susceptibility to infection (e.g., those who are immunocompromised 43, 44 or have cystic fibrosis 20 ) require special efforts to protect them from exposures to infected patients in common waiting areas.
On page 59
Consult other guidelines for detailed guidance in developing specific protocols for cleaning and reprocessing medical equipment and patient care items in both routine and special circumstances 11, 14, 18, 20, 740, 836, 848 .
On page 61
Implement the following measures to contain respiratory secretions in patients and accompanying individuals who have signs and symptoms of a respiratory infection, beginning at the point of initial encounter in a healthcare setting (e.g., triage, reception and waiting areas in emergency departments, outpatient clinics and physician offices) 20, 24, 145, 902, 989 .
On page 80
C.2.b. Provide tissues and no-touch receptacles (e.g.,foot-pedaloperated lid or open, plastic-lined waste basket) for disposal of tissues 20 .
On page 80
B.2.c. In ambulatory settings, place patients who require Contact Precautions in an examination room or cubicle as soon as possible 20 .
On page 85
20. Saiman L, Siegel J. Infection control recommendations for patients with cystic fibrosis: microbiology, important pathogens, and infection control practices to prevent patient-to-patient transmission. Infect Control Hosp Epidemiol 2003;24(5 Suppl):S6-52.
Journal of Infectious Diseases (Oxford University Press (OUP))
R. W. Haley et al. 1995
The association of nursing staff shortages with increased rates of HAIs has been demonstrated in several outbreaks in hospitals and long term care settings, and with increased transmission of hepatitis C virus in dialysis units 22, 418, 551, 585-597 .
On page 43
used extensively for managing outbreaks of MDROs including MRSA 22, 807 , VRE
On page 57
Extension of the use of triple dye to low birth weight infants in the NICU was one component of a program that controlled one longstanding MRSA outbreak 22 .
On page 63
22. Haley RW, Cushion NB, Tenover FC, et al. Eradication of endemic methicillin-resistant Staphylococcus aureus infections from a neonatal intensive care unit. J Infect Dis 1995;171(3):614-24.
Clinical Infectious Diseases (Oxford University Press (OUP))
R. A. Weinstein et al. 2003
Examples of infectious agents that are transmitted via the droplet route include Bordetella pertussis 110 , influenza virus 23 , adenovirus 111 , rhinovirus 104 , Mycoplasma pneumoniae 112 21, 96,
On page 18
Influenza viruses are transmitted primarily by close contact with respiratory droplets 23, 102 and acquisition by healthcare personnel has been prevented by Droplet Precautions, even when positive pressure rooms were used in one center 144 However, inhalational transmission could not be excluded in an outbreak of influenza in the passengers and crew of a single aircraft 130 .
On page 19
Single-patient rooms are always indicated for patients placed on Airborne Precautions and in a Protective Environment and are preferred for patients who require Contact or Droplet Precautions 23, 24, 410, 435, 796, 797 .
On page 57
These measures should be effective in decreasing the risk of transmission of pathogens contained in large respiratory droplets (e.g., influenza virus 23 , adenovirus 111 , B.
On page 68
23. Bridges CB, Kuehnert MJ, Hall CB. Transmission of influenza: implications for control in health care settings. Clin Infect Dis 2003;37(8):1094-101.
Clinical Infectious Diseases (Oxford University Press (OUP))
C. B. Hall 2000
respiratory syncytial virus may be transmitted by the droplet route, direct contact with infected respiratory secretions is the most important determinant of transmission and consistent adherence to Standard plus Contact Precautions prevents transmission in healthcare settings 24, 116, 117 .
On page 18
The result is more patients and their sibling visitors with transmissible infections present in pediatric healthcare settings, especially during seasonal epidemics (e.g., pertussis 36, 40, 41 , respiratory viral infections including those caused by RSV 24 , influenza viruses 373 , parainfluenza virus 374 , human metapneumovirus 375 , and adenoviruses 376 ; rubeola [measles] 34 , varicella [chickenpox] 377 , and rotavirus 38, 378 ).
On page 33
E.2. Isolation gowns Isolation gowns are used as specified by Standard and Transmission-Based Precautions, to protect the HCW’s arms and exposed body areas and prevent contamination of clothing with blood, body fluids, and other potentially infectious material 24, 88, 262, 744-746 .
On page 51
However, subsequent studies demonstrated that RSV transmission is effectively prevented by adherence to Standard plus Contact Precations and that for this virus routine use of goggles is not necessary 24, 116, 117, 684, 762 .
On page 53
only a limited number of single-patient rooms, it is prudent to prioritize them for those patients who have conditions that facilitate transmission of infectious material to other patients (e.g., draining wounds, stool incontinence, uncontained secretions) and for those who are at increased risk of acquisition and adverse outcomes resulting from HAI (e.g., immunosuppression, open wounds, indwelling catheters, anticipated prolonged length of stay, total dependence on HCWs for activities of daily living) 15, 24, 43, 430, 794, 795 .
On page 57
Furthermore, the inability of infants and children to contain body fluids, and the close physical contact that occurs during their care, increases infection transmission risks for patients and personnel in this setting 24, 795 .
On page 58
difficile, VRE, MRSA, MDR-GNB 11, 24, 88, 435, 746, 796, 837 ).
On page 60
tuberculosis 42, 892 , influenza, and other respiratory viruses 24, 43, 44, 373 and SARS 21, 252-254 ).
On page 64
Implement the following measures to contain respiratory secretions in patients and accompanying individuals who have signs and symptoms of a respiratory infection, beginning at the point of initial encounter in a healthcare setting (e.g., triage, reception and waiting areas in emergency departments, outpatient clinics and physician offices) 20, 24, 145, 902, 989 .
On page 80
A.1. In addition to Standard Precautions, use Transmission-Based Precautions for patients with documented or suspected infection or colonization with highly transmissible or epidemiologically-important pathogens for which additional precautions are needed to prevent transmission (see Appendix A) 24, 93, 126, 141, 306, 806, 1008 .
On page 83
If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient 24, 88, 796, 836, 837, 854, 1016 .
On page 85
Wear mask according to Standard Precautions 24 CB 116, 117 .
24. Hall CB. Nosocomial respiratory syncytial virus infections: the "Cold War" has not ended. Clin Infect Dis 2000;31(2):590-6.
Infection Control and Hospital Epidemiology (Cambridge University Press (CUP))
Judith R. Campbell et al. 1998
25. Campbell JR, Zaccaria E, Mason EO, Jr., Baker CJ. Epidemiological analysis defining concurrent outbreaks of Serratia marcescens and methicillin-resistant Staphylococcus aureus in a neonatal intensive-care unit. Infect Control Hosp Epidemiol 1998;19(12):924-8.
Antimicrobial Agents and Chemotherapy (American Society for Microbiology)
Carmen Peña et al. 1998
26. Pena C, Pujol M, Ardanuy C, et al. Epidemiology and successful control of a large outbreak due to Klebsiella pneumoniae producing extendedspectrum beta-lactamases. Antimicrob Agents Chemother 1998;42(1):53­ 8.
Archives of Internal Medicine (American Medical Association (AMA))
Marc J. M. Bonten et al. 1998
Although early guidelines for VRE suggested discontinuation of Contact Precautions after three stool cultures obtained at weekly intervals proved negative 740 , subsequent experiences have indicated that such screening may fail to detect colonization that can persist for >1 year 27, 936-938 .
On page 72
27. Bonten MJ, Slaughter S, Ambergen AW, et al. The role of "colonization pressure" in the spread of vancomycin-resistant enterococci: an important infection control variable. Arch Intern Med 1998;158(10):1127-32.
Scandinavian Journal of Infectious Diseases (Informa UK Limited)
Mogens Jensenius, Signe Holta Ringe 1998
28. Jensenius M, Ringertz SH, Berild D, Bell H, Espinoza R, Grinde B. Prolonged nosocomial outbreak of hepatitis A arising from an alcoholic with pneumonia. Scand J Infect Dis 1998;30(2):119-23.
Infection Control & Hospital Epidemiology (Cambridge University Press (CUP))
Anne Zawacki et al. 2004
MDR-ESBLs 810 ; Pseudomonas aeruginosa 29 ; methicillin-susceptible
On page 57
Place together in the same room (cohort) patients who are infected or colonized with the same pathogen and are suitable roommates 29, 638, 808, 811-813, 815, 818, 819 Category IB
On page 84
29. Zawacki A, O'Rourke E, Potter-Bynoe G, Macone A, Harbarth S, Goldmann D. An outbreak of Pseudomonas aeruginosa pneumonia and bloodstream infection associated with intermittent otitis externa in a healthcare worker. Infect Control Hosp Epidemiol 2004;25(12):1083-9.
New England Journal of Medicine (Massachusetts Medical Society)
Marc Foca et al. 2000
In 2002, CDC/HICPAC recommended (Category IA) that artificial fingernails and extenders not be worn by healthcare personnel who have contact with high-risk patients (e.g., those in ICUs, ORs) due to the association with outbreaks of gramnegative bacillus and candidal infections as confirmed by molecular typing of isolates 30, 31, 559, 722-725 .
On page 49
30. Foca M, Jakob K, Whittier S, et al. Endemic Pseudomonas aeruginosa infection in a neonatal intensive care unit. N Engl J Med 2000;343(10):695-700.
Infection Control & Hospital Epidemiology (Cambridge University Press (CUP))
Archana Gupta et al. 2004
Outbreaks associated with a variety of bacterial, fungal and viral pathogens due to commonsource and person-to-person transmissions are frequent in adult and pediatric ICUs 31, 333-336, 337 , 338 .
On page 32
In 2002, CDC/HICPAC recommended (Category IA) that artificial fingernails and extenders not be worn by healthcare personnel who have contact with high-risk patients (e.g., those in ICUs, ORs) due to the association with outbreaks of gramnegative bacillus and candidal infections as confirmed by molecular typing of isolates 30, 31, 559, 722-725 .
On page 49
31. Gupta A, Della-Latta P, Todd B, et al. Outbreak of extended-spectrum beta-lactamase-producing Klebsiella pneumoniae in a neonatal intensive care unit linked to artificial nails. Infect Control Hosp Epidemiol 2004;25(3):210-5.
32. Boyce JM, Opal SM, Potter-Bynoe G, Medeiros AA. Spread of methicillin-resistant Staphylococcus aureus in a hospital after exposure to a health care worker with chronic sinusitis. Clin Infect Dis 1993;17(3):496-504.
American Journal of Infection Control (Elsevier BV)
Phyllis E. Fllegel et al. 1982
Rubella has been transmitted in the outpatient obstetric setting 33 ; there are no published reports of varicella transmission in the outpatient setting.
On page 36
Also, reports of healthcare-associated transmission of rubella in obstetrical clinics 33, 876 and measles in acute care settings 34 demonstrate the importance of immunization of susceptible healthcare personnel against childhood diseases.
On page 63
Pregnant women who are not immune should not care for these patients 17, 33 .
33. Fliegel PE, Weinstein WM. Rubella outbreak in a prenatal clinic: management and prevention. Am J Infect Control 1982;10(1):29-33.
outbreaks and increasing attention is being directed toward improving influenza vaccination rates in healthcare personnel 35 , 611, 690, 877, 878 , 879 .
On page 64
35. Carman WF, Elder AG, Wallace LA, et al. Effects of influenza vaccination of health-care workers on mortality of elderly people in longterm care: a randomised controlled trial. Lancet 2000;355(9198):93-7.
Infection Control & Hospital Epidemiology (Cambridge University Press (CUP))
Leonard A. Mermel et al. 2003
37. Mermel LA, McKay M, Dempsey J, Parenteau S. Pseudomonas surgicalsite infections linked to a healthcare worker with onychomycosis. Infect Control Hosp Epidemiol 2003;24(10):749-52.
39. Wang JT, Chang SC, Ko WJ, et al. A hospital-acquired outbreak of methicillin-resistant Staphylococcus aureus infection initiated by a surgeon carrier. J Hosp Infect 2001;47(2):104-9.
Archives of Pediatrics & Adolescent Medicine (American Medical Association (AMA))
WILLIAM M. VALENTI 1980
visitors 40-45 .
On page 14
The result is more patients and their sibling visitors with transmissible infections present in pediatric healthcare settings, especially during seasonal epidemics (e.g., pertussis 36, 40, 41 , respiratory viral infections including those caused by RSV 24 , influenza viruses 373 , parainfluenza virus 374 , human metapneumovirus 375 , and adenoviruses 376 ; rubeola [measles] 34 , varicella [chickenpox] 377 , and rotavirus 38, 378 ).
On page 33
N.3.a. Visitors as sources of infection Visitors have been identified as the source of several types of HAIs (e.g., pertussis 40, 41 , M.
On page 64
40. Valenti WM, Pincus PH, Messner MK. Nosocomial pertussis: possible spread by a hospital visitor. Am J Dis Child 1980;134(5):520-1.
Infection Control and Hospital Epidemiology (Cambridge University Press (CUP))
Celia D. C. Christie et al. 1995
visitors 40-45 .
On page 14
The result is more patients and their sibling visitors with transmissible infections present in pediatric healthcare settings, especially during seasonal epidemics (e.g., pertussis 36, 40, 41 , respiratory viral infections including those caused by RSV 24 , influenza viruses 373 , parainfluenza virus 374 , human metapneumovirus 375 , and adenoviruses 376 ; rubeola [measles] 34 , varicella [chickenpox] 377 , and rotavirus 38, 378 ).
On page 33
N.3.a. Visitors as sources of infection Visitors have been identified as the source of several types of HAIs (e.g., pertussis 40, 41 , M.
On page 64
41. Christie CD, Glover AM, Willke MJ, Marx ML, Reising SF, Hutchinson NM. Containment of pertussis in the regional pediatric hospital during the Greater Cincinnati epidemic of 1993. Infect Control Hosp Epidemiol 1995;16(10):556-63.
Infection Control & Hospital Epidemiology (Cambridge University Press (CUP))
Flor M. Muñoz et al. 2002
visitors 40-45 .
On page 14
Patients, family members, and visitors can be partners in preventing transmission of infections in healthcare settings 9, 42, 709-711 .
On page 48
tuberculosis have been found to have unsuspected pulmonary tuberculosis with cavitary lesions, even when asymptomatic 42, 831 .
On page 59
tuberculosis 42, 892 , influenza, and other respiratory viruses 24, 43, 44, 373 and SARS 21, 252-254 ).
On page 64
For children, airborne precautions until active tuberculosis ruled out in visiting family members (see tuberculosis below) 42
For infants and children, use Airborne Precautions until active pulmonary tuberculosis in visiting family members ruled out 42
42. Munoz FM, Ong LT, Seavy D, Medina D, Correa A, Starke JR. Tuberculosis among adult visitors of children with suspected tuberculosis and employees at a children's hospital. Infect Control Hosp Epidemiol 2002;23(10):568-72.
Infection Control and Hospital Epidemiology (Cambridge University Press (CUP))
Ricardo Garcia et al. 1997
visitors 40-45 .
On page 14
y a limited number of single-patient rooms, it is prudent to prioritize them for those patients who have conditions that facilitate transmission of infectious material to other patients (e.g., draining wounds, stool incontinence, uncontained secretions) and for those who are at increased risk of acquisition and adverse outcomes resulting from HAI (e.g., immunosuppression, open wounds, indwelling catheters, anticipated prolonged length of stay, total dependence on HCWs for activities of daily living) 15, 24, 43, 430, 794, 795 .
On page 57
Patients with underlying conditions that increase their susceptibility to infection (e.g., those who are immunocompromised 43, 44 or have cystic fibrosis 20 ) require special efforts to protect them from exposures to infected patients in common waiting areas.
On page 59
tuberculosis 42, 892 , influenza, and other respiratory viruses 24, 43, 44, 373 and SARS 21, 252-254 ).
On page 64
Visitor screening is used consistently on HSCT units 15, 43 .
On page 65
43. Garcia R, Raad I, Abi-Said D, et al. Nosocomial respiratory syncytial virus infections: prevention and control in bone marrow transplant patients. Infect Control Hosp Epidemiol 1997;18(6):412-6.
Clinical Infectious Diseases (Oxford University Press (OUP))
E. Whimbey et al. 1996
visitors 40-45 .
On page 14
Patients with underlying conditions that increase their susceptibility to infection (e.g., those who are immunocompromised 43, 44 or have cystic fibrosis 20 ) require special efforts to protect them from exposures to infected patients in common waiting areas.
On page 59
tuberculosis 42, 892 , influenza, and other respiratory viruses 24, 43, 44, 373 and SARS 21, 252-254 ).
On page 64
44. Whimbey E, Champlin RE, Couch RB, et al. Community respiratory virus infections among hospitalized adult bone marrow transplant recipients. Clin Infect Dis 1996;22(5):778-82.
Clinical Infectious Diseases (Oxford University Press (OUP))
L. Saiman et al. 2003
visitors 40-45 .
On page 14
45. Saiman L, O'keefe M, Graham PL, et al. Hospital transmission of community-acquired methicillin-resistant Staphylococcus aureus among postpartum women. Clin Infect Dis 2003;37(10):1313-9.
Critical Care Medicine (Ovid Technologies (Wolters Kluwer Health))
Marc J. M. Bonten et al. 1998
The endogenous flora of patients (e.g., bacteria residing in the respiratory or gastrointestinal tract) also are the source of HAIs 46-54 .
On page 14
46. Bonten MJ, Slaughter S, Hayden MK, Nathan C, van Voorhis J, Weinstein RA. External sources of vancomycin-resistant enterococci for intensive care units. Crit Care Med 1998;26(12):2001-4.
Journal of Infectious Diseases (Oxford University Press (OUP))
D. M. Flynn et al. 1987
The endogenous flora of patients (e.g., bacteria residing in the respiratory or gastrointestinal tract) also are the source of HAIs 46-54 .
On page 14
47. Flynn DM, Weinstein RA, Nathan C, Gaston MA, Kabins SA. Patients' endogenous flora as the source of "nosocomial" Enterobacter in cardiac surgery. J Infect Dis 1987;156(2):363-8.
Journal of Infectious Diseases (Oxford University Press (OUP))
B. Olson et al. 1984
The endogenous flora of patients (e.g., bacteria residing in the respiratory or gastrointestinal tract) also are the source of HAIs 46-54 .
On page 14
48. Olson B, Weinstein RA, Nathan C, Chamberlin W, Kabins SA. Epidemiology of endemic Pseudomonas aeruginosa: why infection control efforts have failed. J Infect Dis 1984;150(6):808-16.
The endogenous flora of patients (e.g., bacteria residing in the respiratory or gastrointestinal tract) also are the source of HAIs 46-54 .
On page 14
care facilities have been associated with importing extended-spectrum cephalosporin-resistant, gram-negative bacilli into one PICU 50 .
On page 35
50. Toltzis P, Hoyen C, et al. Factors that predict preexisting colonization with antibiotic-resistant gram-negative bacilli in patients admitted to a pediatric intensive care unit. Pediatrics 1999;103 (4 Pt1):719-23.
Critical Care Medicine (Ovid Technologies (Wolters Kluwer Health))
R. E. Sarginson et al. 2004
The endogenous flora of patients (e.g., bacteria residing in the respiratory or gastrointestinal tract) also are the source of HAIs 46-54 .
On page 14
51. Sarginson RE, Taylor N, Reilly N, Baines PB, Van Saene HK. Infection in prolonged pediatric critical illness: A prospective four-year study based on knowledge of the carrier state. Crit Care Med 2004;32(3):839-47.
The endogenous flora of patients (e.g., bacteria residing in the respiratory or gastrointestinal tract) also are the source of HAIs 46-54 .
On page 14
52. Silvestri L, Monti Bragadin C, Milanese M, et al. Are most ICU infections really nosocomial? A prospective observational cohort study in mechanically ventilated patients. J Hosp Infect 1999;42(2):125-33.
Journal of Burn Care & Rehabilitation (Ovid Technologies (Wolters Kluwer Health))
J. P. Heggers et al. 1988
The endogenous flora of patients (e.g., bacteria residing in the respiratory or gastrointestinal tract) also are the source of HAIs 46-54 .
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Methicillin-susceptible Staphylococcus aureus, MRSA, enterococci, including VRE, gram-negative bacteria, and candida are prevalent pathogens in burn infections 53, 340, 343-350 and outbreaks of these organisms have been reported 351-354 .
On page 32
53. Heggers JP, Phillips LG, Boertman JA, et al. The epidemiology of methicillin-resistant Staphylococcus aureus in a burn center. J Burn Care Rehabil 1988;9(6):610-2.
Clinical Infectious Diseases (Oxford University Press (OUP))
C. J. Donskey 2004
The endogenous flora of patients (e.g., bacteria residing in the respiratory or gastrointestinal tract) also are the source of HAIs 46-54 .
On page 14
Assignment of a dedicated commode to a patient,and cleaning and disinfecting fixtures and equipment that may have fecal contamination (e.g., bathrooms, commodes 798 , scales used for weighing diapers) and the adjacent surfaces with appropriate agents may be especially important when a single-patient room can not be used since environmental contamination with intestinal tract pathogens is likely from both continent and incontinent patients 54, 799 .
On page 57
The frequency or intensity of cleaning may need to change based on the patient’s level of hygiene and the degree of environmental contamination and for certain for infectious agents whose reservoir is the intestinal tract 54 .
On page 60
54. Donskey CJ. The role of the intestinal tract as a reservoir and source for transmission of nosocomial pathogens. Clin Infect Dis 2004;39(2):219-26.
Host factors such as extremes of age and underlying disease (e.g. diabetes 56, 57 ), human immunodeficiency virus/acquired immune deficiency syndrome [HIV/AIDS] 58, 59 , malignancy, and transplants 18, 60, 61 can increase susceptibility to infection as do a variety of medications that alter the normal flora (e.g., antimicrobial agents, gastric acid suppressants, corticosteroids, antirejection drugs, antineoplastic agents, and immunosuppressive drugs).
On page 15
56. Thomsen RW, Hundborg HH, Lervang HH, Johnsen SP, Schonheyder HC, Sorensen HT. Risk of community-acquired pneumococcal bacteremia in patients with diabetes: a population-based case-control study. Diabetes Care 2004;27(5):1143-7.
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Robert E. Hirschtick et al. 1995
Host factors such as extremes of age and underlying disease (e.g. diabetes 56, 57 ), human immunodeficiency virus/acquired immune deficiency syndrome [HIV/AIDS] 58, 59 , malignancy, and transplants 18, 60, 61 can increase susceptibility to infection as do a variety of medications that alter the normal flora (e.g., antimicrobial agents, gastric acid suppressants, corticosteroids, antirejection drugs, antineoplastic agents, and immunosuppressive drugs).
On page 15
58. Hirschtick RE, Glassroth J, Jordan MC, et al. Bacterial pneumonia in persons infected with the human immunodeficiency virus. Pulmonary Complications of HIV Infection Study Group. N Engl J Med 1995;333(13):845-51.
Host factors such as extremes of age and underlying disease (e.g. diabetes 56, 57 ), human immunodeficiency virus/acquired immune deficiency syndrome [HIV/AIDS] 58, 59 , malignancy, and transplants 18, 60, 61 can increase susceptibility to infection as do a variety of medications that alter the normal flora (e.g., antimicrobial agents, gastric acid suppressants, corticosteroids, antirejection drugs, antineoplastic agents, and immunosuppressive drugs).
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59. Rosenberg AL, Seneff MG, Atiyeh L, Wagner R, Bojanowski L, Zimmerman JE. The importance of bacterial sepsis in intensive care unit patients with acquired immunodeficiency syndrome: implications for future care in the age of increasing antiretroviral resistance. Crit Care Med 2001;29(3):548-56.
Host factors such as extremes of age and underlying disease (e.g. diabetes 56, 57 ), human immunodeficiency virus/acquired immune deficiency syndrome [HIV/AIDS] 58, 59 , malignancy, and transplants 18, 60, 61 can increase susceptibility to infection as do a variety of medications that alter the normal flora (e.g., antimicrobial agents, gastric acid suppressants, corticosteroids, antirejection drugs, antineoplastic agents, and immunosuppressive drugs).
On page 15
60. Malone JL, Ijaz K, Lambert L, et al. Investigation of healthcare-associated transmission of Mycobacterium tuberculosis among patients with malignancies at three hospitals and at a residential facility. Cancer 2004;101(12):2713-21.
New England Journal of Medicine (Massachusetts Medical Society)
Jay A. Fishman et al. 1998
Host factors such as extremes of age and underlying disease (e.g. diabetes 56, 57 ), human immunodeficiency virus/acquired immune deficiency syndrome [HIV/AIDS] 58, 59 , malignancy, and transplants 18, 60, 61 can increase susceptibility to infection as do a variety of medications that alter the normal flora (e.g., antimicrobial agents, gastric acid suppressants, corticosteroids, antirejection drugs, antineoplastic agents, and immunosuppressive drugs).
On page 15
61. Fishman JA, Rubin RH. Infection in organ-transplant recipients. N Engl J Med 1998;338(24):1741-51.
62. Safdar N, Kluger DM, Maki DG. A review of risk factors for catheterrelated bloodstream infection caused by percutaneously inserted, noncuffed central venous catheters: implications for preventive strategies. Medicine (Baltimore) 2002;81(6):466-79.
as urinary catheters, endotracheal tubes, central venous and arterial catheters 62­ 64 and synthetic implants facilitate development of HAIs by allowing potential
On page 15
D.1.c. Pediatrics Studies of the epidemiology of HAIs in children have identified unique infection control issues in this population 63, 64, 366-370 .
On page 33
64. Yogaraj JS, Elward AM, Fraser VJ. Rate, risk factors, and outcomes of nosocomial primary bloodstream infection in pediatric intensive care unit patients. Pediatrics 2002;110(3):481-5.
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Rodney M. Donlan 2002
65. Donlan RM. Biofilms: microbial life on surfaces. Emerg Infect Dis 2002;8(9):881-90.
American Journal of Infection Control (Elsevier BV)
E Beltrami 2003
blood or other blood-containing body fluids from a patient directly enters a caregiver’s body through contact with a mucous membrane 66 or breaks (i.e., cuts, abrasions) in the skin 67 .
On page 16
67. Beltrami EM, Kozak A, Williams IT, et al. Transmission of HIV and hepatitis C virus from a nursing home patient to a health care worker. Am J Infect Control 2003;31(3):168-75.
Infection Control & Hospital Epidemiology (Cambridge University Press (CUP))
Olugbenga O. Obasanjo et al. 2001
mites from a scabies-infested patient are transferred to the skin of a caregiver while he/she is having direct ungloved contact with the patient’s skin 68, 69 .
On page 16
68. Obasanjo OO, Wu P, Conlon M, et al. An outbreak of scabies in a teaching hospital: lessons learned. Infect Control Hosp Epidemiol 2001;22(1):13-8.
Journal of Hospital Infection (Elsevier BV)
B.M. Andersen et al. 2000
mites from a scabies-infested patient are transferred to the skin of a caregiver while he/she is having direct ungloved contact with the patient’s skin 68, 69 .
On page 16
Infections of home care providers, that could pose a risk to home care patients include infections transmitted by the airborne or droplet routes (e.g., chickenpox, tuberculosis, influenza), and skin infestations (e.g., scabies 69 and lice) and infections (e.g.,impetigo) transmitted by direct or indirect contact.
On page 37
69. Andersen BM, Haugen H, Rasch M, Heldal Haugen A, Tageson A. Outbreak of scabies in Norwegian nursing homes and home care patients: control and prevention. J Hosp Infect 2000;45(2):160-4.
a healthcare provider develops herpetic whitlow on a finger after contact with HSV when providing oral care to a patient without using gloves or HSV is transmitted to a patient from a herpetic whitlow on an ungloved hand of a healthcare worker (HCW) 70, 71 .
On page 16
70. Avitzur Y, Amir J. Herpetic whitlow infection in a general pediatrician-­ an occupational hazard. Infection 2002;30(4):234-6.
American Journal of Epidemiology (Oxford University Press (OUP))
GARRETT ADAMS et al. 1981
a healthcare provider develops herpetic whitlow on a finger after contact with HSV when providing oral care to a patient without using gloves or HSV is transmitted to a patient from a herpetic whitlow on an ungloved hand of a healthcare worker (HCW) 70, 71 .
On page 16
71. Adams G, Stover BH, Keenlyside RA, et al. Nosocomial herpetic infections in a pediatric intensive care unit. Am J Epidemiol 1981;113(2):126-32.
Infection Control & Hospital Epidemiology (Cambridge University Press (CUP))
Anita Bhalla et al. 2004
Hands of healthcare personnel may transmit pathogens after touching an infected or colonized body site on one patient or a contaminated inanimate object, if hand hygiene is not performed before touching another patient. 72, 73 .
On page 16
E.1. Gloves Gloves are used to prevent contamination of healthcare personnel hands when 1) anticipating direct contact with blood or body fluids, mucous membranes, nonintact skin and other potentially infectious material; 2) having direct contact with patients who are colonized or infected with pathogens transmitted by the contact route e.g., VRE, MRSA, RSV 559, 727, 728 ; or 3) handling or touching visibly or potentially contaminated patient care equipment and environmental surfaces 72, 73, 559 .
On page 50
The cleaning and disinfection of all patient-care areas is important for frequently touched surfaces, especially those closest to the patient, that are most likely to be contaminated (e.g., bedrails, bedside tables, commodes, doorknobs, sinks, surfaces and equipment in close proximity to the patient) 11, 72, 73, 835 .
On page 60
transmission of pathogens from contaminated hands to surfaces 72,
On page 78
surrounding toilets in patients’ rooms) on a more frequent schedule compared to that for other surfaces (e.g., horizontal surfaces in waiting rooms) 11 73, 740, 746, 993, 994 72, 800, 835 995 .
On page 82
medical equipment, bed rails) 72, 73, 88, 837 .
On page 85
After gown removal, ensure that clothing and skin do not contact potentially contaminated environmental surfaces that could result in possible transfer of microorganism to other patients or environmental surfaces 72, 73 .
On page 85
72. Bhalla A, Pultz NJ, Gries DM, et al. Acquisition of nosocomial pathogens on hands after contact with environmental surfaces near hospitalized patients. Infect Control Hosp Epidemiol 2004;25(2):164-7.
Archives of Internal Medicine (American Medical Association (AMA))
Amy N. Duckro 2005
Hands of healthcare personnel may transmit pathogens after touching an infected or colonized body site on one patient or a contaminated inanimate object, if hand hygiene is not performed before touching another patient. 72, 73 .
On page 16
E.1. Gloves Gloves are used to prevent contamination of healthcare personnel hands when 1) anticipating direct contact with blood or body fluids, mucous membranes, nonintact skin and other potentially infectious material; 2) having direct contact with patients who are colonized or infected with pathogens transmitted by the contact route e.g., VRE, MRSA, RSV 559, 727, 728 ; or 3) handling or touching visibly or potentially contaminated patient care equipment and environmental surfaces 72, 73, 559 .
On page 50
The cleaning and disinfection of all patient-care areas is important for frequently touched surfaces, especially those closest to the patient, that are most likely to be contaminated (e.g., bedrails, bedside tables, commodes, doorknobs, sinks, surfaces and equipment in close proximity to the patient) 11, 72, 73, 835 .
On page 60
surrounding toilets in patients’ rooms) on a more frequent schedule compared to that for other surfaces (e.g., horizontal surfaces in waiting rooms) 11 73, 740, 746, 993, 994 72, 800, 835 995 .
On page 82
medical equipment, bed rails) 72, 73, 88, 837 .
On page 85
After gown removal, ensure that clothing and skin do not contact potentially contaminated environmental surfaces that could result in possible transfer of microorganism to other patients or environmental surfaces 72, 73 .
On page 85
73. Duckro AN, Blom DW, Lyle EA, Weinstein RA, Hayden MK. Transfer of vancomycin-resistant enterococci via health care worker hands. Arch Intern Med 2005;165(3):302-7.
In all healthcare settings, providing patients who are on Transmission-Based Precautions with dedicated noncritical medical equipment (e.g., stethoscope, blood pressure cuff, electronic thermometer) has been beneficial for preventing transmission 74, 89, 740, 853, 854 .
On page 61
74. Brooks SE, Veal RO, Kramer M, Dore L, Schupf N, Adachi M. Reduction in the incidence of Clostridium difficile-associated diarrhea in an acute care hospital and a skilled nursing facility following replacement of electronic thermometers with single-use disposables. Infect Control Hosp Epidemiol 1992;13(2):98-103.
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75. CDC. Nosocomial hepatitis B virus infection associated with reusable fingerstick blood sampling devices--Ohio and New York City, 1996. MMWR Morb Mortal Wkly Rep 1997;46 (10):217-21.
76. Desenclos JC, Bourdiol-Razes M, Rolin B, et al. Hepatitis C in a ward for cystic fibrosis and diabetic patients: possible transmission by springloaded finger-stick devices for self-monitoring of capillary blood glucose. Infect Control Hosp Epidemiol 2001;22(11):701-7.
77. CDC. Transmission of hepatitis B virus among persons undergoing blood glucose monitoring in long-term-care facilities--Mississippi, North Carolina, and Los Angeles County, California, 2003-2004. MMWR Morb Mortal Wkly Rep 2005;54(9):220-3.
The Journal of Pediatrics (Elsevier BV)
Caroline Breese Hall et al. 1981
Shared toys may become a vehicle for transmitting respiratory viruses (e.g., respiratory syncytial virus 24, 78, 79 or pathogenic bacteria (e.g., Pseudomonas aeruginosa 80 ) among pediatric patients.
On page 16
78. Hall CB, Douglas RG, Jr. Modes of transmission of respiratory syncytial virus. J Pediatr 1981;99(1):100-3.
Journal of Infectious Diseases (Oxford University Press (OUP))
C. B. Hall et al. 1980
Shared toys may become a vehicle for transmitting respiratory viruses (e.g., respiratory syncytial virus 24, 78, 79 or pathogenic bacteria (e.g., Pseudomonas aeruginosa 80 ) among pediatric patients.
On page 16
79. Hall CB, Douglas RG, Jr., Geiman JM. Possible transmission by fomites of respiratory syncytial virus. J Infect Dis 1980;141(1):98-102.
The Pediatric Infectious Disease Journal (Ovid Technologies (Wolters Kluwer Health))
JIM P. BUTTERY et al. 1998
aeruginosa on a pediatric oncology unit 80 .
On page 33
F.4. In facilities that provide health care to pediatric patients or have waiting areas with child play toys (e.g., obstetric/gynecology offices and clinics), establish policies and procedures for cleaning and disinfecting toys at regular intervals 379 80 .
On page 82
80. Buttery JP, Alabaster SJ, Heine RG, et al. Multiresistant Pseudomonas aeruginosa outbreak in a pediatric oncology ward related to bath toys. Pediatr Infect Dis J 1998;17(6):509-13.
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Tracy Agerton 1997
81. Agerton T, Valway S, Gore B, et al. Transmission of a highly drugresistant strain (strain W1) of Mycobacterium tuberculosis. Community outbreak and nosocomial transmission via a contaminated bronchoscope. JAMA 1997;278(13):1073-7.
New England Journal of Medicine (Massachusetts Medical Society)
Jean-Pierre Bronowicki et al. 1997
These outbreaks often are related to common source exposures, usually a contaminated medical device, multi-dose vial, or intravenous solution 82, 449-453 .
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82. Bronowicki JP, Venard V, Botte C, et al. Patient-to-patient transmission of hepatitis C virus during colonoscopy. N Engl J Med 1997;337(4):237-40.
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Theresa M. Michele 1997
83. Michele TM, Cronin WA, Graham NM, et al. Transmission of Mycobacterium tuberculosis by a fiberoptic bronchoscope. Identification by DNA fingerprinting. JAMA 1997;278(13):1093-5.
84. Schelenz S, French G. An outbreak of multidrug-resistant Pseudomonas aeruginosa infection associated with contamination of bronchoscopes and an endoscope washer-disinfector. J Hosp Infect 2000;46(1):23-30.
Infection Control & Hospital Epidemiology (Cambridge University Press (CUP))
David J. Weber et al. 2001
85. Weber DJ, Rutala WA. Lessons from outbreaks associated with bronchoscopy. Infect Control Hosp Epidemiol 2001;22(7):403-8.
Infection Control & Hospital Epidemiology (Cambridge University Press (CUP))
John M. Boyce et al. 1997
E.2. Isolation gowns Isolation gowns are used as specified by Standard and Transmission-Based Precautions, to protect the HCW’s arms and exposed body areas and prevent contamination of clothing with blood, body fluids, and other potentially infectious material 24, 88, 262, 744-746 .
On page 51
difficile, VRE, MRSA, MDR-GNB 11, 24, 88, 435, 746, 796, 837 ).
On page 60
medical equipment, bed rails) 72, 73, 88, 837 .
On page 85
If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient 24, 88, 796, 836, 837, 854, 1016 .
On page 85
88. Boyce JM, Potter-Bynoe G, Chenevert C, King T. Environmental contamination due to methicillin-resistant Staphylococcus aureus: possible infection control implications. Infect Control Hosp Epidemiol 1997;18(9):622-7.(mj).
200. Muto CA, Jernigan JA, Ostrowsky BE, et al. SHEA guideline for preventing nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus and enterococcus. Infect Control Hosp Epidemiol 2003;24(5):362-86.
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Kimon C. Zachary et al. 2001
In all healthcare settings, providing patients who are on Transmission-Based Precautions with dedicated noncritical medical equipment (e.g., stethoscope, blood pressure cuff, electronic thermometer) has been beneficial for preventing transmission 74, 89, 740, 853, 854 .
On page 61
89. Zachary KC, Bayne PS, Morrison VJ, Ford DS, Silver LC, Hooper DC. Contamination of gowns, gloves, and stethoscopes with vancomycinresistant enterococci. Infect Control Hosp Epidemiol 2001;22(9):560-4.
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90. Perry C, Marshall R, Jones E. Bacterial contamination of uniforms. J Hosp Infect 2001;48(3):238-41.
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RAO S. PAPINENI et al. 1997
91. Papineni RS, Rosenthal FS. The size distribution of droplets in the exhaled breath of healthy human subjects. J Aerosol Med 1997;10(2):105-16.
Emerging Infectious Diseases (Centers for Disease Control and Prevention (CDC))
Mark Loeb et al. 2004
SARS-CoV transmission has been associated with endotracheal intubation, noninvasive positive pressure ventilation, and cardiopulmonary resuscitation 93, 94, 96, 98, 141 .
On page 19
procedures (e.g., endotracheal intubation, suctioning) was associated with transmission of infection to large numbers of healthcare personnel outside of the United States 93, 94, 96, 98, 253 .
On page 27
However, in Toronto, consistent use of an N95 respirator was slightly more protective than a mask 93 .
On page 27
The protective effect of masks for exposed healthcare personnel has been demonstrated 93, 113, 755, 756 .
On page 52
Procedures that generate splashes or sprays of blood, body fluids, secretions, or excretions (e.g., endotracheal suctioning, bronchoscopy, invasive vascular procedures) require either a face shield (disposable or reusable) or mask and goggles 93-95, 96 , 113, 115, 262, 739, 757 .
On page 52
tuberculosis 790 , SARS- CoV 93, 94, 98 and N.
On page 56
tuberculosis, SARS or hemorrhagic fever viruses), wear one of the following: a face shield that fully covers the front and sides of the face, a mask with attached shield, or a mask and goggles (in addition to gloves and gown) 95, 96, 113, 126 93 94, 134 .
On page 80
A.1. In addition to Standard Precautions, use Transmission-Based Precautions for patients with documented or suspected infection or colonization with highly transmissible or epidemiologically-important pathogens for which additional precautions are needed to prevent transmission (see Appendix A) 24, 93, 126, 141, 306, 806, 1008 .
On page 83
and large droplets 93, 94, 96 .
93. Loeb M, McGeer A, Henry B, et al. SARS among critical care nurses, Toronto. Emerg Infect Dis 2004;10(2):251-5.
American Journal of Respiratory and Critical Care Medicine (American Thoracic Society)
Robert A. Fowler et al. 2004
SARS-CoV transmission has been associated with endotracheal intubation, noninvasive positive pressure ventilation, and cardiopulmonary resuscitation 93, 94, 96, 98, 141 .
On page 19
procedures (e.g., endotracheal intubation, suctioning) was associated with transmission of infection to large numbers of healthcare personnel outside of the United States 93, 94, 96, 98, 253 .
On page 27
Procedures that generate splashes or sprays of blood, body fluids, secretions, or excretions (e.g., endotracheal suctioning, bronchoscopy, invasive vascular procedures) require either a face shield (disposable or reusable) or mask and goggles 93-95, 96 , 113, 115, 262, 739, 757 .
On page 52
tuberculosis 790 , SARS- CoV 93, 94, 98 and N.
On page 56
tuberculosis, SARS or hemorrhagic fever viruses), wear one of the following: a face shield that fully covers the front and sides of the face, a mask with attached shield, or a mask and goggles (in addition to gloves and gown) 95, 96, 113, 126 93 94, 134 .
On page 80
and large droplets 93, 94, 96 .
94. Fowler RA, Guest CB, Lapinsky SE, et al. Transmission of severe acute respiratory syndrome during intubation and mechanical ventilation. Am J Respir Crit Care Med 2004;169(11):1198-202.
Infection Control & Hospital Epidemiology (Cambridge University Press (CUP))
Jean-François Gehanno et al. 1999
Procedures that generate splashes or sprays of blood, body fluids, secretions, or excretions (e.g., endotracheal suctioning, bronchoscopy, invasive vascular procedures) require either a face shield (disposable or reusable) or mask and goggles 93-95, 96 , 113, 115, 262, 739, 757 .
On page 52
meningitidis 95 .
On page 56
tuberculosis, SARS or hemorrhagic fever viruses), wear one of the following: a face shield that fully covers the front and sides of the face, a mask with attached shield, or a mask and goggles (in addition to gloves and gown) 95, 96, 113, 126 93 94, 134 .
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95. Gehanno JF, Kohen-Couderc L, Lemeland JF, Leroy J. Nosocomial meningococcemia in a physician. Infect Control Hosp Epidemiol 1999;20(8):564-5.
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Damon C. Scales et al. 2003
SARS-CoV transmission has been associated with endotracheal intubation, noninvasive positive pressure ventilation, and cardiopulmonary resuscitation 93, 94, 96, 98, 141 .
On page 19
There is ample evidence for droplet and contact transmission 96, 101, 113 ; however, opportunistic airborne transmission cannot be excluded 101, 135-139, 149, 255 .
On page 26
procedures (e.g., endotracheal intubation, suctioning) was associated with transmission of infection to large numbers of healthcare personnel outside of the United States 93, 94, 96, 98, 253 .
On page 27
Procedures that generate splashes or sprays of blood, body fluids, secretions, or excretions (e.g., endotracheal suctioning, bronchoscopy, invasive vascular procedures) require either a face shield (disposable or reusable) or mask and goggles 93-95, 96 , 113, 115, 262, 739, 757 .
On page 52
tuberculosis, SARS or hemorrhagic fever viruses), wear one of the following: a face shield that fully covers the front and sides of the face, a mask with attached shield, or a mask and goggles (in addition to gloves and gown) 95, 96, 113, 126 93 94, 134 .
On page 80
and large droplets 93, 94, 96 .
96. Scales D, et al. Illness in intensive-care staff after brief exposure to severe acute respiratory syndrome. Emerg Infect Dis 2003;9(10):1205-10.
Successful infection control measures used to prevent transmission of respiratory secretions include segregation of CF patients from each other in ambulatory and hospital settings (including use of private rooms with separate showers), environmental decontamination of surfaces and equipment contaminated with respiratory secretions, elimination of group chest physiotherapy sessions, and disbanding of CF camps 97, 526 .
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97. Ensor E, Humphreys H, Peckham D, Webster C, Knox AJ. Is Burkholderia (Pseudomonas) cepacia disseminated from cystic fibrosis patients during physiotherapy? J Hosp Infect 1996;32(1):9-15.
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Michael D. Christian et al. 2004
SARS-CoV transmission has been associated with endotracheal intubation, noninvasive positive pressure ventilation, and cardiopulmonary resuscitation 93, 94, 96, 98, 141 .
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procedures (e.g., endotracheal intubation, suctioning) was associated with transmission of infection to large numbers of healthcare personnel outside of the United States 93, 94, 96, 98, 253 .
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tuberculosis 790 , SARS- CoV 93, 94, 98 and N.
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98. Christian MD, Loutfy M, McDonald LC, et al. Possible SARS coronavirus transmission during cardiopulmonary resuscitation. Emerg Infect Dis 2004;10(2):287-93.
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99. Valenzuela TD, Hooton TM, Kaplan EL, Schlievert P. Transmission of 'toxic strep' syndrome from an infected child to a firefighter during CPR. Ann Emerg Med 1991;20(1):90-2.
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However, experimental studies with smallpox 107, 108 and investigations during the global SARS outbreaks of 2003 101 suggest that droplets from patients with these two infections could reach persons located 6 feet or more from their source.
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There is ample evidence for droplet and contact transmission 96, 101, 113 ; however, opportunistic airborne transmission cannot be excluded 101, 135-139, 149, 255 .
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101. Wong TW, Lee CK, Tam W, et al. Cluster of SARS among medical students exposed to single patient, Hong Kong. Emerg Infect Dis 2004;10(2):269-76.
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C. T. Pachucki 1989
Influenza viruses are transmitted primarily by close contact with respiratory droplets 23, 102 and acquisition by healthcare personnel has been prevented by Droplet Precautions, even when positive pressure rooms were used in one center 144 However, inhalational transmission could not be excluded in an outbreak of influenza in the passengers and crew of a single aircraft 130 .
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102. Pachucki CT, Pappas SA, Fuller GF, Krause SL, Lentino JR, Schaaff DM. Influenza A among hospital personnel and patients. Implications for recognition, prevention, and control. Arch Intern Med 1989;149(1):77-80.
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Ralph D. Feigin et al. 1982
Historically, the area of defined risk has been a distance of <3 feet around the patient and is based on epidemiologic and simulated studies of selected infections 103, 104 .
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meningitidis 103 and group A streptococcus 114 and therefore supports the practice of distancing infected persons from others who are not infected.
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Draw the privacy curtain between beds to minimize opportunities for close contact 103, 104 410 .
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103. Feigin RD, Baker CJ, Herwaldt LA, Lampe RM, Mason EO, Whitney SE. Epidemic meningococcal disease in an elementary-school classroom. N Engl J Med 1982;307(20):1255-7.
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E. C. Dick et al. 1987
Historically, the area of defined risk has been a distance of <3 feet around the patient and is based on epidemiologic and simulated studies of selected infections 103, 104 .
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Examples of infectious agents that are transmitted via the droplet route include Bordetella pertussis 110 , influenza virus 23 , adenovirus 111 , rhinovirus 104 , Mycoplasma pneumoniae 112 21, 96,
On page 18
For certain other respiratory infectious agents, such as influenza 130, 131 and rhinovirus 104 , and even some gastrointestinal viruses (e.g., norovirus 132 and rotavirus 133 ) there is some evidence that the pathogen may be transmitted via small-particle aerosols, under natural and experimental conditions.
On page 18
Draw the privacy curtain between beds to minimize opportunities for close contact 103, 104 410 .
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Droplet most important route of transmission 104 1090 .
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in the air 109 .
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Also, aerosolized particles <100 μm can remain suspended in air when room air current velocities exceed the terminal settling velocities of the particles 109 .
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109. Cole EC, Cook CE. Characterization of infectious aerosols in health care facilities: an aid to effective engineering controls and preventive strategies. Am J Infect Control 1998;26(4):453-64.
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Celia Christie et al. 1995
Examples of infectious agents that are transmitted via the droplet route include Bordetella pertussis 110 , influenza virus 23 , adenovirus 111 , rhinovirus 104 , Mycoplasma pneumoniae 112 21, 96,
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110. Christie C, Mazon D, Hierholzer W, Jr., Patterson JE. Molecular heterogeneity of Acinetobacter baumanii isolates during seasonal increase in prevalence. Infect Control Hosp Epidemiol 1995;16(10):590-4.
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Daniel M. Musher 2003
Examples of infectious agents that are transmitted via the droplet route include Bordetella pertussis 110 , influenza virus 23 , adenovirus 111 , rhinovirus 104 , Mycoplasma pneumoniae 112 21, 96,
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These measures should be effective in decreasing the risk of transmission of pathogens contained in large respiratory droplets (e.g., influenza virus 23 , adenovirus 111 , B.
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Add Contact Precautions if copious moist secretions and close contact likely to occur (e.g., young infants) 111, 833 .
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PAUL STEINBERG et al. 1969
Examples of infectious agents that are transmitted via the droplet route include Bordetella pertussis 110 , influenza virus 23 , adenovirus 111 , rhinovirus 104 , Mycoplasma pneumoniae 112 21, 96,
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pertussis 827 and Mycoplasma pneumoniae 112 .
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There is ample evidence for droplet and contact transmission 96, 101, 113 ; however, opportunistic airborne transmission cannot be excluded 101, 135-139, 149, 255 .
On page 26
In Hong Kong, the use of Droplet and Contact Precautions, which included use of a mask but not a respirator, was effective in protecting healthcare personnel 113 .
On page 27
The protective effect of masks for exposed healthcare personnel has been demonstrated 93, 113, 755, 756 .
On page 52
Select masks, goggles, face shields, and combinations of each according to the need anticipated by the task performed 113, 739, 780, 896 .
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tuberculosis, SARS or hemorrhagic fever viruses), wear one of the following: a face shield that fully covers the front and sides of the face, a mask with attached shield, or a mask and goggles (in addition to gloves and gown) 95, 96, 113, 126 93 94, 134 .
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113. Seto WH, Tsang D, Yung RW, et al. Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS). Lancet 2003;361(9368):1519-20.
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respiratory syncytial virus may be transmitted by the droplet route, direct contact with infected respiratory secretions is the most important determinant of transmission and consistent adherence to Standard plus Contact Precautions prevents transmission in healthcare settings 24, 116, 117 .
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However, subsequent studies demonstrated that RSV transmission is effectively prevented by adherence to Standard plus Contact Precations and that for this virus routine use of goggles is not necessary 24, 116, 117, 684, 762 .
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Wear mask according to Standard Precautions 24 CB 116, 117 .
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However, subsequent studies demonstrated that RSV transmission is effectively prevented by adherence to Standard plus Contact Precations and that for this virus routine use of goggles is not necessary 24, 116, 117, 684, 762 .
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Wear mask according to Standard Precautions 24 CB 116, 117 .
117. Madge P, Paton JY, McColl JH, Mackie PL. Prospective controlled study of four infection-control procedures to prevent nosocomial infection with respiratory syncytial virus. Lancet 1992;340(8827):1079-83.
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118. Bassetti S, Bischoff WE, Walter M, et al. Dispersal of Staphylococcus aureus Into the Air Associated With a Rhinovirus Infection. Infect Control Hosp Epidemiol 2005;26(2):196-203.
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121. Coronado VG, Beck-Sague CM, Hutton MD, et al. Transmission of multidrug-resistant Mycobacterium tuberculosis among persons with human immunodeficiency virus infection in an urban hospital: epidemiologic and restriction fragment length polymorphism analysis. J Infect Dis 1993;168(4):1052-5.
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Infectious agents to which this applies include Mycobacterium tuberculosis 124-127 , rubeola virus (measles) 122 , and varicella-zoster virus (chickenpox) 123 .
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D.1. Use Airborne Precautions as recommended in Appendix A for patients known or suspected to be infected with infectious agents transmitted person-to-person by the airborne route (e.g., M tuberculosis 12 , measles 34, 122, 1020 , chickenpox 123, 773, 1021 , disseminated herpes zoster 1022 .
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However, infections transmitted via the airborne route (e.g., M tuberculosis, measles, chickenpox) require additional precautions 12, 125, 829 .
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tuberculosis and measles in ambulatory settings, most frequently emergency departments, has been reported 34, 127, 446, 448, 455-457 .
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In addition, published data suggest the possibility that variola virus (smallpox) may be transmitted over long distances through the air under unusual circumstances and AIIRs are recommended for this agent as well; however, droplet and contact routes are the more frequent routes of transmission for smallpox 108, 128, 129 .
On page 18
Respiratory protection is recommended for all healthcare personnel, including those with a documented “take” after smallpox vaccination due to the risk of a genetically engineered virus against which the vaccine may not provide protection, or of exposure to a very large viral load (e.g., from high-risk aerosol-generating procedures, immunocompromised patients, hemorrhagic or flat smallpox 108, 129 .
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Nonvaccinated HCWs should not provide care when immune HCWs are available; N95 or higher respiratory protection for susceptible and successfully vaccinated individuals; postexposure vaccine within 4 days of exposure protective 108, 129, 1038-1040 .
129. Gelfand HM, Posch J. The recent outbreak of smallpox in Meschede, West Germany. Am J Epidemiol 1971;93(4):234-7.
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For certain other respiratory infectious agents, such as influenza 130, 131 and rhinovirus 104 , and even some gastrointestinal viruses (e.g., norovirus 132 and rotavirus 133 ) there is some evidence that the pathogen may be transmitted via small-particle aerosols, under natural and experimental conditions.
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This is true of other infectious agents such as influenza virus 130 and noroviruses 132, 142, 143 .
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130. Moser MR, Bender TR, Margolis HS, Noble GR, Kendal AP, Ritter DG. An outbreak of influenza aboard a commercial airliner. Am J Epidemiol 1979;110(1):1-6.
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For certain other respiratory infectious agents, such as influenza 130, 131 and rhinovirus 104 , and even some gastrointestinal viruses (e.g., norovirus 132 and rotavirus 133 ) there is some evidence that the pathogen may be transmitted via small-particle aerosols, under natural and experimental conditions.
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131. Alford RH, Kasel JA, Gerone PJ, Knight V. Human influenza resulting from aerosol inhalation. Proc Soc Exp Biol Med 1966;122(3):800-4.
For certain other respiratory infectious agents, such as influenza 130, 131 and rhinovirus 104 , and even some gastrointestinal viruses (e.g., norovirus 132 and rotavirus 133 ) there is some evidence that the pathogen may be transmitted via small-particle aerosols, under natural and experimental conditions.
On page 18
This is true of other infectious agents such as influenza virus 130 and noroviruses 132, 142, 143 .
On page 19
Reported outbreaks in hospitals 132, 142, 277 , nursing homes 275, 278-283 , cruise ships 284, 285 , hotels 143, 147 , schools 148 , and large crowded shelters established for hurricane evacuees 286 , demonstrate their highly contagious nature, the disruptive impact they have in healthcare facilities and the community, and the difficulty of controlling outbreaks in settings where people share common facilites and space.
On page 29
The epidemiology of norovirus outbreaks shows that even though primary cases may result from exposure to a fecally-contaminated food or water, secondary and tertiary cases often result from person-to-person transmission that is facilitated by contamination of fomites 273, 288 and dissemination of infectious particles, especially during the process of vomiting 132, 142, 143, 147, 148, 273, 279, 280 .
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132. Chadwick PR, McCann R. Transmission of a small round structured virus by vomiting during a hospital outbreak of gastroenteritis. J Hosp Infect 1994;26(4):251-9.
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C.4. Severe Acute Respiratory Syndrome (SARS) SARS is a newly discovered respiratory disease that emerged in China late in 2002 and spread to several countries 135, 140 ; Mainland China, Hong Kong, Hanoi, Singapore, and Toronto were affected significantly.
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There is ample evidence for droplet and contact transmission 96, 101, 113 ; however, opportunistic airborne transmission cannot be excluded 101, 135-139, 149, 255 .
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135. Peiris JS, Yuen KY, Osterhaus AD, Stohr K. The severe acute respiratory syndrome. N Engl J Med 2003;349(25):2431-41.
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There is ample evidence for droplet and contact transmission 96, 101, 113 ; however, opportunistic airborne transmission cannot be excluded 101, 135-139, 149, 255 .
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137. Wilder-Smith A, Leong HN, Villacian JS. In-flight transmission of Severe Acute Respiratory Syndrome (SARS): A Case Report. J Travel Med 2003;10(5):299-300.
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There is ample evidence for droplet and contact transmission 96, 101, 113 ; however, opportunistic airborne transmission cannot be excluded 101, 135-139, 149, 255 .
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At the time of this publication, CDC recommends Standard Precautions, with emphasis on the use of hand hygiene, Contact Precautions with emphasis on environmental cleaning due to the detection of SARS CoV RNA by PCR on surfaces in rooms occupied by SARS patients 138, 254, 258 , Airborne Precautions, including use of fit-tested NIOSH-approved N95 or higher level respirators, and eye protection 259 .
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138. Booth TF, Kournikakis B, Bastien N, et al. Detection of airborne severe acute respiratory syndrome (SARS) coronavirus and environmental contamination in SARS outbreak units. J Infect Dis 2005;191(9):1472-7.
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There is ample evidence for droplet and contact transmission 96, 101, 113 ; however, opportunistic airborne transmission cannot be excluded 101, 135-139, 149, 255 .
On page 26
139. Yu IT, Li Y, Wong TW, et al. Evidence of airborne transmission of the severe acute respiratory syndrome virus. N Engl J Med 2004;350(17):1731-9.
Although SARS-CoV is transmitted primarily by contact and/or droplet routes, airborne transmission over a limited distance (e.g. within a room), has been suggested, though not proven 134-141 .
On page 19
A.1. In addition to Standard Precautions, use Transmission-Based Precautions for patients with documented or suspected infection or colonization with highly transmissible or epidemiologically-important pathogens for which additional precautions are needed to prevent transmission (see Appendix A) 24, 93, 126, 141, 306, 806, 1008 .
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141. CDC. Cluster of severe acute respiratory syndrome cases among protected health-care workers--Toronto, Canada, April 2003. MMWR Morb Mortal Wkly Rep 2003;52(19):433-6.
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This is true of other infectious agents such as influenza virus 130 and noroviruses 132, 142, 143 .
On page 19
Reported outbreaks in hospitals 132, 142, 277 , nursing homes 275, 278-283 , cruise ships 284, 285 , hotels 143, 147 , schools 148 , and large crowded shelters established for hurricane evacuees 286 , demonstrate their highly contagious nature, the disruptive impact they have in healthcare facilities and the community, and the difficulty of controlling outbreaks in settings where people share common facilites and space.
On page 29
The epidemiology of norovirus outbreaks shows that even though primary cases may result from exposure to a fecally-contaminated food or water, secondary and tertiary cases often result from person-to-person transmission that is facilitated by contamination of fomites 273, 288 and dissemination of infectious particles, especially during the process of vomiting 132, 142, 143, 147, 148, 273, 279, 280 .
On page 29
Persons who clean areas heavily contaminated with feces or vomitus may benefit from wearing masks since virus can be aerosolized from these body substances 142, 147 148 ; ensure consistent environmental cleaning and disinfection with focus on restrooms even when apparently unsoiled
142. Sawyer LA, Murphy JJ, Kaplan JE, et al. 25- to 30-nm virus particle associated with a hospital outbreak of acute gastroenteritis with evidence for airborne transmission. Am J Epidemiol 1988;127(6):1261-71.
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This is true of other infectious agents such as influenza virus 130 and noroviruses 132, 142, 143 .
On page 19
Reported outbreaks in hospitals 132, 142, 277 , nursing homes 275, 278-283 , cruise ships 284, 285 , hotels 143, 147 , schools 148 , and large crowded shelters established for hurricane evacuees 286 , demonstrate their highly contagious nature, the disruptive impact they have in healthcare facilities and the community, and the difficulty of controlling outbreaks in settings where people share common facilites and space.
On page 29
The epidemiology of norovirus outbreaks shows that even though primary cases may result from exposure to a fecally-contaminated food or water, secondary and tertiary cases often result from person-to-person transmission that is facilitated by contamination of fomites 273, 288 and dissemination of infectious particles, especially during the process of vomiting 132, 142, 143, 147, 148, 273, 279, 280 .
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143. Marks PJ, Vipond IB, Carlisle D, Deakin D, Fey RE, Caul EO. Evidence for airborne transmission of Norwalk-like virus (NLV) in a hotel restaurant. Epidemiol Infect 2000;124(3):481-7.
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Influenza viruses are transmitted primarily by close contact with respiratory droplets 23, 102 and acquisition by healthcare personnel has been prevented by Droplet Precautions, even when positive pressure rooms were used in one center 144 However, inhalational transmission could not be excluded in an outbreak of influenza in the passengers and crew of a single aircraft 130 .
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144. Salgado CD, Farr BM, Hall KK, Hayden FG. Influenza in the acute hospital setting. Lancet Infect Dis 2002;2(3):145-55.
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Although the most frequent routes of transmission of noroviruses are contact and food and waterborne routes, several reports suggest that noroviruses may be transmitted through aerosolization of infectious particles from vomitus or fecal material 142, 143, 147, 148 .
On page 19
Reported outbreaks in hospitals 132, 142, 277 , nursing homes 275, 278-283 , cruise ships 284, 285 , hotels 143, 147 , schools 148 , and large crowded shelters established for hurricane evacuees 286 , demonstrate their highly contagious nature, the disruptive impact they have in healthcare facilities and the community, and the difficulty of controlling outbreaks in settings where people share common facilites and space.
On page 29
The epidemiology of norovirus outbreaks shows that even though primary cases may result from exposure to a fecally-contaminated food or water, secondary and tertiary cases often result from person-to-person transmission that is facilitated by contamination of fomites 273, 288 and dissemination of infectious particles, especially during the process of vomiting 132, 142, 143, 147, 148, 273, 279, 280 .
On page 29
Persons who clean areas heavily contaminated with feces or vomitus may benefit from wearing masks since virus can be aerosolized from these body substances 142, 147 148 ; ensure consistent environmental cleaning and disinfection with focus on restrooms even when apparently unsoiled
147. Cheesbrough JS, Green J, Gallimore CI, Wright PA, Brown DW. Widespread environmental contamination with Norwalk-like viruses (NLV) detected in a prolonged hotel outbreak of gastroenteritis. Epidemiol Infect 2000;125(1):93-8.
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Although the most frequent routes of transmission of noroviruses are contact and food and waterborne routes, several reports suggest that noroviruses may be transmitted through aerosolization of infectious particles from vomitus or fecal material 142, 143, 147, 148 .
On page 19
Reported outbreaks in hospitals 132, 142, 277 , nursing homes 275, 278-283 , cruise ships 284, 285 , hotels 143, 147 , schools 148 , and large crowded shelters established for hurricane evacuees 286 , demonstrate their highly contagious nature, the disruptive impact they have in healthcare facilities and the community, and the difficulty of controlling outbreaks in settings where people share common facilites and space.
On page 29
The epidemiology of norovirus outbreaks shows that even though primary cases may result from exposure to a fecally-contaminated food or water, secondary and tertiary cases often result from person-to-person transmission that is facilitated by contamination of fomites 273, 288 and dissemination of infectious particles, especially during the process of vomiting 132, 142, 143, 147, 148, 273, 279, 280 .
On page 29
Persons who clean areas heavily contaminated with feces or vomitus may benefit from wearing masks since virus can be aerosolized from these body substances 142, 147 148 ; ensure consistent environmental cleaning and disinfection with focus on restrooms even when apparently unsoiled
148. Marks PJ, Vipond IB, Regan FM, Wedgwood K, Fey RE, Caul EO. A school outbreak of Norwalk-like virus: evidence for airborne transmission. Epidemiol Infect 2003;131(1):727-36.
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may be transmitted via fine particle aerosols 149 .
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There is ample evidence for droplet and contact transmission 96, 101, 113 ; however, opportunistic airborne transmission cannot be excluded 101, 135-139, 149, 255 .
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For example, anthrax spores present in a finely milled powdered preparation can be aerosolized from contaminated environmental surfaces and inhaled into the respiratory tract 150, 151 .
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151. Weis CP, Intrepido AJ, Miller AK, et al. Secondary aerosolization of viable Bacillus anthracis spores in a contaminated US Senate Office. JAMA 2002;288(22):2853-8.
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are ubiquitous in the environment and may cause disease in immunocompromised patients who inhale aerosolized (e.g., via construction dust) spores 152, 153 .
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in the ICU setting that was most likey due to the aerosolization of spores during wound debridement 154 .
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A Protective Environment refers to isolation practices designed to decrease the risk of exposure to environmental fungal agents in allogeneic HSCT patients 11, 14, 15, 155-158 .
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155. Buffington J, Reporter R, Lasker BA, et al. Investigation of an epidemic of invasive aspergillosis: utility of molecular typing with the use of random amplified polymorphic DNA probes. Pediatr Infect Dis J 1994;13(5):386­ 93.
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A Protective Environment refers to isolation practices designed to decrease the risk of exposure to environmental fungal agents in allogeneic HSCT patients 11, 14, 15, 155-158 .
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A Protective Environment refers to isolation practices designed to decrease the risk of exposure to environmental fungal agents in allogeneic HSCT patients 11, 14, 15, 155-158 .
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Published data provide evidence to support placing allogeneic HSCT patients in a Protective Environment 15, 157, 158 .
On page 39
The need for such controls has been demonstrated in studies of aspergillus outbreaks associated with construction 11, 14, 15, 157, 158 .
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Protective Environment (Table 4) VI.A. Place allogeneic hematopoietic stem cell transplant (HSCT) patients in a Protective Environment as described in the “Guideline to Prevent Opportunistic Infections in HSCT Patients” 15 , the “Guideline for Environmental Infection Control in Health-Care Facilities” 11 , and the “Guidelines for Preventing Health-Care-Associated Pneumonia, 2003” 14 to reduce exposure to environmental fungi (e.g., Aspergillus sp) 157, 158 .
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A Protective Environment refers to isolation practices designed to decrease the risk of exposure to environmental fungal agents in allogeneic HSCT patients 11, 14, 15, 155-158 .
On page 20
Published data provide evidence to support placing allogeneic HSCT patients in a Protective Environment 15, 157, 158 .
On page 39
The need for such controls has been demonstrated in studies of aspergillus outbreaks associated with construction 11, 14, 15, 157, 158 .
On page 73
Protective Environment (Table 4) VI.A. Place allogeneic hematopoietic stem cell transplant (HSCT) patients in a Protective Environment as described in the “Guideline to Prevent Opportunistic Infections in HSCT Patients” 15 , the “Guideline for Environmental Infection Control in Health-Care Facilities” 11 , and the “Guidelines for Preventing Health-Care-Associated Pneumonia, 2003” 14 to reduce exposure to environmental fungi (e.g., Aspergillus sp) 157, 158 .
On page 91
D. Minimize the length of time that patients who require a Protective Environment are outside their rooms for diagnostic procedures and other activities 11, 158, 945 .
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E. During periods of construction, to prevent inhalation of respirable particles that could contain infectious spores, provide respiratory protection (e.g., N95 respirator) to patients who are medically fit to tolerate a respirator when they are required to leave the Protective Environment 945 158 .
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have been recovered from hospital water systems 159 , the role of water as a reservoir for immunosuppressed patients remains uncertain.
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anthracis after environmental exposure to aeosolizable material 865 , influenza virus 611 , HIV 866 , and group A streptococcus 160 .
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for antimicrobial prophylaxis in selected conditions 160 .
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repeatedly in studies of HCW adherence to recommended hand hygiene practices 176, 177, 434, 548, 549, 559-564 .
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pneumoniae 197, 198 , other MDROs, and Clostridium difficile 416 ) These pathogens can lead to substantial
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pneumoniae 197, 198 , other MDROs, and Clostridium difficile 416 ) These pathogens can lead to substantial
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198. Carter RJ, Sorenson G, Heffernan R, et al. Failure to control an outbreak of multidrug-resistant Streptococcus pneumoniae in a long-term-care facility: emergence and ongoing transmission of a fluoroquinoloneresistant strain. Infect Control Hosp Epidemiol 2005;26(3):248-55.
Infection Control & Hospital Epidemiology (Cambridge University Press (CUP))
Hetty E. M. Blok et al. 2003
199. Blok HE, Troelstra A, Kamp-Hopmans TE, et al. Role of healthcare workers in outbreaks of methicillin-resistant Staphylococcus aureus: a 10­ year evaluation from a Dutch university hospital. Infect Control Hosp Epidemiol 2003;24(9):679-85.
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Ann Tammelin et al. 2003
201. Tammelin A, Klotz F, Hambraeus A, Stahle E, Ransjo U. Nasal and hand carriage of Staphylococcus aureus in staff at a Department for Thoracic and Cardiovascular Surgery: endogenous or exogenous source? Infect Control Hosp Epidemiol 2003;24(9):686-9.
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Thomas V. Inglesby et al. 2002
Until decontamination of environment complete 203 .
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203. Inglesby TV, O'Toole T, Henderson DA, et al. Anthrax as a biological weapon, 2002: updated recommendations for management. JAMA 2002;287(17):2236-52.
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Donald A. Henderson et al. 1999
event of mass exposures, barrier precautions and containment within a designated area are most important 204, 212 .
204. Henderson DA, Inglesby TV, Bartlett JG, et al. Smallpox as a biological weapon: medical and public health management. Working Group on Civilian Biodefense. JAMA 1999;281(22):2127-37.
JAMA (American Medical Association (AMA))
Thomas V. Inglesby et al. 2000
Sources of information on specific agents include: anthrax 203 ; smallpox 204-206 ; plague 207, 208 ; botulinum toxin 209 ; tularemia 210 ; and hemorrhagic fever viruses: 211, 212 .
On page 24
208. Inglesby TV, Dennis DT, Henderson DA, et al. Plague as a biological weapon: medical and public health management. Working Group on Civilian Biodefense. JAMA 2000;283(17):2281-90.
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Stephen S. Arnon et al. 2001
Sources of information on specific agents include: anthrax 203 ; smallpox 204-206 ; plague 207, 208 ; botulinum toxin 209 ; tularemia 210 ; and hemorrhagic fever viruses: 211, 212 .
On page 24
209. Arnon SS, Schechter R, Inglesby TV, et al. Botulinum toxin as a biological weapon: medical and public health management. JAMA 2001;285(8):1059-70.
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David T. Dennis et al. 2001
Sources of information on specific agents include: anthrax 203 ; smallpox 204-206 ; plague 207, 208 ; botulinum toxin 209 ; tularemia 210 ; and hemorrhagic fever viruses: 211, 212 .
On page 24
210. Dennis DT, Inglesby TV, Henderson DA, et al. Tularemia as a biological weapon: medical and public health management. JAMA 2001;285(21):2763-73.
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1995
Sources of information on specific agents include: anthrax 203 ; smallpox 204-206 ; plague 207, 208 ; botulinum toxin 209 ; tularemia 210 ; and hemorrhagic fever viruses: 211, 212 .
On page 24
Guidance on infection control precautions for HVFs that are transmitted personto-person have been published by CDC 1, 211 and by the Johns Hopkins Center for Civilian Biodefense Strategies 212 .
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211. CDC. Notice to Readers Update: Management of Patients with Suspected Viral Hemorrhagic Fever -- United States. MMWR Recomm Rep 1995;44(25):475-9.
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and Dengue and Yellow fever viruses (Flaviviridae) 212, 297 .
On page 30
Evidence concerning the transmission of HFVs has been summarized 212, 302 .
On page 30
Guidance on infection control precautions for HVFs that are transmitted personto-person have been published by CDC 1, 211 and by the Johns Hopkins Center for Civilian Biodefense Strategies 212 .
On page 30
officials immediately if Ebola is suspected 212, 314, 740, 772 Also see Table
event of mass exposures, barrier precautions and containment within a designated area are most important 204, 212 .
212. Borio L, Inglesby T, Peters CJ, et al. Hemorrhagic fever viruses as biological weapons: medical and public health management. JAMA 2002;287(18):2391-405.
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John M. Neff 2002
213. Neff JM, Lane JM, Fulginiti VA, Henderson DA. Contact vaccinia-­ transmission of vaccinia from smallpox vaccination. JAMA 2002;288(15):1901-5.
New England Journal of Medicine (Massachusetts Medical Society)
Kent A. Sepkowitz 2003
214. Sepkowitz KA. How contagious is vaccinia? N Engl J Med 2003;348(5):439-46.
Clinical Infectious Diseases (Oxford University Press (OUP))
J. M. Lane et al. 2003
215. Lane JM, Fulginiti VA. Transmission of vaccinia virus and rationale for measures for prevention. Clin Infect Dis 2003;37(2):281-4.
Clinical Infectious Diseases (Oxford University Press (OUP))
V. A. Fulginiti et al. 2003
These include the need for meticulous screening for vaccine contraindications in persons who are at increased risk for adverse vaccinia events; containment and monitoring of the vaccination site to prevent transmission in the healthcare setting and at home; and the management of patients with vaccinia-related adverse events 216, 217 .
On page 24
Vaccinia adverse events with lesions containing infectious virus include inadvertent autoinoculation, ocular lesions (blepharitis, conjunctivitis), generalized vaccinia, progressive vaccinia, eczema vaccinatum; bacterial superinfection also requires addition of contact precautions if exudates cannot be contained 216, 217 .
217. Fulginiti VA, Papier A, Lane JM, Neff JM, Henderson DA. Smallpox vaccination: a review, part II. Adverse events. Clin Infect Dis 2003;37(2):251-71.
There were no cases of eczema vaccinatum, progressive vaccinia, fetal vaccinia, or contact transfer of vaccinia in healthcare settings or in military workplaces 218, 219 .
On page 24
219. CDC. Update: adverse events following civilian smallpox vaccination-­ United States, 2003. MMWR Morb Mortal Wkly Rep 2003;52(18):419­ 20.
Outside the healthcare setting, there were 53 cases of contact transfer from military vaccinees to close personal contacts (e.g., bed partners or contacts during participation in sports such as wrestling 220 ).
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220. CDC. Secondary and tertiary transfer of vaccinia virus among U.U. military personnel--United States and worldwide, 2002-2004. MMWR Morb Mortal Wkly Rep 2004;53(5):103-5.
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221. Talbot TR, Ziel E, Doersam JK, LaFleur B, Tollefson S, Edwards KM. Risk of vaccinia transfer to the hands of vaccinated persons after smallpox immunization. Clin Infect Dis 2004;38(4):536-41.
222. Hepburn MJ, Dooley DP, Murray CK, et al. Frequency of vaccinia virus isolation on semipermeable versus nonocclusive dressings covering smallpox vaccination sites in hospital personnel. Am J Infect Control 2004;32(3):126-30.
223. Waibel KH, Ager EP, Topolski RL, Walsh DS. Randomized trial comparing vaccinia on the external surfaces of 3 conventional bandages applied to smallpox vaccination sites in primary vaccinees. Clin Infect Dis 2004;39(7):1004-7.
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227. Johnson RT, Gibbs CJ, Jr. Creutzfeldt-Jakob disease and related transmissible spongiform encephalopathies. N Engl J Med 1998;339(27):1994-2004.
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Paul Brown et al. 1985
Iatrogenic transmission has occurred with most resulting from treatment with human cadaveric pituitary-derived growth hormone or gonadotropin 228, 229 , from implantation of contaminated human dura mater grafts 230 or from corneal transplants 231 ).
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228. Brown P, Gajdusek DC, Gibbs CJ, Jr., Asher DM. Potential epidemic of Creutzfeldt-Jakob disease from human growth hormone therapy. N Engl J Med 1985;313(12):728-31.
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S D Frasier et al. 1994
Iatrogenic transmission has occurred with most resulting from treatment with human cadaveric pituitary-derived growth hormone or gonadotropin 228, 229 , from implantation of contaminated human dura mater grafts 230 or from corneal transplants 231 ).
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229. Frasier SD, Foley TP, Jr. Clinical review 58: Creutzfeldt-Jakob disease in recipients of pituitary hormones. J Clin Endocrinol Metab 1994;78(6):1277-9.
Iatrogenic transmission has occurred with most resulting from treatment with human cadaveric pituitary-derived growth hormone or gonadotropin 228, 229 , from implantation of contaminated human dura mater grafts 230 or from corneal transplants 231 ).
On page 25
Reported infections transmitted by transfusion or transplantation include West Nile Virus infection 530 cytomegalovirus infection 531 , Creutzfeldt-Jacob disease 230 , hepatitis C 532 , infections with Clostridium spp.
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230. CDC. Update: Creutzfeldt-Jakob disease associated with cadaveric dura mater grafts--Japan, 1979-2003. MMWR Morb Mortal Wkly Rep 2003;52(48):1179-81.
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Iatrogenic transmission has occurred with most resulting from treatment with human cadaveric pituitary-derived growth hormone or gonadotropin 228, 229 , from implantation of contaminated human dura mater grafts 230 or from corneal transplants 231 ).
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neurosurgical instruments or stereotactic electroencephalogram electrodes 232,
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Prion diseases in animals include scrapie in sheep and goats, bovine spongiform encephalopathy (BSE, or “mad cow disease”) in cattle, and chronic wasting disease in deer and elk 236 .
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The public health impact of prion diseases has been reviewed 238 .
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vCJD in humans has different clinical and pathologic characteristics from sporadic or classic CJD 239 , including the following: 1) younger median age at death: 28 (range 16-48) vs.
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However, bloodborne transmission of vCJD is believed to have occurred in two UK patients 244, 245 .
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C.-w. Leung et al. 2004
Compared with adults, children have been affected less frequently, have milder disease, and are less likely to transmit SARS-CoV 135, 249-251 .
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250. Leung CW, Kwan YW, Ko PW, et al. Severe acute respiratory syndrome among children. Pediatrics 2004;113(6):e535-43.
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Compared with adults, children have been affected less frequently, have milder disease, and are less likely to transmit SARS-CoV 135, 249-251 .
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251. Bitnun A, Allen U, Heurter H, et al. Children hospitalized with severe acute respiratory syndrome-related illness in Toronto. Pediatrics 2003;112(4):e261.
Outbreaks in healthcare settings, with transmission to large numbers of healthcare personnel and patients have been a striking feature of SARS; undiagnosed, infectious patients and visitors were important initiators of these outbreaks 21, 252-254 .
On page 26
tuberculosis 42, 892 , influenza, and other respiratory viruses 24, 43, 44, 373 and SARS 21, 252-254 ).
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Outbreaks in healthcare settings, with transmission to large numbers of healthcare personnel and patients have been a striking feature of SARS; undiagnosed, infectious patients and visitors were important initiators of these outbreaks 21, 252-254 .
On page 26
procedures (e.g., endotracheal intubation, suctioning) was associated with transmission of infection to large numbers of healthcare personnel outside of the United States 93, 94, 96, 98, 253 .
On page 27
tuberculosis 42, 892 , influenza, and other respiratory viruses 24, 43, 44, 373 and SARS 21, 252-254 ).
On page 64
Develop and implement systems for early detection and management (e.g., use of appropriate infection control measures, including isolation precautions, PPE) of potentially infectious persons at initial points of patient encounter in outpatient settings (e.g., triage areas, emergency departments, outpatient clinics, physician offices) and at the time of admission to hospitals and long-term care facilities (LTCF) 9, 122, 134, 253, 827 .
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253. Shen Z, Ning F, Zhou W, et al. Superspreading SARS events, Beijing, 2003. Emerg Infect Dis 2004;10(2):256-60.
A review of the infection control literature generated from the SARS outbreaks of 2003 concluded that the greatest risk of transmission is to those who have close contact, are not properly trained in use of protective infection control procedures, do not consistently use PPE; and that N95 or higher respirators may offer additional protection to those exposed to aerosol- generating procedures and high risk activities 256, 257 .
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256. Gamage B, Moore D, Copes R, Yassi A, Bryce E. Protecting health care workers from SARS and other respiratory pathogens: a review of the infection control literature. Am J Infect Control 2005;33(2):114-21.
A review of the infection control literature generated from the SARS outbreaks of 2003 concluded that the greatest risk of transmission is to those who have close contact, are not properly trained in use of protective infection control procedures, do not consistently use PPE; and that N95 or higher respirators may offer additional protection to those exposed to aerosol- generating procedures and high risk activities 256, 257 .
On page 27
Each of these factors has a direct bearing on adherence to transmission prevention recommendations 257 .
On page 45
A recent review of the literature concluded that variations in organizational factors (e.g., safety climate, policies and procedures, education and training) and individual factors (e.g., knowledge, perceptions of risk, past experience) were determinants of adherence to infection control guidelines for protection against SARS and other respiratory pathogens 257 .
On page 46
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S. F. Dowell et al. 2004
At the time of this publication, CDC recommends Standard Precautions, with emphasis on the use of hand hygiene, Contact Precautions with emphasis on environmental cleaning due to the detection of SARS CoV RNA by PCR on surfaces in rooms occupied by SARS patients 138, 254, 258 , Airborne Precautions, including use of fit-tested NIOSH-approved N95 or higher level respirators, and eye protection 259 .
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258. Dowell SF, Simmerman JM, Erdman DD, et al. Severe acute respiratory syndrome coronavirus on hospital surfaces. Clin Infect Dis 2004;39(5):652-7.
Centers for Disease Control and Prevention (CDC)
At the time of this publication, CDC recommends Standard Precautions, with emphasis on the use of hand hygiene, Contact Precautions with emphasis on environmental cleaning due to the detection of SARS CoV RNA by PCR on surfaces in rooms occupied by SARS patients 138, 254, 258 , Airborne Precautions, including use of fit-tested NIOSH-approved N95 or higher level respirators, and eye protection 259 .
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259. Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS). 2004. (Accessed at http://www.cdc.gov/ncidod/sars/guidance/I/occupational.htm.)
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Research laboratories where SARS-CoV was under investigation were the source of most cases reported after the first series of outbreaks in the winter and spring of 2003 261, 262 .
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261. Lim PL, Kurup A, Gopalakrishna G, et al. Laboratory-acquired severe acute respiratory syndrome. N Engl J Med 2004;350(17):1740-5.
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Environmental contamination also has been documented as a contributing factor in ongoing transmission during outbreaks 274, 275 .
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274. Evans MR, Meldrum R, Lane W, et al. An outbreak of viral gastroenteritis following environmental contamination at a concert hall. Epidemiol Infect 2002;129(2):355-60.
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Environmental contamination also has been documented as a contributing factor in ongoing transmission during outbreaks 274, 275 .
On page 28
Reported outbreaks in hospitals 132, 142, 277 , nursing homes 275, 278-283 , cruise ships 284, 285 , hotels 143, 147 , schools 148 , and large crowded shelters established for hurricane evacuees 286 , demonstrate their highly contagious nature, the disruptive impact they have in healthcare facilities and the community, and the difficulty of controlling outbreaks in settings where people share common facilites and space.
On page 29
Widespread, persistent and inapparent contamination of the environment and fomites can make outbreaks extremely difficult to control 147, 275, 284 .
On page 29
Documented LTCF outbreaks have been caused by various viruses (e.g., influenza virus 35, 410-412 , rhinovirus 413 , adenovirus (conjunctivitis) 414 , norovirus 278, 279 275, 281 ) and bacteria, including group A streptococcus 162 , B.
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275. Wu HM, Fornek M, Kellogg JS, et al. A Norovirus Outbreak at a Long- Term-Care Facility: The Role of Environmental Surface Contamination. Infect Control Hosp Epidemiol 2005;26(10):802-10.
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Walter Zingg et al. 2005
Reported outbreaks in hospitals 132, 142, 277 , nursing homes 275, 278-283 , cruise ships 284, 285 , hotels 143, 147 , schools 148 , and large crowded shelters established for hurricane evacuees 286 , demonstrate their highly contagious nature, the disruptive impact they have in healthcare facilities and the community, and the difficulty of controlling outbreaks in settings where people share common facilites and space.
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Reported outbreaks in hospitals 132, 142, 277 , nursing homes 275, 278-283 , cruise ships 284, 285 , hotels 143, 147 , schools 148 , and large crowded shelters established for hurricane evacuees 286 , demonstrate their highly contagious nature, the disruptive impact they have in healthcare facilities and the community, and the difficulty of controlling outbreaks in settings where people share common facilites and space.
On page 29
Documented LTCF outbreaks have been caused by various viruses (e.g., influenza virus 35, 410-412 , rhinovirus 413 , adenovirus (conjunctivitis) 414 , norovirus 278, 279 275, 281 ) and bacteria, including group A streptococcus 162 , B.
On page 34
278. Calderon-Margalit R, Sheffer R, Halperin T, Orr N, Cohen D, Shohat T. A large-scale gastroenteritis outbreak associated with Norovirus in nursing homes. Epidemiol Infect 2005;133(1):35-40.
Reported outbreaks in hospitals 132, 142, 277 , nursing homes 275, 278-283 , cruise ships 284, 285 , hotels 143, 147 , schools 148 , and large crowded shelters established for hurricane evacuees 286 , demonstrate their highly contagious nature, the disruptive impact they have in healthcare facilities and the community, and the difficulty of controlling outbreaks in settings where people share common facilites and space.
On page 29
The epidemiology of norovirus outbreaks shows that even though primary cases may result from exposure to a fecally-contaminated food or water, secondary and tertiary cases often result from person-to-person transmission that is facilitated by contamination of fomites 273, 288 and dissemination of infectious particles, especially during the process of vomiting 132, 142, 143, 147, 148, 273, 279, 280 .
On page 29
Documented LTCF outbreaks have been caused by various viruses (e.g., influenza virus 35, 410-412 , rhinovirus 413 , adenovirus (conjunctivitis) 414 , norovirus 278, 279 275, 281 ) and bacteria, including group A streptococcus 162 , B.
On page 34
279. Marx A, Shay DK, Noel JS, et al. An outbreak of acute gastroenteritis in a geriatric long-term-care facility: combined application of epidemiological and molecular diagnostic methods. Infect Control Hosp Epidemiol 1999;20(5):306-11.
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Reported outbreaks in hospitals 132, 142, 277 , nursing homes 275, 278-283 , cruise ships 284, 285 , hotels 143, 147 , schools 148 , and large crowded shelters established for hurricane evacuees 286 , demonstrate their highly contagious nature, the disruptive impact they have in healthcare facilities and the community, and the difficulty of controlling outbreaks in settings where people share common facilites and space.
On page 29
The epidemiology of norovirus outbreaks shows that even though primary cases may result from exposure to a fecally-contaminated food or water, secondary and tertiary cases often result from person-to-person transmission that is facilitated by contamination of fomites 273, 288 and dissemination of infectious particles, especially during the process of vomiting 132, 142, 143, 147, 148, 273, 279, 280 .
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Reported outbreaks in hospitals 132, 142, 277 , nursing homes 275, 278-283 , cruise ships 284, 285 , hotels 143, 147 , schools 148 , and large crowded shelters established for hurricane evacuees 286 , demonstrate their highly contagious nature, the disruptive impact they have in healthcare facilities and the community, and the difficulty of controlling outbreaks in settings where people share common facilites and space.
On page 29
Documented LTCF outbreaks have been caused by various viruses (e.g., influenza virus 35, 410-412 , rhinovirus 413 , adenovirus (conjunctivitis) 414 , norovirus 278, 279 275, 281 ) and bacteria, including group A streptococcus 162 , B.
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Gemma Navarro et al. 2005
Reported outbreaks in hospitals 132, 142, 277 , nursing homes 275, 278-283 , cruise ships 284, 285 , hotels 143, 147 , schools 148 , and large crowded shelters established for hurricane evacuees 286 , demonstrate their highly contagious nature, the disruptive impact they have in healthcare facilities and the community, and the difficulty of controlling outbreaks in settings where people share common facilites and space.
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Kim Y. Green et al. 2002
Reported outbreaks in hospitals 132, 142, 277 , nursing homes 275, 278-283 , cruise ships 284, 285 , hotels 143, 147 , schools 148 , and large crowded shelters established for hurricane evacuees 286 , demonstrate their highly contagious nature, the disruptive impact they have in healthcare facilities and the community, and the difficulty of controlling outbreaks in settings where people share common facilites and space.
On page 29
283. Green KY, Belliot G, Taylor JL, et al. A predominant role for Norwalklike viruses as agents of epidemic gastroenteritis in Maryland nursing homes for the elderly. J Infect Dis 2002;185(2):133-46.