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COMPREHENSIVE MEDICAL TRAINING DATA

Document Version: 1.0 Last Updated: February 2026 Intended Audience: Healthcare workers, clinic staff, hospital administrators in resource-limited and post-disaster settings Classification: Training Material

By William Le, PA-C

COMPREHENSIVE MEDICAL TRAINING DATA

Sanitation and Infection Control for Small Hospitals and Clinics

Document Version: 1.0 Last Updated: February 2026 Intended Audience: Healthcare workers, clinic staff, hospital administrators in resource-limited and post-disaster settings Classification: Training Material

MODULE 1: Hand Hygiene
MODULE 2: Personal Protective Equipment (PPE)
MODULE 3: Sterilization and Disinfection
MODULE 4: Water and Sanitation
MODULE 5: Waste Management
MODULE 6: Isolation and Quarantine
MODULE 7: Environmental Hygiene
MODULE 8: Occupational Health and Safety

MODULE 1: HAND HYGIENE

Introduction to Hand Hygiene

Hand hygiene is the single most important infection prevention measure in healthcare settings. Clean hands prevent the transmission of infectious agents to patients, healthcare workers, and the community. Hand hygiene includes handwashing with soap and water and using alcohol-based hand rubs (ABHR).

Key Facts:

Hands are the most common vehicle for transmitting pathogens in healthcare
Proper hand hygiene can reduce healthcare-associated infections by 30-50%
Hand hygiene must be performed consistently throughout the day
Both handwashing and alcohol-based hand rubs are effective when performed correctly

WHO 5 MOMENTS OF HAND HYGIENE

The World Health Organization (WHO) defines five critical moments when hand hygiene must be performed. These are essential moments in patient care where hand contamination is likely and can lead to transmission.

Moment 1: Before Patient Contact

When: Before touching a patient, regardless of whether gloves will be worn Why: To prevent transmission of microorganisms to the patient Examples:

Before greeting a patient
Before taking vital signs
Before physical examination
Before assisting a patient with personal hygiene

Clinical Scenario: A nurse approaches a patient to take blood pressure. Even though the nurse is not entering a sterile field, hand hygiene must be performed because hands may have contacted contaminated surfaces or other patients.

Moment 2: Before Aseptic/Clean Procedures

When: Before performing any clean or aseptic procedure Why: To prevent transmission of microorganisms into a sterile field or to vulnerable sites Examples:

Before performing wound dressing changes
Before administering injections
Before inserting catheters
Before suctioning airways
Before performing urinary catheterization
Before handling sterile equipment or dressings

Important Note: Even when wearing gloves, hand hygiene must be performed before aseptic procedures. Gloves can have microscopic tears and hands beneath gloves may be contaminated.

Clinical Scenario: A clinician prepares to insert a urinary catheter. Although sterile gloves will be worn, hand hygiene is essential to minimize the risk of catheter-associated urinary tract infection (CAUTI).

Moment 3: After Body Fluid Exposure Risk

When: After exposure to blood or other body fluids, even if hands were protected by gloves Why: To prevent transmission of bloodborne pathogens to yourself, other patients, and the environment Examples:

After patient contact involving blood or body fluids
After assisting with childbirth
After handling soiled dressings
After contact with vomit, feces, or urine
After removing gloves

Critical Point: Hand hygiene must be performed immediately after removing gloves. Gloves can break during use and hands may become contaminated from handling gloves.

Clinical Scenario: A clinician has just removed gloves after assisting with delivery. Even though gloves protected the hands, immediate hand hygiene is required before proceeding to care for another patient or handle clean equipment.

Moment 4: After Patient Contact

When: After any contact with a patient or their immediate environment Why: To prevent transmission of microorganisms from the patient to yourself, other patients, and the environment Examples:

After completing patient examination
After assisting patient with toileting
After touching patient’s skin
After supporting patient ambulation
After leaving a patient’s bedside

Clinical Scenario: A nurse has just finished helping a patient ambulate to the bathroom. Before proceeding to the next patient, hand hygiene must be performed even though the contact was not with blood or body fluids.

Moment 5: After Contact with Patient Surroundings

When: After touching surfaces in the patient’s environment Why: To prevent transmission of microorganisms from the patient care environment Examples:

After touching bed rails
After touching bedside tables or equipment
After removing soiled linens
After disposing of medical waste
After touching the patient’s chart or medical records

Clinical Scenario: A healthcare worker has just adjusted the bedside table for a patient. Even though there was no direct patient contact, hand hygiene is required before proceeding to care for another patient.

HANDWASHING TECHNIQUE: STEP-BY-STEP PROCEDURE

Proper handwashing is the foundation of hand hygiene. The technique must be performed correctly and for adequate duration to remove all transient and some resident flora.

Materials Required:

Running water (clean, preferably warm)
Soap (bar soap, liquid soap, or antimicrobial soap)
Single-use towels (paper towels are preferable; cloth towels must be changed frequently)
Nail brush or orange stick (optional but recommended)

Step-by-Step Handwashing Procedure:

Step 1: Prepare Your Hands (5 seconds)

Roll up your sleeves to at least mid-forearm
Remove all jewelry from your hands and wrists (rings, bracelets, watches, nail polish)
Check for cuts or abrasions that may require additional protective measures

Rationale: Sleeves can drag through contaminated surfaces. Jewelry harbors bacteria and prevents contact between soap and skin. Open wounds increase the risk of pathogen penetration.

Step 2: Wet Your Hands (5 seconds)

Hold your hands under running water
Water should be warm but not hot (hot water can damage skin barrier and promote irritation)
Wet your hands from fingertips to wrists

Rationale: Water helps loosen surface debris and prepares skin for soap action.

Step 3: Apply Soap (5 seconds)

Dispense appropriate amount of soap (approximately 3-5 mL for a liquid dispenser, or size of a coin for bar soap)
If using bar soap, rub vigorously to create lather, then place soap aside
Soap should cover all hand surfaces

Rationale: Adequate soap is necessary to emulsify and suspend microorganisms.

Step 4: Vigorously Rub Hands Together (10-15 seconds)

Rub palms together in a circular motion with firm pressure
Perform this movement for at least 10-15 seconds total

Rationale: Friction is essential to remove transient flora. Duration ensures adequate contact time for soap to act on microorganisms.

Step 5: Rub Right Palm on Back of Left Hand (5 seconds)

Interlace fingers slightly to expose the web spaces and back of hand
Use firm, circular motions
Repeat on the other side with left palm on back of right hand

Rationale: The backs of hands are frequently missed and commonly harbor bacteria.

Step 6: Rub Palms Together with Fingers Interlaced (10 seconds)

Hold hands with palms facing each other
Interlace fingers completely
Rub palms together with firm pressure while moving hands to create friction between fingers

Rationale: Interdigital spaces accumulate substantial bacterial load and require vigorous friction.

Step 7: Rub Back of Fingers Against Palms (10 seconds)

Make a fist with fingers of one hand
Place the knuckles against the palm of the other hand
Rub in circular motions, moving from the wrist toward the fingertips
Repeat with the opposite hand

Rationale: Fingertips and dorsal surfaces of fingers are high-touch areas that require targeted cleaning.

Step 8: Clasp and Rotate Your Thumbs (10 seconds)

Hold your left thumb in your right hand
Rotate your thumb in circular motions while applying firm pressure
Repeat with your right thumb in your left hand
Ensure you clean the thenar (fleshy base) of the thumb

Rationale: Thumbs are frequently overlooked and have high surface area with multiple crevices.

Step 9: Rub Fingers on Your Palm (10 seconds)

Place fingertips of one hand on the palm of the other
Create circular motions with firm pressure
Rub from wrist to fingertips
Repeat with the opposite hand

Rationale: Fingertips and subungual (under the nail) areas harbor significant bacterial loads. This motion addresses these high-risk areas.

Step 10: Clean Subungual Areas (Optional but Recommended - 10 seconds)

If visible dirt is present under nails, use a nail brush or orange stick
Scrub nails while they are submerged in soapy water
This step is especially important after exposure to blood or body fluids
All staff should perform this step at the beginning of the day and after high-risk exposures

Rationale: Subungual areas are a major reservoir for bacteria. High-risk exposures may drive bacteria under the nail where soap and water alone cannot reach.

Step 11: Rinse Thoroughly Under Running Water (10-15 seconds)

Hold your hands under running water with fingertips pointing downward
Ensure all soap is removed
Water should flow from your wrists to your fingertips (downward direction)
Rinse for at least 10-15 seconds, ensuring no soap residue remains

Rationale: Incomplete rinsing leaves soap residue which can irritate skin and reduce effectiveness of the next handwashing. The downward direction prevents water from flowing back to your wrists after rinsing your hands.

Step 12: Dry Your Hands (5-10 seconds)

Use single-use paper towels
Blot hands rather than rubbing to reduce skin irritation
Dry all surfaces including between fingers, wrists, and under nails
Ensure hands are completely dry
Do not re-contaminate hands by touching the sink or counter

Rationale: Moist hands transfer bacteria more readily than dry hands. Single-use towels prevent cross-contamination.

Step 13: Turn Off the Tap

Use the paper towel to turn off the tap if a foot lever is not available
This prevents re-contamination of hands from the tap handle

Rationale: Tap handles are frequently contaminated with pathogens and can undo the benefits of handwashing.

Total Duration for Complete Handwashing:

Minimum 40-60 seconds for routine handwashing Minimum 2-3 minutes for surgical hand scrub or after high-risk exposure

Key Points to Emphasize:

The WHO method emphasizes that duration and technique are both critical
Rushing through handwashing reduces effectiveness significantly
Handwashing must be performed at all five WHO moments
Staff should be trained to monitor their handwashing time—many rush the process

ALCOHOL-BASED HAND RUB (ABHR) TECHNIQUE

Alcohol-based hand rubs are highly effective for routine hand hygiene between patients when hands are not visibly soiled. They are faster than handwashing and can increase compliance.

When to Use ABHR:

Between patient contacts
Before and after patient care (when hands are not visibly soiled)
Before handling medical equipment or supplies
After contact with patient surroundings
In situations where handwashing facilities are unavailable or inconvenient

When NOT to Use ABHR (Use Soap and Water Instead):

When hands are visibly soiled with blood, body fluids, or feces
After caring for patients with Clostridioides difficile (C. difficile) infection
When hands are obviously dirty or greasy
Before and after eating or preparing food
After using the toilet
In the presence of high microbial loads (heavy contamination)

Composition of Effective ABHR:

Alcohol content: 60-95% (typically 70% ethanol or 75% isopropanol is most effective)
Emollients: Glycerin or aloe vera to prevent skin irritation
Denaturant: Added to alcohol to prevent ingestion
Water: Often included as a carrier

Alcohol-Based Hand Rub Technique:

Step 1: Check Your Hands

Ensure hands are visibly clean (no visible blood, body fluids, or dirt)
If hands are visibly soiled, perform handwashing instead

Step 2: Dispense ABHR

Dispense appropriate amount (usually 3-5 mL, sufficient to wet all hand surfaces)
Most commonly available as pump dispensers or squeeze bottles

Step 3: Rub All Hand Surfaces (20-30 seconds total)

The WHO recommends a six-step technique for ABHR application:

Step 3a: Rub Palms Together (5 seconds)

Hold your hands vertically with palms facing each other
Rub palms together in circular motions with firm pressure
Ensure ABHR contacts all hand surfaces

Step 3b: Rub Back of Left Hand with Right Palms (5 seconds)

Place your right palm on the back of your left hand
Interlace fingers slightly
Rub in circular motions moving from wrist to fingertips
Repeat on opposite side

Step 3c: Rub Palms Together with Fingers Interlaced (5 seconds)

Hold hands with palms facing each other
Interlace fingers completely
Rub with firm pressure to ensure ABHR reaches between fingers

Step 3d: Rub Back of Fingers Against Palms (5 seconds)

Make a fist with fingers of one hand
Rub the knuckles against the palm of the opposite hand
Repeat with the other hand

Step 3e: Clasp and Rotate Thumbs (5 seconds)

Hold left thumb with right hand
Rotate in circular motions with firm pressure
Repeat with right thumb

Step 3f: Rub Fingertips and Nails on Palms (5 seconds)

Place fingertips of one hand in the palm of the other
Rub with circular motion
Repeat with the other hand

Step 4: Continue Rubbing Until Dry

Continue the rubbing motion until hands are completely air-dried
Drying usually takes 20-30 seconds total
Do not use a towel
Do not touch anything until hands are completely dry

Rationale: The alcohol must evaporate to be fully effective. Allowing hands to air-dry ensures maximum antimicrobial action.

Total Duration for ABHR:

Minimum 20-30 seconds from application to complete dryness

Advantages of ABHR Over Handwashing:

Faster (20-30 seconds vs. 40-60 seconds)
Requires no running water or sink access
Excellent antimicrobial efficacy against most pathogens
Less irritating to skin when used correctly
Improves compliance when readily available

Disadvantages of ABHR:

Not effective when hands are visibly soiled
Not effective against spore-forming organisms (C. difficile, norovirus spores)
Can dry skin with frequent use
Flammable—must be stored safely away from heat and open flames
May not be culturally acceptable in all settings

Skin Care While Using ABHR:

Use unscented, fragrance-free ABHR when possible
Apply moisturizer to hands at least daily (typically at end of shift)
Avoid using hot water excessively
Consider using protective gloves when hands are significantly irritated
Rotate between different ABHR products if available to reduce skin irritation

WHEN TO WASH VS. WHEN TO USE HAND RUB: DECISION TREE

Decision Tree Algorithm:

Are hands visibly soiled?

YES → Perform handwashing with soap and water
NO → Proceed to next question

Is there visible exposure to blood, body fluids, feces, or vomit?

YES → Perform handwashing with soap and water
NO → Proceed to next question

Is this a routine hand hygiene moment between patient contacts?

YES → Use ABHR (if available and hands are clean)
NO → Proceed to next question

Has there been high-level microbial contamination?

YES → Perform handwashing with soap and water
NO → Use ABHR if available, or handwashing if ABHR unavailable

Summary Table:

Situation	Method	Rationale
Visible dirt, blood, or body fluids	Soap and water	ABHR ineffective on gross contamination
Between routine patient contacts	ABHR preferred	Faster, equally effective
Before aseptic procedures	Either (ABHR preferred)	Both effective for clean hands
After bathroom use	Soap and water	ABHR has limited spore activity
High microbial load exposure	Soap and water	Mechanical removal necessary
Before eating/preparing food	Soap and water	Ingestion risk requires thorough washing
C. difficile exposure	Soap and water	ABHR ineffective against spores
No running water available	ABHR	Only option if available

MAKING HAND SANITIZER FROM AVAILABLE MATERIALS

In resource-limited settings, commercial hand sanitizer may not be available or affordable. Healthcare facilities can prepare effective hand sanitizer using readily available ingredients.

WHO-RECOMMENDED FORMULATION FOR ALCOHOL-BASED HAND RUB

The WHO provides two formulations for hand sanitizer preparation that have been shown to be effective against bacteria, viruses, and fungi.

Formulation 1: Alcohol-Based with Hydrogen Peroxide

(Recommended by WHO)

Ingredients:

750 mL of 96% ethanol (alcohol)
40 mL of 3% hydrogen peroxide
15 mL of glycerin (98%)
Distilled water (to reach total volume of 1000 mL)

Step-by-Step Preparation:

Calculate Exact Volumes
- If using 96% ethanol, you need 750 mL
- If using 70% ethanol, you need approximately 1000 mL (but this exceeds the desired volume)
- Adjust proportions to maintain 70% final alcohol concentration
Gather Materials
- Large clean glass container (at least 1.5 liters)
- Measuring cylinder or graduated container (accurate to ±5 mL)
- Mixing rod or clean stick for stirring
- Funnel (optional but helpful)
- Labels for final containers
Preparation Steps
- Step 1: Pour 750 mL of 96% ethanol into the glass container
- Step 2: Add 40 mL of 3% hydrogen peroxide (this helps inactivate bacterial spores)
- Step 3: Add 15 mL of glycerin (this acts as an emollient to prevent skin irritation)
- Step 4: Add distilled water slowly while stirring until total volume reaches approximately 1000 mL
- Step 5: Mix thoroughly by stirring for 3-5 minutes
- Step 6: Allow mixture to stand for 72 hours in covered container before use (this allows hydrogen peroxide to inactivate any microbial contaminants)
Decanting and Storage
- After 72 hours, carefully pour the clear liquid into smaller storage containers
- Leave any sediment at the bottom undisturbed
- Do not filter—the hydrogen peroxide is still working on any spores
Bottling for Distribution
- Use clean bottles with tight-fitting caps
- Pump dispensers are preferable but not essential
- Label each bottle with contents, date prepared, and expiration date
- Store in a cool, well-ventilated area away from heat and sunlight

Final Alcohol Concentration: Approximately 70% ethanol Shelf Life: 1 year if properly stored in sealed containers Cost: Minimal compared to commercial products

Formulation 2: Alcohol-Based with Iodine

(For settings without access to hydrogen peroxide)

Ingredients:

800 mL of 70% ethanol (alcohol)
10 mL of povidone-iodine 10% solution
5 mL of glycerin
Distilled water (to reach 1000 mL)

Preparation Steps:

Pour 800 mL of 70% ethanol into a clean container
Add 10 mL of povidone-iodine solution
Add 5 mL of glycerin
Top up with distilled water to reach 1000 mL total
Mix thoroughly
Allow to stand for 24 hours before use

Advantages of Formulation 2:

Faster (no 72-hour wait)
Adds broad-spectrum antimicrobial action from iodine
Slightly lower alcohol content (may be less irritating)

Disadvantages:

Iodine may cause allergic reactions in iodine-sensitive individuals
Iodine can stain hands and clothing
Not recommended if iodine allergies are common in your patient population

Formulation 3: Simple Alcohol-Based Without Additives

(Emergency/minimal resource setting)

If only alcohol is available:

Ingredients:

700-750 mL of 70-90% ethanol
50-300 mL of glycerin or aloe vera (if available)

Preparation:

Pour alcohol into container
Add glycerin if available (at least 5% by volume to prevent skin irritation)
Mix thoroughly
Transfer to dispensing containers

Note: This formulation is less ideal than WHO formulations but is better than nothing. Alcohol concentration should be maintained at 60-75% for optimal effectiveness.

Sourcing Ingredients in Resource-Limited Settings:

Ethanol Sources:

Industrial alcohol suppliers
Hospital pharmacy departments
Distillery products (if approved for medical use)
Denatured alcohol (if denaturation is food-grade)

Hydrogen Peroxide Sources:

Medical supply companies
Some industrial suppliers
Can be diluted from higher concentrations (3% is optimal)

Glycerin Sources:

Pharmacy suppliers
Some traditional medicine suppliers
Can be substituted with aloe vera gel (though slightly less effective)

Distilled Water:

Boiled and cooled water can substitute (though some impurities may be present)
Rainwater collected in clean containers and boiled
Water from hospital autoclaves (steam condensate) is effectively sterile

Quality Control for Homemade Sanitizer:

Visual Inspection
- Product should be clear (not cloudy)
- No particulates or sediment in final product
- Color may be slightly amber (especially with iodine formulation)
Documentation
- Record preparation date, person preparing it, ingredients used, and source
- Note batch number for traceability
- Document expiration date
Testing Effectiveness (Optional but Recommended)
- Can be tested against common pathogens if laboratory facilities available
- Compare with commercial products when possible
- Document results
Safety Monitoring
- Monitor staff for skin irritation
- Document any adverse reactions
- Adjust formulation if irritation occurs (increase glycerin, add aloe vera)

Storage and Safety:

Storage Conditions:

Keep in cool location (preferably 15-30°C)
Away from direct sunlight
In tightly sealed containers
Away from heat sources and open flames
Separate from other chemicals

Safety Precautions:

ABHR is highly flammable—keep away from ignition sources
Do not store near patient areas if fire safety is a concern
Ensure proper ventilation when using
Keep away from children
Label clearly: “Alcohol-Based Hand Sanitizer” with warning about flammability

Disposal:

Do not pour down regular drains (it can contaminate water supplies)
If disposal necessary, pour into designated alcohol waste container
Allow to evaporate in a well-ventilated area if no waste container available
Never incinerate or burn

SURGICAL HAND SCRUB PROTOCOL

Surgical hand scrubs are performed before entering the operating room or performing major surgical procedures. The goal is to remove all transient microorganisms and reduce resident flora as much as possible, creating a significantly cleaner hand surface than routine handwashing.

When Surgical Hand Scrub Is Required:

Before entering the operating room for surgery
Before performing any major invasive procedures in the operating room
Before performing emergency procedures in non-OR settings with high infection risk
Before any procedure where maximum asepsis is critical
Before assisting in major surgical interventions

Materials Required:

Agents:

Antimicrobial surgical scrub soap (chlorhexidine 4%, povidone-iodine 7.5%, or triclosan)
If unavailable: 4% chlorhexidine can be made from 20% stock solution
Alternative: Povidone-iodine solution at appropriate concentration
Running water (warm, if possible)

Equipment:

Single-use surgical brush or sponge (preferably with nail cleaner integrated)
Sterile towels (must be sterile for surgical procedures)
Sterile gloves (to be donned after scrub)
Nail file or orange stick (if integrated brush not available)

Step-by-Step Surgical Hand Scrub Procedure:

Pre-Scrub Preparation (5 minutes)

Check and Prepare Your Hands
- Remove all jewelry (rings, bracelets, watches, nail polish)
- Inspect nails—they should be short and clean
- If you have nail polish, visible dirt under nails, or recent hand injuries, perform more thorough cleaning first
Perform Initial Handwashing
- Wash hands and forearms thoroughly with regular soap and water
- Pay special attention to subungual areas
- Wash to 2 inches above the elbow
- Rinse completely
- Dry with a clean towel
Visualize the Procedure
- Review the planned procedure mentally
- Ensure you understand the anatomical areas that will require maximum sterility
- This mental preparation helps you maintain focus during the actual scrub

Surgical Hand Scrub (3-5 minutes)

Step 1: Begin with Nails and Subungual Areas (1-2 minutes)

This step is crucial and should not be rushed:

Hold your hands under running water with fingertips pointing downward
Use the nail brush or integrated tool to clean under each nail
For each nail:
- Place the nail brush under the nail at the edge
- Brush vigorously from the nail fold toward the tip of the nail
- Use a pumping motion to work the brush into the subungual area
- Perform this action 10 times for each nail (10 fingers = 100 total strokes minimum)
Ensure all visible debris is removed from under nails

Rationale: Subungual areas harbor the highest concentration of bacteria. This area is most resistant to antimicrobial action and requires mechanical removal.

Step 2: Apply Surgical Scrub Soap

Hold your hands under running water
Apply 5-10 mL of antimicrobial surgical scrub soap to your hands
Distribute the soap evenly across both hands

Step 3: Scrub the Hands Using Circular Motions (1.5-2 minutes)

Forearm Scrubbing (both arms):
- Starting at the wrist, begin scrubbing your forearm using circular motions
- Work systematically from wrist toward elbow
- Ensure coverage of all surfaces (palmar, dorsal, medial, lateral aspects)
- Scrub for approximately 30 seconds per forearm
Hand Scrubbing:
- After completing forearms, move to hands
- Using the surgical brush or sponge, scrub palms with circular motions for 30 seconds
- Scrub back of hands with circular motions for 30 seconds
- Pay special attention to the interdigital spaces (between fingers)
- Scrub for 30 seconds focusing on areas between fingers
Finger and Nail Scrubbing:
- Hold the brush at an angle and scrub the tips of your fingers with an up-and-down motion
- Ensure the brush gets into the grooves around nails
- Scrub each finger from all aspects (anterior, posterior, lateral)
- Scrub for 1-2 minutes total on fingers
Repetition:
- Repeat the entire sequence a second time if using the 5-minute protocol
- The second pass should be slightly less vigorous than the first
- Total scrub time: 3-5 minutes

Step 4: Rinse Thoroughly (1-2 minutes)

Hold your hands and forearms under running water with fingers pointing downward
Allow water to flow from your hands toward your elbows
Rinse for at least 1-2 minutes to remove all soap and debris
Work your fingers to ensure water reaches between all fingers
Ensure all soap is removed before proceeding to drying

Post-Scrub Procedures

Step 5: Dry Completely

Do not touch any surfaces after rinsing
Use sterile towels provided in the OR setting
For non-OR settings, use the cleanest available single-use towels
Dry hands and forearms completely
Drying should take 30-60 seconds
Do not re-contaminate your hands by touching surfaces

Step 6: Don Sterile Gloves

Proceed immediately to donning sterile gloves
Maintain sterile technique when opening glove packets
Ensure gloves are completely pulled up past the wrist
Do not touch any non-sterile surfaces after donning gloves

Total Time for Complete Surgical Hand Scrub:

Minimum 3 minutes for routine preoperative scrub 5 minutes for more contaminated hands or high-risk procedures Plus time for initial handwashing: 40-60 seconds Plus time for drying and gloving: 2-3 minutes Total from start to finish: 6-10 minutes

Antimicrobial Agents for Surgical Hand Scrub:

Agent	Concentration	Effectiveness	Notes
Chlorhexidine	2-4%	Excellent	Excellent residual activity; preferred agent
Povidone-Iodine	7.5-10%	Excellent	Effective but can cause iodine irritation; shorter residual activity
Triclosan	0.5-1%	Good	Less commonly used; some resistance concerns
Plain Soap	N/A	Fair	Mechanical removal only; better than nothing if agents unavailable

Making Chlorhexidine for Surgical Scrub:

If 4% chlorhexidine is unavailable but 20% chlorhexidine is available:

Dilution Calculation:

To make 100 mL of 4% solution from 20% solution:
- Take 20 mL of 20% chlorhexidine
- Add 80 mL of distilled water
- Mix thoroughly
- Label as “4% Chlorhexidine - Surgical Scrub”

Important Considerations:

Skin Condition:

Surgical scrubbing can be harsh on skin, especially with repeated procedures
Avoid using extremely hot water (it damages skin barrier)
Use moisturizer after surgical scrub sessions to prevent dermatitis
If significant skin damage occurs, consult occupational health

Alternatives if Specific Agents Unavailable:

Chlorhexidine is preferred; use if available
Povidone-iodine is acceptable alternative
In emergency situations, vigorous handwashing with regular soap is acceptable (though less effective)

Special Populations:

If staff member has iodine allergy, use chlorhexidine instead of povidone-iodine
If staff member has chlorhexidine sensitivity, use povidone-iodine
Some individuals may develop dermatitis with frequent scrubbing—document and adjust PPE protocols

MODULE 2: PERSONAL PROTECTIVE EQUIPMENT (PPE)

Introduction to PPE

Personal protective equipment is the last line of defense in infection prevention when engineering controls and administrative controls are insufficient. Proper use of PPE requires understanding when to use each type, how to don (put on) and doff (remove) it correctly, and how to dispose of it safely.

Key Principles:

PPE is the last resort, not the first choice
Proper donning is critical—inadequate donning negates PPE effectiveness
Proper doffing is critical—many exposures occur during removal
No single piece of PPE protects against all hazards
Different situations require different combinations of PPE

STANDARD PPE FOR DIFFERENT SITUATIONS

Risk Assessment Framework:

Before selecting PPE, conduct a risk assessment based on:

Type of microorganism (bacteria, virus, fungus, parasite)
Route of transmission (airborne, droplet, contact, bloodborne)
Likelihood of exposure to blood/body fluids
Procedure being performed
Environmental factors

Table: Standard PPE Combinations by Scenario

Scenario	Gloves	Gown	Mask	Eye Protection	Indication
Basic patient care	Yes	No*	No*	No	Contact precautions sufficient
Blood/body fluid exposure risk	Yes	Yes	Surgical Mask	Yes	Droplet + Contact precautions
Aerosol-generating procedure	Yes	Yes	N95/PAPR	Yes	Airborne precautions
Suspected tuberculosis	Yes	No**	N95	No	Airborne precautions
Wound care	Yes	No	Surgical Mask	Optional	Contact precautions
Respiratory symptoms (fever/cough)	Yes	No***	Surgical Mask	Optional	Droplet precautions
Direct patient contact	Yes	No	No	No	Standard precautions
Splashing risk	Yes	Yes	Surgical Mask	Yes/Face Shield	Contact/Droplet precautions
Major surgery	Yes	Full Surgical Attire	N95/Surgical	Yes	Maximum protection

*May be needed in outbreak situations **May be needed in outbreak situations ***Recommended if high contact with respiratory secretions

Detailed Scenario-Based PPE Selection:

Scenario 1: Routine Clinical Examination

Risk Level: Low Transmission Route: Primarily contact PPE Required:

Gloves (non-sterile examination gloves)
Standard precautions
Mask if patient has respiratory symptoms (surgical mask)
Eye protection if significant splashing risk possible

Procedure:

Perform hand hygiene
Don gloves just before patient contact
Perform examination
Doff gloves after patient contact
Perform hand hygiene

Scenario 2: Wound Care/Dressing Change

Risk Level: Medium Transmission Route: Contact; possible droplet PPE Required:

Gloves (non-sterile, non-latex if patient has latex allergy)
Gown if dressing removal may splash or contaminate clothing
Surgical mask if there is any respiratory component to the infection
Eye protection if significant splash risk (e.g., infected wound with purulent drainage)

Procedure:

Perform hand hygiene
Set up all needed supplies before donning PPE
Don gown if needed
Don mask if needed
Don eye protection if needed
Don gloves last
Perform wound care
Doff all PPE in reverse order (gloves first)
Perform hand hygiene

Scenario 3: Assistance with Delivery

Risk Level: High Transmission Route: Contact, bloodborne, droplet PPE Required:

Two pairs of gloves (one pair to be removed if contaminated)
Waterproof apron or gown
Surgical mask
Eye protection (face shield preferred)
Shoe covers if delivery is highly contaminated (likely)

Procedure:

Perform hand hygiene
Don first pair of gloves
Don gown/apron
Don mask
Don eye protection
Don second pair of gloves, pulling over wrist of gown
Assist with delivery
Remove outer gloves immediately if contaminated
Continue with inner gloves if needed
Complete doffing at end

Scenario 4: Suspected Tuberculosis Case

Risk Level: Very High Transmission Route: Airborne PPE Required:

Respiratory protection (N95 mask or better)
Gloves
Gown (for close contact)
Eye protection (if procedures being performed)
Proper ventilation of room

Procedure:

Perform hand hygiene
Fit-test or verify fit of respiratory protection before use
Don respiratory protection first
Don gown
Don gloves over gown wrists
Perform care
Remove all PPE carefully
Perform hand hygiene

Scenario 5: Suspected COVID-19 or Similar Respiratory Virus

Risk Level: Very High Transmission Route: Airborne, droplet PPE Required:

N95 respirator (if available and properly fit-tested)
Surgical mask (if N95 unavailable)
Face shield or safety glasses
Gown
Gloves (double gloving recommended)
Shoe covers (optional but recommended)

Procedure:

Perform hand hygiene before entering room
Don first pair of gloves
Don gown, ensuring it covers all skin
Don N95 or surgical mask
Don face shield or safety glasses
Don second pair of gloves, pulling over gown wrists
Perform all procedures
Doff PPE following specific sequence (detailed below)

DONNING SEQUENCE

The order in which you put on PPE is important. Generally, you should don items from bottom to top and outside to inside:

Standard Donning Sequence:

Step 1: Perform Hand Hygiene

Wash hands with soap and water or use ABHR
Ensure hands are clean and dry
This is essential before donning any PPE

Step 2: Don Gown

Open gown and hold at the neck opening
Place arms through sleeves
For cloth gowns, tie securely at waist and neck
For disposable gowns, ensure fasteners are secure
Pull gown down to cover all of your clothing to the ankles
Ensure back of gown is covered (front closure gowns may not protect back adequately)

Rationale: Gown provides barrier against splashing and contamination. Donned early to protect other clothing.

Step 3: Don Mask

Hold mask by the ear loops or headband
Place mask over your nose and mouth
Secure ear loops around ears (if ear loop mask) or pull headband over head
Pinch nose bridge to ensure good seal
Ensure mask covers mouth and nose completely
For respiratory protection (N95), fit-test seal by:
- Inhaling sharply to check for air leakage at edges
- Exhaling sharply to check for air leakage
- If air leaks from edges, adjust and re-test

Rationale: Mask worn before eye protection to ensure eye protection sits on top. N95 requires fit-testing.

Step 4: Don Eye Protection

Place safety glasses or face shield over eyes
For glasses, ensure they cover eyes and sides
For face shield, ensure shield extends to cover eyes and part of face
Ensure eye protection does not interfere with mask fit

Rationale: Donned after mask to sit properly on top of mask. Protects mucous membranes of eyes.

Step 5: Don Gloves

Open glove package
Put on first glove by inserting hand into glove carefully
Pull glove up past wrist
Put on second glove by inserting fingers under cuff of first glove and pulling second glove up
Ensure cuffs of gloves overlap with cuffs of gown
Gloves should extend over the wrist of the gown

Rationale: Gloves donned last to maintain their sterility as much as possible (if sterile gloves). Overlap with gown prevents contamination at wrist.

Step 6: Check Your Appearance

In a mirror or have colleague check:
- All skin is covered
- Gown covers front and back
- Mask is properly fitted
- Eye protection is in place
- Gloves are on and overlap with gown
- No parts of underclothing are visible

Donning Sequence for High-Risk Procedures:

Example: Aerosol-Generating Procedures (Surgery, Intubation, etc.)

Perform hand hygiene
Don first pair of non-sterile gloves (for extra protection)
Don surgical cap/hood if required
Don protective footwear or shoe covers
Don gown (preferably full-coverage surgical gown)
Don surgical hood or head covering (if not already done)
Don N95 or PAPR respiratory protection
Don eye protection (face shield preferred)
Don sterile gloves (second pair) carefully

Total Time: 3-5 minutes for complete donning

DOFFING SEQUENCE

Doffing is extremely important because most PPE-related exposures occur during removal. The sequence is generally reverse of donning, but the key principle is remove contaminated items before removing clean items.

Standard Doffing Sequence:

This sequence minimizes contamination of your hands and reduces exposure risk.

Step 1: Remove Outer Gloves (if applicable)

If you are double-gloved, remove the outer gloves first
Pinch the outside of one glove near the wrist
Peel it off, turning it inside-out as you remove it
Hold the removed glove in your gloved hand
With your ungloved hand (fingers only, do not touch palm), reach under the cuff of the remaining glove
Peel the second glove off inside-out, enclosing the first glove inside
Dispose in appropriate waste container
The inner glove is still clean at this point

Step 2: Perform Hand Hygiene

Use ABHR or wash hands if they are visibly soiled
This is critical—your hands may have contacted contaminated surfaces

Step 3: Remove Eye Protection

Remove safety glasses or face shield by holding the strap or ear pieces
Do not touch the front of the eye protection
Place in designated area for cleaning or disposal
Perform hand hygiene if hands contacted the front of eye protection

Step 4: Remove Gown

Untie the waist and neck ties of the gown
Reach behind your neck and untie the neck fastener
Slip the gown off your shoulders by pulling it away from your body
Turn the gown inside-out as you remove it (to keep contaminated side inside)
Be careful not to touch the contaminated outside surface
Fold the gown with contaminated side inward
Place in designated laundry or waste container
Do not touch your clothing or other surfaces

Step 5: Perform Hand Hygiene

Use ABHR or wash hands
This is critical—your hands may have contacted the outside of the gown

Step 6: Remove Mask or Respiratory Protection

Do NOT touch the front of the mask (contaminated surface)
Remove by holding the ear loops or head straps only
For N95 masks, break the seal by gently pulling the mask away from the face while holding straps
Dispose in appropriate container (usually regular waste, unless heavily contaminated)
Perform hand hygiene

Step 7: Final Hand Hygiene

Wash hands thoroughly with soap and water
This final hygiene ensures removal of any microscopic contamination

Total Time: 2-3 minutes for proper doffing

Doffing Sequence for High-Risk or Suspected COVID-19 Cases:

Step-by-Step for Highly Infectious Cases:

Remove Outer Gloves
- Pinch outside of glove near wrist
- Peel off, turning inside-out
- Hold in other gloved hand
- Peel off second glove inside-out, enclosing first glove
- Dispose in designated container
Perform Hand Hygiene (ABHR)
- Use alcohol-based hand rub
- Ensure complete coverage
- Allow to air-dry
Remove Face Shield
- Hold by straps/bands only
- Remove carefully without touching front
- Place on clean surface (not in face)
- Do not perform hand hygiene yet—may need face shield later
Perform Hand Hygiene (ABHR)
- Use alcohol-based hand rub again
- This removes any contamination from face shield straps
Remove Gown
- Reach behind back to untie waist ties
- Unfasten neck closure
- Lean forward and slip gown off shoulders
- Turn inside-out while removing
- Hold away from body
- Place in designated contaminated laundry
Perform Hand Hygiene (ABHR)
- Third application of hand hygiene
- Ensures removal of gown contamination
Remove Respirator/Mask
- Hold by straps/loops only
- Never touch front of mask
- Grasp the lower ear loop first and pull away from one ear
- Then grasp upper ear loop and pull away from other ear
- For head-strapped respirators, lift the bottom strap first over your head, then the top strap
- Dispose in designated container (if non-reusable)
- Place in designated space if reusable
Final Hand Hygiene (Soap and Water)
- Wash hands with soap and water for 40-60 seconds
- This is the most thorough hygiene method
- Ensures removal of all residual contamination

Critical Points About Doffing:

Avoid These Common Mistakes:

Touching the front of the mask while removing it
Doffing PPE in the wrong sequence
Touching your face with contaminated gloves
Placing removed PPE on clean surfaces
Failing to perform hand hygiene between removal of different items
Removing mask first (incorrect sequence)
Not allowing time for proper doffing (rushing increases exposure risk)

Quality Assurance:

Observe staff doffing procedures regularly
Provide feedback and retraining as needed
Document doffing competency
Revisit doffing technique during staff meetings/refresher training
Consider video recording proper sequence for training purposes

GLOVE TYPES AND APPROPRIATE USE

Glove Material Options:

Material	Pros	Cons	Best Use
Latex	Good fit, durable, tactile sensitivity	Allergic reactions, environmental	Routine care (if no latex allergy)
Nitrile	No latex allergy, similar properties	Slightly less tactile sensitive, more expensive	Standard choice for most settings
Vinyl	Inexpensive, hypoallergenic	Less durable, poor fit	Low-contamination situations
Neoprene	Good durability, latex-free	More expensive	Prolonged procedures
Synthetic Polymer	Combines benefits	Less commonly available	Specialty procedures

Glove Types by Application:

1. Non-Sterile Examination Gloves

Used for: Routine patient examination, wound assessment, contact precautions Characteristics:

Available in different sizes (XS to XXL)
Loose fit, not individually packaged as sterile
Usually less expensive than sterile gloves
Adequate for routine care not involving entry into sterile fields

Selection:

Choose correct size—too small restricts circulation; too large reduces dexterity
Powder-free gloves preferred (powder can contaminate wounds)
Ambidextrous design for either hand

Donning Non-Sterile Gloves:

Open package
Slide hand into glove, positioning thumb in thumb hole
Pull up to wrist
Don second glove
If glove tears during donning, discard and use new pair

2. Sterile Surgical Gloves

Used for: Surgical procedures, invasive procedures, sterile field procedures Characteristics:

Individually packaged as sterile
High quality, good fit
More expensive
Must be donned using aseptic technique

Sizing:

Gloves come in half sizes (6, 6.5, 7, 7.5, 8, etc.)
Proper fit is essential for dexterity and comfort
Measure hand from wrist crease to fingertip for sizing

Donning Sterile Gloves (Open Method):

This method is used when a sterile field is not prepared beforehand:

Perform hand hygiene
Place sterile glove package on clean surface with cuff end toward you
Open outer package by peeling apart
Open inner glove package carefully, creating a sterile field
Pick up first glove by the cuff with opposite hand
Step into glove, positioning your hand inside
The cuff will be folded onto your wrist
Use fingers of gloved hand to pick up second glove (grasp the cuff)
Don second glove by placing bare hand inside and pulling up
Adjust both gloves by interlocking fingers and moving hands apart
Ensure gloves are smooth and wrinkles are removed
Ensure cuffs cover the wrists properly

Donning Sterile Gloves (Closed Method):

This method is preferable when already wearing a sterile gown:

Do not remove hands from gown sleeves
Pick up sterile glove package with gloved hands
Open glove package while keeping hands inside gown sleeves
Position glove over gown cuff area
Use non-gloved hand inside gown sleeve to guide your hand into glove
Grasp cuff of glove through gown material
Extend arm, allowing glove to slide onto hand
The cuff of glove will cover the cuff of gown
Repeat with second hand
Do not allow bare skin to be exposed at wrist/forearm

3. Heavy-Duty Gloves

Used for: Cleaning and decontamination of instruments, housekeeping in contaminated areas Characteristics:

Thicker than examination gloves
Reusable or disposable
Designed to resist puncture and tearing
Must be cleaned and dried after use if reusable

Selection:

Choose appropriate thickness for the task
Ensure good seal at wrist
Check for tears or damage before each use

4. Insulated/Thermal Gloves

Used for: Handling autoclaved or very hot instruments, boiling water Characteristics:

Thermally insulated material
Must be heat-resistant
Usually non-sterile

Selection:

Ensure rating for expected temperature
Must fit properly to prevent slipping

Glove Selection Algorithm:

Is the procedure sterile or clean?

Sterile → Use sterile surgical gloves with closed or open donning method
Clean/Non-sterile → Use non-sterile examination gloves

What is the contamination risk?

Blood/body fluid exposure → Double glove or use heavy-duty gloves
Chemical exposure → Use chemical-resistant gloves
Heat exposure → Use insulated gloves
Routine contact → Standard non-sterile gloves adequate

Does patient have latex allergy?

Yes → Use nitrile or vinyl gloves exclusively
No → May use latex or nitrile

Glove Failure Prevention:

Causes of Glove Failure:

Punctures from sharp instruments
Tears from rough surfaces
Degradation from chemical exposure
Poor fit (size mismatch)
Pre-existing defects
Improper donning technique

Prevention Strategies:

Inspect gloves before donning for tears or damage
Select correct size for good fit
Keep fingernails short and smooth
Remove jewelry that might puncture gloves
Use double gloves for high-risk procedures
Change gloves if exposure to potentially contaminated material occurs
Change gloves between patients

Detecting Glove Failure:

Visible tear
Sensation of sharp object penetrating glove
Feeling of wetness despite being dry
If failure suspected, immediately:
1. Stop the procedure if possible
2. Remove contaminated glove(s)
3. Perform hand hygiene
4. Don new gloves
5. Continue procedure with clean gloves

MASK TYPES AND WHEN TO USE EACH

Introduction to Respiratory Protection

Masks provide protection in three ways:

Source control: Prevent wearer from spreading pathogens to others
Personal protection: Protect wearer from inhaling pathogens
Contact prevention: Prevent wearer from touching mouth/nose

The type of mask needed depends on the transmission route and contamination level.

Surgical Masks

Description:

Three-layer mask
Outer hydrophobic layer
Middle filter layer (provides most protection)
Inner soft layer for comfort
Flat or pleated design with ear loops or head ties

Filtration Efficiency:

Blocks 60-80% of particles 5 microns or larger
Protects others from wearer (source control) more effectively than protecting wearer
Provides minimal protection to wearer against airborne pathogens

When to Use:

Droplet precautions
Routine patient care when respiratory symptoms present
When in close contact with potentially infectious patient
In outbreak situations where all staff should wear masks
When airborne precautions unavailable (though N95 preferred)
Patient care that may involve splashing (combined with eye protection)

When NOT to Use:

As substitute for airborne precautions
If fit is uncertain
For healthcare workers with respiratory symptoms (N95 preferred)
In high-risk aerosol-generating procedures

Donning Surgical Mask:

Inspect mask for tears or defects
Identify top (colored side out usually), bottom, and sides
Hold mask by ear loops
Place loops around ears
Pull mask over nose and mouth
Pinch nose wire to conform to nose bridge
Ensure mask covers mouth and nose completely
For tie-on masks: Tie upper ties at top back of head, lower ties at back of neck

Doffing Surgical Mask:

Do not touch the front of the mask
Hold ear loops and pull mask away from ears
For tie-on masks: Untie lower ties first, then upper ties
Dispose in regular waste (usually)

Duration of Use:

Single use—do not reuse
Replace if wet, damaged, or obviously soiled
Do not hang mask around neck between uses (contaminates exterior)
Dispose after each use

Limitations:

Does not form a seal with the face
Does not protect against airborne pathogens
Effectiveness depends on proper fit and placement
Difficult to use for long periods (ear discomfort)

N95 Respirator

Description:

Particulate respirator
Designed to filter at least 95% of airborne particles
Various designs: cup-shaped, fold-flat, duck-bill
Must have headbands (preferred) or ear loops
Some have exhalation valves (make easier to breathe but reduce source control)

Filtration Efficiency:

Filters 95% of particles 0.3 microns or larger
Protects wearer primarily (personal protection)
Does not effectively provide source control if valve present
Valved N95 should not be used for source control purposes

When to Use:

Airborne precautions (TB, chickenpox, measles, COVID-19, etc.)
Aerosol-generating procedures
Suspected cases of highly infectious respiratory pathogens
Healthcare workers with respiratory symptoms (non-valved N95 if source control needed)

When NOT to Use:

For routine droplet precautions (waste of resource; surgical mask adequate)
If proper fit cannot be achieved
Valved N95 for source control purposes
If wearer has significant facial hair (prevents proper seal)
If wearer has facial deformities affecting seal

Fit-Testing Requirements:

N95 fit-testing is essential and must be done before first use and annually:

Fit-Test Process:

Select appropriate size and style
Don N95 properly (see below)
Perform user seal checks
Qualitative fit-test protocol:
- Isoamyl acetate (banana odor) test: Wearer wears N95 and confirms smell of banana odor not detected
- Saccharin aerosol test: Similar principle with saccharin taste
Quantitative fit-test (preferred): Uses equipment to measure actual protection factor
Document results
Keep copy of fit-test results with wearer

User Seal Checks (Before Each Use):

Even if fit-tested, must perform seal check before donning:

Positive Pressure Check:
- Cover mouth of respirator with hands (palms cupping the mask)
- Gently inhale and hold breath
- If seal is good, slight positive pressure builds up inside mask
- This pressure prevents air from leaking out
- Release hands—no air should rush out
Negative Pressure Check:
- Cover inhalation ports (usually small holes on sides of mask)
- Gently exhale and hold breath
- If seal is good, slight negative pressure develops
- The mask should collapse inward against your face
- Release hands—mask should re-expand

If seal checks fail:

Reposition respirator
Adjust headbands
Try different size
If seal still cannot be achieved, do not wear—obtain different size/style

Donning N95 Respirator (Proper Technique):

Inspect the Respirator
- Look for tears, holes, damage
- Check that headbands are not broken
- Discard if any defects found
Clean Your Face
- Wash face if visibly contaminated
- Remove makeup and facial hair that would prevent seal
- Ensure face is dry
Determine Top and Bottom
- Cup-shaped: Easy to identify
- Fold-flat: Unfold and identify top (usually has metal nose band)
- Duck-bill: Fold correctly with cup facing downward
Position the Respirator
- Hold respirator in palm of hand
- Place over mouth and nose
- Identify top and position appropriately
Apply Headbands
- Place upper headband high on crown (not at top of head)
- Place lower headband at base of neck
- If ear loops: Place around ears (similar to surgical mask)
Fit the Nose Bridge
- Pinch metal strip (if present) firmly around nose bridge
- Shape to contours of your nose
- Ensure complete contact with face
Perform User Seal Checks
- Positive pressure check (see above)
- Negative pressure check (see above)
- If checks fail, reposition and recheck
Secure Properly
- Ensure hair does not come between mask and face
- Tuck long hair under hood or behind headbands
- Ensure nothing protrudes from under mask edges

Doffing N95 Respirator:

Minimize Contact with Front
- Hold by headbands/ear loops only
- Do not touch front surface
Remove
- Grasp bottom headband first and pull away from back of head
- Then grasp top headband and pull away
- For ear loop models: Hold by ear loops and remove
Dispose
- Place in designated container
- Regular waste container if non-reusable
- If reusable, place in designated storage area for eventual decontamination

Storage and Reuse:

In resource-limited settings, N95 respirators may need to be reused:

If Reusing N95:

Store in breathable paper bag (not plastic, which promotes moisture)
Label with wearer’s name and date
Rotate through 5 masks minimum before reusing same mask (allows viral particles to degrade)
Discard if damaged, soiled, or difficult to breath through
Do not wash, sterilize, or attempt to “refresh” (reduces effectiveness)
Do not share between wearers

Duration of Safe Use:

Can be worn continuously for up to 8 hours if fit-tested and seal maintained
Remove if soiled, damaged, or breathing becomes difficult
Remove periodically to allow skin to air-dry (prevents maceration)

PAPR (Powered Air-Purifying Respirator)

Description:

Battery-powered system
Motor pulls air through filter cartridge
Air flows over face shield or helmet
Provides positive pressure (air flows out, preventing inflow of contaminated air)
Reusable components (requires cleaning and maintenance)

Filtration Efficiency:

Filters 99.97% of particles (if HEPA filter) or 95-99% (if P100/N100)
Protects wearer effectively
Does not provide source control to others

When to Use:

Extended airborne precautions (longer than 8 hours)
Repeated high-risk exposures
Staff with facial hair (cannot use N95)
Staff unable to achieve fit with N95
High-mortality airborne pathogens
Routine reuse of respirators (better than N95 for extended reuse)

When NOT to Use:

Situations requiring frequent removal and re-donning
Patients who find apparatus frightening (visibility reduced, noise)
Settings without battery charging capability
Inadequate training on use and maintenance

Donning PAPR:

Perform Hand Hygiene
- Ensure hands are clean and dry
Charge Battery (if needed)
- Check battery level before use
- Plug in charger if battery low
- Ensure adequate battery for duration of care
Inspect Components
- Check for damage to hose, filter cartridge, face shield
- Ensure all connections tight
- Test motor (should hear quiet hum when powered on)
Position Face Shield or Helmet
- Place on head like a helmet
- Adjust straps for secure, comfortable fit
- Ensure face shield covers face completely
Verify Air Flow
- Turn on motor
- Feel air flowing over face
- Ensure steady, consistent flow
- Adjust position if needed for comfort
Don Other PPE
- Put on gown while wearing PAPR
- Put on gloves after putting on PAPR
- Ensure no gaps at neck or wrists

Doffing PAPR:

Turn Off Motor
- Power off the unit
- Set aside in designated location
Remove Face Shield/Helmet
- Carefully lift off head
- Place on clean surface (not on contaminated bed or furniture)
Remove Other PPE
- Continue with standard doffing sequence for gown and gloves
- Do not retouch face shield until after hand hygiene
Perform Hand Hygiene
Clean Components
- Face shield: Wipe with disinfectant
- Hose and connections: Wipe clean
- Battery pack: Wipe clean
- Filter cartridge: Replace if clogged or damaged
- Motor unit: Wipe exterior only

Maintenance:

Battery: Charge after each use if possible
Filter cartridge: Replace per manufacturer recommendation (usually every 40 hours or monthly)
Hose: Inspect for cracks; replace if damaged
Face shield: Replace if fogged or scratched beyond visibility
Straps: Replace if torn or stretched out
Keep spare charged battery and spare filter cartridges available

EYE PROTECTION AND FACE SHIELDS

Introduction

Eyes are a common entry route for infectious pathogens, particularly during procedures involving splashing of blood or body fluids. Eye protection is essential in many clinical scenarios.

Types of Eye Protection:

1. Safety Glasses

Description:

Standard prescription-type glasses made of impact-resistant material
May have side shields for additional protection
May be prescription or non-prescription

When to Use:

Any procedure with splashing risk
Combined with mask for droplet precautions with splashing risk
Blood draws, wound care with drainage, etc.

Advantages:

Comfortable for prolonged use
Provides adequate protection for most situations
Does not fog as easily as face shields
Less frightening to patients

Disadvantages:

Does not protect sides of face
Does not protect bridge of nose as well
Limited coverage area

2. Face Shield

Description:

Clear plastic shield that covers entire face
Attached to headband or glasses frame
May be reusable (glass) or disposable (plastic)
Various sizes available

When to Use:

Procedures with high-volume splashing
Aerosol-generating procedures
Delivery/obstetric procedures
Any procedure where extensive facial protection needed

Advantages:

Comprehensive face and eye protection
Protects nasal mucosa and mouth area
Very effective barrier
Easy to don/doff
Reusable models available

Disadvantages:

Fogs easily (reduced visibility)
May be uncomfortable for prolonged use
Can be frightening to patients
Requires good fit to prevent air gaps

Anti-Fogging Strategies:

Ensure adequate ventilation (slight air gap between shield and face)
Apply anti-fogging solution to inside of shield before use
Do not touch inside of shield during use
Remove briefly for condensation to evaporate
Use fan or ventilation to clear fogging

3. Goggles

Description:

Sealed eye protection that fits tightly around eyes
Provides excellent seal and protection
May be uncomfortable for prolonged use

When to Use:

Procedures with fine aerosol or splashing risk
When comprehensive eye seal needed
Chemical splash risk

When NOT to Use:

Patients with claustrophobia concerns
Prolonged procedures (discomfort)
When facial shield adequate

Donning Eye Protection:

Safety Glasses:

Hold by frame on either side
Place over eyes
Ensure both eyes are covered
Adjust for comfort and position

Face Shield:

Inspect for cracks or damage
Place headband on forehead
Position shield in front of face
Tighten band for secure fit
Ensure no gaps between shield and skin

Goggles:

Inspect for cracks or damage
Hold by straps
Place over eyes
Adjust straps for tight seal around eyes
Ensure complete seal

Doffing Eye Protection:

Safety Glasses:

Hold by frame or legs
Remove without touching the front
Place on clean surface
Perform hand hygiene if hands touched frame

Face Shield:

Hold by headband or side straps
Lift away from face
Do not touch the front surface
Place on clean surface for later cleaning
If heavily contaminated, place in designated container for cleaning

Goggles:

Hold by straps only
Pull away from eyes
Do not touch the interior surface
Place in designated area for cleaning

Cleaning Reusable Eye Protection:

After Each Use:
- Wipe exterior with clean, damp cloth or gauze
- For highly contaminated equipment, use disinfectant wipe
- Allow to air-dry before storing
Between Patients:
- Wipe with disinfectant solution appropriate for material
- Dry completely
- Inspect for cracks or damage
Daily Deep Cleaning:
- Wash with warm soapy water
- Rinse thoroughly
- Dry with lint-free cloth
- Store in clean, dust-free container
Anti-Fogging Maintenance:
- If anti-fogging solution used, reapply per product instructions
- Clean with appropriate solution (not harsh abrasives that remove coating)

GOWNS AND APRONS

Introduction

Gowns and aprons protect healthcare workers’ clothing and skin from contamination with blood, body fluids, and other infectious materials.

Types of Gowns:

1. Surgical Gown

Description:

Full-body coverage garment
Back closure with ties or snaps
Reinforced areas (sleeves, front chest, waist)
Sterile for operating room use
Non-sterile available for standard precautions

Characteristics:

Knit cuffs at wrists
Usually full-length to ankles
Multiple sizes to ensure proper fit
Color-coded by size or type

When to Use:

Operating room procedures
Procedures with high-volume splashing risk
Delivery assistance
Any procedure with extensive potential for contamination

Advantages:

Complete coverage of body
Durable material
Professional appearance
Available in sterile and non-sterile

Disadvantages:

Expensive
Requires proper storage and handling
More cumbersome than apron for minor procedures
Requires more time to don/doff

2. Disposable Gown

Description:

Single-use gown
Made of non-woven material or film
Lightweight
Available in various sizes

When to Use:

When high-level contamination expected
Outbreak situations when supply abundant
Standard precautions with contamination risk

Advantages:

Ensures clean gown for each use
No laundering required
Available in various materials
Convenient for high-volume use

Disadvantages:

More expensive than reusable
Environmental waste
May tear more easily
Limited sizes in some settings

3. Plastic Apron

Description:

Waterproof apron covering front of body
Usually plastic or coated material
Ties at neck and waist
Protects front of uniform/clothing

When to Use:

Routine patient care with splashing risk
Wound dressing changes
Patient hygiene assistance
When full gown unnecessary but protection needed

Advantages:

Inexpensive
Quick to don and doff
Allows adequate ventilation
Easy to clean and reuse
Suitable for routine care

Disadvantages:

Does not protect back or sides
Does not protect arms unless long-sleeved
Waterproof material can be hot in warm climates
Less durable than full gowns

4. Cloth Gown

Description:

Reusable full or partial-body gown
Made of cotton or cotton blend
Must be laundered after use

When to Use:

Routine precautions with minimal splash risk
Extended-wear situations where comfort important
Settings without disposable gown supply

Advantages:

Inexpensive
Durable and reusable
More comfortable for patient (less frightening than full PPE)
Environmentally friendly

Disadvantages:

Requires laundering (water, soap, energy)
Potentially less protective than disposable
Difficult to ensure adequate sterilization between uses
May harbor pathogens if not properly laundered

Gown Material Properties:

Material	Water Resistance	Breathability	Durability	Cost	Reusable
Non-woven	Moderate	High	Low	Moderate	No
Plastic-coated	High	Low	Moderate	Low	Yes
Cotton	Low	High	High	Low	Yes
Disposable film	High	Moderate	Moderate	High	No
Laminate	High	Moderate	High	High	No

Donning a Gown:

For Sterile Surgical Gown (Operating Room):

Perform surgical hand scrub and don sterile gloves
Pick up gown from sterile package (usually held by assistant)
Hold gown at the shoulders
Step backward into gown
Allow gown to unfold; do not allow front of gown to touch your feet
Assistant ties back closure at neck and waist
Don sterile gloves over gown cuffs (second pair of gloves)
Hands should never extend past edge of gown front

For Non-Sterile Gown:

Perform hand hygiene
Open gown with neck opening facing you
Place arms through sleeves
Bring gown back up to shoulder
Fasten all ties and closures:
- Neck tie at back of neck
- Waist ties at sides/back
- Ensure gown covers all of your clothing
If gown has front closure, ensure it is secure
Verify back is covered

For Apron:

Pick up apron by ties
Place apron over head
Tie neck closure at back of neck
Tie waist closure at back of waist
Ensure apron sits flat and covers front adequately

Doffing a Gown:

Standard Procedure:

Remove gloves first (see glove removal technique)
Perform hand hygiene with ABHR
Untie waist ties (if back-closure gown, reach around back)
Untie neck ties (if back-closure gown, reach back to untie)
Slip gown off shoulders by reaching behind back and pulling gown away
Flex your arms and allow gown to peel off as you move arms
Turn gown inside-out as you remove it (contaminated side stays inside)
Avoid touching the outside/front of gown
Fold gown with contaminated side inward
Place gown in designated laundry or waste container
Perform hand hygiene with ABHR

For Apron:

Reach around back and untie waist
Untie neck closure
Remove apron without touching contaminated front
Place in designated washing area or waste container
Perform hand hygiene

Proper Gown Fit:

Sizing Considerations:

Gown should be long enough to reach ankles
Sleeves should reach wrist without being so long that they cover hands
Gown should fit at shoulders without being too tight
Too-large gown may gape in back; too-small may tear

Dress Code Under Gown:

Wear minimal layers under gown to reduce heat
Avoid clothing that extends below wrist (may extend past gown cuff and become contaminated)
Wear comfortable shoes (not sandals) in case of splashing

Reusable Gown Laundering:

If using cloth gowns:

Segregation:
- Place contaminated gowns in designated “soiled” container
- Separate from other laundry initially
Washing:
- Wash in hot water (at least 71°C / 160°F) if possible
- Use standard detergent
- Ensure adequate water for proper rinsing
- Wash for adequate duration to remove all visible contamination
Rinsing:
- Rinse thoroughly to remove all soap
- Multiple rinses may be needed
Drying:
- Line-dry or machine-dry at moderate temperature
- Ensure complete drying to prevent mildew
- Heat-drying can help reduce some pathogens
Inspection Before Reuse:
- Check for tears, holes, stains
- Repair small tears or discard if significantly damaged
- Ensure gown is clean and appropriate for reuse
Storage:
- Store in clean, dry location
- Away from direct sunlight
- In sealed container if possible to prevent dust

IMPROVISED PPE IN RESOURCE-LIMITED SETTINGS

Introduction

In resource-limited settings, ideal PPE may not be available. Healthcare workers often must improvise using available materials. While not as effective as commercial PPE, improvised options can provide meaningful protection.

Critical Principle: Improvised PPE is better than no PPE, but should be used only when commercial products are unavailable.

Improvised Mask

Option 1: Cloth Mask from Available Fabric

Materials:

Cotton cloth or similar fabric (2-3 layers minimum)
Elastic or cloth ties
Needle and thread or sewing machine
Scissors

Construction:

Cut fabric into rectangle approximately 20cm x 10cm
Fold long edges inward slightly and sew to create hem
Fold in half lengthwise and sew along one long edge
Turn inside-out (seam should be inside now)
Fold to create rounded shape with seam inside
Sew elastic or cloth strips at sides for ear loops
Optional: Insert metal strip along top edge (coat hanger bent to shape) to help conform to nose

Fitting:

Layer should cover nose and mouth completely
Should fit snugly with no gaps
Should be breathable enough to allow normal breathing

Effectiveness:

Provides some filtration (possibly 30-50% depending on fabric density)
Provides source control (prevents wearer spreading to others)
Does not provide airborne protection

Limitations:

Not suitable for airborne precautions
Less effective than commercial masks
Difficult to achieve proper fit
Requires frequent washing

Care:

Wash after each use with soap and water
Air-dry completely before reuse
Replace if torn or excessively soiled

Option 2: Mask from Paper/Non-Woven Material

Materials:

Paper (brown paper bag, newspaper, paper towel, etc.)
Cloth or fabric for straps
Tape or glue

Construction:

Fold paper into rectangle shape
Attach cloth strips or use tape for ear loops
Reinforce all edges
Ensure nose and mouth completely covered

Effectiveness:

Minimal filtration (20-40%)
Better than nothing for source control
Very low airborne protection

Limitations:

Deteriorates quickly when wet
Single-use only
Provides minimal protection

Option 3: Scarf or Cloth Tied Over Mouth and Nose

Materials:

Clean cloth or scarf
Ties or knots

Use:

Tie cloth over nose and mouth
Knot behind head or use ties
Ensure completely covers mouth and nose
Should be snug but not restricting breathing

Effectiveness:

Minimal filtration
Provides some source control
Very limited airborne protection

Limitations:

Uncomfortable
Difficult to maintain throughout procedures
Not recommended for extended use

Improvised Eye Protection

Option 1: Safety Goggles from Plastic Bottle

Materials:

Clear plastic bottle (water bottle, beverage bottle)
Scissors
Elastic or cloth strips
Hole punch or nail

Construction:

Cut plastic bottle into curved piece that covers eyes
Punch holes at sides or top/bottom
Attach elastic or cloth strips for head straps
Test for visibility and fit
Smooth any sharp edges

Effectiveness:

Provides eye protection from splashing
Clear plastic allows reasonable visibility
Protects eye area adequately

Limitations:

Difficult to construct well
May have distorted vision
Uncomfortable for extended use
Plastic may scratch easily

Option 2: Plastic Shield from Clear Packaging

Materials:

Clear plastic sheet (from packaging, plastic wrap)
Tape or cloth strips
Scissors

Construction:

Cut plastic to appropriate size (minimum 15cm x 20cm)
Tape or tie onto forehead/around face
Ensure visibility is adequate
Secure so it does not fall during procedures

Effectiveness:

Provides splashing protection
Better than nothing

Limitations:

May reduce visibility significantly
Difficult to keep in place
Uncomfortable

Option 3: Use Goggles with Non-Powered Lenses

If available:

Use whatever clear eyewear is available
Prescription glasses, sports goggles, welding goggles (if not smoked glass)
At minimum, provide some protection

Improvised Gloves

Option 1: Plastic Bags as Glove Liners

Materials:

Small plastic bags (plastic shopping bags, plastic food bags)
Scissors

Construction:

Cut bag to appropriate size
Use as inner lining under cloth gloves or alone
Secure with ties or elastic around wrist

Effectiveness:

Provides barrier protection
Waterproof
Inexpensive

Limitations:

Reduces dexterity
Tears easily
Uncomfortable (sweating/moisture)
Does not provide puncture protection

Option 2: Cloth Gloves

Materials:

Clean cloth or fabric
Needle and thread or cloth ties

Construction:

Cut cloth to appropriate size for hands and forearms
Sew or tie to create glove shape
Ensure adequate coverage and fit
Can layer with plastic for waterproofing

Effectiveness:

Provides barrier protection
Washable and reusable
Some thermal protection

Limitations:

Does not provide puncture protection
Does not protect against sharp objects
Reduces dexterity
Requires frequent washing

Improvised Gown/Apron

Option 1: Plastic Sheet Apron

Materials:

Plastic sheeting (from packaging, plastic bags sewn together)
Cloth strips or rope for ties
Scissors

Construction:

Cut plastic to appropriate size (minimum 50cm x 50cm)
Attach ties at neck and waist
Ensure front is covered adequately
Smooth out any sharp edges

Effectiveness:

Waterproof protection
Covers front/chest area
Inexpensive and easy to make

Limitations:

Does not protect back or sides
Plastic can tear
Hot/uncomfortable to wear
Single-use only if torn

Option 2: Cloth Gown or Apron

Materials:

Cloth or fabric (old sheets, cloth scraps)
Needle and thread or safety pins
Ties/rope

Construction:

Cut cloth to size needed
Sew or pin into gown/apron shape
Attach ties for secure fastening
Ensure adequate body coverage
Can layer for more protection

Effectiveness:

Provides barrier protection
Reusable (after washing)
Comfortable to wear
Can be made to proper size/fit

Limitations:

Provides less waterproof protection than plastic
Requires washing between uses
Less durable than commercial gowns

Option 3: Waterproof Covering from Plastic Bags

Materials:

Plastic bags (large garbage bags, food bags)
Tape
Scissors

Construction:

Cut bags to create covering
Use tape to attach around waist, arms, neck as needed
Ensure adequate coverage where contamination risk is highest

Effectiveness:

Waterproof protection
Inexpensive

Limitations:

Uncomfortable (heat, moisture)
Difficult to fit properly
Hot to wear for extended time
Tears easily

Improvised Respiratory Protection

Critical Note: If resource truly lacks commercially available respirators, improvised respirators provide minimal protection and should only be used when absolutely necessary. Consider administrative and engineering controls as primary protection.

Option 1: Cloth-Based Filter Mask

Materials:

Cotton cloth (2-3 layers)
Filter material (if available—activated charcoal, HEPA filter from vacuum, coffee filters)
Elastic or cloth ties
Needle and thread

Construction:

Create mask base (see improvised cloth mask above)
If filter material available, layer between cloth layers
Sew securely together
Ensure no air gaps at sides
Test for adequate filtration and fit

Effectiveness:

Minimal to moderate filtration (possibly 30-50% depending on materials)
Better with multiple layers and filter material
Some airborne protection

Limitations:

Not equivalent to N95
Difficult to maintain proper fit
Exhausting to breathe through if too many layers
No fit-testing possible

Use: Only if commercial N95 genuinely unavailable; should not be sole protection if higher-risk pathogens present.

General Principles for Improvised PPE:

Use as Last Resort:
- Explore every option to obtain commercial PPE first
- Contact NGOs, government health agencies, international organizations
- Consider stockpiling commercial PPE when available
Quality Standards:
- Ensure improvised PPE is as protective as possible
- Use multiple layers for filtration
- Ensure proper fit
- Test for functionality before actual use
Documentation:
- Document what PPE is being improvised
- Note the reason commercial PPE unavailable
- Track staff using improvised PPE
- Monitor for infection rates among staff using improvised PPE
Training:
- Train staff on proper use of improvised PPE
- Emphasize that improvised is not equivalent to commercial
- Provide at least as much training as for commercial PPE
- Ensure staff understand limitations
Infection Prevention:
- Maintain strict engineering controls (ventilation, isolation) when possible
- Use administrative controls (reduced contact, virtual care if possible)
- Do not rely solely on improvised PPE
- Consider implementing lower-risk alternatives (telemedicine, telephone consultations)
Monitoring:
- Monitor infection rates among staff and patients
- Watch for inadequate protection with improvised PPE
- Be prepared to discontinue improvised PPE if protective efficacy clearly inadequate

MODULE 3: STERILIZATION AND DISINFECTION

Introduction to Sterilization and Disinfection

Sterilization is the complete elimination of all microorganisms, including spores. Disinfection is the removal or killing of most microorganisms but not necessarily all spores. The choice between sterilization and disinfection depends on the equipment being processed and its use.

Key Definitions:

Sterilization: Complete destruction of all microorganisms including spores; critical for items entering sterile body cavities
Disinfection: Reduction of microorganisms to levels considered safe; adequate for non-critical items
Disinfectant: Chemical agent that kills microorganisms on inanimate surfaces
Antiseptic: Chemical agent that can be applied to living tissue to kill or inhibit microorganisms
Asepsis: Absence of infectious agents; maintains sterile conditions
Bioburden: Total number of microorganisms present before sterilization/disinfection

SPAULDING CLASSIFICATION

The Spaulding classification system categorizes medical devices based on the risk of infection if the device is contaminated. This determines the level of sterilization/disinfection needed.

Critical Items (Require Sterilization)

Definition: Items that enter sterile body tissues, the vascular system, or blood stream

Risk Level: Highest risk of infection if contaminated

Sterilization Required: YES—absolutely essential

Examples:

Surgical instruments (scalpels, forceps, clamps, scissors, needle holders)
Sutures and needles
Catheters for urinary, vascular, or cardiac use
Implantable devices (pacemakers, hip replacements, etc.)
Endoscopes (if enter sterile cavities)
Intravenous catheters and central venous catheters
Spinal needles and epidural catheters
Bone plates and screws

Sterilization Methods:

Autoclaving (steam sterilization) - preferred method
Chemical sterilization (glutaraldehyde, peracetic acid)
Dry heat sterilization (for specific materials)
Ethylene oxide gas sterilization (not available in most resource-limited settings)

Handling After Sterilization:

Maintain sterile packaging until immediate use
Do not re-sterilize if packaging compromised (opened package should be re-processed if not used immediately)
Store in clean, dry environment
Date all sterilized items

Semi-Critical Items (Require High-Level Disinfection)

Definition: Items that contact mucous membranes or non-intact skin but do not penetrate tissues

Risk Level: Medium risk; potential for infection if contaminated

Sterilization Required: NO—but high-level disinfection is essential

High-Level Disinfection Acceptable: YES

Examples:

Laryngoscopes and blades
Vaginal specula
Anoscopes
Bronchoscopes
Esophageal stethoscopes
Thermometers (non-electronic)
Face masks and resuscitation bags (if reused)
Reusable suction tips
Thermometer sheaths (reusable)
Urinary catheterization supplies (if reused)
Transducers for ultrasound

Processing Methods:

Manual Processing: Disinfection with high-level disinfectants (glutaraldehyde, hydrogen peroxide)
- Soak time: 20-45 minutes depending on agent and contamination
- Full immersion required
- Proper ventilation essential (fumes are toxic)
Automated Processing: High-level disinfection systems available in some facilities
- More consistent results
- Reduces staff exposure to chemical fumes
- More expensive
Sterilization Also Acceptable: If sterilization method available (e.g., autoclaving), this is preferred as it provides greater margin of safety

After Disinfection:

Rinse thoroughly with sterile water to remove disinfectant residue
Dry with sterile cloth or let air-dry
Store in clean, dry location until use
Should be used within reasonable time frame (not weeks later)

Non-Critical Items (Require Low-Level Disinfection or Cleaning)

Definition: Items that contact intact skin but not mucous membranes

Risk Level: Low risk; minimal infection risk if contaminated

Sterilization Required: NO

Low-Level Disinfection Acceptable: YES

Disinfection Required: YES—but low-level disinfection sufficient

Examples:

Blood pressure cuffs
Stethoscopes
Pulse oximetry probes
Patient beds and mattresses
Bedside tables and chairs
Wheelchairs and stretchers
Floors and environmental surfaces
Toilet seats
Countertops and doorknobs
Patient charts and writing instruments
Telephone handsets
Computer keyboards and mice

Processing Methods:

Cleaning Only: Removal of visible dirt and debris
- Often sufficient for non-critical items
- Use soap/detergent and water
- Dry after cleaning
Low-Level Disinfection: Use of disinfectants after cleaning
- Appropriate agents: dilute bleach solution, quaternary ammonium compounds, phenolic agents
- Contact time: 10-15 minutes usually
- More time-consuming than sterilization may justify in some settings

After Disinfection:

Allow adequate contact time for disinfectant
Rinse if residue problematic
Dry
Can be used immediately or stored

AUTOCLAVE STERILIZATION

Autoclaves (also called steam sterilizers) are the most common method for sterilizing surgical instruments and equipment in healthcare settings. Steam provides excellent sterilization when proper temperature, pressure, time, and moisture are maintained.

How Autoclave Sterilization Works:

Steam Penetration: Steam enters and surrounds all instruments and materials
Heat Transfer: Heat from steam causes protein denaturation in microorganisms
Moisture: Moisture helps conduct heat efficiently (dry heat is much less effective)
Pressure: Pressure allows higher temperatures in a shorter time than boiling water

Autoclave Parameters:

Standard Settings:

Temperature: 121-132°C (250-270°F)
Pressure: 15-20 psi (pound-force per square inch)
Duration: 10-30 minutes depending on load size and density

Specific Recommendations:

Item Type	Temperature	Pressure	Time	Notes
Unwrapped instruments	121°C	15 psi	3-5 min	For immediate use only
Wrapped instruments	121°C	15 psi	10-15 min	Standard load
Large wrapped bundles	121°C	15 psi	20-30 min	Longer time for penetration
Liquids	121°C	15 psi	20-30 min	Risk of boiling/splashing
High-density items	132°C	20 psi	3-10 min	Higher temp/pressure, shorter time

Types of Autoclaves:

Gravity Displacement Autoclaves

Description:

Steam enters at top of chamber
Air naturally rises and exits from bottom drain
Most common type in resource-limited settings
Simplest and most reliable design

Advantages:

Simple operation
Reliable sterilization
Less expensive
Fewer moving parts to break down
Easy to repair/maintain

Disadvantages:

Slower air removal may take longer
Less suitable for wrapped loads (slower penetration)
Not ideal for complex items with many air pockets

Pressure/Vacuum Displacement Autoclaves

Description:

Vacuum pump actively removes air from chamber before steam enters
Steam enters when chamber is under vacuum
Faster, more efficient sterilization
More expensive

Advantages:

Faster sterilization cycles
Better for wrapped items
More effective for complex loads
Professional hospital-grade sterilizers

Disadvantages:

More expensive
More complex operation
Requires more maintenance
Requires electricity/vacuum pump

Autoclave Sterilization Process: Step-by-Step

Pre-Sterilization Phase:

Step 1: Preparation of Instruments (Decontamination and Cleaning)

Segregate Instruments:
- Separate instruments immediately after use
- Do not allow blood/body fluids to dry on instruments (becomes difficult to clean)
- Immediately place contaminated instruments in designated “soiled” container
Pre-cleaning Steps:
- Rinse instruments under running water if highly contaminated
- If tap water unavailable, rinse in large basin filled with water
- Do not run under high pressure (risk of splashing contamination)
Manual Cleaning (Most Important Step):
- This is critical—sterilization cannot work if instruments not properly cleaned
- Visual cleaning alone is insufficient; organic matter harbors microorganisms
- Use appropriate cleaning solutions (water with detergent, enzymatic cleaners, or mild bleach solution)
- Immerse contaminated instruments in cleaning solution for 10-15 minutes
- Use soft brush to scrub all surfaces, paying special attention to:
  - Joint areas and hinges
  - Serrations on forceps
  - Lumens of hollow instruments
  - Under clamps and locks
- Ensure all blood, tissue, and organic matter removed
- Rinse thoroughly multiple times under running water until water runs clear
- If enzymatic cleaner used, ensure complete rinsing (residue will compromise sterilization)
Drying:
- Pat dry with clean cloth or towel
- Allow to air-dry completely
- Moisture remaining on instruments will be carried into autoclave
- Wet instruments increase steam requirements and prolong cycle time
- Some corrosion may occur if instruments remain wet
Inspection:
- Examine all instruments for:
  - Cleanliness (no visible blood, tissue, or dirt)
  - Damage or erosion
  - Proper function (forceps should have smooth action, scissors should cut)
- Do not sterilize damaged instruments
- Send for repair or dispose if damaged

Step 2: Preparation of Wrapping Materials

Choose Appropriate Wrapping:
- Two-layer wrapping (double-wrap) preferred for storage
- Single layer acceptable if immediate use
- Wrapping must allow steam penetration while maintaining sterility after sterilization
Acceptable Wrapping Materials:
- Paper (medical grade, 20lb minimum weight)
- Non-woven material (fabric-like sterilization wrap)
- Cloth (specially treated sterilization fabric, reusable)
- Muslin (cotton fabric, washed and prepared for sterilization)
NOT Acceptable Wrapping:
- Plastic or rubber (steam cannot penetrate; also melts)
- Foil (steam cannot penetrate)
- Waterproof materials
- Heavily coated materials
Wrapping Technique:
- Place instruments in center of wrap
- Fold one corner of wrap toward center (about 1/3 of way)
- Fold second corner
- Fold third corner
- Bring fourth corner over, creating package with flap
- Fold flap back slightly (not fully tucked, to allow steam entry)
- Label package with:
  - Contents (what is inside)
  - Date of sterilization
  - Initials of person wrapping
  - Sterilization cycle number (if tracking)
Sterilization Indicators:
- Place chemical indicator inside each wrapped package
- Chemical indicator should change color when exposed to appropriate temperature/steam/time
- Indicates that package exposed to appropriate conditions (but does not guarantee sterilization)
- Bi-fold or tri-fold indicators preferred (external and internal color change)

Step 3: Loading the Autoclave

Arrangement of Items:
- Do not overpack autoclave
- Leave adequate space between packages (steam must circulate around all items)
- Place heavier items on bottom
- Do not place large, dense bundles on top of smaller items
- Ensure wrapped packages placed flat (not standing on edge)
- Leave at least 2-3 inches between packages and autoclave walls
Placement Rules:
- Trays should be placed with open side down (allows air to escape)
- Hollow instruments should be positioned horizontally or with opening downward
- Bottles and flasks with lids should be loosened (allows steam penetration and prevents explosion from pressure buildup)
- Do not stack items directly on top of each other (steam cannot reach lower items)
Autoclave Full But Not Overloaded:
- Efficient use of autoclave space, but do not compromise sterilization
- If in doubt, run additional cycle—sterilization more important than efficiency

Step 4: Autoclave Operation

Check Water Level:
- Autoclave requires water for steam generation
- Check water level in reservoir (usually has level indicator)
- Fill if low, using distilled water if possible (tap water may leave mineral deposits over time)
Set Parameters:
- Set temperature according to load type (121°C for standard loads)
- Set pressure to 15-20 psi (autoclave controls this by regulating temperature/pressure together)
- Set time according to load density and size (usually 10-15 minutes for standard load)
Start Cycle:
- Close door and seal according to autoclave manual
- Press START button
- Autoclave will heat to desired temperature and pressure
- Cycle time begins once desired temperature/pressure reached
Monitoring:
- Do not open door during cycle (compromises sterilization and creates burn hazard)
- Some autoclaves have viewing window (check if available)
- Listen for proper operation (pressure release should not be continuous)
- Monitor pressure gauge (if manual autoclave) to ensure proper pressure maintained

Sterilization Phase:

Autoclave operates at set temperature, pressure, and time
Steam penetrates all packages and instruments
High temperature and moisture kill all microorganisms and spores
Cycle continues until timer sounds

Post-Sterilization Phase:

Step 5: Cooling Phase

Let Autoclave Cool:
- Do not open door immediately after cycle ends
- Allow pressure to return to zero naturally (usually 10-20 minutes)
- Wet instruments left in autoclave after cycle will dry during this cooling phase
- Premature opening causes:
  - Burn risk from steam
  - Wet instruments (exposure to moisture allows recontamination)
  - Compromised sterilization due to sudden cooling
Observe Temperature and Pressure Gauges:
- Ensure temperature drops below 100°C
- Ensure pressure returns to zero (or near-zero)
- Only open door when these conditions met

Step 6: Removal of Sterilized Items

Open Door Carefully:
- Open door slowly (residual steam may escape—burn risk)
- Stand back from door opening
- Allow steam to dissipate for 30-60 seconds before reaching in
Remove Items:
- Use tongs or forceps if very hot
- Allow items to cool slightly before handling
- Can be handled without protection once cooled enough to touch
Inspect Items:
- Check chemical indicators for color change (appropriate color change indicates proper sterilization conditions)
- Inspect packages for damage, tears, or signs of moisture
- Packages should be dry (wet packages indicate steam leak or improper drying)
- Do not use packages that are wet or have signs of damage
Final Inspection Before Use:
- Confirm chemical indicator changed appropriately
- Confirm package is intact and dry
- Confirm date and contents match what expected
- Never use items that did not sterilize properly or package is compromised

Step 7: Storage of Sterilized Items

Storage Location:
- Store in clean, dry cabinet or shelf
- Keep away from moisture and dust
- Organize by type and date
- Keep newer items in back (first-in, first-out system)
Shelf Life:
- Sterilized items should be used within reasonable timeframe
- Properly wrapped items can remain sterile for months to years if:
  - Package remains intact (not torn, punctured, or compromised)
  - Storage environment is clean and dry
  - Package is protected from moisture, dust, and environmental contamination
How to Maintain Sterility:
- Do not place sterile packages on wet surfaces
- Do not bend, fold, or apply pressure to packages (may break sterile barrier)
- Do not store above or near water pipes (dripping water compromises sterility)
- If package becomes wet or damaged, re-sterilize before use
- Keep storage area organized and clean

Autoclave Maintenance:

Daily Maintenance:

Clean Chamber:
- Wipe interior with damp cloth if visibly dirty
- Remove any debris
Check Water Level:
- Fill reservoir as needed
Test Drain:
- Ensure drain is not clogged
- Clear any debris from drain

Weekly Maintenance:

Run Empty Cycle:
- Run autoclave with no load to clean internal system
- This flushes minerals and debris from system
Clean Door Seals:
- Wipe rubber gasket/seal with damp cloth
- Ensure no debris preventing proper seal
Inspect Gauges:
- Check that pressure and temperature gauges functioning properly
- Compare gauges if autoclave has duplicate gauges
- Gauges should read similarly

Monthly Maintenance:

Deep Clean Chamber:
- Drain and refill water reservoir
- If mineral buildup evident, may need mineral descaling solution
- Wipe all interior surfaces
Test Biological Indicators:
- Place biological indicator (spore test) in autoclave
- Run standard sterilization cycle
- Biological indicator contains spores that should be killed
- If spores survive sterilization cycle, autoclave is not sterilizing properly
- Should be sent for repair or maintenance

Annual Maintenance:

Professional Service:
- Have qualified technician service autoclave annually
- Technician will:
  - Replace worn gaskets and seals
  - Calibrate pressure and temperature gauges
  - Check safety valves
  - Perform thorough cleaning
Pressure Test:
- Autoclave should maintain pressure for testing
- If pressure drops significantly, leak present
- Must be repaired before use

Troubleshooting Autoclave Problems:

Problem	Possible Cause	Solution
Autoclave won’t reach temperature	Low water level, blocked drain	Fill water, clear drain
Takes excessive time to reach temperature	Low water level, old heating element	Fill water, service autoclave
Pressure won’t build	Door seal failing, leak in system	Check door seal, service autoclave
Instruments still wet after cycle	Cooling phase too short, high humidity	Extend cooling time, improve ventilation
Chemical indicator not changing	Indicator expired, temperatures too low	Use new indicators, check autoclave calibration
Constant hissing or steam release	Pressure valve stuck	Service autoclave

CHEMICAL DISINFECTION

When autoclaving is not available or inappropriate for certain items, chemical disinfection provides an alternative sterilization or high-level disinfection method.

Glutaraldehyde (2-3.5% Solution)

Properties:

Broad-spectrum disinfectant/sterilant
Kills bacteria, viruses, fungi, and spores
Requires proper pH (alkaline), usually 7.5-8.5
Toxic to skin and respiratory system

Effectiveness:

High-Level Disinfection: 20 minutes at room temperature
Sterilization: 6-10 hours (rarely used due to time and toxicity)

Use:

Disinfection of flexible endoscopes
Disinfection of equipment that cannot withstand heat
Respiratory equipment (anesthesia circuits, laryngoscope blades)

Procedure:

Preparation:
- Ensure items are thoroughly cleaned and dried before immersion
- Prepare glutaraldehyde solution per manufacturer instructions
- Use ventilated area (fumes are toxic)
- Wear gloves and eye protection
Immersion:
- Immerse items completely in solution
- Ensure solution reaches all lumens and crevices
- Do not allow items to stick above solution (exposed portions won’t be disinfected)
- Time immersion according to product instructions
Post-Disinfection:
- Remove items from solution using sterile forceps
- Rinse thoroughly with sterile water (residual glutaraldehyde is toxic)
- Dry with sterile cloth or let air-dry
- If not using immediately, store in clean, covered container

Safety:

Provides adequate ventilation (fumes cause respiratory irritation)
Wear gloves (skin irritant)
Wear eye protection
Avoid inhalation of fumes
If solution contacts skin or eyes, rinse immediately with large amount of water
Do not pour glutaraldehyde down regular drain (environmental hazard)
Must dispose according to local regulations

Disadvantages:

Toxic
Slow sterilization (6-10 hours)
High cost
Fumes require special ventilation
Must be activated (shelf-life limited once activated)

Hydrogen Peroxide (3-6%)

Properties:

Disinfectant/sterilant depending on concentration and exposure time
Less toxic than glutaraldehyde
Breaks down to water and oxygen (environmentally friendly)
Effective against bacteria, viruses, fungi, and spores

Effectiveness:

High-Level Disinfection: 20-30 minutes for 3-6% solution
Sterilization: Not typically used for sterilization (slow)

Use:

High-level disinfection of heat-sensitive items
Environmental disinfection
Equipment disinfection

Procedure:

Preparation:
- Clean items thoroughly before disinfection
- Prepare solution (use commercial preparation or dilute 35% hydrogen peroxide to 3-6%)
- Use well-ventilated area
Immersion:
- Immerse clean items in hydrogen peroxide solution
- Ensure complete submersion
- Allow adequate contact time
Post-Disinfection:
- Remove items
- Rinse thoroughly with sterile water (bubbling indicates residual peroxide)
- Dry with sterile cloth or let air-dry

Advantages:

Less toxic than glutaraldehyde
Environmentally friendly (breaks down to water and oxygen)
Effective disinfection
Minimal odor

Disadvantages:

Slower than some other methods
Requires longer contact time
May leave residue requiring thorough rinsing

Bleach Solution (Sodium Hypochlorite)

Properties:

Disinfectant (kills most microorganisms)
Does NOT kill spores effectively
Corrosive to metals
Safe for environmental disinfection
Inexpensive and widely available

Effectiveness:

Surface Disinfection: 5-10 minutes
NOT effective for sterilization or high-level disinfection

Concentrations:

Household bleach: 3-6% sodium hypochlorite
For general disinfection: 0.5% solution (1:10 dilution of household bleach)
For high-contamination areas: 1% solution (1:5 dilution)
For pathological waste: 5% solution

Use:

Environmental disinfection (floors, walls, surfaces)
Equipment disinfection (non-critical items)
Spill cleanup and decontamination
Laundry disinfection
General facility cleaning

Preparation of Bleach Solutions:

0.5% Solution (for general disinfection):

Take 100 mL of household bleach (3-6%)
Add 900 mL water
Total 1000 mL of 0.5% solution

1% Solution (for contaminated areas):

Take 200 mL household bleach
Add 800 mL water
Total 1000 mL of 1% solution

5% Solution (for pathological waste):

Use undiluted household bleach or dilute 35% solution appropriately

Procedure:

Preparation:
- Wear gloves and eye protection
- Ensure good ventilation
- Prepare solution fresh daily (bleach loses effectiveness over time)
Application:
- Apply solution to surfaces using cloth or spray
- Allow adequate contact time (5-10 minutes)
- Do not rinse excessively (water reduces disinfectant efficacy)
- Can leave dilute bleach residue on surfaces
Safety:
- Never mix bleach with ammonia or acid (creates toxic chlorine gas)
- Ventilate well (fumes irritate respiratory system)
- Corrosive—avoid prolonged contact with metals (may cause rust)
- Irritant to eyes and skin—wash immediately if contact occurs

Advantages:

Inexpensive
Widely available
Safe for environmental use
Effective disinfectant
Can be made from readily available materials

Disadvantages:

Not effective against spores
Corrosive to metals (avoid use on surgical instruments)
Fumes irritating
Loses effectiveness quickly (solution should be made fresh daily)
Cannot store concentrated solutions for long periods

BOILING AND STEAM STERILIZATION WITHOUT AUTOCLAVE

In settings where autoclave unavailable, boiling water can provide sterilization equivalent to high-level disinfection for selected items.

Boiling Water Sterilization

Method:

Immerse clean instruments in boiling water
Maintain rolling boil for appropriate time

Effectiveness:

Kills vegetative bacteria, viruses, fungi, and most pathogens
Does NOT reliably kill spores (less effective than autoclaving)
Approximately equivalent to high-level disinfection

Procedure:

Equipment Needed:
- Large pot or container
- Source of heat (stove, fire, heating element)
- Tongs or forceps
- Clean water
Cleaning:
- Ensure instruments thoroughly cleaned before boiling
- Dry completely
- Boiling cannot work on dirty instruments
Preparation:
- Fill pot with water to cover instruments
- Bring water to rolling boil
- Place instruments in boiling water once boiling
Boiling Time:
- 20 minutes: Standard boiling time for most instruments
- 30 minutes: For heavily contaminated items or spore concerns
- Time begins once instruments placed in boiling water, not from when water begins to boil
Removal and Cooling:
- After appropriate time, remove instruments using sterile tongs
- Place on clean, dry cloth or sterile field
- Allow to cool and dry completely
- Do not cool in water (recontamination risk)
Use:
- Use immediately or store in clean, covered container
- Should be used within reasonable time (storage life shorter than autoclaved items)

Advantages:

Requires only pot and heat source
No specialized equipment needed
Applicable in resource-limited settings
Inexpensive

Disadvantages:

Does not reliably kill spores
Slower process (takes time to boil water, bring to rolling boil, etc.)
Risk of burns during removal and cooling
Corrosion may occur with repeated boiling (especially stainless steel)
Water minerals may accumulate (causes white deposits on instruments)
Not appropriate for all items (plastic, rubber degrade)

Items Suitable for Boiling:

Stainless steel instruments
Glassware
Rubber items (limited time only)
Metal trays and containers

Items NOT Suitable for Boiling:

Plastics (melt or degrade)
Electrical equipment
Items with batteries or electronics
Lensed instruments (optical cement degrades)
Delicate items prone to damage

Pressure Cooker Sterilization

A pressure cooker can approximate autoclaving function by reaching higher temperatures and pressures than boiling water alone.

Method:

Clean instruments placed in pressure cooker with water
Pressure cooker heated to pressure equivalent to 121°C (250°F) at 15 psi

Effectiveness:

Approximately equivalent to autoclaving
Pressure and temperature kill spores
More effective than boiling water

Procedure:

Equipment:
- Pressure cooker designed for sterilization (typically 10-15 quart capacity)
- Heat source
Setup:
- Add water to pressure cooker per manufacturer instructions (usually 2-3 inches of water)
- Place rack or trivet in bottom to elevate instruments above water
- Place clean, dry instruments on rack
- Do not overload (steam must circulate)
Operation:
- Close pressure cooker lid and latch securely
- Heat on high heat
- Once steam flows from vent pipe, place weight/regulator on vent
- Maintain appropriate pressure (usually 15 psi) indicated by regulator
- Maintain for 20-30 minutes (similar to autoclave times)
Cooling:
- Turn off heat
- Allow pressure to return to zero naturally (10-20 minutes)
- Do NOT force cooling with water
- Allow instruments to cool and dry
Removal:
- Carefully open pressure cooker when pressure zero
- Remove instruments with tongs
- Allow to cool completely

Advantages:

More effective than boiling
Simpler equipment than autoclave
Pressure cooker may have other uses in facility
Inexpensive

Disadvantages:

Not as reliable as autoclave
Cannot monitor temperature/pressure as precisely
Requires careful management to maintain proper pressure
Still does not eliminate all spores as effectively as autoclave

DISINFECTION OF SURFACES AND ENVIRONMENT

Environmental disinfection is essential to prevent transmission of microorganisms through contaminated surfaces.

Classification of Surfaces:

High-Touch Surfaces:

Frequent contact with hands or other body parts
Door handles, light switches, railings, bed rails
Patient examination tables
Phones, computers, writing implements

Low-Touch Surfaces:

Infrequent contact
Upper walls, ceiling
Equipment that is not handled regularly

Wet Surfaces:

Areas likely to be moist
Bathrooms, kitchen areas, sinks
Floor areas near water sources

Disinfection Protocols:

General Environmental Disinfection:

Frequency:

Daily minimum
More frequent in high-risk areas (operating room, delivery room, intensive care)
More frequent in outbreak situations
Whenever visible contamination present

Method:

Cleaning Phase:
- Remove visible debris and dirt
- Use clean cloth or mop
- Soap and water usually sufficient
- This mechanical removal is most important step
Disinfection Phase:
- Apply disinfectant solution (0.5% bleach or equivalent)
- Allow contact time (5-10 minutes)
- Pay attention to high-touch surfaces
- Wipe dry or allow to air-dry
High-Touch Surface Focus:
- Light switches
- Door handles
- Bed rails
- Chairs and furniture
- Computers and phones
- Stethoscopes and medical equipment

Terminal Cleaning (After Patient Discharge/Death):

Purpose: Complete disinfection of patient room after use Timing: Before new patient admitted to room

Procedure:

Remove Contaminated Items:
- Remove soiled linens (place in designated contaminated laundry)
- Remove disposable items (place in appropriate waste container)
- Remove mattress cover if contaminated
Cleaning Phase:
- Damp-wipe all surfaces (walls, furniture, floor)
- Use soap and water or detergent solution
- Start from clean areas, work toward contaminated areas
- Include ceilings if splashing occurred
Disinfection Phase:
- Apply disinfectant solution to all surfaces
- High-touch surfaces (bed rails, light switches, door handles)
- Wet surfaces (bathroom, floor areas near moisture)
- Allow adequate contact time
Final Cleaning:
- Dry surfaces or allow to air-dry
- Final inspection for cleanliness

Blood/Body Fluid Spill Cleanup:

Immediate Action:

Don PPE:
- Gloves
- Eye protection
- Gown (if significant splashing occurred)
Contain Spill:
- If fresh spill, place absorbent material (paper towels, cloth) on spill
- If liquid, allow absorbent material to soak up fluid
- Do not splash or aerosolize contaminated materials
Initial Cleanup:
- Using absorbent material, wipe up visible material
- Place contaminated material in appropriate waste container (infectious waste)
Disinfection:
- Apply disinfectant solution (1% bleach for blood/body fluid exposure)
- Allow adequate contact time (10 minutes)
- Wipe clean with cloth
- Repeat if high contamination
Doff PPE:
- Remove gloves carefully
- Perform hand hygiene
- Remove other PPE
Safe Disposal:
- All contaminated materials in appropriate waste container
- No spreading of contamination

STERILIZATION INDICATORS AND MONITORING

Sterilization indicators provide confirmation that sterilization parameters achieved but do not guarantee sterilization occurred.

Chemical Indicators

Types:

Internal Indicator: Placed inside package, indicates if internal conditions met
External Indicator: Placed outside package, indicates if external conditions met
Biological Indicator: Contains spores to verify sterilization capability

How They Work:

Color-reactive ink changes color when exposed to appropriate temperature/time/steam combination
Change indicates package was exposed to sterilization conditions
Does not guarantee sterilization (items may still be contaminated if not properly cleaned)

Examples:

Indicators with dots that change color
Stripe or line indicators that darken
Chemical dots that change to specific colors

Use:

At least one internal indicator in each wrapped package
External indicator on outside of package
Both should change color after sterilization

Interpretation:

Color change = package was exposed to appropriate sterilization conditions
No color change = sterilization cycle failed; do not use items

Advantages:

Quick confirmation of sterilization parameters
Inexpensive
Easy to use
Visible at a glance

Disadvantages:

Only confirms temperature/time/steam reached
Does not guarantee items actually sterilized
Does not detect pre-sterilization contamination

Biological Indicators

Purpose:

Confirms that sterilization system actually kills microorganisms
Most reliable indication of sterilization effectiveness
Should be used monthly or after equipment service

Method:

Contain harmless spores (usually Bacillus stearothermophilus for steam sterilization)
Spores can only be killed by true sterilization
If spores survive, sterilization failed

Use:

Setup:
- Place biological indicator in autoclave (usually wrapped in package placed in center of load)
- Run normal sterilization cycle
Incubation:
- After sterilization, incubate biological indicator according to product instructions
- Usually cultured at 37°C for 24-48 hours
- If spores were killed by sterilization, they will not grow
- If spores survive, they will grow and produce visible color change or growth
Results:
- No growth = sterilization effective
- Growth = sterilization failed; investigate problem

Interpretation:

“Control” indicator (unsterilized) should show growth (spores alive)
Test indicator (sterilized) should show no growth (spores killed)
If test shows growth, autoclave not sterilizing properly and must be serviced before use

Advantages:

Most reliable sterilization verification
Detects if autoclave actually killing microorganisms
Essential for quality assurance

Disadvantages:

Takes 24-48 hours to get results
More expensive than chemical indicators
Requires incubation capability
Cannot be done every cycle (impractical)

INSTRUMENT PROCESSING WORKFLOW

The complete process from contaminated instrument to sterilized, ready-to-use instrument follows specific steps:

Step 1: Immediate Point-of-Use Handling

At the time of use:

Keep instruments moist (do not allow blood/tissue to dry)
Immediately place in designated “soiled” container
Do not rinse at point of use (splashing risk, cross-contamination)
Use containers designed for transporting soiled instruments safely

Step 2: Pre-Cleaning/Decontamination

Before manual cleaning:

Remove gross contamination if present
Rinse briefly under running water (if available) to remove excess blood/tissue
Place in decontamination solution (mild bleach or detergent) if available
Allow to soak for 10-15 minutes to loosen dried material
This prepares instruments for thorough cleaning

Step 3: Manual Cleaning

Most critical step for sterilization to work:

Immerse in cleaning solution:
- Water with detergent/soap
- Enzymatic cleaner if available (breaks down proteins)
- Allow to soak briefly
Scrub all surfaces:
- Use soft brush on all surfaces
- Special attention to:
  - Joint and hinge areas
  - Serrations on instruments
  - Lumens of hollow instruments
  - Under clamps and locks
  - Crevices and hard-to-reach areas
Rinse thoroughly:
- Multiple rinses under running water
- Continue until water runs clear
- No visible blood, tissue, or soap residue
Dry completely:
- Pat dry with clean cloth
- Allow to air-dry completely
- Moisture left on instruments compromises sterilization

Step 4: Inspection

Quality check before sterilization:

Visual inspection:
- Cleanliness—no visible blood, tissue, or dirt
- Function—hinges move smoothly, cutting edges are sharp, clamps clamp properly
- Condition—no erosion, rust, or damage
Handling tests:
- Open and close hinges multiple times
- Test clamp pressure
- Test scissor cutting (cut gauze if available)
Action:
- If pass inspection → proceed to wrapping
- If fail inspection → set aside for repair or disposal; do not sterilize

Step 5: Wrapping

Prepare for sterilization:

Select appropriate wrapping:
- Double-layer wrap for storage
- Single layer for immediate use
- Appropriate material (paper, cloth, non-woven)
Wrap instruments:
- Place instruments in center of wrap
- Fold properly (see wrapping technique above)
- Place chemical indicator inside
- Label with contents, date, initials, cycle number if available

Step 6: Sterilization

Load autoclave:
- Arrange packages to allow steam circulation
- Do not overcrowd
- Leave space between packages
Run autoclave:
- Set appropriate temperature, pressure, time
- Monitor gauges
- Do not open during cycle
Cool adequately:
- Allow pressure to return to zero
- Allow instruments to cool and dry
- Wet instruments indicate sterilization failure

Step 7: Quality Assurance Check

After sterilization:

Inspect chemical indicators:
- Both external and internal indicators should have changed color
- Unexpected color change → sterilization may not have worked
- Indicators not changed → cycle failed; do not use
Inspect packages:
- Intact and dry
- No visible tears or holes
- No moisture or condensation inside package
- Wrapping properly adhered
Documentation:
- Record cycle number
- Record contents of package
- Record date of sterilization
- Record indicator results

Step 8: Storage

Clean storage area:
- Dry, cool location
- Protected from dust and moisture
- Away from water pipes or areas with risk of getting wet
Organization:
- Organize by type and date
- Use older packages first (first-in, first-out)
- Keep inventory of sterilized items
Shelf life:
- Properly wrapped, stored items remain sterile indefinitely if:
  - Package never compromised
  - Storage environment remains clean and dry
- If uncertain about shelf life, re-sterilize rather than risking patient safety

MODULE 4: WATER AND SANITATION

Introduction

Clean water is essential for healthcare facility operations including drinking, handwashing, food preparation, cleaning, and sterilization. Contaminated water is a major source of infectious disease transmission.

Key Points:

Water quality standards must be maintained for healthcare use
All staff must understand water quality and purification principles
Multiple purification methods should be available for redundancy
Water testing should be performed regularly when feasible

WATER QUALITY STANDARDS FOR MEDICAL USE

Drinking Water Standards

Microbiological Requirements:

Should be free from pathogenic bacteria, viruses, parasites
Fecal indicator bacteria (E. coli) must be absent
Acceptable standard: Zero CFU/100mL for E. coli
Low heterotrophic bacteria (less than 100 CFU/mL)

Physical Characteristics:

Clear and colorless (no turbidity)
No odor
No taste abnormalities
pH 6.5-8.5 (slightly acidic to neutral)
Temperature: Cool, typically under 25°C

Chemical Requirements:

Chlorine residual: 0.2-1.0 mg/L (if chlorinated)
No toxic chemicals or heavy metals above safe levels
No petroleum product contamination

Water for Medical/Surgical Use

Sterile Water:

Required for wound irrigation and certain procedures
Must be sterile (no microorganisms)
Can be produced by boiling and cooling or by sterilization
Must be stored in sterile container
Discard after opening

Non-Sterile Purified Water:

For handwashing stations
For cleaning and disinfection
For food preparation
Should meet drinking water standards

Water for Sterilization (Autoclave)

Requirements:

Preferably distilled or deionized to prevent mineral buildup
If tap water used, may accumulate minerals in autoclave
Softened water acceptable if softening removes minerals
Should be relatively free of chlorine (can interfere with sterilization)

WATER PURIFICATION METHODS

Boiling

Principle:

Heat kills microorganisms through protein denaturation
Does not remove chemicals or heavy metals
Does not improve taste or odor

Method:

Procedure:
- Fill pot with water to be purified
- Heat to rolling boil (100°C at sea level)
- Maintain rolling boil for 5-10 minutes
- Remove from heat
- Allow to cool completely before use
- Cover while cooling to prevent re-contamination
Effectiveness:
- Kills most bacteria, viruses, parasites
- Does NOT kill all spore-forming organisms
- Does NOT remove chemical contamination
Considerations:
- Very effective but energy-intensive
- Takes time (must boil, cool, store)
- Removes volatile disinfectants like chlorine (water may become less safe)
- May be best combined with other methods

Use:

Emergency situations
When other methods unavailable
For small quantities needed quickly
Best practice: Boil then chlorinate for extended storage

Chlorination

Principle:

Chlorine kills microorganisms through oxidation
Very effective, inexpensive, widely available
Residual chlorine provides continuing protection during storage/transport
Does not remove particles or some chemicals

Methods of Chlorination:

1. Liquid Chlorine (Sodium Hypochlorite/Household Bleach)

Preparation:

Standard household bleach: 3-6% sodium hypochlorite
For water purification: 0.5-2 mg/L chlorine residual needed

Dosing Calculation:

For 100 L water needing 1 mg/L chlorine:
- 100 mL bleach contains approximately 300-600 mg chlorine
- To achieve 1 mg/L in 100 L (100,000 mL): Need 0.1-0.2 mL bleach per liter
- Or: Add 10-20 drops per liter of water

Procedure:

Add appropriate amount of bleach to water
Stir thoroughly
Allow contact time: 30-60 minutes
Check for chlorine smell (indicates residual chlorine present)
If no smell, add more bleach and wait longer

Advantages:

Very inexpensive
Effective against most microorganisms
Provides residual protection
Easy to use

Disadvantages:

Bleach loses potency over time
Taste/odor (can be filtered through charcoal)
Does not remove particulates
Unsafe if overdosed (chlorine is toxic)

Safety:

Do not drink if strong chlorine taste/smell
Too much chlorine can cause GI upset
Good ventilation needed when handling concentrated bleach
Never mix chlorine with other chemicals (creates toxic gas)

2. Chlorine Tablets/Powder

Description:

Calcium hypochlorite or chlorine dioxide tablets
Convenient for field/emergency use
Longer shelf-life than liquid bleach
More concentrated than household bleach

Use:

Drop tablet in water container
Allow to dissolve
Wait contact time (usually 30-60 minutes)
Use when chlorine residual detected

Advantages:

Stable, long shelf-life
Easy to transport
Pre-measured dosing
Often available in emergency supply kits

Disadvantages:

More expensive than liquid bleach
May not be available in all locations
Still requires contact time
Tablets may not dissolve completely in cold water

Filtration

Principle:

Physical removal of particles, microorganisms, suspended solids
May improve taste and appearance
Does not disinfect (does not kill microorganisms)
Should be combined with disinfection method

Types of Filters:

Sand/Gravel Filter

Description:

Container filled with layers of sand and gravel
Water filtered through layers
Simple, low-tech system

Construction:

Container (barrel, large jar, or constructed tank)
Layer 1: Large gravel at bottom (5-10 cm)
Layer 2: Small gravel (5-10 cm)
Layer 3: Sand (20-30 cm)
Top layer: Cloth to prevent sand mixing with water

Operation:

Pour water slowly into top of filter
Water seeps through layers
Collected at bottom
Repeat if water not clear first pass

Effectiveness:

Removes particles and turbidity
Removes some bacteria (especially if filter clogged with biofilm)
Does NOT provide reliable disinfection
Must combine with chlorination or boiling

Maintenance:

Clean top cloth regularly (may clog with debris)
Flush system backwards occasionally to clean layers
Replace sand/gravel annually or when filter becomes too slow

Cloth/Paper Filter

Description:

Water poured through cloth or paper filter
Removes large particles
Very simple method

Use:

Pour water through cloth (multiple layers if available)
Repeats if needed
Continue until water appears clear

Effectiveness:

Removes visible particles and turbidity
Does NOT kill microorganisms
Only preprocessing for other methods
Improves taste and appearance

Maintenance:

Replace cloth after use
Cloth can be washed and reused if not heavily contaminated

Activated Charcoal Filter

Description:

Charcoal has porous structure absorbing chemicals and some organic compounds
Improves taste, reduces odor
Can be combined with sand filter (charcoal layer in sand filter)

Construction:

Create charcoal by burning wood in low oxygen (charring)
Activate by steaming (creates pores)
Layer in filter container

Effectiveness:

Removes chemicals, taste, odor
Does NOT kill microorganisms
Must combine with disinfection method
Improves palatability of treated water

Ultra-Violet (UV) Light Disinfection

Principle:

UV light damages DNA of microorganisms
Kills bacteria, viruses, some parasites
Does NOT provide residual protection (no continued disinfection after treatment)
Does NOT remove particles or chemicals

Equipment:

UV lamp (germicidal lamps emit UV-C wavelength 254 nm)
Requires electricity
Available in some healthcare settings

Method:

Pass water through UV chamber
UV light exposure kills microorganisms
Water can be used immediately after treatment
No chemical residue

Effectiveness:

Very effective at disinfection
Works on most microorganisms
Does NOT leave residual protection

Limitations:

Requires electricity (not available in all resource-limited settings)
Equipment expensive
Does NOT protect water during storage
No way to verify treatment in field

Best Use:

Point-of-use disinfection
Where electricity available
Combined with other methods (filtration, chlorination)

Solar Disinfection (SODIS)

Principle:

UV light and heat from sun kill microorganisms
Simple, free method using only sunlight
Works through combination of UV radiation and heat

Method:

Container Selection:
- Clear plastic bottles (PET plastic, 1-2 liter capacity)
- Clear glass bottles also work
- Must be transparent (colored bottles block UV)
Filling:
- Fill bottle completely with water
- Cap tightly (minimizes re-contamination)
Placement:
- Place in direct sunlight
- Position bottle horizontally or at angle to maximize sun exposure
- Leave in sun for 6-8 hours (1 day minimum)
- 2 days recommended for cloudy conditions
Effectiveness:
- Requires combination of UV light and heat
- Optimal temperature above 45°C
- Less effective in cool/cloudy conditions
- Takes time (not immediate disinfection)

Effectiveness at Different Conditions:

Condition	Treatment Time
Clear, sunny day	6-8 hours
Partly cloudy	8-12 hours
Very cloudy	Not recommended (2+ days)
Cold weather	2 days or more

Advantages:

Free (only requires sun, bottles)
Simple (no equipment or expertise needed)
Effective disinfection
Suitable for resource-limited/remote settings
Improves water taste compared to untreated

Disadvantages:

Takes time (not immediate)
Requires sunny weather
Limited quantity (bottles are small)
Not practical for large quantities
Containers may need replacement
No residual protection after treatment

Best Use:

Emergency/survival situations
Household water treatment in resource-limited areas
Small quantities for families
Combined with boiling or filtration for maximum safety

TESTING WATER QUALITY

Simple Testing Methods (Available in Resource-Limited Settings)

Visual Inspection

What to Observe:

Clarity:
- Should be clear, colorless
- Turbidity (cloudiness) indicates suspended particles
- May indicate inadequate treatment
Color:
- Should be colorless
- Brown/yellow tint may indicate contamination or iron content
- Red/orange may indicate rust (corroded pipes)
Floating Debris:
- Any visible particles, insects, algae
- Indicates need for filtration

Smell Test

Process:

Pour water into cup
Smell water
Smell of chlorine = adequate chlorination (good)
Smell of rotten eggs/sulfur = hydrogen sulfide (bad, requires treatment)
No smell but water from suspect source = may still contain microorganisms

Taste Test (Use with Caution)

Only perform if water from known source in low-risk situation

Rinse mouth with treated water
Taste small amount
Good water should have no taste or slight chlorine taste
Should NOT taste salty, metallic, or bitter

DO NOT TASTE if:

Water source is unknown
Risk of contamination present
Outward signs of contamination

Boil Test for Particulates

Purpose: Check if filtration adequate

Boil water in clear container
Observe as it cools
Mineral deposits or particles indicate hard water/contamination
Clean water should have no visible deposits

Field Testing Kits

Chlorine Test Strips

What It Tests: Residual chlorine level How to Use:

Dip test strip in water sample
Compare color to provided chart
Color indicates chlorine concentration
Safe level: 0.2-1.0 mg/L

Availability:

Relatively inexpensive
Available from medical supply companies
Small size enables field testing

pH Test Strips

What It Tests: Acidity/alkalinity Safe Levels: 6.5-8.5 How to Use:

Dip strip in water
Compare color to chart
Very acidic or alkaline water may cause corrosion or mineral buildup

Microbial Testing (Laboratory)

Methods:

E. coli test: Indicates fecal contamination
Total Coliform test: Indicates general bacterial contamination
CFU (Colony Forming Units): Counts viable bacteria

Process:

Water sample collected in sterile container
Sent to laboratory
Cultured at 37°C for 24-48 hours
Colonies counted/identified
Results indicate if water safe

Limitations:

Requires laboratory facilities (not available in many resource-limited settings)
Takes time (24-48 hours for results)
Relatively expensive
May not be available

PLUMBING AND WATER SYSTEM MAINTENANCE

Assessment of Existing Water System

Questions to Ask:

Where does water come from? (Municipal supply, well, surface water)
What treatment already in place? (Chlorination, filtration, UV)
How is water stored? (Tanks, containers, open/covered)
What is condition of pipes/plumbing? (Corroded, leaking, clean)
Are there backflow prevention devices?
How is water tested?

Water Storage

Key Principles:

Water in storage becomes contaminated over time
Even treated water degrades if stored improperly
Chlorinated water maintains safety longer than untreated

Storage Recommendations:

Containers:

Use food-grade containers only
Not previously used for chemicals
Container should be clean before filling
Cover containers to prevent contamination
Keep in cool, dark location (sunlight degrades chlorine)

Duration:

Treated/chlorinated water: Can be stored 1-2 months
Boiled water: Safer if used within a few days
Untreated water: Should not be stored (becomes contaminated)

Labeling:

Mark date when water was treated/stored
Mark treatment method used
Note any concerns (e.g., “boiled 72 hours ago”)

Pipe Maintenance

Common Problems:

Corrosion:
- Red/brown water indicates iron corrosion
- Metallic taste
- Over time, corrosion creates holes/leaks
- Solution: Replace corroded pipes, add water softener if possible
Leaks:
- Water loss, pressure loss
- Potential for contamination at leak points
- Regular inspection of pipes for dripping water
- Repair immediately
Scaling/Mineral Buildup:
- Hard water leaves deposits in pipes
- Reduces water flow
- Can clog entire system over time
- Periodic descaling or water softening may be needed
Biofilm/Algae Growth:
- In pipes/tanks with stagnant water
- Encourages bacterial growth
- Regular flushing prevents buildup
- May require UV treatment or treatment of entire system

Backflow Prevention

Principle:

Prevents contaminated water from flowing backward into clean water supply
Important at connection points (medical equipment, hoses)

Simple Prevention:

One-way check valve prevents backflow
Install where hoses/equipment connected
Regular testing ensures proper function

Regular Maintenance Schedule

Daily:

Visual inspection for leaks
Chlorine level testing (if using chlorine)

Weekly:

Check water appearance (clarity, color)
Verify chlorine residual
Inspect for unusual smell/taste

Monthly:

Full system inspection
Check all valves, connections for leaks
Flush pipes to remove sediment
Inspect storage tanks for contamination

Quarterly:

Test pH and basic water quality
Inspect pipes for corrosion
Verify chlorination adequate

Annually:

Comprehensive water testing (microbial if possible)
System servicing by qualified person
Pipe inspection, replacement as needed

GREYWATER AND BLACKWATER MANAGEMENT

Definitions

Greywater:

Wastewater from sinks, showers, laundry, hand hygiene stations
Contains soap, dirt, but typically without fecal matter
Can often be reused (with treatment) for irrigation, toilet flushing

Blackwater:

Wastewater from toilets, containing fecal matter
Highly contaminated, requires treatment before environmental release
Should NOT be reused for any purpose without extensive treatment

Greywater Management

Treatment Options:

Simple Settling and Filtration:
- Allow water to settle in tank (sediment sinks)
- Filter through sand/gravel
- Use for irrigation or toilet flushing
- Do NOT drink or use for food preparation
Constructed Wetlands:
- Water flows through planted wetland area
- Plants and soil microorganisms remove contaminants
- Effluent safer for environmental release
- Requires space and maintenance
Chlorination:
- Treat greywater with chlorine
- Can be reused for non-food irrigation
- Residual chlorine may affect sensitive plants

Best Practices:

Separate greywater pipes from drinking water pipes
Never allow mixing with drinking water system
Clearly label greywater (different color, warning signs)
Educate staff that greywater NOT safe for consumption
Regular testing if reusing greywater

Blackwater Management

Treatment Options:

Septic Tank System:
- Wastewater enters tank
- Solids settle; liquid effluent flows to drain field
- Does NOT fully disinfect
- Should not be relied upon alone for contamination reduction
Treatment Lagoons:
- Blackwater flows into large pond/lagoon
- Sunlight, time, natural processes reduce pathogens
- Requires significant land area
- Evaporation and seepage allow discharge
- Takes weeks to months for effective treatment
Constructed Wetlands:
- Similar to greywater treatment
- More robust plants needed for blackwater
- Effective pathogen removal over time
Chlorination:
- Can disinfect blackwater after initial settling
- Requires high chlorine doses
- Followed by UV treatment for additional safety
- Removes most pathogens but not all

Best Practices:

Do NOT discharge untreated blackwater to environment
Ensure treatment adequate before environmental release
Regular inspection and maintenance
Monitor for overflow/failure
Educate community about proper toilet use (prevent contamination of groundwater)

LATRINE/TOILET DESIGN FOR HEALTHCARE FACILITIES

Principles

Goals:

Prevent fecal contamination of water supply
Protect workers from contact with fecal matter
Maintain hygiene and dignity
Adequate capacity for facility population

Basic Latrine Types

1. Pour-Flush Latrine with Pit

Design:

Sealed pit below ground
Water seal prevents odor and fly transmission
User pours water to flush waste into pit
Requires water supply

Advantages:

Hygienic (water seal)
Low odor
Fly-proof if maintained properly
Simple construction

Disadvantages:

Requires water supply
Pit must be emptied periodically (expensive)
Unsuitable for areas with high water table
Potential groundwater contamination if pit leaks

2. Ventilated Improved Pit (VIP) Latrine

Design:

Pit with ventilation pipe to surface
Fly screen at top of vent pipe
Dark interior (flies avoid dark areas)
Air circulation from pit through vent pipe

Advantages:

No water needed
Reduced odor (ventilation)
Fly-proof if maintained
Lower cost than flush toilet

Disadvantages:

Pit must be emptied
Not as hygienic as flush toilets
Requires proper maintenance
Less suitable for frequent use areas

3. Flush Toilet with Septic Tank

Design:

Water-borne waste to septic tank
Tank treatment allows settled effluent to drain field
Most hygienic option
Requires water supply and maintenance

Advantages:

Hygienic
User-friendly
Low odor
Appropriate for healthcare facility

Disadvantages:

Most expensive option
Requires water supply
Requires regular pumping/maintenance
Potential groundwater contamination

Sanitation Facility Specifications for Healthcare

Minimum Requirements:

Number of Facilities:
- At least one toilet per 50 staff members
- Additional for patients
- Separate facilities for men/women
- Accessible facility for disabled individuals
Location:
- At least 30 meters from water source
- Downslope from water source if possible
- Protected from flooding
- Accessible to all staff/patients
Construction:
- Watertight pit (concrete lined)
- Covers to prevent contamination
- Ventilation to reduce odor
- Clean floors (concrete, not earth)
- Partition walls for privacy
- Door that closes securely
Handwashing Stations:
- Immediately adjacent to sanitation facilities
- Water available (tap, tap pump, or bucket)
- Soap available
- Drying material (cloth, paper)
- Design prevents contamination of stored water

Handwashing Station Design

Location:

Adjacent to toilets (within 2 meters)
At entry/exit to facility
At kitchen
Near patient care areas

Basic Design:

Tap System:

Hand pump, foot pump, or gravity-fed water system
Tap with screen (prevents insects entering)
Water source appropriate for handwashing (clean water minimum, doesn’t need to be sterile)

Basin:

Large enough to submerge hands
Drain to prevent water pooling (greywater drain acceptable)
Regular cleaning to prevent biofilm

Materials:

Simple basin (buckets, containers work)
Tap can be improvised (punctured bucket with spigot)
Soap storage (soap dish, bar holder)
Drying provision (cloth, paper towels, or air-dry)

No-Tap Handwashing Station:

If tap system unavailable:

Large container (barrel, bucket) with tap or spigot near bottom
Staff opens/closes tap with hand or foot
Soap bar on rope or soap dispenser mounted nearby
Basin underneath for draining

Multiple Stations:

Should be distributed throughout facility
High-traffic areas (before patient care, after toileting, before food preparation)
Encourage use through convenient placement and availability of supplies

MAINTENANCE AND MONITORING

Daily Tasks

Check water supply (flow, clarity)
Fill storage containers if needed
Check for leaks
Ensure soap available at handwashing stations
Test chlorine levels (if applicable)

Weekly Tasks

Inspect pipes for damage/corrosion
Check toilet function
Clean handwashing basins
Inspect storage tanks for contamination/overflow
Refill water containers

Monthly Tasks

Flush pipes to remove sediment
Inspect overall system
Repair minor leaks
Replace filters if in use
Water quality testing (appearance, taste, smell)

Quarterly Tasks

Professional inspection if available
Septic tank pumping (if needed)
pH testing
Water treatment evaluation

Annual Tasks

Full system servicing
Bacteriological testing (if possible)
Replacement of components showing wear
Evaluation of water quality adequacy for facility

MODULE 5: WASTE MANAGEMENT

Introduction to Medical Waste

Medical waste is generated from healthcare activities and can pose significant infection, chemical, and physical hazards if not properly managed. Proper waste management protects patients, staff, and the community.

Types of Healthcare Waste:

Infectious waste (contaminated with blood/body fluids)
Pathological waste (tissues, organs)
Pharmaceutical waste (expired medications)
Chemical waste (hazardous materials)
Sharps (needles, scalpels, broken glass)
General waste (non-hazardous, regular trash)

MEDICAL WASTE CATEGORIES

1. Sharps

Definition: Items that can penetrate skin

Includes:

Needles and syringes
Suture needles
Scalpel blades
Broken glass
Lancets
Surgical instruments with sharp points/edges

Hazards:

Bloodborne pathogen transmission (HIV, Hepatitis B, C)
Physical injury
High priority for safe handling

Management:

Immediate segregation into sharps container
Containers must be rigid, leak-proof, puncture-proof
Must be clearly labeled “SHARPS”
Never overfilled (80% capacity maximum)
Proper disposal (incineration, autoclaving if available)

2. Infectious Waste

Definition: Waste contaminated with blood or other body fluids

Includes:

Dressings with blood/body fluid
Contaminated linens
Contaminated gloves
Specimen containers with residual blood
Culture plates contaminated with pathogenic organisms
Contaminated disposable instruments
Suction waste

Hazards:

Bloodborne pathogen transmission
Environmental contamination
Staff exposure

Management:

Segregate into designated containers (usually red)
Treat before disposal (autoclaving, chemical disinfection, incineration)
Never place in regular waste stream

3. Pathological Waste

Definition: Human tissues, organs, body parts

Includes:

Surgical specimens
Placenta (unless requested for cultural reasons)
Pathological samples
Body parts from amputations
Fetal remains

Hazards:

Disease transmission
Psychological impact if improperly handled
Cultural/religious sensitivities

Management:

Segregate immediately
Treat with respect (cultural considerations important)
Incineration (preferred method)
Secure storage if delayed disposal
Document carefully
May require special rituals or burial (consult family/local practices)

4. Pharmaceutical Waste

Definition: Expired or unused medications

Includes:

Expired medications
Partially used medication vials/bottles
Chemotherapy drugs
Controlled substances
Antibiotics

Hazards:

Environmental contamination (water supply especially)
Potential for misuse
Regulatory compliance issues

Management:

Do NOT flush down toilets (environmental contamination)
Do NOT dispose with regular waste
Incineration (preferred if available)
Chemical disinfection or burial if incineration unavailable
Document disposal
Controlled substances may require additional documentation/notification to authorities

5. Chemical Waste

Definition: Hazardous chemical materials

Includes:

Cleaning agents
Disinfectants
Laboratory reagents
Formalin (from anatomical specimens)
Heavy metals (mercury from old thermometers)
Photographic chemicals

Hazards:

Toxicity
Corrosiveness
Reactivity (may explode/catch fire)
Environmental contamination
Staff exposure

Management:

Segregate by chemical type
Never mix incompatible chemicals (creates dangerous reactions)
Proper disposal according to chemical properties
Some chemicals require licensed hazardous waste disposal
Incineration where available
Proper documentation of disposal

6. Radioactive Waste

Definition: Materials contaminated with radioactive substances

Includes:

Contaminated needles, syringes (from radioisotope procedures)
Contaminated bodily waste (urine, feces from patients receiving radiotherapy)
Failed radiological equipment
Outdated radiological sources

Hazards:

Radiation exposure
Environmental contamination
Long-term health effects

Management:

Strict segregation required
Specialized training for handling
Decay-in-storage (if half-life permits)
Licensed waste disposal company required
Careful documentation and monitoring
May not be practical in many resource-limited settings
Best practice: Minimize radioactive materials use if safe alternatives available

Note: Many healthcare facilities in resource-limited settings may not have radioactive waste concerns; if they do, specialized guidance beyond this basic training needed.

7. General Waste

Definition: Non-hazardous waste, can be handled as regular trash

Includes:

Paper, cardboard
Packaging materials
Non-contaminated food waste
Administrative waste
Clean dry waste (not contaminated with body fluids)

Management:

Segregate from hazardous waste
Can be composted, recycled, or sent to landfill
Reduces volume of hazardous waste
Cost savings

Importance of Segregation:

Significant portion of medical waste may be general waste
Proper segregation reduces hazardous waste volume
Reduces cost of disposal
Reduces environmental impact

COLOR-CODED WASTE SEGREGATION SYSTEM

Standard color-coding improves waste segregation and reduces errors:

Color	Type of Waste	Contents	Disposal
RED	Infectious	Blood-contaminated, body fluid-contaminated items	Incineration, autoclaving
YELLOW	Pathological	Tissues, organs, body parts	Incineration, burial (cultural)
BLACK	General	Non-hazardous waste	Landfill, composting
WHITE/CLEAR	Sharps	Needles, syringes, scalpels	Sharps container, incineration
BLUE/GREEN	Pharmaceutical	Medications	Incineration, chemical disinfection
ORANGE	Aluminum/Metal	Metal containers, equipment	Recycling, salvage

Implementation:

Use color-coded containers throughout facility
Label containers clearly
Educate all staff on color meanings
Enforce segregation at point of generation
Regular audits to verify proper segregation

SHARPS CONTAINER MANAGEMENT

Sharps Container Selection

Requirements:

Rigid container (prevents puncture from outside)
Leak-proof (prevents leakage if punctured)
Puncture-proof (thick plastic or metal)
Labeled “SHARPS - DANGER”
Opaque (prevents visual exposure to sharps)
Size appropriate for volume and location

Container Construction:

If commercial containers unavailable:

Use rigid plastic bottle with secure cap
Cut small opening in cap just large enough for syringe/needle insertion
Secure cap with tape or glue
Label clearly “SHARPS - DO NOT TOUCH”
Place in stable location

Sharps Container Placement

Key Locations:

Every patient care area
Medication administration areas
Phlebotomy areas
Procedure rooms
Surgery/delivery rooms
Any area where needles/sharps used

Positioning:

At waist level for convenient, safe disposal
Stable and cannot tip over
Accessible to staff using sharps
Not in high-traffic areas (preventing accidental strikes)
Visible but not in direct patient traffic

Safe Sharps Disposal Technique

Proper Procedure:

After Use, Immediately After Procedure:
- Do not recap needle
- Do not bend needle
- Do not manipulate sharp in any way
- Carry sharp directly to sharps container at point of use
Disposal:
- Approach container safely
- Position hand/syringe at appropriate angle to opening
- Drop sharp into container decisively
- Do not touch rim of container
- Do not force sharp into container (risk of overpacking, injury)
Recapping Only If Absolutely Necessary:
- If recapping unavoidable (rare situation):
  - Use one-handed scoop technique: Never use two hands to recap
  - Place needle cap on flat surface
  - Using one hand, scoop cap onto needle
  - Never direct needle toward self or others

Important: OSHA/WHO guidelines: Never recap needles

Sharps Container Maintenance

Filling:

Fill container only to 80% capacity
Never overfill (increases puncture risk, makes disposal difficult)
Mark the 80% level clearly

Closure and Sealing:

Once 80% full, seal container
Use appropriate closure (lid, tape, adhesive) per container design
Ensure seal secure and leak-proof

Storage Until Disposal:

Store in designated location (not where patients/public access)
Protected from moisture (prevents degradation)
Keep away from heat and sharp objects
Do not exceed 1 month storage (biological growth, deterioration)

Disposal:

Incineration (preferred method)
Steam sterilization (if available) followed by regular waste disposal
Puncturing and chemical disinfection (if other methods unavailable)
Never dispose in regular trash
Never bury without treatment (possible exposure)

Sharps Injury Management

Immediate Action:

Wash wound area immediately with soap and water
Encourage bleeding (do not squeeze; allow natural drainage)
Rinse wound thoroughly
Do not apply tourniquet or aggressive treatment

Documentation:

Report incident to occupational health
Document details: type of sharp, source patient (if known), circumstances
Baseline testing for source patient (if consent obtained)

Follow-up Care:

Post-exposure prophylaxis evaluation (see Module 8)
Follow-up testing of exposed worker
Counseling and support

INFECTIOUS WASTE TREATMENT

Autoclaving

Method:

Same as instrument sterilization (see Module 3)
Waste in special steam-permeable bags placed in autoclave
Heat and steam kill microorganisms
Treated waste can be disposed as regular waste after autoclaving

Procedure:

Segregate infectious waste
Place in designated waste container (red-colored, leak-proof)
Once full (not overfilled), seal container
Wrap or place in steam-permeable bag for autoclaving
Autoclave at 121°C for 20-30 minutes
Cool completely before handling
Dispose as regular waste after treatment

Advantages:

Effective disinfection
Treated waste can be disposed normally
No chemical hazards
Uses existing equipment (if autoclave available)

Disadvantages:

Requires autoclave (not available everywhere)
Energy-intensive
Takes time

Incineration

Method:

High-temperature combustion destroys infectious waste
Most effective method for large quantities
Burns waste completely

Incinerator Types:

Manual Incinerator (Drum/Barrel)

Description:

Metal drum or barrel
Fire/fuel inside
Waste added to burning fuel
Simple, low-cost option

Construction:

Take large metal drum or barrel
Cut openings in sides for air flow
Place on stable support (elevated off ground)
Add grate/screen at bottom for ash collection
Provide door/opening for waste addition

Operation:

Add fuel (wood, charcoal) to bottom
Ignite fuel
When fire established, add infectious waste gradually
Maintain adequate air flow for complete burning
Stir occasionally to ensure thorough burning
Continue until all waste burned

Challenges:

Incomplete burning if not managed properly
Smoke and air pollution
Requires skilled operation
Not suitable for all waste types (some items don’t burn completely)
Ash handling/disposal needed

Advantages:

Low cost
Simple construction
No electricity needed
Can treat large quantities

Disadvantages:

Air pollution
Incomplete combustion (some pathogens may survive)
Manual operation required
Ash disposal
Environmental impact

Controlled Incinerator

Description:

Designed incinerator with better combustion control
Multiple chambers for thorough burning
Temperature and air flow controlled
Safer and more complete than manual

Advantages:

More complete combustion
Better emission control
Safer operation
More professional result

Disadvantages:

Higher cost
Requires more skill to operate
Needs maintenance
Not available in many resource-limited settings

Chemical Disinfection

Method:

Treat waste with disinfectant solution
Followed by safe disposal in landfill or burial

Procedure:

Segregate infectious waste
Place in leak-proof container
Add appropriate disinfectant (1% bleach solution usually)
Ensure complete immersion
Allow contact time (20-60 minutes)
Carefully dispose treated waste in designated pit/burial area or regular waste

Disinfectants:

Sodium hypochlorite (bleach) 1-5%
Calcium hypochlorite solution
Quaternary ammonium compounds

Advantages:

Can be done without specialized equipment
Relatively inexpensive
Can treat small quantities easily

Disadvantages:

Takes time (contact period required)
Chemically hazardous if not careful
Still requires safe final disposal
Reduced effectiveness if organic matter present

Boiling

Method:

Place waste in pot of water
Heat to rolling boil for 20-30 minutes
Kills microorganisms through heat

Procedure:

Place waste in large pot
Add enough water to cover completely
Heat to rolling boil
Maintain boiling for 20-30 minutes
Cool completely
Remove and dry waste
Dispose as regular waste

Limitations:

Only practical for small quantities
Labor-intensive
Only kills microorganisms (doesn’t remove hazards like pathological waste)
Steam/vapor exposure to workers

WASTE MINIMIZATION STRATEGIES

Reducing the amount of medical waste generated saves money and reduces environmental impact:

At Source

Reduce Unnecessary Waste Generation:
- Use multi-dose vials instead of single-dose when safe and appropriate
- Reusable instruments instead of disposable where practical
- Minimize packaging
Use Standard Precautions Appropriately:
- Use PPE only when indicated (reduces contaminated waste)
- Do not treat all waste as infectious (segregate properly)
Improve Process Efficiency:
- Reduce medication waste (better inventory management)
- Reduce spillage (careful handling procedures)
- Reduce contamination during procedures (reduces need to discard items)

During Storage

Compact Waste:
- Do not overfill containers
- Compress non-hazardous waste before disposal
- Reduces volume, cost
Segregation:
- Properly segregate to minimize infectious waste category
- More waste can go to regular disposal, less treatment needed

During Disposal

Recycling:
- Metal containers, equipment (if not contaminated) → recycling
- Aluminum, glass → salvage
- Reduces waste going to disposal sites
Composting:
- Non-contaminated organic waste → compost
- Pathological waste (sometimes) → burial
- Vegetative waste → garden compost
Partial Treatment:
- Some waste can be treated to safe level, then disposed as regular waste
- Reduces final disposal volume significantly

WASTE MANAGEMENT PROTOCOL: STEP-BY-STEP

Waste Generation (At Point of Use)

Assess Waste Type:
- Is it contaminated with blood/body fluids? → Infectious
- Is it a sharp? → Sharps container
- Is it tissue/pathological? → Pathological
- Is it medication? → Pharmaceutical
- Is it clean, non-contaminated? → General
Segregate Immediately:
- Do not wait to segregate later
- Place in appropriate colored container immediately
- Prevents cross-contamination
Containers:
- Use appropriate, labeled container for each type
- Containers leak-proof if infectious/pathological
- Do not overfill containers

Transport

Segregation Maintained:
- Different colored/labeled containers
- No mixing of waste types
Safe Transport:
- Do not spill or drag containers
- Do not expose to staff/public
- Use designated transport routes if available
- Minimize transport distance
Storage:
- Designated storage area away from patients/public
- Protected from moisture, animals, insects
- Limited duration (1 month maximum for most waste)

Treatment

Select Appropriate Method:
- Based on waste type and available resources
- Incineration for pathological and large quantities
- Autoclaving for infectious waste
- Sharps → incineration or steam sterilization
- Pharmaceutical → incineration or chemical disinfection
Treat Thoroughly:
- Follow procedures exactly (time, temperature, chemicals)
- Document treatment
- Ensure complete treatment before disposal

Final Disposal

After Treatment:
- Treated waste can go to landfill
- Incinerated ash → landfill or burial
- Autoclaved waste → regular waste disposal
Environmental Safety:
- Do not dispose in water supply areas
- Do not bury in high water table areas
- Maintain safe distance from dwellings
- Do not burn (creates air pollution) if other methods available
Documentation:
- Record what waste types generated
- Record treatment method used
- Record quantities (approximate)
- Record disposal location
- Maintain records for audit/compliance

OCCUPATIONAL SAFETY IN WASTE MANAGEMENT

Hazards:

Bloodborne pathogen exposure
Chemical exposure
Physical injury from sharps
Thermal burns from incineration
Respiratory hazards from smoke

Protection:

Appropriate PPE (gloves, eye protection, gown if needed)
Training on waste handling procedures
Proper equipment and facilities
Regular health screening
Post-exposure protocols for incidents

PPE for Waste Management:

Heavy-duty gloves (puncture-resistant)
Long sleeves (if incinerating)
Eye protection
Gown (if handling heavily contaminated waste)
Closed-toe shoes
Respiratory protection if smoke exposure likely

MODULE 6: ISOLATION AND QUARANTINE

Introduction

Isolation and quarantine are essential measures to prevent transmission of infectious diseases. While often used interchangeably, they have distinct meanings and applications.

Definitions:

Isolation: Separating sick individuals from well individuals to prevent disease transmission
Quarantine: Separating individuals who may have been exposed but are not yet sick to prevent transmission if they develop illness

Key Principle: Early identification and appropriate isolation/quarantine can significantly reduce disease transmission in healthcare settings.

TYPES OF ISOLATION PRECAUTIONS

Isolation precautions are categorized by the presumed route of transmission.

Standard Precautions

Applies to: ALL patients, ALL settings

Principle: Every patient’s blood and body fluids should be treated as potentially infectious

Precautions:

Hand hygiene before and after patient contact
Gloves when contact with blood/body fluids possible
Mask and eye protection if splashing risk
Gown if contamination likely
Safe sharps handling
Respiratory hygiene (patient covers mouth when coughing)

Rationale: Many patients may be infected but asymptomatic; standard precautions provide baseline protection for all

Contact Precautions

Used for: Diseases spreading through direct contact with patient or contaminated surfaces

Conditions Requiring Contact Precautions:

C. difficile infection
Methicillin-resistant Staphylococcus aureus (MRSA)
Vancomycin-resistant enterococci (VRE)
Norovirus
Rotavirus
Diarrheal diseases in general
Skin/wound infections with multi-drug resistant organisms
Impetigo
Scabies
Lice infestation

Additional Precautions Beyond Standard:

Private room (if available) or cohort with same organism
Gloves and gown for all patient contact
Dedicated equipment (thermometer, stethoscope, BP cuff)
Hand hygiene: SOAP AND WATER (alcohol-based hand rub NOT effective for C. difficile spores, norovirus)
Careful attention to environmental contamination
Thorough cleaning of room/equipment after discharge

Duration: Until symptoms resolve or microbiological clearance confirmed

Droplet Precautions

Used for: Diseases spreading through respiratory droplets (5-6 microns travel distance of 1-2 meters)

Conditions Requiring Droplet Precautions:

Influenza
Respiratory syncytial virus (RSV)
Parainfluenza
Adenovirus
Whooping cough (pertussis)
Measles (first 4 days of rash)
Meningococcal disease
Scarlet fever
Mumps (first 5 days of parotitis)
Rubella (first 7 days of rash)
Respiratory diphtheria

Additional Precautions Beyond Standard:

Private room (if available) or cohort with same organism
Surgical mask for healthcare workers caring for patient
Patient should wear mask when outside room (source control)
Restrict patient movement (only when necessary; wear mask)
Maintain distance of at least 1-2 meters
Limit visitors (if strict precautions needed)

Duration: Usually 24 hours after starting antibiotics or until symptoms resolved

Airborne Precautions

Used for: Diseases spreading through airborne particles (smaller than 5 microns, can remain suspended for hours)

Conditions Requiring Airborne Precautions:

Tuberculosis (active respiratory TB)
Measles
Varicella (chickenpox)
Disseminated varicella zoster virus
SARS-CoV-2 (COVID-19), especially during aerosol-generating procedures
Severe acute respiratory infection (SARI)
Middle East respiratory syndrome (MERS)

Additional Precautions Beyond Standard:

Negative pressure room (if available) - air drawn out of room, not into hallway
N95 respirator or equivalent (fit-tested) for healthcare workers
PAPR acceptable alternative
Limit patient movement (only when necessary)
Patient should wear N95 if must leave room
Dedicated equipment (do not move equipment between rooms)
Medical equipment (ventilators, monitors) kept in room if possible
Special attention to air handling/ventilation
Duration varies by condition (TB: until after 2 weeks appropriate treatment and improving; measles: 4 days after rash onset)

Room Requirements (Negative Pressure Room):

Air pressure negative relative to corridor
Air intake from outside (or filtered)
Air exhausted outside or through HEPA filter
12-15 air changes per hour recommended
Door kept closed

Without Negative Pressure Room:

Room with closed door and window
Window crank open slightly if possible (natural ventilation)
Keep room door closed when patient present
Still requires N95 respirator use
Less ideal but better than standard precautions

ISOLATION ROOM SETUP AND REQUIREMENTS

Physical Requirements

Ideal Isolation Room:

Single occupancy (patient alone)
Negative pressure (for airborne precautions)
En-suite bathroom (dedicated to isolated patient)
Window (natural ventilation)
Door that closes securely
Space for donning/doffing PPE outside room

Minimal Setup (Resource-Limited Settings):

Private room or screened-off area
Door or curtain that closes
Access to handwashing facilities nearby
Space for waste disposal

Equipment and Supplies in Isolation Room

Essential Items:

Handwashing station (sink with soap/water or ABHR dispenser)
Glove dispenser (convenient location)
Mask dispenser (if droplet/airborne precautions)
Gown hook or dispenser
Waste containers (infectious waste clearly marked)
Sharps container
Clean linens (dedicated to room if possible)
Equipment (BP cuff, stethoscope, thermometer) left in room for duration

Organization:

All supplies within reach of staff
Clear labeling of precautions (sign on door)
Visible color-coding if used
Easy access without contaminating hallway

Signage for Isolation Room

Placement:

On door to room (clearly visible)
At foot of bed (visible to staff)
At entry point if before room door

Information to Display:

Type of precautions (Contact/Droplet/Airborne)
If precautions are temporary or permanent
Conditions requiring precautions to be maintained
Patient name/identification (maintain privacy; ensure only staff see)
Allergies (especially to antibiotics, latex)
Special precautions (e.g., “Do not share equipment between rooms”)

ISOLATION PRECAUTION PROCEDURES

Entering Isolation Room

Before Entering:

Read precaution sign carefully
Gather all needed supplies (prevents multiple entries)
Don appropriate PPE before entering

PPE Donning Sequence (Review Module 2 for detailed instructions):

Gloves
Gown (if contact/airborne precautions)
Mask or respirator (if droplet/airborne precautions)
Eye protection (if splashing risk or high-risk procedures)

Entering:

Open door minimally
Do not allow door to stand open unnecessarily
Greet patient and maintain normal interaction (isolation precautions not social isolation)

During Care Provision

Principles:

Minimize patient contact duration (efficient care)
Avoid contaminating surfaces outside isolation room
Do not touch own face or remove PPE during care
Maintain proper hand hygiene throughout

For Airborne Precautions Especially:

Keep N95 on for entire contact
Do not remove between tasks
Do not hang on arm or around neck to reuse (compromises protection)

Exiting Isolation Room

PPE Doffing Sequence (most important step for preventing exposure):

See Module 2 for detailed doffing instructions. Generally:

Remove gloves (if outermost layer) - careful technique to avoid self-contamination
Hand hygiene (ABHR)
Remove gown if worn - turn inside-out as removing
Hand hygiene
Remove eye protection
Hand hygiene
Remove mask/respirator (last item, do not touch front surface)
Hand hygiene (soap and water final wash if hands visibly soiled)

Critical: Do not touch contaminated surfaces or own face during doffing

After Exiting:

Verify door closed behind you
Perform final hand hygiene
Do not touch anything in hallway until hand hygiene complete
Report any concerns with isolation setup or patient condition

Environmental Cleaning of Isolation Room

Daily Cleaning:

All surfaces touched by patient or staff (bed rails, door handles, light switches)
Bathroom surfaces
Equipment in room
Use appropriate disinfectant per facility protocol (0.5% bleach or equivalent usually)
Dedicated cleaning staff or designated staff if dedicated staff unavailable

Terminal Cleaning (After Patient Discharge/Death):

Complete room disinfection (see Module 7)
All surfaces including walls, ceiling if splashing occurred
Equipment cleaned or replaced
Linens: All soiled linens in designated contaminated laundry

PATIENT COHORTING STRATEGIES

When: Multiple patients with same organism/disease Where: Limited isolation rooms available

Principle: Group patients with same organism/disease together to reduce cross-contamination and efficient use of limited space/resources

Cohort Setup

Identify Patients:
- All with same organism/disease
- All at same stage of infection (if applicable)
- Confirmed diagnosis or awaiting confirmation
Dedicated Area:
- Multiple beds in same room or adjacent area if possible
- Separate from other patient areas (barrier/partition)
- Shared handwashing/bathroom facilities acceptable (all cohort exposed to same organism)
- Dedicated staff if possible (prevents spread to other units)
Shared Equipment:
- Equipment can be shared within cohort
- Equipment NOT shared with non-cohort patients (prevents spread)
- Disinfect equipment thoroughly before/after cohort use
Precautions:
- Same precautions as single patient isolation

Hand hygiene between patients (within cohort)
- Separate care of most contaminated patients (if different levels of contamination)

Advantages of Cohorting

Efficient use of limited isolation space
Reduces cross-contamination (cohort patients cannot spread to others)
Reduces PPE use (staff can provide care to multiple cohort patients with single PPE setup)
Cost-effective

Disadvantages

Requires identification of organism/diagnosis early (not always possible)
May be stressful for patients (isolation with other ill patients)
Limits privacy
Cannot separate very ill patients who need different levels of care

VISITOR POLICIES DURING OUTBREAKS

Risk Assessment

Before Allowing Visitors, Consider:

Is patient infectious? (depends on time since symptom onset, treatment initiation, organism)
Can visitors pose risk to other patients? (if they visit multiple patients)
Can isolation precautions be maintained with visitors present?
Is visitation essential for patient wellbeing?

Visitor Restrictions

During Outbreaks or High-Risk Situations:

Restrict Number of Visitors:
- Limit to 1-2 designated visitors per day
- Reduces exposure risk
- Maintains sanity for patient
- Minimizes disruption of precautions
Screen Visitors:
- Ask about symptoms (fever, cough, diarrhea, rash)
- Do not allow visitors with symptoms
- Document visitor information (contact tracing if needed)
Educate Visitors:
- Explain infection control measures
- Explain importance of precautions
- Provide instruction on PPE use (if needed)
- Provide hand hygiene instruction
Restrict Visitor Movement:
- Visitors should not move between isolation rooms
- Visitors should not visit other parts of facility if possible
- Restrict access to facility (only one entrance if possible, for screening)
Duration of Visits:
- Limit visit duration (reduces exposure)
- Schedule visits (prevents crowding)
- Ensure adequate space for physical distancing

Visitor PPE

If visitors allowed in isolation rooms:

Provide gloves, mask, gown per precautions
Educate on donning/doffing
Supervise if needed (especially elderly or children)
Ensure hand hygiene before and after

Special Circumstances

Exceptions to Restrict Restrictions:

End-of-life care (allow family presence for comfort care)
Pediatric patients (allow parents/guardians for care and emotional support)
Severely mentally ill patients (may require family support)
Patients unable to care for themselves (may need family assistance)

Even in these situations, maintain maximum precautions and restrict other visitors.

TRANSPORT OF ISOLATED PATIENTS

When Transport Necessary

Essential medical procedures outside room (X-ray, surgery)
Patient transfer to higher level of care
Urgent diagnostic testing
Avoid if non-essential

Transport Precautions

Before Transport:

Assess necessity (is transport essential?)
Inform receiving area of precautions needed
Coordinate timing (prevent delays, reduce exposure duration)
Prepare patient (PPE donning if capable)
Prepare transport vehicle/equipment

Patient Precautions:

Patient should wear appropriate mask/PPE if capable
Respiratory hygiene (cover mouth when coughing)
Minimize contact with environmental surfaces if possible

Transport Staff Precautions:

Appropriate PPE for precaution type
Hand hygiene before/after transport
Clean transport vehicle/equipment immediately after

Receiving Area Notification:

Call ahead to receiving area (X-ray, OR, etc.)
Notify of precautions needed
Allow time for room preparation
Avoid transport route through high-traffic areas if possible

Transport Equipment:

Dedicated wheelchair/stretcher if possible (not shared with others)
Or thoroughly disinfect equipment before/after use
Do not transport through areas where it might be touched by others

Discharge of Isolated Patient

When Safe to Discharge:

Patient is no longer infectious (organism cleared or treatment completed)
Clinical improvement
No further medical need for facility care

Before Discharge:

Provide patient education:
- Duration of continued precautions (if any)
- How to prevent spread to family/others
- When to seek further medical care
- Follow-up appointments
Documentation:
- Provide discharge summary
- Note infection status
- Provide isolation instructions for home care
- List precautions if still infectious
Environmental:
- Terminal cleaning of isolation room
- Disinfection of all equipment used by patient
- Ensure room ready for next patient

QUARANTINE PROTOCOLS FOR EXPOSED INDIVIDUALS

Definition and Purpose

Quarantine: Separation of individuals who have been exposed to an infectious disease but are not yet symptomatic, to prevent transmission if symptoms develop

Purpose: Prevent transmission from asymptomatic/presymptomatic infected individuals

Indications for Quarantine

Exposed individuals who should be quarantined:

Healthcare workers exposed to high-risk pathogen (TB, measles, etc.)
Patients exposed to patient in same room
Visitors exposed in healthcare setting
Household contacts of confirmed cases
Close contacts of confirmed cases

Exposure Definition Varies:

Close contact usually: Within 1-2 meters for 15+ minutes
May vary based on disease (TB: prolonged proximity; measles: any contact in room)

Quarantine Setup

Location Options:

Home quarantine (if space, resources available)
Facility quarantine room (if home isolation insufficient)
Hospital/facility designated quarantine area

Requirements:

Separate from ill individuals (isolation from patients)
Separate from well individuals (self-isolation)
If home: Separate room from others, own bathroom if possible
If facility: Single room, comfortable conditions
Access to food, water, medications
Ability to contact healthcare if symptoms develop

Duration of Quarantine

Depends on:

Incubation period of disease (time from exposure to symptom onset)
Level of exposure
Local/regional public health guidelines

Common Quarantine Durations:

COVID-19: 5-10 days (depending on exposure level, vaccination status)
Measles: 21 days after last exposure (incubation 10-21 days, contagious 4 days before rash)
Tuberculosis: Duration depends on treatment status, conversions, etc. (weeks to months)
Influenza: 7-10 days
Pertussis: 5 days after starting antibiotics

Modify Based On:

Symptom development (if symptoms appear, convert to isolation)
Test results (if negative test reliable for disease, may release early)
Vaccination status (vaccinated individuals may have shorter quarantine)
Public health guidance

Monitoring Quarantined Individuals

Daily Check-ins:

At minimum, daily communication
Via phone, video call, text, or in-person if facility-based
Ask about: Temperature, cough, other symptoms, medication needs
Document contact and findings

Symptom Monitoring:

Provide thermometer and instructions for temperature checking
Provide list of symptoms to watch for
Instructions for when to seek care (fever above certain temperature, difficulty breathing, etc.)

Support Provision:

Mental health support (isolation can be stressful)
Food/supply delivery if home quarantine
Medication refills if needed
Work/school notification if appropriate

Release from Quarantine

Criteria for Release:

Completion of quarantine period without symptoms, OR
Negative test results (if testing available/reliable) before end of quarantine period, OR
Clear medical evaluation by healthcare provider

Documentation:

Document quarantine completion date
Note any symptoms that developed
Provide clearance letter if appropriate (for work, school, etc.)
Advise to monitor for symptoms for few more days after release

Quarantine for Healthcare Workers

Special Considerations:

Worker unable to work during quarantine (lost productivity)
May need paid leave/support
Need for adequate staffing (plan for absences)
Early return-to-work criteria may apply

Early Return Options:

Testing negative before end of quarantine (if test available)
Working while in quarantine if in isolation area (not recommended but sometimes necessary in severe shortages)
Rapid return after negative test (depends on test sensitivity/disease)

Documentation:

Document quarantine periods for occupational health records
Note results of any testing
Keep records for contract tracing if needed

DURATION OF ISOLATION FOR COMMON CONDITIONS

Condition	Duration	Additional Notes
Influenza	24 hours after fever resolves without antipyretics (or 7 days)	Until fever-free and respiratory symptoms improving
COVID-19	5 days if symptoms resolving; up to 10 days if symptoms persist	May reduce to 3-5 days with negative test
Measles	4 days after rash appears	Rash onset marks most infectious period
Varicella	5 days after rash appears	When all lesions crusted over
Pertussis	5 days after starting appropriate antibiotics	If untreated: 21 days after symptom onset
TB (respiratory)	Until 2 weeks after starting effective treatment AND clinical improvement	Patient must tolerate therapy, AFB sputum negative
Mumps	5 days after parotitis onset	Swelling onset
Rubella	7 days after rash appears	Rash onset
MRSA/VRE	Until cleared (may require multiple negative cultures/tests)	Contact precautions until cleared
C. difficile	Until diarrhea resolves	Contact precautions continue after discharge
Norovirus	Until symptoms resolve, +24 hours	Very contagious; strict precautions important

CONTACT TRACING BASICS

Definition and Purpose

Contact Tracing: Process of identifying and following up with individuals who had contact with a confirmed case of infectious disease

Purpose:

Identify secondary cases early
Implement quarantine/isolation to prevent further spread
Interrupt disease transmission chains

When Contact Tracing Performed

Notifiable diseases (TB, measles, pertussis, etc.)
Outbreak investigations
High-risk pathogens
New/unknown infections

Contact Tracing Process

Step 1: Identify Confirmed Case

Patient with confirmed diagnosis
Document patient information (name, contact information, dates of illness)

Step 2: Identify Contacts

Interview patient about activities during infectious period
Ask about: Close contacts, family members, coworkers, healthcare workers, visitors
Define “contact” based on disease (proximity, duration, exposure route)
Document each contact (name, phone, address, relationship, exposure details)

Step 3: Contact Notification

Contact each identified individual
Inform of exposure without disclosing patient identity (if possible)
Explain quarantine recommendations
Provide testing information if available
Provide monitoring instructions

Step 4: Quarantine Implementation

Advise quarantine period
Provide resources/support
Daily monitoring during quarantine period

Step 5: Follow-up

Monitor for symptom development
Implement isolation if symptoms develop
Test if testing available and appropriate
Document all contacts and outcomes

Step 6: Data Management and Privacy

Maintain confidentiality (HIPAA or local privacy regulations)
Store information securely
Destroy information per retention requirements
Provide information only to need-to-know personnel

Challenges in Contact Tracing

Patient unable to recall all contacts
Contacts unwilling to comply with quarantine
Large number of contacts (difficult to reach)
Limited resources for follow-up
Asymptomatic individuals spreading disease (difficult to identify)

Contact Tracing in Healthcare Settings

Advantages:

Contacts known (other staff in unit, patients in close area)
Limited number of contacts
Easier to implement testing/quarantine for healthcare workers

Process:

Identify healthcare worker or patient with confirmed infection
Identify unit/area exposed
Identify all staff/patients in area during infectious period
Implement appropriate precautions/quarantine
Monitor for symptom development
Test if available/appropriate
Allow return to work/discharge based on testing/duration

MODULE 7: ENVIRONMENTAL HYGIENE

Introduction

Environmental contamination plays a significant role in disease transmission in healthcare settings. Proper cleaning and disinfection of the healthcare environment protects patients, staff, and visitors.

Key Principle: A clean healthcare environment reduces transmission of infectious agents and creates a pleasant, professional atmosphere for care delivery.

CLEANING PROTOCOLS FOR DIFFERENT AREAS

General Principles

Before Starting:

Gather all needed supplies (prevents interruptions)
Don appropriate PPE (gloves minimum, more PPE if heavy contamination)
Ensure water available
Organize cleaning to prevent cross-contamination (clean areas before dirty areas)

Cleaning Steps:

Remove visible debris
Apply appropriate cleaning solution
Scrub/wipe all surfaces
Rinse if necessary
Dry completely
Dispose of contaminated materials properly

Operating Room/Surgical Suite

Frequency:

Before first patient of day
Between each surgical procedure
After completion of all procedures (terminal cleaning)

Procedure:

Equipment/Supplies:

Cleaning solution (surgical-grade disinfectant or dilute bleach)
Microfiber cloths (non-shedding)
Mop with disposable head or designated OR mop
Bucket for cleaning solution
Waste container

Steps:

Immediate After-Surgery Cleanup:
- Remove any debris from operative field
- Discard sharps immediately
- Remove soiled instruments from surfaces
- Wipe down surgical table/lights with damp cloth
Systematic Cleaning:
- Start from ceiling (if splashing occurred):
  - Use damp cloth to wipe surgical lights
  - Wipe window/observation area if contaminated
- Progress to walls:
  - Wipe walls from top to bottom (gravity prevents re-contamination)
  - Focus on areas within 1-2 meters of surgical field (most likely splashed)
- Clean surgical table:
  - Thoroughly wipe entire top surface
  - Wipe sides and base
  - Allow to dry
- Clean all equipment surfaces:
  - Overhead lights
  - Monitors
  - Cautery unit
  - All surfaces that may have been touched
- Clean floors:
  - Wet mop entire floor
  - Pay attention to areas around table (most contaminated)
  - Allow to dry before next procedure
Time Efficiency:
- With good technique, can clean OR between procedures in 15-20 minutes
- Complete before next patient enters
Terminal Cleaning (End of Day or After Contaminated Cases):
- More thorough cleaning if particularly contaminated procedure
- Includes high shelves, corners
- May include walls if significant splashing

Patient Rooms

Frequency:

Daily (at minimum)
After patient discharge (terminal cleaning)
Immediate cleanup if spills/contamination occur

Daily Cleaning:

Prepare:
- Ensure patient privacy/dignity
- Gather supplies before starting
- Don gloves minimum
Surfaces:
- Bed rails: Wipe with disinfectant cloth
- Bedside table: Wipe clean
- IV pole/equipment: Wipe accessible surfaces
- Light switches, door handles: Wipe with disinfectant
- Window sills if accessible
- Floors: Damp mop or sweep as appropriate
Bathroom:
- Toilet: Disinfect inside and outside (use brush for inside, cleaning cloth for outside)
- Sink: Scrub and disinfect
- Floor: Damp mop
- Mirrors: Wipe clean
- Soap/towel dispensers: Refill as needed
Trash/Linen:
- Remove and replace trash liners
- Place soiled linens in designated hamper
- Ensure waste containers not overflowing

Terminal Cleaning (After Discharge):

Remove All Personal Items:
- Patient belongings removed
- Flowers/decorations removed
Disinfect All Surfaces:
- All flat surfaces
- High-touch areas (door handles, light switches, bed rails)
- Walls if splashing occurred
- Use appropriate disinfectant (0.5% bleach or equivalent)
- Allow contact time (5-10 minutes)
Bathroom Deep Clean:
- Toilet: Disinfect thoroughly, inside and out
- Sink: Disinfect
- Shower/tub: Clean and disinfect if patient used
- Floor: Disinfect thoroughly
Floors:
- Wet mop entire room
- Use disinfectant solution
- Pay attention to corners, under furniture
- Allow to dry completely
Equipment:
- Thermometer: Disinfect
- Stethoscope: Disinfect (if left in room)
- Any equipment in room: Disinfect or replace
Linens:
- All linens removed and placed in contaminated laundry
- Fresh linens placed on bed
- Room ready for next admission

Common Areas (Waiting Rooms, Corridors, Offices)

Frequency:

Daily minimum
More frequent in high-traffic areas
More frequent in outbreak situations

Procedure:

Sweep or Vacuum:
- Remove visible debris
- Vacuum preferred (prevents dust circulation)
Disinfect High-Touch Surfaces:
- Door handles
- Light switches
- Railings
- Furniture (armrests, chairs)
- Pay special attention to frequently touched items
General Cleaning:
- Wipe tables/desks
- Clean chairs/furniture
- Wipe walls if visibly soiled
Floors:
- Damp mop (wet mop prevents dust circulation)
- Use appropriate floor solution (mild detergent)
- Allow to dry

Bathroom/Toilet Facilities

Frequency:

Minimum 2-3 times daily
More frequent if heavily used
Immediately if soiled

Procedure:

Toilets:
- Put on gloves
- Use brush to scrub inside toilet with toilet disinfectant
- Let cleaner sit for 5-10 minutes
- Scrub again and flush
- Wipe outside with disinfectant cloth
- Do not splash cleaning solution on surroundings
Sinks:
- Scrub with disinfectant
- Rinse thoroughly
- Dry to prevent stains
Mirrors:
- Wipe with dry cloth or glass cleaner
- Dry immediately to prevent streaks
Floors:
- Sweep to remove debris
- Wet mop with disinfectant
- Pay special attention to areas around toilet (most contaminated)
- Allow to dry
Walls:
- Wipe lower portion if soiled
- Focus on areas around toilet (splashing occurs)
Supply Refill:
- Soap (bar or liquid)
- Toilet paper
- Paper towels or air dryer
- Trash container
- Ensure supplies never empty

TERMINAL CLEANING AFTER DISCHARGE/DEATH

Terminal cleaning is comprehensive disinfection of a room after patient discharge or death.

Preparation

Gather Supplies:
- Cleaning solution (disinfectant)
- Microfiber cloths or paper towels
- Mop and bucket
- Gloves, eye protection, gown
- Waste container
- Clean linens
Timing:
- Schedule after patient discharge/before new admission
- Allow adequate time (45-90 minutes)
- Do not rush process
Privacy:
- Ensure room closed off from other patients
- Do not clean while other patients viewing (distressing)

Cleaning Steps

Step 1: Prepare Room

Remove patient belongings
Remove flowers and decorations
Place soiled linens in designated hamper
Empty trash and waste containers

Step 2: High-Touch Surfaces

Door handles (inside and outside)
Light switches
Bed rails
IV poles
Monitors and controls
Cabinet handles and knobs
Window sills

Step 3: Furniture and Fixtures

Wipe entire bed frame
Wipe bedside tables
Wipe chairs
Wipe desk/writing area
Wipe shelves

Step 4: Walls and Ceiling

Wipe walls (at least bottom 2 meters where patient contact most likely)
If splashing occurred, wipe ceiling areas
Pay attention to corners (dust accumulation)

Step 5: Bathroom

Thorough disinfection of toilet (inside and outside)
Disinfect sink
Clean shower/tub if used
Disinfect floor thoroughly
Disinfect walls

Step 6: Floors

Damp mop entire room with disinfectant
Pay attention to corners and under furniture
Allow to dry completely
Repeat if heavily contaminated

Step 7: Equipment

Disinfect thermometer
Disinfect stethoscope
Disinfect BP cuff
Any other equipment in room

Step 8: Final Inspection

Walk through room checking for cleanliness
Ensure no missed areas
Ensure room odor-free
Ensure ready for new patient

Special Situations

After Death:

Handle with respect (some families present for farewell)
Allow adequate time for family if present
Do not rush cleaning (shows respect)
Extra attention to cleaning (thorough disinfection appropriate)

After Highly Infectious Patient:

Extra thorough cleaning
Double-disinfect high-touch surfaces
May repeat mop of floors
Ensure all equipment thoroughly disinfected or replaced

After Contaminated Incident:

Immediate cleanup of blood/body fluid spill
Follow spill protocol (contains, disinfects, cleans)
Then proceed with terminal cleaning

CLEANING AFTER BLOOD SPILLS AND BODY FLUID EXPOSURE

Immediate Response

Do NOT delay—biohazard exposure requires immediate action

Step 1: Personal Safety

Don appropriate PPE (gloves, eye protection, gown minimum)
Ensure own safety before addressing spill

Step 2: Contain Spill

Do not allow spill to spread
For liquid: Place absorbent material over spill
Allow material to soak up contamination
For solid/tissue: Place absorbent material over spill

Step 3: Cleaning

Using absorbent material, carefully collect contaminated material
Place contaminated material in appropriate waste container (infectious waste)
Avoid splashing or aerosolizing contamination

Step 4: Disinfection

Apply disinfectant solution to affected area (1% bleach for blood exposure)
Allow contact time (10-15 minutes)
Wipe clean with cloth

Step 5: PPE Doffing

Remove contaminated PPE carefully
Perform hand hygiene immediately
Do not touch contaminated surfaces after removing PPE

Step 6: Report

Report incident to supervisor
Document location and extent of spill
If staff exposure occurred, follow exposure protocol (see Module 8)

Large Spill Protocol

For Extensive Blood/Body Fluid Spill:

Isolate Area:
- Restrict access to area
- Place warning sign if possible
- Do not allow patients/staff through area
Assemble Team:
- More than one person if spill large
- Ensure appropriate PPE for all
- Assign roles (one person directs, others assist)
Contain and Clean:
- Use absorbent material to contain
- Collect contaminated material carefully
- Use disinfectant solution liberally
- Clean thoroughly (may require multiple applications)
Restoration:
- Ensure area dry and safe before allowing access
- Continue normal cleaning/disinfection of area
- Re-disinfect if necessary

PEST CONTROL IN HEALTHCARE SETTINGS

Common Healthcare Facility Pests

Rodents (Rats, Mice):

Disease vectors: Salmonella, Hantavirus, plague
Signs: Droppings, gnaw marks, holes
Risk: Food contamination, spread of pathogens

Insects:

Flies: Contaminate food, surfaces; disease vectors
Cockroaches: Contaminate food; allergen source
Mosquitoes: Disease vectors (dengue, malaria, etc.)
Lice/Fleas: Direct parasites

Birds:

Contaminate food/surfaces with droppings
Potential disease vectors
Noise/nesting damage

Prevention Strategies

Facility Design:

Seal cracks and holes in walls/floors
Ensure doors/windows close properly
Remove potential nesting sites
Maintain clear spaces (reduce hiding places)

Sanitation:

Store food in sealed containers
Clean spills immediately
Do not leave food/water accessible
Remove trash regularly and completely
Keep area dry (prevents mosquito breeding)
Maintain clean laundry (insects hide in soiled linens)

Maintenance:

Regular inspection for pest signs
Repair damaged screens/seals
Maintain vegetation outside building (trim bushes away from building)
Remove standing water (mosquito breeding)

Pest Control Methods

Non-Chemical:

Physical traps (snap traps, sticky traps for insects)
Regular cleaning (removes food sources)
Sealing entry points

Chemical:

Pesticide spraying (must follow safety guidelines)
Bait stations (rodent poison in secure stations, prevents patient/staff access)
Repellents

Professional Pest Control:

When infestation significant
Licensed pest control company
Coordinate with facility for access
May require temporary evacuation/closure of areas
Follow all safety protocols

Special Considerations in Healthcare

Careful use of pesticides near patient areas
Ensure compatibility with sterilization procedures (pesticide residue interferes with disinfectants)
Separate pesticide use from food preparation areas
Ensure proper ventilation after pesticide treatment
Do not use pesticides in OR or critical care areas if avoidable

VENTILATION REQUIREMENTS

Importance of Ventilation

Functions:

Removes odors from patient areas
Reduces airborne pathogens (especially in isolation rooms)
Prevents accumulation of anesthetic gases (OR)
Controls temperature and humidity
Improves air quality

Natural Ventilation

Method:

Opening windows and doors
Relies on air pressure differences
Free method

Limitations:

Not always controllable
Weather-dependent
May not be adequate in all conditions
Introduces outdoor contaminants (pollen, dust)

When Acceptable:

General patient areas
Offices
Common areas
Acceptable combined with other ventilation

When NOT Adequate:

OR (requires specific air handling)
Isolation rooms (especially airborne precautions)
High-contamination areas

Mechanical Ventilation

Components:

Intake fans (pull fresh air in)
Exhaust fans (push air out)
Ductwork (carries air)
Filters (clean incoming air)

Specifications by Area:

Area	Air Changes/Hour	Pressure	Filtration
Operating Room	12-15	Positive	HEPA
Isolation Room (airborne)	12-15	Negative	HEPA
General Patient Room	6-8	Neutral	Standard
Common Areas	6-8	Neutral	Standard

Positive Pressure: Air flows out (protects room from outside contamination) Negative Pressure: Air flows in (protects outside from room contamination)

Maintenance

Regular filter replacement (monthly or per manufacturer)
Annual professional inspection
Ensure intakes and exhausts not blocked
Monitor for proper operation (listen, feel air flow)

LAUNDRY MANAGEMENT

Types of Laundry

Clean Linen:

Unused linens
Storage in clean, dry area
Covered to prevent dust contamination

Soiled Linen:

Patient-used linens
Linens contaminated with body fluids or blood
Linens from isolation patients
Linens from patients with known infections

Contaminated (Hazardous) Linen:

Severely blood-contaminated
Contaminated with highly infectious pathogens
May require special handling

Laundry Management Steps

At Point of Use:

Do not shake or handle contaminated linens roughly (aerosolizes pathogens)
Place in designated hamper or bag (usually red for contaminated)
Immediately (do not let accumulate in patient room)
Close/seal container before transporting

Transport:

Use designated transport containers
Keep separate from clean linens
Use designated transport routes
Do not set on clean surfaces

Laundering:

Pre-Laundering:

Inspect for hazards (sharps, medications, jewelry)
Remove and discard hazards appropriately
Do not process hazardous items through laundry

Washing:

Separate contaminated from clean loads (if available)
Use hot water (if available and safe for fabric)
Use appropriate detergent (commercial laundry detergent usually adequate)
Use disinfectant additive if available (not always necessary if hot water used)
Ensure complete agitation and rinsing

Disinfection:

Hot water (above 65°C/150°F) kills most microorganisms
If hot water unavailable: Add disinfectant to wash cycle
Adequate time in wash cycle for disinfection
Multiple rinses to remove all disinfectant

Drying:

Machine dry or line dry
Ensure complete drying (prevents mildew, reduces microbial growth)
Heat drying preferred (additional disinfection)

Post-Laundering:

Inspect for cleanliness
Fold/process
Store in clean, covered area
Protect from dust and contamination

Linen Shortage Management

If linen supplies limited:

Prioritize reusable linens (cotton linens can be washed multiple times)
Limit linen changes (necessary ones only, not frequent unnecessary changes)
Expedite laundering (same-day if possible)
Educate staff on appropriate linen use

Special Laundry Situations

Highly Contaminated:

Pre-wash in bleach solution if available
Hot water wash if possible
May require multiple washes

From Isolation Patients:

Segregate during laundering if possible
Additional disinfection step if available
Process separately if feasible

KITCHEN AND FOOD SAFETY IN HEALTHCARE

Food Service Goals

Provide safe, nutritious food
Prevent foodborne illness outbreaks
Maintain appropriate food temperatures
Ensure clean food preparation areas

Personnel

Handwashing Before Food Handling:

Mandatory before all food handling
Before taking break for food consumption
After toilet use
After smoking, coughing, or touching hair/face
After touching contaminated materials

Health Screening:

Do not work if ill with infectious symptoms
Report diarrhea immediately (risks pathogen spread)
Do not work with open cuts/sores on hands (unless covered with watertight bandage and glove)
Vaccination requirements (if local public health requires)

Food Hygiene

Raw Food Storage:

Separate raw meat, poultry, fish from other foods
Store below ready-to-eat foods (prevents dripping)
Keep frozen foods frozen
Keep refrigerated foods cold (below 4°C/40°F)

Food Preparation:

Use separate cutting boards for raw meat vs. vegetables
Wash utensils and cutting boards between uses
Do not allow cross-contamination
Cook foods to appropriate temperatures:
- Poultry: 75°C (165°F) internal temperature
- Beef: 63°C (145°F) for medium
- Fish: 63°C (145°F)
- Eggs: Cook until both white and yolk firm

Food Storage:

Leftovers refrigerated immediately (within 2 hours)
Use within 3-4 days if refrigerated
Label with date prepared
Do not store near chemicals or cleaning supplies

Service:

Keep hot foods hot (above 60°C/140°F)
Keep cold foods cold (below 4°C/40°F)
Do not leave food at room temperature (bacteria multiply rapidly)
Use clean utensils/equipment
Staff do not touch ready-to-eat foods with bare hands (use gloves or utensils)

Water Quality for Food Preparation

Use drinking water (clean, safe water)
If water quality questionable, use boiled water
Do not use water from irrigation systems

Kitchen Sanitation

Equipment:

Sanitize all cutting boards, knives, utensils after each use
Wash dishes in hot soapy water or use dishwashing machine
Clean food service equipment regularly

Environment:

Clean floors daily (damp mop prevents dust circulation)
Clean walls and surfaces
Maintain pest-free environment
Proper waste disposal (food waste should not attract pests)
Handwashing stations with soap/water always available

MORGUE MANAGEMENT AND HANDLING OF DECEASED

Facilities and Environment

Space Requirements:

Cool storage area (if refrigeration available)
Separate from patient care areas
Dignified, respectful setting
Accessible for family viewings
Equipped for necessary procedures (autopsy, preparation)

Temperature:

Refrigerated morgue: 2-4°C (prevents decomposition)
If refrigeration unavailable: Separate cool room, well-ventilated
Keep away from heat sources

Ventilation:

Adequate air circulation (prevents odor accumulation)
Opens to outside (prevents odors infiltrating hospital)
Negative pressure morgue preferred (protects outside areas)

Handling Deceased Individuals

Respect and Dignity:

Handle body respectfully (especially with family present)
Use clean, sterile sheets for body wrapping
Follow religious/cultural practices (consult family)
Identify body clearly (name tag)

Infection Prevention:

Use standard precautions when handling body
Gloves minimum, gown/mask if splashing risk
Hand hygiene after contact
Do not expose body to staff/other patients unnecessarily

Documentation:

Record death time, circumstances
Note any infectious diseases/conditions
Document any special handling requirements
Maintain confidentiality

Storage

Identification:

Attach identification to body (toe tag or wrist band)
Double-check identity before release
Maintain identification throughout storage period

Duration:

Do not exceed 24-48 hours before burial/cremation if refrigeration unavailable
Refrigeration allows longer storage (3-5 days typical)
Family notification and arrangements needed quickly

Release of Body

Procedures:

Ensure proper identification confirmed
Verify death certificate completed and signed
Ensure arrangements made (burial, cremation, etc.)
Release to funeral home or family
Document release (who released to, when, signature)

Autopsy

If autopsy to be performed:

Obtain consent from family or legal authority
Maintain aseptic conditions if possible
Use standard precautions throughout
Proper disposal of pathological materials
Allow for religious/cultural practices as appropriate

Disinfection of Morgue

After body storage/removal:

Disinfect storage areas
Disinfect any equipment used
Clean entire morgue with appropriate disinfectant
Maintain cleanliness between bodies

This completes Module 7. Module 8 (Occupational Health and Safety) follows.

MODULE 8: OCCUPATIONAL HEALTH AND SAFETY

Introduction

Healthcare workers face occupational hazards that can result in injury or illness. Proper prevention, training, and support protect workers while maintaining quality patient care.

Key Occupational Hazards in Healthcare:

Bloodborne pathogen exposure
Sharps injuries
Chemical exposure
Ergonomic injuries
Infectious disease exposure
Burnout and psychological stress

NEEDLESTICK AND SHARPS INJURY PROTOCOL

Prevention is Primary Goal

Principles to Reduce Injuries:

Never recap needles (most common cause of injury)
Use safety-engineered devices when available
Proper technique and training
Use sharps containers properly
Maintain awareness and focus during procedures
Do not rush procedures

Immediate Response to Needlestick/Sharps Injury

First Aid (Immediate, Within Minutes):

Wound Care:
- Wash needle stick site immediately with soap and water
- Do not aggressively squeeze wound (may force pathogen deeper)
- Allow wound to bleed naturally (first aid)
- Rinse wound thoroughly with running water
- Wash for at least 30 seconds
If Splashing in Eye/Mouth:
- Rinse immediately with large amount of water or saline
- Continue rinsing for 15-20 minutes
- Seek medical attention immediately
Seek Medical Evaluation:
- Report to occupational health immediately
- Do not delay (time-sensitive for prophylaxis)
- Bring contaminated item if possible (for identification of source patient)

Do NOT:

Ignore injury (increased risk if no prophylaxis)
Delay seeking care (prophylaxis effectiveness time-dependent)
Hide injury (affects medical care decision and safety monitoring)

Occupational Health Assessment

Source Patient Identification:

If Possible:
- Identify source patient
- Obtain consent for source patient testing (if possible)
- Test source patient for:
  - HIV (rapid test if available)
  - Hepatitis B surface antigen
  - Hepatitis C antibody
If Source Unknown:
- Proceed with worst-case assumption
- Treat as high-risk exposure
- Provide prophylaxis

Exposure Assessment:

Evaluate Injury:
- Type of sharp (hollow needle like syringe/IV catheter higher risk than solid needle/blade)
- Depth of penetration
- Amount of blood transfer
- Visible blood on device
Risk Stratification:
- High-risk: Deep penetration, hollow needle, visible blood
- Medium-risk: Moderate penetration, some blood
- Low-risk: Superficial, minimal blood
Source Patient Status:
- Known HIV-positive: Highest risk
- Known Hepatitis B surface antigen positive: Risk
- Known Hepatitis C positive: Lower risk but risk present
- Unknown status: Treat as potentially positive

POST-EXPOSURE PROPHYLAXIS (PEP)

HIV Post-Exposure Prophylaxis

Indication:

Occupational exposure to blood or body fluids
Risk of HIV transmission through injury/splash

Timing:

Ideally started within 2 hours
Effective if started within 24-72 hours
Less effective after 72 hours
Some benefit even up to 28 days but less reliable

Regimen:

Typically: 2-3 antiretroviral drugs for 28 days
Common combination: Zidovudine (AZT) + Lamivudine + Nevirapine
Alternative: TDF + FTC + EFV
Local availability/guidelines vary

Side Effects:

Nausea, vomiting common
GI disturbance
Headache
Rash (especially with nevirapine)
Hepatotoxicity (monitor liver function)

Adherence Support:

Educate worker on importance of adherence
Provide anti-nausea medication if needed
Monitor for side effects
Encourage reporting problems (alternatives available)

Hepatitis B Post-Exposure Prophylaxis

Indication:

Occupational exposure to blood
Not previously vaccinated or response to vaccine unknown
Source patient HBsAg positive or unknown status

Option 1: Unvaccinated Worker

Hepatitis B immune globulin (HBIG): 0.06 mL/kg IM, once
Hepatitis B vaccine series: Start immediately (0, 1 month, 6 months)

Option 2: Previously Vaccinated, Good Response

No treatment needed
Check anti-HBs if needed for confirmation

Option 3: Previously Vaccinated, Poor/Unknown Response

Test anti-HBs immediately
If adequate response: No treatment
If inadequate response: HBIG + vaccine booster

Timing:

HBIG most effective within 24 hours
Can be given up to 7 days after exposure
Hepatitis B vaccine can start anytime

Hepatitis C Post-Exposure Prophylaxis

Status:

No specific post-exposure prophylaxis (antiviral therapy not recommended prophylactically)
Focus on monitoring

Management:

Baseline testing: Hepatitis C antibody
Follow-up testing:
- 4-12 weeks (repeat if negative at 4 weeks)
- 6 months (final test)
If seroconversion occurs: Refer to infectious disease specialist for treatment options

Monitoring After Exposure

Testing Schedule:

Baseline (Day 0-2):

HIV: p24 antigen or NAT (most sensitive initially)
Hepatitis B: HBsAg, Anti-HBc, Anti-HBs (if not vaccinated)
Hepatitis C: Anti-HCV, HCV RNA if available
Consider complete blood count, liver function

At 6 Weeks:

HIV: Repeat testing
Hepatitis B: Continue only if started vaccine series
Hepatitis C: Repeat if initial test negative

At 3 Months:

HIV: Repeat testing
Hepatitis C: Repeat if initial test negative

At 6 Months:

HIV: Final test (window period closed)
Hepatitis C: Final test

Counseling After Exposure

Topics to Cover:

Transmission risk (usually low for single exposure)
Prophylaxis benefits and importance of adherence
Testing schedule and importance of follow-up
What to do if symptoms develop (though prophylaxis reduces symptom risk)
Occupational accommodations if needed (usually can continue work)
Psychological support (exposure is traumatic even with low actual risk)
Restrictions (blood donation, organ donation during window period)
Return to work restrictions (none usually, but may vary by exposure)

Prevention of Future Injuries

After Injury:

Identify Contributing Factors:
- What led to injury?
- Human error, equipment failure, or procedural issue?
- System problem or individual problem?
Implementation of Prevention:
- Safety training for injured worker
- Equipment improvements if needed
- Procedure review with whole team
- Use as teaching case (without breaching privacy)
Reporting and Documentation:
- Accurate documentation of incident
- Report to occupational health
- Report to safety committee
- Report to regulatory agency if required

BLOODBORNE PATHOGEN EXPOSURE MANAGEMENT

Types of Bloodborne Pathogen Exposures

Parenteral (Percutaneous):

Needlestick injury
Cut from contaminated instrument
Skin puncture wound

Mucosal:

Splashing to eyes, nose, mouth
Exposure to mucous membranes

Skin:

Contact with blood on non-intact skin
Contact on intact skin (minimal risk but still exposure)

Risk Stratification

High-Risk:

Visible blood in syringe
Needle in artery/vein (higher viral load)
Large volume exposure
Deep wound

Medium-Risk:

Moderate amount of blood
Superficial to moderate wound

Low-Risk:

Minimal blood
Non-intact skin exposure
Splash to intact skin

Management

Assessment Same as Above:

Source patient identification
Testing of source if possible
Exposure risk assessment

Prophylaxis:

Determined by risk and source status

Monitoring:

Testing schedule per risk/exposure type
Occupational health follow-up

Support:

Psychological support (exposure anxiety common)
Medical support (side effects management)
Work accommodations if needed

HEALTHCARE WORKER VACCINATION REQUIREMENTS

Recommended Vaccinations

Mandatory (for most settings):

Hepatitis B: Series of 3 vaccines, document immunity by anti-HBs
Influenza: Annual vaccine
Tetanus/Diphtheria/Pertussis (TDaP): Initial series, booster every 10 years

Highly Recommended:

Measles/Mumps/Rubella (MMR): 2 doses if born 1957 or later; immunity verification
Varicella (Chickenpox): 2 doses if no history of disease; immunity verification
Tuberculosis (TB): Skin test or IGRA baseline; repeat as per local guidelines

Considered Depending on Setting/Exposure:

Hepatitis A: If high risk
Meningococcal: If high risk
HPV: May be offered to healthcare workers
Coronavirus: Based on current pandemic status

Documentation

Maintain vaccination records
Document vaccine name, lot number, date, provider
Document immunity results (antibody levels)
Flag non-immune individuals for enhanced precautions
Document declination if worker refuses vaccine

Non-Immune Healthcare Workers

For Critical Pathogens (Hepatitis B, Measles, Varicella):

Counsel on risks
Encourage vaccination
Implement enhanced precautions during outbreaks
May restrict from certain duties if non-immune
Post-exposure prophylaxis immediately available

TUBERCULOSIS SCREENING AND PREVENTION FOR STAFF

Baseline Screening

Required Before Employment:

Tuberculin skin test (TST) or
Interferon-gamma release assay (IGRA) - preferred if available
Chest X-ray if TST or IGRA positive
Baseline documentation

Tests:

Tuberculin Skin Test (TST/Mantoux Test):

Intradermal injection of purified protein derivative (PPD)
Read at 48-72 hours
Measurement of induration (swelling), not erythema (redness)
Interpretation depends on risk group:
- Healthcare workers: ≥10 mm = positive
- Others: ≥15 mm = positive

Interferon-Gamma Release Assay (IGRA):

Blood test
May be more specific than TST
Does not react to BCG vaccination
More expensive but increasingly available

Interpretation

Negative Test:

No TB infection
Standard precautions sufficient
Repeat testing as per facility guidelines (usually annually for high-risk settings)

Positive Test (First Time):

Indicates TB infection (latent or active)
Chest X-ray essential to rule out active TB
If X-ray normal: Latent TB infection
Evaluation for TB disease symptoms

Convert (Negative to Positive):

Likely recent TB exposure
Chest X-ray needed
Possible start of latent TB treatment (if approved by physician)

TB Prevention in Healthcare Workers

For Non-Infected Workers:

Annual screening (or per facility guidelines)
Prompt testing if exposure suspected
Early start of prophylaxis if conversion occurs

For Those with Latent TB Infection:

Monitoring for TB disease symptoms
Possible preventive therapy (isoniazid or other regimen)
Educational counseling
Monitoring for TB disease development

For Those with Active TB Disease:

Immediate medical evaluation
Initiation of appropriate therapy
Occupational leave until non-infectious (usually after 2 weeks treatment and improvement)
Occupational health follow-up

Exposure Investigations

If TB Exposure Suspected:

Identify exposure source
Identify potentially exposed individuals
Provide testing to exposed individuals
Initiate prophylaxis if conversion occurs
Monitor for TB disease development

ERGONOMICS AND INJURY PREVENTION

Common Injuries in Healthcare Settings

Back Injuries:

Patient lifting/transfers
Prolonged standing
Poor body mechanics
Most common occupational injury in healthcare

Neck/Shoulder Injuries:

Computer use (poor posture)
Reaching overhead
Repetitive tasks

Wrist/Hand Injuries:

Repetitive motions
Forceful gripping (instruments)
Computer work

Foot/Leg Injuries:

Prolonged standing
Long shifts without adequate breaks
Slipping on contaminated floors

Prevention Strategies

Facility Engineering:

Proper furniture height (desks, chairs)
Mechanical lifts for patient transfers
Anti-fatigue mats for prolonged standing areas
Good lighting (reduces eye strain)
Ergonomic equipment (keyboards, mice, monitors)

Work Practice Controls:

Proper body mechanics training
Regular breaks during shifts
Job rotation (reduces repetitive strain)
Stretching programs
Use of mechanical aids (lift equipment, transfer boards)

Personal Protective Equipment:

Supportive footwear (closed-toe, non-slip)
Gloves when needed (for grip strength)
Back support belt (for patients at high risk of transfer injury)

Staff Education:

Proper lifting technique
Ergonomic awareness
Importance of reporting injuries/pain
Early intervention for injury symptoms

Reporting and Management of Injuries

Immediate Reporting:

Report all injuries/pain, even if minor
Seek medical evaluation immediately
Document incident details

Medical Evaluation:

Occupational health assessment
Appropriate imaging/testing if needed
Treatment initiation
Work restrictions if necessary

Modified Duty:

Light duty assignments during recovery
Gradual return to full duties
Monitor for recurring pain

Prevention of Recurrence:

Identify factors causing injury
Implement corrections
Ergonomic evaluation of workplace
Return-to-work training

MENTAL HEALTH AND BURNOUT PREVENTION

Occupational Stress in Healthcare

Sources of Stress:

Long shifts, irregular hours
Emotionally demanding patient interactions
Exposure to suffering, death
Resource limitations
Staff conflicts
Moral distress (wanting to do more for patients but unable)
Fear of errors/liability
Financial pressures (if in resource-limited settings)

Signs and Symptoms of Burnout

Physical:

Fatigue despite adequate sleep
Frequent headaches
GI upset
Muscle tension
Sleep disturbances

Emotional:

Increased irritability/anger
Emotional detachment
Feeling helpless
Loss of enthusiasm
Anxiety, depression

Behavioral:

Increased absences
Decreased productivity
Withdrawn from colleagues
Increased substance use
Decline in self-care

Professional:

Loss of compassion (“compassion fatigue”)
Decreased job satisfaction
Making more errors
Avoiding patient contact when possible

Prevention Strategies

Organizational Level:

Adequate staffing (reduces individual burden)
Reasonable work hours and shifts
Support for continuing education
Clear expectations and roles
Recognition of good work
Fair compensation
Safe working environment (physical and psychological safety)
Open communication channels
Supportive leadership

Unit/Team Level:

Supportive team environment
Regular debriefing after difficult cases
Peer support programs
Team-building activities
Clear communication and role clarity

Individual Level:

Self-awareness of stress signs
Healthy coping mechanisms:
- Physical activity
- Adequate sleep
- Nutrition
- Social support
- Hobbies/interests outside work
Seeking help when needed (no shame in mental health support)
Setting boundaries (leaving work at work)
Mindfulness and stress reduction techniques

Support Resources

Occupational Health Services:

Mental health evaluation
Counseling referral
Medical care for stress-related conditions
Workplace accommodation for mental health needs

Employee Assistance Programs (if available):

Confidential counseling
Support for personal problems
Substance abuse programs
Financial/legal consultation

Peer Support:

Colleague support groups
Mentorship programs
Experienced staff guidance

Professional Mental Health:

Psychiatric evaluation and treatment
Psychotherapy
Medication management if needed

Critical Incident Stress Management

After Traumatic Events:

Patient death despite full efforts
Mass casualty incident
Staff injury
Workplace violence
Occupational exposure incident

Immediate Response (Debriefing):

Gather affected staff together
Allow expression of feelings
Normalize stress responses
Provide information about available support
Plan for follow-up

Follow-up:

Individual counseling if needed
Group debriefing sessions
Monitoring for post-traumatic stress symptoms
Support resources availability

REPORTING AND DOCUMENTATION OF OCCUPATIONAL EXPOSURES

What to Report

Mandatory Reporting:

All sharps injuries
All bloodborne pathogen exposures
Chemical exposures
Significant injury/illness (varies by jurisdiction)
Occupational infection exposures
Near-misses (incidents that could have caused injury but didn’t)

Non-Mandatory but Recommended:

Minor injuries
Ergonomic concerns
Safety hazards (even if no injury yet)
Incidents that contributed to injury

Documentation Process

Immediate Documentation (Day of Incident):

What happened (describe incident clearly)
When and where
Who was involved
Witnesses present
Injuries sustained
First aid provided
Medical evaluation sought (or not)
Equipment/materials involved

Medical Evaluation Documentation:

Healthcare provider assessment
Tests performed and results
Prophylaxis given (if any)
Medications prescribed
Work restrictions
Follow-up appointments scheduled
Worker’s compensation information

Follow-up Documentation:

Baseline testing results
Follow-up testing schedule
Results of follow-up tests
Clinical outcome
Any return-to-work restrictions released
Timeline for resolution

Incident Investigation

Immediate Investigation:

Secure scene (prevent further injury from same hazard)
Interview worker and witnesses
Identify root causes
Assess if system problem or individual error

Root Cause Analysis:

What was the direct cause? (sharps injury: needle stuck in hand)
What was the underlying cause? (no safety device on needle, worker distracted)
What system failure contributed? (training inadequate, equipment unavailable, procedure unclear)

Corrective Actions:

Immediate (prevent repeat of same injury)
Long-term (system improvements)
Document actions taken
Verify effectiveness

Regulatory Reporting

Varies by jurisdiction but may include:

OSHA (Occupational Safety and Health Administration) in US
Public health agencies (for occupational infections)
Workplace safety agencies
Insurance carriers

Documentation Requirements:

Date, time, place of incident
Specific details of exposure
Testing results
Prophylaxis given
Medical evaluation findings
Contact information of exposed worker
Contact information of source (if known)

Privacy and Confidentiality

Important Principles:

All information should be kept confidential
Only need-to-know personnel should have access
Worker’s privacy protected
Source patient’s confidentiality protected (if possible)
Investigation information kept secure

Legal Considerations:

State laws vary on disclosure requirements
Healthcare provider may be required to report to authorities
Worker may have right to see documentation
Liability concerns (document objectively, accurately)

CONCLUSION

Summary of Key Messages

Hand Hygiene:

Most important infection prevention measure
Must be performed at WHO 5 moments
Proper technique essential
Both handwashing and ABHR important

PPE:

Required based on risk assessment
Proper donning and doffing critical
Isolation precautions stratified by transmission route
Should be available in all healthcare settings

Sterilization and Disinfection:

Different methods for different items (Spaulding classification)
Cleaning is most critical step
Autoclave sterilization reliable and practical
Chemical disinfection alternative for heat-sensitive items

Water and Sanitation:

Clean water essential for healthcare
Multiple purification methods available
Handwashing stations critical and strategic placement
Proper plumbing and maintenance prevent contamination

Waste Management:

Segregation at point of generation reduces costs
Safe handling protects workers and environment
Multiple disposal methods available
Documentation and compliance important

Isolation and Quarantine:

Early identification essential
Appropriate precautions based on transmission route
Environmental disinfection critical
Contact tracing can interrupt transmission

Environmental Hygiene:

Clean environment reduces infection transmission
Different protocols for different areas
Terminal cleaning essential between patients
Ventilation and pest control important

Occupational Health:

Prevention of injury/illness primary goal
Rapid response to exposures essential
Post-exposure prophylaxis time-sensitive
Vaccination critical for protection
Mental health and burnout prevention important
Accurate reporting and documentation essential

Implementation in Resource-Limited Settings

The principles outlined in this training apply universally but implementation must be adapted to available resources:

With Minimal Resources:

Prioritize hand hygiene (soap and water, or improvised ABHR)
Use WHO precautions framework
Improvise PPE if necessary
Boil instruments if autoclave unavailable
Use bleach solutions for disinfection
Manual waste management
Isolation precautions with improvised negative pressure
Standard environmental cleaning with available materials
Occupational health awareness and basic support

With Standard Resources:

All measures outlined in this training
Autoclave sterilization
Chemical disinfection capability
Waste management systems
Proper isolation rooms
Ventilation systems
Comprehensive occupational health

With Advanced Resources:

All standard measures
Advanced sterilization (ETO, gamma)
Negative pressure isolation rooms
Advanced ventilation
Comprehensive occupational health services
Regular training and competency assessment
Research and continuous improvement

Ongoing Training and Quality Assurance

Recommended:

Initial training for all staff (tailored to role)
Annual refresher training
Training with onboarding of new staff
Competency assessment
Supervision and feedback
Regular audits of compliance
Incident investigations and learning
Staff input on improvements
Recognition of good practices

Final Thoughts

Sanitation and infection control are foundational to quality healthcare. Every member of the healthcare team has a role—from physicians to cleaning staff to administrative personnel. Commitment to these principles protects patients, staff, and the broader community. Resource limitations should not be an excuse for poor practices but rather a challenge to be creative with available tools and materials. Above all, respect for infection prevention principles and commitment to continuous improvement will result in safer healthcare for all.

END OF COMPREHENSIVE MEDICAL TRAINING DATA Sanitation and Infection Control for Small Hospitals and Clinics

Document Statistics:

Total Modules: 8
Total Estimated Length: 1000+ lines of comprehensive content
Coverage: Hand hygiene, PPE, sterilization, water/sanitation, waste management, isolation/quarantine, environmental hygiene, occupational health
Format: Step-by-step procedures, decision trees, tables, practical guidelines
Intended Use: Training for healthcare workers in resource-limited and post-disaster settings

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adrenal fatigue consciousness toxicology trauma neuroscience

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COMPREHENSIVE MEDICAL TRAINING DATA

Sanitation and Infection Control for Small Hospitals and Clinics

TABLE OF CONTENTS

MODULE 1: HAND HYGIENE

Introduction to Hand Hygiene

WHO 5 MOMENTS OF HAND HYGIENE

Moment 1: Before Patient Contact

Moment 2: Before Aseptic/Clean Procedures

Moment 3: After Body Fluid Exposure Risk

Moment 4: After Patient Contact

Moment 5: After Contact with Patient Surroundings

HANDWASHING TECHNIQUE: STEP-BY-STEP PROCEDURE

Materials Required:

Step-by-Step Handwashing Procedure:

Total Duration for Complete Handwashing:

Key Points to Emphasize:

ALCOHOL-BASED HAND RUB (ABHR) TECHNIQUE

When to Use ABHR:

When NOT to Use ABHR (Use Soap and Water Instead):

Composition of Effective ABHR:

Alcohol-Based Hand Rub Technique:

Total Duration for ABHR:

Advantages of ABHR Over Handwashing:

Disadvantages of ABHR:

Skin Care While Using ABHR:

WHEN TO WASH VS. WHEN TO USE HAND RUB: DECISION TREE

Decision Tree Algorithm:

Summary Table:

MAKING HAND SANITIZER FROM AVAILABLE MATERIALS

WHO-RECOMMENDED FORMULATION FOR ALCOHOL-BASED HAND RUB

Formulation 1: Alcohol-Based with Hydrogen Peroxide

Formulation 2: Alcohol-Based with Iodine

Formulation 3: Simple Alcohol-Based Without Additives

Sourcing Ingredients in Resource-Limited Settings:

Quality Control for Homemade Sanitizer:

Storage and Safety:

SURGICAL HAND SCRUB PROTOCOL

When Surgical Hand Scrub Is Required:

Materials Required:

Step-by-Step Surgical Hand Scrub Procedure:

Total Time for Complete Surgical Hand Scrub:

Antimicrobial Agents for Surgical Hand Scrub:

Making Chlorhexidine for Surgical Scrub:

Important Considerations:

MODULE 2: PERSONAL PROTECTIVE EQUIPMENT (PPE)

Introduction to PPE

STANDARD PPE FOR DIFFERENT SITUATIONS

Risk Assessment Framework:

Table: Standard PPE Combinations by Scenario

Detailed Scenario-Based PPE Selection:

Scenario 1: Routine Clinical Examination

Scenario 2: Wound Care/Dressing Change

Scenario 3: Assistance with Delivery

Scenario 4: Suspected Tuberculosis Case

Scenario 5: Suspected COVID-19 or Similar Respiratory Virus

DONNING SEQUENCE

Standard Donning Sequence:

Donning Sequence for High-Risk Procedures:

DOFFING SEQUENCE

Standard Doffing Sequence:

Doffing Sequence for High-Risk or Suspected COVID-19 Cases:

Critical Points About Doffing:

GLOVE TYPES AND APPROPRIATE USE

Glove Material Options:

Glove Types by Application:

1. Non-Sterile Examination Gloves

2. Sterile Surgical Gloves

3. Heavy-Duty Gloves

4. Insulated/Thermal Gloves

Glove Selection Algorithm:

Glove Failure Prevention:

MASK TYPES AND WHEN TO USE EACH

Introduction to Respiratory Protection

Surgical Masks

N95 Respirator

PAPR (Powered Air-Purifying Respirator)

EYE PROTECTION AND FACE SHIELDS

Introduction

Types of Eye Protection:

1. Safety Glasses