Enhanced Traffic Control Bundling (eTCB) to prevent

COVID-19 Nosocomial InfectionsDr. Marybeth C. Maritim

Outline

• Introduction• What is eTCB?• Aims of eTCB• How to Implement eTCB• Conclusion

Introduction

WHO has defined 4 transmission scenarios for COVID-19: 1. Countries with no cases (No Cases) 2. Countries with 1 or more cases, imported or locally detected (Sporadic Cases)3. Countries experiencing cases clusters in time, geographic location, or common exposure (Clusters of cases)4. Countries experiencing larger outbreaks of local transmission (Community transmission)

WHO 2020

Cluster of Cases

Reflecting on Reasons for HCW COVID-19 Infections in China

• Inadequate personal protection of healthcare workers at the beginning of the epidemic• Long-time exposure to large numbers of

infected patients directly increased the risk of infection for healthcare workers • Shortage of PPE • The front-line healthcare workers received

inadequate training for IPC, leaving them with a lack of knowledge of IPC for respiratory-borne infectious diseases

Journal of Hospital Infections Volume 105, Issue 1, P100-101, May 01, 2020

Strategies to prevent COVID-19 in Healthcare Settings

OSHA guidelines

• Engineering controls - involve isolating employees from work-related hazards - adequate ventilation (installing high-efficiency air filters, increasing ventilation rates ; installing physical barriers, such as clear plastic sneeze guards; adequate environmental cleaning

• Administrative controls - require action by the worker or employer; changes in work policy or procedures to reduce or minimize exposure to a hazard

• Safe work practices - are types of administrative controls that include procedures for safe and proper work used to reduce the duration, frequency, or intensity of exposure to a hazard – provision of hand hygiene facilities, signage, job aids to reinforce

• PPEs - Is in addition to both engineering and administrative controls help prevent some exposures

Administrative Controls relating to HCWs

Kenya COVID -19 IPC Guidelines 2020

• Provision of adequate training for HCWs• Ensuring an adequate patient-to-staff ratio• Establishing a surveillance process for acute

respiratory infections potentially caused by COVID-19 among HCWs• Ensuring that HCWs and the public understand the

importance of promptly seeking medical care• Monitoring HCW compliance with standard

precautions and providing mechanisms for improvement as needed• Workflow processes should be adjusted to ensure

rapid triaging and separation of suspected COVID-19 patients

History of TCB

• TCB aims to prevent epidemic nosocomial infections• Developed by Yen et al in Taiwan and initially

implemented during the Taiwan SARS outbreak in 2003 • When coupled with strict PPE use and standard

infection control procedures, hospital fomite, contact and droplet transmissions were efficiently controlled. TCB strategy achieved 100% hand hygiene compliance among HCW• As a result, community SARS infection rates declined

as well • Success was evidenced by no new diagnosed cases

over 2 one-week incubation periods following TCB implementation

Fomites and Nosocomial Spread of Infections

• Fomite transmission played a central role in SARS 2003 and fomite-related nosocomial and community transmissions during H1N1 2009 and Ebola 2014• During MERS-CoV 2015 outbreak, numerous

examples of HCWs contracting the virus even when fully gowned and having had no direct contact with carriers

Fomites and Nosocomial Spread of Infections II

• During the Korean MERS-CoV outbreak, 1 super-spreader infected 82 people in a medical center• Initial analyses pointed to transmission by the index

case via droplets and contact with exposed people in the same care zone

• Those without contact history with the index case were likely infected by fomites on bed curtains and/or public rest room fixtures touched by the index case who had been suffering from pneumonia and diarrhea

• TCB is particularly effective as regards to the role of fomites

What is Traffic Control Bundling?

• TCB is an integrated infection control strategy that include:§ triage prior to entering hospitals; § strict separation among zones of risk, and; § strict requirements and protocols for personal

protective equipment (PPE) use coupled with checkpoint hand disinfection

TCB CID 2015:60 (1 March)

Traffic Control Bundling (TCB)

• TCB protocols include: § initial “triage outside of hospitals”- patients

found to be infected with SARS-CoV during triage at outdoor fever screening stations are sent directly through a guarded control route to a designated contamination zone;

§ “zones of risk” - clearly distinguished contamination, transition and clean zones

• HCWs moving from contamination to clean zones must undertake decontamination and degowning in the transition zone, and hand disinfection at every checkpoint between the zones

Enhanced TCB

• TCB (eTCB) includes 2 enhancements to traditional TCB• Firstly, eTCB expands the transition zone to

incorporate a quarantine ward which houses patients with atypical manifestations and patients awaiting final diagnosis. Patients are transferred to the quarantine ward directly from outdoor triage and are held there for the full incubation period

Journal of Microbiology, Immunology and Infection March 2020

Enhanced TCB II

• ACE2 receptors resulting in high transmissibility; falsThisenhancement is because SARS-CoV-2 includes asymptomatic infection; ahyperaffinity to e negatives, and; an incubation period of 14 upto 22 days.

• Secondly, to address community to hospital infection threats, checkpoint hand disinfection and face masksare required of all visitors entering the hospital. This is supplemented with heightened environmental cleaning and disinfection.

Journal of Microbiology, Immunology and Infection March 2020

PPEs for Different Clinical Settings Anaesthesia and Analgesia 2020 Apr 20

COVID-19: Case Definition – Kenya V250320202

Suspect case

• A. A patient with acute respiratory illness (fever or cough or shortness of breath) AND• A history of travel to a foreign country

during the 14 days prior to symptom onset, or

• Having been in contact* with a confirmed or probable case of COVID-19 in the 14 days prior to symptom onset, or

• B. A patient with severe acute respiratory illness (fever or cough or shortness of breath; AND requiring hospitalization) And in the absence of alternative diagnosis that fully

explains the clinical presentation

Probable case

• A suspect case for whom testing could not be performed for any reason OR

• A suspect case for whom testing for COVID-19 is inconclusive*** or for whom testing was positive on a pan-coronavirus assay.

Confirmed case

• A person with laboratory confirmation of COVID-19 infection, irrespective of clinical signs and symptoms.

COVID-19: Case definition – Kenya V250320202

Closed contact is defined as:Working together in close proximity or sharing the

same environment with a COVID-19 patient

Face-to-face contact within 1 metre and for more than

15 minutes

Travelling together with a COVID-19 patient in any

kind of conveyance

Living in the same household as a COVID-19

patient

Healthcare associated exposure to COVID-19

Definition of a Contact - A contact is a person who experienced the following exposures during the 2 days before and the 14 days

after the onset of symptoms of a probable or confirmed case.

Example of COVID-19 Buffer Zones in the EDTravel Medicine and Infectious Disease March 2020

PPEs for Different Clinical Settings Anaesthesia and Analgesia 2020 Apr 20

KU Photo Courtesy – Dr Victor Njom

KU Photo Courtesy – Dr Victor Njom

KU Photo Courtesy – Dr Victor Njom

Conclusion

• COVID-19 droplet and fomite transmission has been observed both inside and outside of hospitals• By containing nosocomial transmissions,

eTCB contributes to breaking the cycle of community-hospital-community infection