Protocol No 7 – Hygiene, sanitation and isolation aspects of CTCs
Risks of not implementing hygiene, sanitation & isolation aspects
It is VERY important that basic hygiene, sanitation and isolation procedures are followed at ALL TIMES in health facilities where patients with AWD are being treated. Failure to follow these procedures could lead to cross-infection of other patients or infect people who come to the health centre who did not in fact have AWD.
Helping staff to improve their health facilities
Helping the staff to improve their facilities:
· Observing another well set up CTC centres / improved hygiene centre.
· Discussing what they saw and suggesting any improvements.
· Providing required equipment where not already available.
· Providing additional operational costs for guards, cleaners and medical helpers.
· Working with the staff to discuss and suggest and make the improvements together.
· Follow up visits after a few days to see how the procedures are being followed.
Minimum hygiene, sanitation and isolation activities
Essential principles that all health facilities and CTCs must follow:
1. Isolate severe cases
2. Contain all excreta (faeces and vomit)
3. Only one carer per patient
4. Wash hands with chlorinated water
5. Disinfect feet when leaving the centre
6. Disinfect clothes of infected people before leaving the centre
7. Provide hygienic and with privacy
8. Toilets and bathing areas for patients and carers
9. Follow up on the families and relatives of the patient, ensure there are no other cases and disinfect the house, give hygiene information.
10. If people arrive by public transport the cars should be disinfected.
Cards for hygiene actions to be taken in the treatment centre:
Laminated cards in different colors should also be prepared for the following:
Patients
When they arrive / · Their skin is disinfected with a 0.05% solution (with a sponge or by spray)During their stay / · Their waste (body liquids like vomit and faeces) will be collected in bedpans or buckets
· Do not allow people to vomit on the bare earth
· Their waste must be left for 10 minutes in a strong 2% solution (pour this solution in the bed pans before empting them)
· Their waste must be emptied in a specific pit.
Before they leave / · Their clothes are sterilized in boiling water or dipped in a 0.2% solution for 10 minutes and then rinsed (ATTENTION the chlorine might bleach the clothes)
· Their skin is disinfected with a 0.05% solution (with a sponge or by spray)
· Their shoes (especially the bottom) or feet are sprayed with 0.2% solution or they walk through a foot bath
In case of death / · Their body needs to be disinfected with a strong 2% solution
· All body openings must be closed with cotton dipped in the same 2% solution
· The body is wrapped in a plastic bag
Relatives
When they arrive / · Only 1 relative allowed (unless the others are also sick)During their stay / · When possible, try to provide separate latrines and washing facilities for the relatives
· Every time they use the toilet they should wash their hands with a 0.05% disinfected water
· The relatives should try to minimize contacts with the patient’s waste
Before they leave / · Every time they leave the camp they have to wash their hands in a 0.05% solution
· The sole of their shoes (especially the bottom) must be sprayed with a 0.2% solution or walk through a footbath
· If food has come from outside, the plates and everything should be washed in a 0.05% solution before being allowed from the camp
· If dirty, their clothes are sterilized in boiling water or dipped in a 0.2% solution for 10 minutes and then rinsed with clean water
In case of death / · The relatives should be advised that funeral ceremonies are a risky practice
· All the people handling the dead body should wash their hands and not handle food
· Hygiene education should be given to the relatives before returning to the center
Staff
When they arrive / · Staff should use gloves when treating patientsDuring their stay / · Staff should try to use separate latrines and washing facilities, ideally in neutral area
· Staff should use gloves when treating patients
· Staff should wear gowns and special outfits which will be disinfected in the center
· After treating the patient the staff member should wash their hands with disinfected 0.05% solution (and their gloves if they are reusable )
What to do with dead bodies / instructions for funerals:
Keep the body separate from the patients.
· Disinfection of corpses and plugging of orifices with cotton in a 2% chlorine solution (note – only effective for a short period). Bury as soon as possible.
· Wrap the body in a plastic sheet when transporting to catch any body fluids.
· Discourage funeral feasts until the end of the outbreak (or limit size).
· Undertake hygiene promotion at funerals.
Minimum key staff and job descriptions
Minimum key staff:
As a minimum the CTCs or health centres which are dealing with AWD infected people, must have the following staff:
1. Medical and support staff (cleaners, guards etc) should work ONLY with the AWD infected patients – they must not switch between different groups as this will lead to infection.
2. There should be one nurse per shift, as the center has to be open 24 hours a day.
3. There should be 1 medical helper per shift that assists the nurse and prepares ORS if possible.
4. 1 Cleaner / sprayer per shift– who deal with all of the cleaning and disinfecting of people’s clothes, disposal of waste etc.
5. 1 guard per shift – to make sure that people follow the hand and foot washing procedures and ensuring that the isolation rules are followed. They need to be very strict about these rules!
6. Cook – to cook for the patients, carer, health and other staff who remain in the centres (where possible).
Job descriptions for staff:
The following simplified job descriptions have been developed from the MSF cholera guidelines. They have been simplified so that they can be realistically followed in all health posts and small CTCs run by any organisation.
The cards should be prepared in different colors and laminated and in both the local language and English. They will be hung up in the centers for use by the staff on a daily basis.
Nurses / Medical helper
Actions / RemarksCase Management / Follow training instructions
Differentiate non AWD from AWD and severe cases from mild / The ‘differentiation area’ should be separated from the centre. Only patients with AWD can enter the contagious area
Preparing ORS every day
(This could be done by a medical helper if available) / Follow training instructions
Supervise cleaners and ensure hygiene and sanitation rules are followed / Be familiar with their tasks and do some inspections
Use personal hygiene / Use separate toilets.
Wear gloves and boots in the center area.
Wash hands after treating patients even when wearing gloves.
Hygiene education when patients and relatives leave or die / Focus on hand washing, safe water and funeral practice
Hygiene education for community members / When giving community education from the centre site, hold the training outside the centre itself.
Put syringes / needles into syringe box / Syringe box should be used until full and given to RHB for disposal
Cleaners
Actions / RemarksCleaning bed pans every hour (soaking them in chlorine and emptying them into the pit) / Pour a 2% solution for 10 minutes, then empty in a covered pit latrines
Clean toilets and showers 2 to 4 times per day / Use 0.2% solution
Cleaning beds and floors 2 times a day or when they become dirty / Clean or spray using 0.2% solution
Disinfecting patients when they arrive
(or this can be done by the guard) / Spray them or use sponge with 0.05% solution
Prepare every day 2 types of disinfecting solutions (0.2% and 0.05% solutions)
(This could be done by the Medical helper if available) / Follow solution table
Prepare every week the 2% solution / Follow solution table
Disinfecting patients when they leave / Spray them or use sponge with 0.05% solution
Cleaning clothes when people leave (patients, relatives and staffs) / Boil them or soak them in 0.2% solution for 10 minutes then rinse with clean water
Refill hand washing containers when empty / Use 0.05% solution
Refill drinking water containers / Use PUR or WaterMaker prepared by the nurses
Refill sprayers and foot bath / Use 0.2% solution
Collect waste in bins with lids / Burn in an open pit
Dispose buckets with excreta / Put half a cup 2% chlorine solution in the empty buckets
Use personal hygiene / Use separate toilets.
Wear gloves, apron or overall and boots in the center area.
Wash hands and gloves after work.
Guard
Actions / RemarksAdmitting only patients and 1 relative / If relatives are sick then they can be admitted
Making whoever exits the camp (patient, relatives, staff) wash their hands every time / Make sure there is chlorinated water in the container
Making whoever enters or exits the camp (patient, relatives, staff) disinfect feet or shoes / Spray the bottom of the shoes
Make sure there is chlorine solution (0,2%) in the sprayer or foot wash
Use personal hygiene / Use separate toilets.
Wear gloves and boots in the center area.
Wash hands and gloves after work.
Making chlorine mixes
Disinfecting solutions:
Depending on the chlorine available, choose the table appropriate and provide this table only for making up the disinfectants:
· 5% liquid - local Birkina yellow bottle
· 10% liquid - provided by UNICEF
· 65-70% HTH powder – imported
2% solution / 0.2% solution / 0.05% solutionWaste and Excreta
Dead Bodies / Floor
Objects / Beds
Footbaths
Clothes / Hands
Skin / Drinking water
Yellow bottle
5% solution / 10 lt. chlorine
10 lt. water
(1:1) / 1 lt. chlorine
19 lt. water
(1:25) / 0.2 lt. chlorine
19.8 lt. water
(1:100)
Blue container
10% solution / 5 lt. Chlorine
15 lt. water
(1:4) / 0.5 lt. chlorine
19.5 lt. water
(1:50) / 0.1 lt. chlorine
20 lt. water
(1:200)
Waterguard / 1 cap
(only transparent water)
Watermaker / 1 sachet
PUR / 2 sachets
NB: The solutions should be freshly prepared every day, since light and heat weaken the solution
If there is no chlorine available, use normal bleach that is locally on the market available (5%).
2% solution / 0.2% solution / 0.05% solutionWaste and Excreta
Dead Bodies / Floor
Objects / Beds
Footbaths
Clothes / Hands
Skin
HTH powder 65-70% / 30g for 1 liter
300g for 10 liter / 3g for 1 liter
30g for 10 liter / 0.75g for 1 liter
7.5g for 10 liter
Never mix the solution with detergent!
Disinfecting transport and the houses of the infected people
When people are transported to a health facility they may leave traces of AWD in the vehicle which may infect others. This needs to be disinfected to prevent cross-contamination. Disinfecting people’s houses can also lead to opportunities for undertaking hygiene promotion or surveillance activities where new cases are identified.
1. Disinfect immediately the car in which the patient was transported in (Ambulance or Taxi) on arrival before it leaves again. Use a 0.05 % Chlorine solution for the car.
2. It is important to go immediately to the house of the patient instead of waiting until the patient is discharged and going home.
3. Explain to the household that spraying of chlorine is done to disinfect and that is not poison.
4. Use a 0.2 Chlorine Solution to do house spraying.
5. Ask in which places the patient was vomiting and where has been stool.
6. Spray also latrine (if there is), clothes and kitchen area (after removing food items).
7. The visit of the affected household is a good opportunity to give extra Hygiene Promotion to the family members and the neighbors.
8. At the same time it is a way of surveillance, as you can detect new cases in the neighborhood.
Layouts of CTC / isolation areas in health facilities
a) A simplified arrangement which can be used at a small health centre
The above layout is for a reasonably large CTC / treatment centre, but the principle of patient flow and isolation is the same for smaller centres. The patients under observations should not be mixed with the patients who are severely affected and except for the patient, staff and one carer, no other people should be allowed to be in the centre.
Simple design guidelines for latrines for the CTCs
Siting:
1. The latrine should be between 5 to 10m from the tents where people are staying. This will hopefully be far enough away to prevent the smell becoming a problem and near enough that people can reach them for use.
2. Care must be taken that these latrines are a minimum 30m from any groundwater source. The safe distance is shorter than this but this allows for a margin of error.
3. The latrine should not be located in any channels where water flows during heavy rains. If it is in this location, then there is a risk of it flooding or collapsing from water entering down the sides of the pit.
4. Ideally therefore should be separate latrines for women and men which are located a small distance away from each other or separated by a screen. In the smaller centres a joint latrine for men and women can be considered after checking the local customs.
5. The patients and the staff should have different latrines. The carers will probably need to use the same latrines as the patients depending on the size of the centre. Particular effort will need to be focused on keeping the latrines clean for all users.
6. The entrance to the latrine should be facing away from the centre so that people are not seen entering or leaving the latrine for the privacy of the user.