2014 Environment CDC

9/21/2016 GuidelinesforEnvironmentalInfectionControlinHealthCareFacilities:RecommendationsofCDCandtheHealthcareInfectionControlPracticesAdvi
RecommendationsandReports
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GuidelinesforEnvironmentalInfectionControlin
HealthCareFacilities
RecommendationsofCDCandtheHealthcareInfectionControlPracticesAdvisory
Committee(HICPAC)
Preparedby
LynneSehulster,Ph.D.1
RaymondY.W.Chinn,M.D.2
1DivisionofHealthcareQualityPromotion
NationalCenterforInfectiousDiseases
2HICPACmember
SharpMemorialHospital
SanDiego,California
ThematerialinthisreportoriginatedintheNationalCenterforInfectiousDiseases,JamesM.Hughes,M.D.,Directorandthe
DivisionofHealthcareQualityPromotion,StevenL.Solomon,M.D.,ActingDirector.
Summary
Thehealthcarefacilityenvironmentisrarelyimplicatedindiseasetransmission,exceptamongpatients
whoareimmunocompromised.Nonetheless,inadvertentexposurestoenvironmentalpathogens(e.g.,
Aspergillusspp.andLegionellaspp.)orairbornepathogens(e.g.,Mycobacteriumtuberculosisand
varicellazostervirus)canresultinadversepatientoutcomesandcauseillnessamonghealthcareworkers.
Environmentalinfectioncontrolstrategiesandengineeringcontrolscaneffectivelypreventtheseinfections.
Theincidenceofhealthcareassociatedinfectionsandpseudooutbreakscanbeminimizedby1)
appropriateuseofcleanersanddisinfectants2)appropriatemaintenanceofmedicalequipment(e.g.,
automatedendoscopereprocessorsorhydrotherapyequipment)3)adherencetowaterqualitystandards
forhemodialysis,andtoventilationstandardsforspecializedcareenvironments(e.g.,airborneinfection
isolationrooms,protectiveenvironments,oroperatingrooms)and4)promptmanagementofwater
intrusionintothefacility.Routineenvironmentalsamplingisnotusuallyadvised,exceptforwaterquality
determinationsinhemodialysissettingsandothersituationswheresamplingisdirectedbyepidemiologic
principles,andresultscanbeapplieddirectlytoinfectioncontroldecisions.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm 1/60
Thisreportreviewspreviousguidelinesandstrategiesforpreventingenvironmentassociatedinfectionsin
healthcarefacilitiesandoffersrecommendations.Theseinclude1)evidencebasedrecommendations
supportedbystudies2)requirementsoffederalagencies(e.g.,FoodandDrugAdministration,U.S.
EnvironmentalProtectionAgency,U.S.DepartmentofLabor,OccupationalSafetyandHealth
Administration,andU.S.DepartmentofJustice)3)guidelinesandstandardsfrombuildingandequipment
professionalorganizations(e.g.,AmericanInstituteofArchitects,AssociationfortheAdvancementof
MedicalInstrumentation,andAmericanSocietyofHeating,Refrigeration,andAirConditioning
Engineers)4)recommendationsderivedfromscientifictheoryorrationaleand5)experiencedopinions
baseduponinfectioncontrolandengineeringpractices.Thereportalsosuggestsaseriesofperformance
measurementsasameanstoevaluateinfectioncontrolefforts.
Introduction
ParametersoftheReport
Thisreport,whichcontainsthecompletelistofrecommendationswithpertinentreferences,isPartIIof
GuidelinesforEnvironmentalInfectionControlinHealthCareFacilities.Thefullfourpartguidelineswill
beavailableonCDC'sDivisionofHealthcareQualityPromotion(DHQP)website.Relativetoprevious
CDCguidelines,thisreport
revisesmultiplesections(e.g.,cleaninganddisinfectionofenvironmentalsurfaces,environmental
sampling,laundryandbedding,andregulatedmedicalwaste)frompreviouseditionsofCDC's
GuidelineforHandwashingandHospitalEnvironmentalControl
incorporatesdiscussionsofairandwaterenvironmentalconcernsfromCDC'sGuidelinefor
PreventionofNosocomialPneumonia
consolidatesrelevantenvironmentalinfectioncontrolmeasuresfromotherCDCguidelinesand
includestwotopicsnotaddressedinpreviousCDCguidelinesinfectioncontrolconcernsrelated
toanimalsinhealthcarefacilitiesandwaterqualityinhemodialysissettings.
Inthefullguidelines,PartI,BackgroundInformation:EnvironmentalInfectionControlinHealthCare
Facilities,providesacomprehensivereviewoftherelevantscientificliterature.Attentionisgivento
engineeringandinfectioncontrolconcernsduringconstruction,demolition,renovation,andrepairof
healthcarefacilities.Useofaninfectioncontrolriskassessmentisstronglysupportedbeforethestartof
theseoranyotheractivitiesexpectedtogeneratedustorwateraerosols.AlsoreviewedinPartIare
infectioncontrolmeasuresusedtorecoverfromcatastrophicevents(e.g.,flooding,sewagespills,lossof
electricityandventilation,ordisruptionofwatersupply)andthelimitedeffectsofenvironmentalsurfaces,
laundry,plants,animals,medicalwastes,clothfurnishings,andcarpetingondiseasetransmissioninhealth
carefacilities.PartIIIandPartIVofthefullguidelinesprovidereferences(forthecompleteguideline)and
appendices,respectively.
PartII(thisreport)containsrecommendationsforenvironmentalinfectioncontrolinhealthcarefacilities,
describingcontrolmeasuresforpreventinginfectionsassociatedwithair,water,orotherelementsofthe
environment.TheserecommendationsrepresenttheviewsofdifferentdivisionswithinCDC'sNational
CenterforInfectiousDiseasesandtheHealthcareInfectionControlPracticesAdvisoryCommittee
(HICPAC),a12membergroupthatadvisesCDConconcernsrelatedtothesurveillance,prevention,and
controlofhealthcareassociatedinfections,primarilyinU.S.healthcarefacilities.In1999,HICPAC's
infectioncontrolfocuswasexpandedfromacutecarehospitalstoallvenueswherehealthcareisprovided
(e.g.,outpatientsurgicalcenters,urgentcarecenters,clinics,outpatientdialysiscenters,physicians'offices,
andskillednursingfacilities).Thetopicsaddressedinthisreportareapplicabletothemajorityofhealth
carefacilitiesintheUnitedStates.Thisreportisintendedforuseprimarilybyinfectioncontrol
practitioners,epidemiologists,employeehealthandsafetypersonnel,engineers,facilitymanagers,
informationsystemsprofessionals,administrators,environmentalserviceprofessionals,andarchitects.Key
recommendationsinclude
infectioncontrolimpactofventilationsystemandwatersystemperformance
establishmentofamultidisciplinaryteamtoconductinfectioncontrolriskassessment
useofdustcontrolproceduresandbarriersduringconstruction,repair,renovation,ordemolition
environmentalinfectioncontrolmeasuresforspecialareaswithpatientsathighrisk
useofairborneparticlesamplingtomonitortheeffectivenessofairfiltrationanddustcontrol
measures
procedurestopreventairbornecontaminationinoperatingroomswheninfectioustuberculosis(TB)
patientsrequiresurgery
guidanceregardingappropriateindicationsforroutineculturingofwateraspartofacomprehensive
controlprogramforlegionellae
guidanceforrecoveringfromwatersystemdisruptions,waterleaks,andnaturaldisasters(e.g.,
flooding)
infectioncontrolconceptsforequipmentusingwaterfrommainlines(e.g.,watersystemsfor
hemodialysis,icemachines,hydrotherapyequipment,dentalunitwaterlines,andautomated
endoscopereprocessors)
environmentalsurfacecleaninganddisinfectionstrategieswithrespecttoantibioticresistant
microorganisms
infectioncontrolproceduresforhealthcarelaundry
useofanimalsinhealthcareforactivitiesandtherapy
managingthepresenceofserviceanimalsinhealthcarefacilities
infectioncontrolstrategiesforwhenanimalsreceivetreatmentinhumanhealthcarefacilitiesand
acalltoreinstatethepracticeofinactivatingamplifiedculturesandstocksofmicroorganismsonsite
duringmedicalwastetreatment.
Topicsoutsidethescopeofthisreportinclude1)noninfectiousadverseevents(e.g.,sickbuilding
syndrome),2)environmentalconcernsinthehome,3)homehealthcare,4)terrorism,and5)healthcare
associatedfoodborneillness.
Whereverpossible,therecommendationsinthisreportarebasedondatafromwelldesignedscientific
studies.However,certainofthesestudieswereconductedbyusingnarrowlydefinedpatientpopulationsor
specifichealthcaresettings(e.g.,hospitalsversuslongtermcarefacilities),makinggeneralizationof
findingspotentiallyproblematic.Constructionstandardsforhospitalsorotherhealthcarefacilitiesmaynot
applytoresidentialhomecareunits.Similarly,infectioncontrolmeasuresindicatedforimmunosuppressed
patientcareareusuallynotnecessaryinthosefacilitieswheresuchpatientsarenotpresent.
Otherrecommendationswerederivedfromknowledgegainedduringinfectiousdiseaseinvestigationsin
healthcarefacilities,wheresuccessfulterminationoftheoutbreakwasoftentheresultofmultiple
interventions,themajorityofwhichcannotbeindependentlyandrigorouslyevaluated.Thisisespecially
trueforconstructionsituationsinvolvingairorwater.
Otherrecommendationswerederivedfromempiricengineeringconceptsandmayreflectindustry
standardsratherthanevidencebasedconclusions.Whererecommendationsrefertoguidancefromthe
AmericanInstituteofArchitects(AIA),thestatementsreflectstandardsintendedfornewconstructionor
renovation.Existingstructuresandengineeredsystemsareexpectedtobeincontinuedcompliancewith
thosestandardsineffectatthetimeofconstructionorrenovation.
Also,intheabsenceofscientificconfirmation,certaininfectioncontrolrecommendationsthatcannotbe
rigorouslyevaluatedarebasedonstrongtheoreticrationaleandsuggestiveevidence.Finally,certain
recommendationsarederivedfromexistingfederalregulations.
PerformanceMeasurements
Infectionscausedbythemicroorganismsdescribedinthisguidelinearerareevents,andtheeffectofthese
recommendationsoninfectionratesinafacilitymaynotbereadilymeasurable.Therefore,thefollowing
stepstomeasureperformancearesuggestedtoevaluatetheserecommendations:
1.Documentwhetherinfectioncontrolpersonnelareactivelyinvolvedinallphasesofahealthcare
facility'sdemolition,construction,andrenovation.Activitiesshouldincludeperformingarisk
assessmentofthenecessarytypesofconstructionbarriers,anddailymonitoringanddocumentingof
thepresenceofnegativeairflowwithintheconstructionzoneorrenovationarea.
2.MonitoranddocumentdailythenegativeairflowinAIIroomsandpositiveairflowinPErooms,
especiallywhenpatientsareintheserooms.
3.Performassaysatleastonceamonthbyusingstandardquantitativemethodsforendotoxininwater
usedtoreprocesshemodialyzers,andforheterotrophicandmesophilicbacteriainwaterusedto
preparedialysateandforhemodialyzerreprocessing.
4.Evaluatepossibleenvironmentalsources(e.g.,water,laboratorysolutions,orreagents)ofspecimen
contaminationwhennontuberculousmycobacteria(NTM)ofunlikelyclinicalimportanceareisolated
fromclinicalcultures.Ifenvironmentalcontaminationisfound,eliminatetheprobablemechanisms.
5.Documentpoliciestoidentifyandrespondtowaterdamage.Suchpoliciesshouldresultineither
repairanddryingofwetstructuralorporousmaterialswithin72hours,orremovalofthewet
materialifdryingisunlikelywithin72hours.
UpdatestoPreviousRecommendations
ContributorstothisreportreviewedprimarilyEnglishlanguagemanuscriptsidentifiedfromreference
searchesusingtheNationalLibraryofMedicine'sMEDLINE,bibliographiesofpublishedarticles,and
infectioncontroltextbooks.Alltherecommendationsmaynotreflecttheopinionsofallreviewers.This
reportupdatesthefollowingpublishedguidelinesandrecommendations:
CDC.Guidelineforhandwashingandhospitalenvironmentalcontrol.MMWR199837(No.24).Replaces
sectionsonmicrobiologicsampling,laundry,infectivewaste,andhousekeeping.
TablanOC,AndersonLJ,ArdenNH,etal.,HospitalInfectionControlPracticesAdvisoryCommittee.
Guidelineforpreventionofnosocomialpneumonia.InfectControlHospEpidemiol199415:587627.
UpdatesandexpandsenvironmentalinfectioncontrolinformationforaspergillosisandLegionnaires
diseaseonlineversionincorporatesAppendicesB,C,andDaddressingenvironmentalcontroland
detectionofLegionellaspp.
CDC.Guidelinesforpreventingthetransmissionofmycobacteriumtuberculosisinhealthcarefacilities.
MMWR199443(No.RR13).Providessupplementalinformationonengineeringcontrols.
CDC.Recommendationsforpreventingthespreadofvancomycinresistance:recommendationsofthe
HospitalInfectionControlPracticesAdvisoryCommittee(HICPAC).MMWR199544(No.RR12).
Supplementsenvironmentalinfectioncontrolinformationfromthesection,HospitalswithEndemicVRE
orContinuedVRETransmission.
GarnerJS,HospitalInfectionControlPracticesAdvisoryCommittee.Guidelineforisolationprecautionsin
hospitals.InfectControlHospEpidemiol199617:5380.SupplementsandupdatestopicsinPartII
RecommendationsforIsolationPrecautionsinHospitals(linenandlaundry,routineandterminalcleaning,
airborneprecautions).
MangramAJ,HoranTC,PearsonML,SilverLC,JarvisWR,HospitalInfectionControlPracticesAdvisory
Committee.Guidelineforpreventionofsurgicalsiteinfection.InfectControlHospEpidemiol19994:250
78.Updatesoperatingroomventilationandsurfacecleaning/disinfectionrecommendationsfromthe
section,IntraoperativeIssues:OperatingRoomEnvironment.
U.S.PublicHealthService,InfectiousDiseasesSocietyofAmerica,PreventionofOpportunisticInfections
WorkingGroup.USPHS/IDSAguidelinesforthepreventionofopportunisticinfectionsinpersonsinfected
withhumanimmunodeficiencyvirus.InfectDisObstetGynecol200210:364.Supplementsinformation
regardingpatientinteractionwithpetsandanimalsinthehome.
CDC,InfectiousDiseasesSocietyofAmerica,AmericanSocietyofBloodandMarrowTransplantation.
Guidelinesforpreventingopportunisticinfectionsamonghematopoieticstemcelltransplantrecipients.
Cytotherapy20013:4154.Supplementsandupdatesthesection,HospitalInfectionControl.
KeyTerms
Airborneinfectionisolation(AII)referstotheisolationofpatientsinfectedwithorganismsspreadvia
airbornedropletnuclei<5mindiameter.Thisisolationareareceivesnumerousairchangesperhour
(ACH)(>12ACHfornewconstructionasof2001>6ACHforconstructionbefore2001),andisunder
negativepressure,suchthatthedirectionoftheairflowisfromtheoutsideadjacentspace(e.g.,the
corridor)intotheroom.TheairinanAIIroomispreferablyexhaustedtotheoutside,butmaybe
recirculatedprovidedthatthereturnairisfilteredthroughahighefficiencyparticulateair(HEPA)filter.
Theuseofpersonalrespiratoryprotectionisalsoindicatedforpersonsenteringtheseroomswhencaring
forTBorsmallpoxpatientsandforstaffwholackimmunitytoairborneviraldiseases(e.g.,measlesor
varicellazostervirus[VZV]infection).
Protectiveenvironment(PE)isaspecializedpatientcarearea,usuallyinahospital,withapositiveair
flowrelativetothecorridor(i.e.,airflowsfromtheroomtotheoutsideadjacentspace).Thecombination
ofHEPAfiltration,highnumbersofairchangesperhour(>12ACH),andminimalleakageofairintothe
roomcreatesanenvironmentthatcansafelyaccommodatepatientswhohaveundergoneallogeneic
hematopoieticstemcelltransplant(HSCT).
Immunocompromisedpatientsarethosepatientswhoseimmunemechanismsaredeficientbecauseof
immunologicdisorders(e.g.,humanimmunodeficiencyvirus[HIV]infectionorcongenitalimmune
deficiencysyndrome),chronicdiseases(e.g.,diabetes,cancer,emphysema,orcardiacfailure),or
immunosuppressivetherapy(e.g.,radiation,cytotoxicchemotherapy,antirejectionmedication,orsteroids).
Immunocompromisedpatientswhoareidentifiedashighriskpatientshavethegreatestriskofinfection
causedbyairborneorwaterbornemicroorganisms.Patientsinthissubsetincludepersonswhoareseverely
neutropenicforprolongedperiodsoftime(i.e.,anabsoluteneutrophilcount[ANC]of<500cells/mL),
allogeneicHSCTpatients,andthosewhohavereceivedthemostintensivechemotherapy(e.g.,childhood
acutemyelogenousleukemiapatients).
Abbreviations
AAMIAssociationfortheAdvancementofMedicalInstrumentation
ACHairchangesperhour
AERautomatedendoscopereprocessor
AHJauthorityhavingjurisdiction
AIAAmericanInstituteofArchitects
AIIairborneinfectionisolation
ANSIAmericanNationalStandardsInstitute
ASHRAEAmericanSocietyofHeating,Refrigeration,andAirConditioningEngineers
BMBLBiosafetyinMicrobiologicalandBiomedicalLaboratories(CDC/NationalInstitutesofHealth)
CFRCodeofFederalRegulations
CJDCreutzfeldtJakobdisease
CPLcompliancedocument(OSHA)
DFAdirectfluorescenceassay
DHHSU.S.DepartmentofHealthandHumanServices
DOTU.S.DepartmentofTransportation
ECenvironmentofcare
EPAU.S.EnvironmentalProtectionAgency
FDAU.S.FoodandDrugAdministration
HBVhepatitisBvirus
HEPAhighefficiencyparticulateair
HIVhumanimmunodeficiencyvirus
HSCThematopoieticstemcelltransplant
HVACheating,ventilation,airconditioning
ICRAinfectioncontrolriskassessment
JCAHOJointCommissiononAccreditationofHealthcareOrganizations
NaOHsodiumhydroxide
NTMnontuberculousmycobacteria
OSHAOccupationalSafetyandHealthAdministration
PEprotectiveenvironment
PPEpersonalprotectiveequipment
TBtuberculosis
USCUnitedStatesCode
USDAU.S.DepartmentofAgriculture
UVultraviolet
UVGIultravioletgermicidalirradiation
VHFviralhemorrhagicfever
VREvancomycinresistantEnterococcus
VRSAvancomycinresistantStaphylococcusaureus
VZVvaricellazostervirus
RecommendationsforEnvironmentalInfectionControlinHealthCareFacilities
RationaleforRecommendations
AsinpreviousCDCguidelines,eachrecommendationiscategorizedonthebasisofexistingscientificdata,
theoreticrationale,applicability,andpossibleeconomiceffect.Therecommendationsareevidencebased
whereverpossible.However,certainrecommendationsarederivedfromempiricinfectioncontrolor
engineeringprinciples,theoreticrationale,orfromexperiencegainedfromeventsthatcannotbereadily
studied(e.g.,floods).
TheHICPACsystemforcategorizingrecommendationshasbeenmodifiedtoincludeacategoryfor
engineeringstandardsandactionsrequiredbystateorfederalregulations.Guidelinesandstandards
publishedbytheAIA,AmericanSocietyofHeating,Refrigeration,andAirConditioningEngineers
(ASHRAE),andtheAssociationfortheAdvancementofMedicalInstrumentation(AAMI)formthebasis
ofcertainrecommendations.Thesestandardsreflectaconsensusofexpertopinionsandextensive
consultationwithagenciesoftheU.S.DepartmentofHealthandHumanServices.Compliancewiththese
standardsisusuallyvoluntary.However,stateandfederalgovernmentsoftenadoptthesestandardsas
regulations.Forexample,thestandardsfromAIAregardingconstructionanddesignofneworrenovated
healthcarefacilities,havebeenadoptedbyreferenceby>40states.Certainrecommendationshavetwo
categoryratings(e.g.,CategoriesIAandICorCategoriesIBandIC),indicatingtherecommendationis
evidencebasedaswellasastandardorregulation.
RatingCategories
Recommendationsareratedaccordingtothefollowingcategories:
CategoryIA.Stronglyrecommendedforimplementationandstronglysupportedbywelldesigned
experimental,clinical,orepidemiologicstudies.
CategoryIB.Stronglyrecommendedforimplementationandsupportedbycertainexperimental,clinical,
orepidemiologicstudiesandastrongtheoreticrationale.
CategoryIC.Requiredbystateorfederalregulation,orrepresentinganestablishedassociationstandard.
(Note:Abbreviationsforgoverningagenciesandregulatorycitationsarelistedwhereappropriate.
Recommendationsfromregulationsadoptedatstatelevelsarealsonoted.RecommendationsfromAIA
guidelinescitetheappropriatesectionsofthestandards.)
CategoryII.Suggestedforimplementationandsupportedbysuggestiveclinicalorepidemiologicstudies,
oratheoreticrationale.
Unresolvedissue.Norecommendationisoffered.Noconsensusorinsufficientevidenceexistsregarding
efficacy.
RecommendationsAir
I.AirHandlingSystemsinHealthCareFacilities
A.UseAIAguidelinesasminimumstandardswherestateorlocalregulationsarenotinplacefordesign
andconstructionofventilationsystemsinneworrenovatedhealthcarefacilities.Ensurethatexisting
structurescontinuetomeetthespecificationsineffectatthetimeofconstruction(1).CategoryIC
(AIA:1.1.A,5.4)
B.Monitorventilationsystemsinaccordancewithengineers'andmanufacturers'recommendationsto
ensurepreventiveengineering,optimalperformanceforremovalofparticulates,andeliminationof
excessmoisture(18).CategoryIB,IC(AIA:7.2,7.31.D,8.31.D,9.31.D,10.31.D,11.31.D,
EnvironmentalProtectionAgency[EPA]guidance)
1.Ensurethatheating,ventilation,airconditioning(HVAC)filtersareproperlyinstalledand
maintainedtopreventairleakagesanddustoverloads(2,4,6,9).CategoryIB
2.Monitorareaswithspecialventilationrequirements(e.g.,AIIorPE)forACH,filtration,and
pressuredifferentials(1,7,8,1026).CategoryIB,IC(AIA:7.2.C7,7.2.D6)
a.DevelopandimplementamaintenancescheduleforACH,pressuredifferentials,andfiltration
efficienciesbyusingfacilityspecificdataaspartofthemultidisciplinaryrisk
assessment.Takeintoaccounttheageandreliabilityofthesystem.
b.Documenttheseparameters,especiallythepressuredifferentials.
3.EngineerhumiditycontrolsintotheHVACsystemandmonitorthecontrolstoensureadequate
moistureremoval(1).CategoryIC(AIA:7.31.D9)
a.Locateducthumidifiersupstreamfromthefinalfilters.
b.Incorporateawaterremovalmechanismintothesystem.
c.Locateallducttakeoffssufficientlydownstreamfromthehumidifiersothatmoistureis
completelyabsorbed.
4.Incorporatesteamhumidifiers,ifpossible,toreducepotentialformicrobialproliferationwithinthe
system,andavoiduseofcoolmisthumidifiers.CategoryII
5.Ensurethatairintakesandexhaustoutletsarelocatedproperlyinconstructionofnewfacilitiesand
renovationofexistingfacilities(1,27).CategoryIC(AIA:7.31.D3,8.31.D3,
9.31.D3,10.31.D3,11.31.D3)
a.Locateexhaustoutlets>25ftfromairintakesystems.
b.Locateoutdoorairintakes>6ftabovegroundor>3ftaboverooflevel.
c.Locateexhaustoutletsfromcontaminatedareasaboveroofleveltominimizerecirculationof
exhaustedair.
6.Maintainairintakesandinspectfiltersperiodicallytoensureproperoperation(1,1116,27).
CategoryIC(AIA:7.31.D8)
7.Bagdustfilledfiltersimmediatelyuponremovaltopreventdispersionofdustandfungalspores
duringtransportwithinthefacility(4,28).CategoryIB
a.Sealorclosethebagcontainingthediscardedfilter.
b.Discardspentfiltersasregularsolidwaste,regardlessoftheareafromwhichtheywere
removed(28).
8.Removebirdroostsandnestsnearairintakestopreventmitesandfungalsporesfromenteringthe
ventilationsystem(27,29,30).CategoryIB
9.Preventdustaccumulationbycleaningairductgrillesinaccordancewithfacilityspecific
proceduresandschedulesandwhenroomsarenotoccupiedbypatients(1,1016).
CategoryIC,II(AIA:7.31.D10)
10.Periodicallymeasureoutputtomonitorsystemfunctioncleanventilationductsaspartofroutine
HVACmaintenancetoensureoptimumperformance(1,31,32).CategoryIC,II
(AIA:7.31.D10)

C.Useportable,industrialgradeHEPAfilterunitscapableoffiltrationratesintherangeof300800
ft3/mintoaugmentremovalofrespirableparticlesasneeded(33).CategoryII
1.SelectportableHEPAfiltersthatcanrecirculateallornearlyalloftheroomairandprovidethe
equivalentof>12ACH(34).CategoryII
2.PortableHEPAfilterunitsplacedinconstructionzonescanbeusedlaterinpatientcareareas,
providedallinternalandexternalsurfacesarecleaned,andthefilterreplacedorits
performanceverifiedbyappropriateparticletesting.CategoryII
3.SituateportableHEPAunitswiththeadviceoffacilityengineerstoensurethatallroomairis
filtered(34).CategoryII
4.Ensurethatfreshairrequirementsfortheareaaremet(33,35).CategoryII

D.Followappropriateproceduresforuseofareaswiththroughthewallventilationunits(1).Category
IC(AIA:8.31.D1,8.31.D8,9.31.D23,10.31.D18,11.31.D15)
1.DonotusesuchareasasPErooms(1).CategoryIC(AIA:7.2.D3)
2.DonotusearoomwithathroughthewallventilationunitasanAIIroomunlessitcanbe
demonstratedthatallrequiredAIIengineeringcontrolsaremet(1,34).CategoryIC(AIA:
7.2.C3)

E.Conductaninfectioncontrolriskassessment(ICRA)andprovideanadequatenumberofAIIandPE
rooms(ifrequired)orotherareastomeettheneedsofthepatientpopulation(1,2,7,8,17,19,20,34,36
43).CategoryIA,IC(AIA:7.2.C,7.2.D)
F.Whenultravioletgermicidalirradiation(UVGI)isusedasasupplementalengineeringcontrol,install
fixtures1)onthewallneartheceilingorsuspendedfromtheceilingasanupperairunit2)inthe
airreturnductofanAIIareaor3)indesignatedenclosedareasorboothsforsputuminduction(34).
CategoryII
G.SealwindowsinbuildingswithcentralizedHVACsystems,includingPEareas(1,3,44).CategoryIB,
IC(AIA:7.2.D3)
H.KeepemergencydoorsandexitsfromPEroomsclosedexceptduringanemergencyequip
emergencydoorsandexitswithalarms.CategoryII
I.Developacontingencyplanforbackupcapacityintheeventofageneralpowerfailure(45).
CategoryIC(JointCommissiononAccreditationofHealthcareOrganizations[JCAHO]:
EnvironmentofCare[EC]1.4)
1.EmphasizerestorationofappropriateairqualityandventilationconditionsinAIIrooms,PE
rooms,operatingrooms,emergencydepartments,andintensivecareunits(1,45).
CategoryIC(AIA:1.5.A1JCAHO:EC1.4)
2.Deployinfectioncontrolprocedurestoprotectoccupantsuntilpowerandsystemsfunctionsare
restored(1,36,45).CategoryIC(AIA:5.1,5.2JCAHO:EC1.4)

J.DonotshutdownHVACsystemsinpatientcareareasexeptformaintenance,repair,testingof
emergencybackupcapacity,ornewconstruction(1,46).CategoryIB,IC(AIA:5.1,5.2.B,C)
1.CoordinateHVACsystemmaintenancewithinfectioncontrolstaffandrelocate
immunocompromisedpatientsifnecessary(1).CategoryIC(AIA:5.1,5.2)
2.Providebackupemergencypowerandairhandlingandpressurizationsystemstomaintain
filtration,constantACH,andpressuredifferentialsinPErooms,AIIrooms,operating
rooms,andothercriticalcareareas(1,37,47).CategoryIC(AIA:5.1,5.2)
3.Forareasnotservedbyinstalledemergencyventilationandbackupsystems,useportableunitsand
monitorventilationparametersandpatientsinthoseareas(33).CategoryII
4.CoordinatesystemstartupswithinfectioncontrolstafftoprotectpatientsinPEroomsfrombursts
offungalspores(1,3,37,47).CategoryIC(AIA:5.1,5.2)
5.AllowsufficienttimeforACHtocleantheaironcethesystemisoperational(Table1)(1,33).
CategoryIC(AIA:5.1,5.2)

K.HVACsystemsservingofficesandadministrativeareasmaybeshutdownforenergyconservation
purposes,buttheshutdownmustnotalteroradverselyaffectpressuredifferentialsmaintainedin
laboratoriesorcriticalcareareaswithspecificventilationrequirements(i.e.,PErooms,AIIrooms,
operatingrooms).CategoryII
L.Wheneverpossible,avoidinactivatingorshuttingdowntheentireHVACsystem,especiallyinacute
carefacilities.CategoryII
M.Wheneverfeasible,designandinstallfixedbackupventilationsystemsforneworrenovated
constructionofPErooms,AIIrooms,operatingrooms,andothercriticalcareareasidentifiedby
ICRA(1).CategoryIC(AIA:1.5.A1)
II.Construction,Renovation,Remediation,Repair,andDemolition
A.Establishamultidisciplinaryteamthatincludesinfectioncontrolstafftocoordinatedemolition,
construction,andrenovationprojectsandconsiderproactivepreventivemeasuresattheinception
produceandmaintainsummarystatementsoftheteam'sactivities(1,9,1116,38,4851).Category
IB,IC(AIA:5.1)
B.Educateboththeconstructionteamandhealthcarestaffinimmunocompromisedpatientcareareas
regardingtheairborneinfectionrisksassociatedwithconstructionprojects,dispersaloffungalspores
duringsuchactivities,andmethodstocontrolthedisseminationoffungalspores(1116,27,50,52
56).CategoryIB
C.Incorporatemandatoryadherenceagreementsforinfectioncontrolintoconstructioncontracts,with
penaltiesfornoncomplianceandmechanismstoensuretimelycorrectionofproblems(1,11,13
16,27,50).CategoryIC(AIA:5.1)
D.Establishandmaintainsurveillanceforairborneenvironmentaldisease(e.g.,aspergillosis)as
appropriateduringconstruction,renovation,repair,anddemolitionactivitiestoensurethehealthand
safetyofimmunocompromisedpatients(27,5759).CategoryIB
1.Usingactivesurveillance,monitorforairborneinfectionsinimmunocompromisedpatients
(27,37,57,58).CategoryIB
2.Periodicallyreviewthefacility'smicrobiologic,histopathologic,andpostmortemdatatoidentify
additionalcases(27,37,57,58).CategoryIB
3.Ifcasesofaspergillosisorotherhealthcareassociatedairbornefungalinfectionsoccur,
aggressivelypursuethediagnosiswithtissuebiopsiesandculturesasfeasible(11,13
16,27,50,5759).CategoryIB

E.Implementinfectioncontrolmeasuresrelevanttoconstruction,renovation,maintenance,demolition,
andrepair(1,16,49,50,60).CategoryIB,IC(AIA:5.1,5.2)
1.Beforetheprojectgetsunderway,performanICRAtodefinethescopeoftheactivityandthe
needforbarriermeasures(1,11,1316,4851,60).CategoryIB,IC(AIA:5.1)
a.Determineifimmunocompromisedpatientsmaybeatriskforexposuretofungalsporesfrom
dustgeneratedduringtheproject(1316,48,51).
b.Developacontingencyplantopreventsuchexposures(1316,48,51).
2.Implementinfectioncontrolmeasuresforexternaldemolitionandconstructionactivities(11,13
16,50,61,62).CategoryIB
a.Determineifthefacilitycanoperatetemporarilyonrecirculatedairiffeasible,sealoffadjacent
airintakes.
b.Ifthisisnotpossibleorpractical,checkthelowefficiency(roughing)filterbanksfrequently
andreplaceasneededtoavoidbuildupofparticulates.
c.Sealwindowsandreducewhereverpossibleothersourcesofoutsideairintrusion(e.g.,open
doorsinstairwellsandcorridors),especiallyinPEareas.
3.Avoiddamagingtheundergroundwatersystem(i.e.,buriedpipes)topreventsoilanddust
contaminationofthewater(1,63).CategoryIB,IC(AIA:5.1)
4.Implementinfectioncontrolmeasuresforinternalconstructionactivities(1,11,1316,4850,64).
CategoryIB,IC(AIA:5.1,5.2)
a.Constructbarrierstopreventdustfromconstructionareasfromenteringpatientcareareas
ensurethatbarriersareimpermeabletofungalsporesandincompliancewithlocalfire
codes(1,45,48,49,55,6466).
b.Sealoffandblockreturnairventsifrigidbarriersareusedforcontainment(1,16,50).
c.Implementdustcontrolmeasuresonsurfacesanddivertpedestriantrafficawayfromwork
zones(1,48,49,64).
d.Relocatepatientswhoseroomsareadjacenttoworkzones,dependingontheirimmunestatus,
thescopeoftheproject,thepotentialforgenerationofdustorwateraerosols,and
themethodsusedtocontroltheseaerosols(1,64,65).

5.Performthoseengineeringandworksiterelatedinfectioncontrolmeasuresasneededforinternal
construction,repairs,andrenovations(1,48,49,51,64,66).CategoryIB,IC(AIA:
5.1,5.2)
a.Ensureproperoperationoftheairhandlingsystemintheaffectedareaaftererectionofbarriers
andbeforetheroomorareaissettonegativepressure(39,47,50,64).Category
IB
b.Createandmaintainnegativeairpressureinworkzonesadjacenttopatientcareareasand
ensurethatrequiredengineeringcontrolsaremaintained(1,48,49,51,64,66).
c.Monitornegativeairflowinsiderigidbarriers(1,67).
d.Monitorbarriersandensureintegrityoftheconstructionbarriersrepairgapsorbreaksinbarrier
joints(1,65,66,68).
e.Sealwindowsinworkzonesifpracticalusewindowchutesfordisposaloflargepiecesof
debrisasneeded,butensurethatthenegativepressuredifferentialfortheareais
maintained(1,13,48).
f.Directpedestriantrafficfromconstructionzonesawayfrompatientcareareastominimize
dispersionofdust(1,1316,44,4851,64).
g.Provideconstructioncrewswith1)designatedentrances,corridors,andelevatorswherever
practical2)essentialservices(e.g.,toiletfacilities)andconvenienceservices(e.g.,
vendingmachines)3)protectiveclothing(e.g.,coveralls,footgear,andheadgear)fortravelto
patientcareareasand4)aspaceoranteroomforchangingclothingandstoring
equipment(1,11,1316,50).
h.Cleanworkzonesandtheirentrancesdailyby1)wetwipingtoolsandtoolcartsbeforetheir
removalfromtheworkzone2)placingmatswithtackysurfacesinsidetheentrance
and3)coveringdebrisandsecuringthiscoveringbeforeremovingdebrisfromtheworkzone
(1,11,1316,50).
i.Inpatientcareareas,formajorrepairsthatincluderemovalofceilingtilesanddisruptionofthe
spaceabovethefalseceiling,useplasticsheetsorprefabricatedplasticunitsto
containdustuseanegativepressuresystemwithinthisenclosuretoremovedustandeitherpass
airthroughanindustrialgrade,portableHEPAfiltercapableoffiltrationratesof
300800ft3/min.,orexhaustairdirectlytotheoutside(16,50,64,67,69).
j.Uponcompletionoftheproject,cleantheworkzoneaccordingtofacilityprocedures,andinstall
barriercurtainstocontaindustanddebrisbeforeremovingrigidbarriers(1,11,13
16,4850).
k.Flushthewatersystemtoclearsedimentfrompipestominimizewaterbornemicroorganism
proliferation(1,63).
l.RestoreappropriateACH,humidity,andpressuredifferentialcleanorreplaceairfiltersdispose
ofspentfilters(3,4,28,47).

F.Useairborneparticlesamplingasatooltoevaluatebarrierintegrity(3,70).CategoryII
G.CommissiontheHVACsystemfornewlyconstructedhealthcarefacilitiesandrenovatedspaces
beforeoccupancyanduse,withemphasisonensuringproperventilationforoperatingrooms,AII
rooms,andPEareas(1,7072).CategoryIC(AIA:5.1ASHRAE:11996)
H.Norecommendationisofferedregardingroutinemicrobiologicairsamplingbefore,during,orafter
construction,orbeforeorduringoccupancyofareashousingimmunocompromisedpatients
(9,48,49,51,64,73,74).Unresolvedissue
I.Ifacaseofhealthcareacquiredaspergillosisorotheropportunisticenvironmentalairbornefungal
diseaseoccursduringorimmediatelyafterconstruction,implementappropriatefollowupmeasures
(40,48,7578).CategoryIB
1.Reviewpressuredifferentialmonitoringdocumentationtoverifythatpressuredifferentialsinthe
constructionzoneandinPEroomsareappropriatefortheirsettings(1,40,78).
CategoryIB,IC(AIA:5.1)
2.Implementcorrectiveengineeringmeasurestorestoreproperpressuredifferentialsasneeded
(1,40,78).CategoryIB,IC(AIA:5.1)
3.Conductaprospectivesearchforadditionalcasesandintensifyretrospectiveepidemiologicreview
ofthehospital'smedicalandlaboratoryrecords(27,48,76,79,80).CategoryIB
4.Ifnoepidemiologicevidenceofongoingtransmissionexists,continueroutinemaintenanceinthe
areatopreventhealthcareacquiredfungaldisease(27,75).CategoryIB

J.Ifnoepidemiologicevidenceexistsofongoingtransmissionoffungaldisease,conductan
environmentalassessmenttofindandeliminatethesource(11,1316,27,44,4951,60,81).Category
IB
1.Collectenvironmentalsamplesfrompotentialsourcesofairbornefungalspores,preferablyby
usingahighvolumeairsamplerratherthansettleplates(2,4,11,13
16,27,44,49,50,64,65,8186).CategoryIB
2.Ifeitheranenvironmentalsourceofairbornefungioranengineeringproblemwithfiltrationor
pressuredifferentialsisidentified,promptlyperformcorrectivemeasurestoeliminatethe
sourceandrouteofentry(49,60).CategoryIB
3.UseanEPAregisteredantifungalbiocide(e.g.,copper8quinolinolate)fordecontaminating
structuralmaterials(16,61,66,87).CategoryIB
4.Ifanenvironmentalsourceofairbornefungiisnotidentified,reviewinfectioncontrolmeasures,
includingengineeringcontrols,toidentifypotentialareasforcorrectionorimprovement
(88,89).CategoryIB
5.Ifpossible,performmolecularsubtypingofAspergillusspp.isolatedfrompatientsandthe
environmenttocomparetheirstrainidentities(9094).CategoryII

K.Ifairsupplysystemstohighriskareas(e.g.,PErooms)arenotoptimal,useportable,industrial
gradeHEPAfiltersonatemporarybasisuntilroomswithoptimalairhandlingsystemsbecome
available(1,1316,27,50).CategoryII
III.InfectionControlandVentilationRequirementsforPErooms
A.Minimizeexposuresofseverelyimmunocompromisedpatients(e.g.,solidorgantransplantpatients
orallogeneicneutropenicpatients)toactivitiesthatmightcauseaerosolizationoffungalspores(e.g.,
vacuumingordisruptionofceilingtiles)(37,48,51,73).CategoryIB
B.MinimizethelengthoftimethatimmunocompromisedpatientsinPEareoutsidetheirroomsfor
diagnosticproceduresandotheractivities(37,62).CategoryIB
C.ProviderespiratoryprotectionforseverelyimmunocompromisedpatientswhentheymustleavePE
fordiagnosticproceduresandotheractivitiesconsultthemostrecentrevisionofCDC'sGuideline
forPreventionofHealthCareAssociatedPneumoniaforinformationregardingtheappropriatetype
ofrespiratoryprotection.(27,37).CategoryII
D.Incorporateventilationengineeringspecificationsanddustcontrollingprocessesintotheplanning
andconstructionofnewPEunits(Figure1).CategoryIB,IC
1.InstallcentralorpointofuseHEPAfiltersforsupply(incoming)air(1,2,27,48,56,70,
80,82,85,95102).CategoryIB,IC(AIA:5.1,5.2,7.2.D)
2.Ensurethatroomsarewellsealedby1)properlyconstructingwindows,doors,andintakeand
exhaustports2)maintainingceilingsthataresmoothandfreeoffissures,openjoints,
andcrevices3)sealingwallsaboveandbelowtheceilingand4)monitoringforleakageand
makinganynecessaryrepairs(1,27,44,100,101).CategoryIB,IC(AIA:7.2.D3)
3.Ventilatetheroomtomaintain>12ACH(1,27,37,100,101,103).CategoryIC(AIA:7.2.D)
4.Locateairsupplyandexhaustgrillessothatclean,filteredairentersfromonesideoftheroom,
flowsacrossthepatient'sbed,andexitsfromtheoppositesideoftheroom
(1,27,100,101).CategoryIC(AIA:7.31.D1)
5.Maintainpositiveroomairpressure(>2.5Pa[0.01inchwatergauge])inrelationtothecorridor
(1,3,27,100,101).CategoryIB,IC(AIA:Table7.2)
6.Maintainairflowpatternsandmonitortheseonadailybasisbyusingpermanentlyinstalledvisual
meansofdetectingairflowinneworrenovatedconstruction,orbyusingothervisual
methods(e.g.,flutterstripsorsmoketubes)inexistingPEunits.Documentthemonitoringresults
(1,13).CategoryIC(AIA:7.2.D6)
7.InstallselfclosingdevicesonallroomexitdoorsinPErooms(1).CategoryIC(AIA:7.2.D4)

E.DonotuselaminarairflowsystemsinnewlyconstructedPErooms(99,101).CategoryII
F.TakemeasurestoprotectimmunocompromisedpatientswhowouldbenefitfromaPEroomandwho
alsohaveanairborneinfectiousdisease(e.g.,acuteVZVinfectionortuberculosis).
1.Ensurethatthepatient'sroomisdesignedtomaintainpositivepressure.
2.Useananteroomtoensureappropriateairbalancerelationshipsandprovideindependentexhaust
ofcontaminatedairtotheoutside,orplaceaHEPAfilterintheexhaustductifthe
returnairmustberecirculated(1,100)(Figure2).CategoryIC(AIA:7.2.D1,A7.2.D)
3.Ifananteroomisnotavailable,placethepatientinAIIanduseportable,industrialgradeHEPA
filterstoenhancefiltrationofsporesintheroom(33).CategoryII

G.Maintainbackupventilationequipment(e.g.,portableunitsforfansorfilters)foremergency
provisionofrequiredventilationforPEareasandtakeimmediatestepstorestorethefixedventilation
system(1,37,47).CategoryIC(AIA:5.1)
IV.InfectionControlandVentilationRequirementsforAIIRooms
A.IncorporatecertainspecificationsintotheplanningandconstructionorrenovationofAIIunits
(1,34,100,101,104)(Figure3).CategoryIB,IC
1.Maintaincontinuousnegativeairpressure(2.5Pa[0.01inchwatergauge])inrelationtotheair
pressureinthecorridormonitorairpressureperiodically,preferablydaily,with
audiblemanometersorsmoketubesatthedoor(forexistingAIIrooms),orwithapermanently
installedvisualmonitoringmechanism.Documenttheresultsofmonitoring
(1,100,101).CategoryIC(AIA:7.2.C7,Table7.2)
2.Ensurethatroomsarewellsealedbyproperlyconstructingwindows,doors,andairintakeand
exhaustportswhenmonitoringindicatesairleakage,locatetheleakandmake
necessaryrepairs(1,99,100).CategoryIB,IC(AIA:7.2.C3)
3.InstallselfclosingdevicesonallAIIroomexitdoors(1).CategoryIC(AIA:7.2.C4)
4.Provideventilationtoensure>12ACHforrenovatedroomsandnewrooms,and>6ACHfor
existingAIIrooms(1,34,104).CategoryIB,IC(AIA:Table7.2)
5.Directexhaustairtotheoutside,awayfromairintakeandpopulatedareas.Ifthisisnotpractical,
airfromtheroomcanberecirculatedafterpassingthroughaHEPAfilter(1,34).
CategoryIC(AIA:Table7.2)

B.Wheresupplementalengineeringcontrolsforaircleaningareindicatedfromariskassessmentofthe
AIIarea,installUVGIunitsintheexhaustairductsoftheHVACsystemtosupplementHEPA
filtrationorinstallUVGIfixturesonorneartheceilingtoirradiateupperroomair(34).CategoryII
C.Implementenvironmentalinfectioncontrolmeasuresforpersonswithdiagnosedorsuspected
airborneinfectiousdiseases.
1.UseAIIroomsforpatientswithorsuspectedofhavinganairborneinfectionwhoalsorequire
coughinducingprocedures,oruseanenclosedbooththatisengineeredtoprovide1)
>12ACH2)airsupplyandexhaustratesufficienttomaintaina2.5Pa(0.01inchwatergauge)
negativepressuredifferencewithrespecttoallsurroundingspaceswithanexhaust
rateof>50ft3/minand3)airexhausteddirectlyoutsideawayfromairintakesandtrafficor
exhaustedafterHEPAfiltrationbeforerecirculation(1,34,105107).CategoryIB,IC
(AIA:7.15.E,7.31.D23,9.10,Table7.2)
2.Althoughairbornespreadofviralhemorrhagicfever(VHF)hasnotbeendocumentedinahealth
caresetting,prudencedictatesplacingaVHFpatientinanAIIroom,preferably
withananteroom,toreducetheriskofoccupationalexposuretoaerosolizedinfectiousmaterialin
blood,vomitus,liquidstool,andrespiratorysecretionspresentinlargeamounts
duringtheendstageofapatient'sillness(108110).CategoryII
a.Ifananteroomisnotavailable,useportable,industrialgradeHEPAfiltersinthepatient'sroom
toprovideadditionalACHequivalentsforremovingairborneparticulates.
b.Ensurethathealthcareworkerswearfaceshieldsorgoggleswithappropriaterespiratorswhen
enteringtheroomsofVHFpatientswithprominentcough,vomiting,diarrhea,or
hemorrhage(109).
3.Placesmallpoxpatientsinnegativepressureroomsattheonsetoftheirillness,preferablyusinga
roomwithananteroom,ifavailable(36).CategoryII

D.Norecommendationisofferedregardingnegativepressureorisolationforpatientswith
Pneumocystiscariniipneumonia(111113).Unresolvedissue.
E.Maintainbackupventilationequipment(e.g.,portableunitsforfansorfilters)foremergency
provisionofventilationrequirementsforAIIrooms,andtakeimmediatestepstorestorethefixed
ventilationsystem(1,34,47).CategoryIC(AIA:5.1)
V.InfectionControlandVentilationRequirementsforOperatingRooms
A.Implementenvironmentalinfectioncontrolandventilationmeasuresforoperatingrooms.
1.Maintainpositivepressureventilationwithrespecttocorridorsandadjacentareas(1,114,115).
CategoryIB,IC(AIA:Table7.2)
2.Maintain>15ACH,ofwhich>3ACHshouldbefreshair(1,116,117).CategoryIC(AIA:Table
7.2)
3.Filterallrecirculatedandfreshairthroughtheappropriatefilters,providing90%efficiency(dust
spottesting)ataminimum(1,118).CategoryIC(AIA:Table7.3)
4.Inroomsnotengineeredforhorizontallaminarairflow,introduceairattheceilingandexhaustair
nearthefloor(1,115,119).CategoryIC(AIA:7.31.D4)
5.Donotuseultraviolet(UV)lightstopreventsurgicalsiteinfections(115,120126).CategoryIB
6.Keepoperatingroomdoorsclosedexceptforthepassageofequipment,personnel,andpatients,
andlimitentrytoessentialpersonnel(127,128).CategoryIB

B.FollowprecautionaryproceduresforinfectiousTBpatientswhoalsorequireemergencysurgery
(34,129,130).CategoryIB,IC
1.UseanN95respiratorapprovedbytheNationalInstituteforOccupationalSafetyandHealth
withoutexhalationvalvesintheoperatingroom(129,131).CategoryIC(Occupational
SafetyandHealthAdministration[OSHA]29CodeofFederalRegulations[CFR]1910.134,139)
2.IntubatethepatientineithertheAIIroomortheoperatingroomifintubatingthepatientinthe
operatingroom,donotallowthedoorstoopenuntil99%oftheairbornecontaminants
areremoved(Table1)(34,117).CategoryIB
3.WhenanesthetizingapatientwithconfirmedorsuspectedTB,placeabacterialfilterbetweenthe
anesthesiacircuitandpatient'sairwaytopreventcontaminationofanesthesia
equipmentordischargeoftuberclebacilliintotheambientair(130,132).CategoryIB
4.ExtubateandallowthepatienttorecoverinanAIIroom(34,117).CategoryIB
5.Ifthepatienthastobeextubatedintheoperatingroom,allowadequatetimeforACHtoclean99%
ofairborneparticlesfromtheair(Table1),becauseextubationisacough
producingprocedure(34,117).CategoryIB

C.Useportable,industrialgradeHEPAfilterstemporarilyforsupplementalaircleaningduring
intubationandextubationforTBpatientswhorequiresurgery(33,34,117).CategoryII
1.Positiontheunitsappropriatelysothatallroomairpassesthroughthefilterobtainengineering
consultationtodeterminetheappropriateplacements(34).CategoryII
2.Switchtheportableunitoffduringthesurgicalprocedure.CategoryII
3.Providefreshairasperventilationstandardsforoperatingroomsportableunitsdonotmeetthe
requirementsforthenumberoffreshACH(1,33,133).CategoryII

D.Ifpossible,scheduleTBpatientsasthelastsurgicalcasesofthedaytomaximizethetimeavailable
forremovalofairbornecontamination.CategoryII
E.Norecommendationisofferedforperformingorthopedicimplantoperationsinroomssuppliedwith
laminarairflow(118,120).Unresolvedissue
F.Maintainbackupventilationequipment(e.g.,portableunitsforfansorfilters)foremergency
ventilationofoperatingrooms,andtakeimmediatestepstorestorethefixedventilationsystem
(1,47,131,134).CategoryIB,IC(AIA:5.1)
VI.OtherPotentialInfectiousAerosolHazardsinHealthCareFacilities
A.Insettingswheresurgicallasersareused,wearappropriatepersonalprotectiveequipment(PPE),
includingN95orN100respirators,tominimizeexposuretolaserplumes(129,135,136).CategoryIC
(OSHA29CFR1910.134,139)
B.Usecentralwallsuctionunitswithinlinefilterstoevacuateminimallaserplumes(135138).
CategoryII
C.Useamechanicalsmokeevacuationsystemwithahighefficiencyfiltertomanagethegenerationof
largeamountsoflaserplume,whenablatingtissueinfectedwithhumanpapillomavirus(HPV)or
performingproceduresonapatientwithextrapulmonaryTB(34,136,137,139141).CategoryII
RecommendationsWater
I.ControllingtheSpreadofWaterborneMicroorganisms
A.Practicehandhygienetopreventthehandtransferofwaterbornepathogens,andusebarrier
precautions(e.g.,gloves)asdefinedbyotherguidelines(36,142146).CategoryIA
B.Eliminatecontaminatedwaterorfluidenvironmentalreservoirs(e.g.,inequipmentorsolutions)
whereverpossible(142,147).CategoryIB
C.CleananddisinfectsinksandwashbasinsonaregularbasisbyusinganEPAregisteredproductas
setbyfacilitypolicies.CategoryII
D.Evaluateforpossibleenvironmentalsources(e.g.,potablewater)ofspecimencontaminationwhen
waterbornemicroorganisms(e.g.,NTM)ofunlikelyclinicalimportanceareisolatedfromclinical
cultures(e.g.,specimenscollectedasepticallyfromsterilesitesor,ifpostprocedural,colonization
afteruseoftapwaterinpatientcare)(148151).CategoryIB
E.Avoidplacingdecorativefountainsandfishtanksinpatientcareareasensuredisinfectionand
fountainmaintenanceifdecorativefountainsareusedinpublicareasofthehealthcarefacility(152).
CategoryIB
II.RoutinePreventionofWaterborneMicrobialContaminationWithintheDistributionSystem
A.Maintainhotwatertemperatureatthereturnatthehighesttemperatureallowablebystateregulations
orcodes,preferably>124F(>51C),andmaintaincoldwatertemperatureat<68F(<20C)(27,153).
CategoryIC(StatesASHRAE:12:2000)
B.Ifthehotwatertemperaturecanbemaintainedat>124F(>51C),exploreengineeringoptions(e.g.,
installingpresetthermostaticvalvesinpointofusefixtures)tohelpminimizetheriskofscalding
(153).CategoryII
C.Whenstateregulationsorcodesdonotallowhotwatertemperaturesabovetherangeof105F120F
(40.6C49C)forhospitalsor95F110F(35C43.3C)fornursingcarefacilitiesorwhen
buildingscannotberetrofittedforthermostaticmixingvalves,followeitherofthesealternative
preventivemeasurestominimizethegrowthofLegionellaspp.inwatersystems.CategoryII
1.Periodicallyincreasethehotwatertemperatureto>150F(>66C)atthepointofuse(153).
CategoryII
2.Alternatively,chlorinatethewaterandthenflushitthroughthesystem(153155).CategoryII

D.Maintainconstantrecirculationinhotwaterdistributionsystemsservingpatientcareareas(1).
CategoryIC(AIA:7.31.E.3)
III.RemediationStrategiesforDistributionSystemRepairorEmergencies
A.Wheneverpossible,disconnecttheicemachinebeforeplannedwaterdisruptions.CategoryII
B.Prepareacontingencyplantoestimatewaterdemandsfortheentirefacilityinadvanceofsignificant
waterdisruptions(i.e.,thoseexpectedtoresultinextensiveandheavymicrobialorchemical
contaminationofthepotablewater),sewageintrusion,orflooding(45,156).CategoryIC(JCAHO:
EC1.4)
C.Whenasignificantwaterdisruptionoranemergencyoccurs,adheretoanyadvisorytoboilwater
issuedbythemunicipalwaterutility(157).CategoryIB,IC(Municipalorder)
1.Alertpatients,families,staff,andvisitorsnottoconsumewaterfromdrinkingfountains,ice,or
drinksmadefrommunicipaltapwater,whiletheadvisoryisineffect,unlessthewater
hasbeendisinfected(e.g.,bybringingtoarollingboilfor>1minute)(157).CategoryIB,IC
(Municipalorder)
2.Aftertheadvisoryislifted,runfaucetsanddrinkingfountainsatfullflowfor>5minutes,oruse
hightemperaturewaterflushingorchlorination(153,157).CategoryIC,II(Municipal
orderASHRAE:12:2000)

D.Maintainahighlevelofsurveillanceforwaterbornediseaseamongpatientsafteraboilwater
advisoryislifted.CategoryII
E.Correctivedecontaminationofthehotwatersystemmightbenecessaryafteradisruptioninservice
oracrossconnectionwithsewerlineshasoccurred.
1.Decontaminatethesystemwhenthefewestoccupantsarepresentinthebuilding(e.g.,nightsor
weekends)(27,153).CategoryIC(ASHRAE:12:2000)
2.Ifusinghightemperaturedecontamination,raisethehotwatertemperatureto160F170F(71C
77C)andmaintainthatlevelwhileprogressivelyflushingeachoutletaroundthe
systemfor>5minutes(27,153).CategoryIC(ASHRAE:12:2000)
3.Ifusingchlorination,addenoughchlorine,preferablyovernight,toachieveafreechlorineresidual
of>2mg/L(>2ppm)throughoutthesystem(153).CategoryIC(ASHRAE:
12:2000)

a.Flusheachoutletuntilchlorineodorisdetected.
b.Maintaintheelevatedchlorineconcentrationinthesystemfor>2(but<24hrs).
4.Useathoroughflushingofthewatersysteminsteadofchlorinationifahighlychlorineresistant
microorganism(e.g.,Cryptosporidiumspp.)issuspectedasthewatercontaminant.
CategoryII

F.Flushandrestartequipmentandfixturesaccordingtomanufacturer'sinstructions.CategoryII
G.ChangethepretreatmentfilteranddisinfectthedialysiswatersystemwithanEPAregisteredproduct
topreventcolonizationofthereverseosmosismembraneanddownstreammicrobialcontamination
(158).CategoryII
H.Runwatersoftenersthrougharegenerationcycletorestoretheircapacityandfunction.CategoryII
I.Ifthefacilityhasawaterholdingreservoirorwaterstoragetank,consultthefacilityengineeror
localhealthdepartmenttodeterminewhetherthisequipmentneedstobedrained,disinfectedwithan
EPAregisteredproduct,andrefilled.CategoryII
J.Implementfacilityprocedurestomanageasewagesystemfailureorflooding(e.g.,arrangingwith
otherhealthcarefacilitiesfortemporarytransferofpatientsorprovisionofservices),andestablish
communicationswiththelocalmunicipalwaterutilityandthelocalhealthdepartmenttoensurethat
advisoriesarereceivedinatimelymannerafterrelease(45,156).CategoryIC(JCAHO:EC1.4
Municipalorder)
K.Implementinfectioncontrolmeasuresduringsewageintrusion,flooding,orotherwaterrelated
emergencies.
1.Relocatepatientsandcleanorsterilizesuppliesfromaffectedareas.CategoryII
2.Ifhandsarenotvisiblysoiledorcontaminatedwithproteinaceousmaterial,includeanalcohol
basedhandrubinthehandhygieneprocess1)beforeperforminginvasiveprocedures
2)beforeandaftereachpatientcontactand3)wheneverhandhygieneisindicated(146).
CategoryII
3.Ifhandsarevisiblysoiledorcontaminatedwithproteinaceousmaterial,usesoapandbottledwater
forhandwashing(146).CategoryII
4.Ifthepotablewatersystemisnotaffectedbyfloodingorsewagecontamination,processsurgical
instrumentsforsterilizationaccordingtostandardprocedures.CategoryII
5.Contactthemanufactureroftheautomatedendoscopereprocessor(AER)forspecificinstructions
ontheuseofthisequipmentduringawateradvisory.CategoryII

L.Remediatethefacilityaftersewageintrusion,flooding,orotherwaterrelatedemergencies.
1.Closeoffaffectedareasduringcleanupprocedures.CategoryII
2.Ensurethatthesewagesystemisfullyfunctionalbeforebeginningremediationsocontaminated
solidsandstandingwatercanberemoved.CategoryII
3.Ifhardsurfacedequipment,floors,andwallsremainingoodrepair,ensurethatthesearedry
within72hourscleanwithdetergentaccordingtostandardcleaningprocedures.
CategoryII
4.Cleanwoodfurnitureandmaterials(ifstillingoodrepair)allowthemtodrythoroughlybefore
restoringvarnishorothersurfacecoatings.CategoryII
5.Containdustanddebrisduringremediationandrepairasoutlinedinairrecommendations(Air:
IIG4,5).CategoryII

M.Regardlessoftheoriginalsourceofwaterdamage(e.g.,floodingversuswaterleaksfrompointof
usefixturesorroofs),removewet,absorbentstructuralitems(e.g.,carpeting,wallboard,and
wallpaper)andclothfurnishingsiftheycannotbeeasilyandthoroughlycleanedanddriedwithin72
hours(e.g.,moisturecontent<20%asdeterminedbymoisturemeterreadings)replacewithnew
materialsassoonastheunderlyingstructureisdeclaredbythefacilityengineertobethoroughlydry
(2,47,159,160).CategoryIB
IV.AdditionalEngineeringMeasuresasIndicatedbyEpidemiologicInvestigationforControlling
Waterborne,HealthCareAssociatedLegionnairesDisease
A.Whenusingapulseoronetimedecontaminationmethod,superheatthewaterbyflushingeachoutlet
for>5minuteswithwaterat160F170F(71C77C)orhyperchlorinatethesystembyflushingall
outletsfor>5minuteswithwatercontaining>2mg/L(>2ppm)freeresidualchlorineusinga
chlorinebasedproductregisteredbytheEPAforwatertreatment(e.g.,sodiumhypochlorite[chlorine
bleach])(153,155,161164).CategoryIB
B.Afterapulsetreatment,maintainboththeheatedwatertemperatureatthereturnandthecoldwater
temperaturepertherecommendation(Water:IIA)whereverpracticalandpermittedbystatecodes,
orchlorinateheatedwatertoachieve12mg/L(12ppm)freeresidualchlorineatthetapbyusinga
chlorinebasedproductregisteredbytheEPAforwatertreatment(e.g.,sodiumhypochlorite[bleach])
(153,165169).CategoryIC(StatesASHRAE:12:2000)
C.Exploreengineeringoreducationaloptions(e.g.,installpresetthermostaticmixingvalvesinpoint
ofusefixturesorpostwarningsignsateachoutlet)tominimizetheriskofscaldingforpatients,
visitors,andstaff.CategoryII
D.Norecommendationisofferedfortreatingwaterinthefacility'sdistributionsystemwithchlorine
dioxide,heavymetalions(e.g.,copperorsilver),monochloramines,ozone,orUVlight(170188).
Unresolvedissue
V.GeneralInfectionControlStrategiesforPreventingLegionnairesDisease
A.Conductaninfectioncontrolriskassessmentofthefacilitytodetermineifpatientsatriskorseverely
immunocompromisedpatientsarepresent(27,189,190).CategoryIB
B.ImplementgeneralstrategiesfordetectingandpreventingLegionnairesdiseaseinfacilitiesthatdo
notprovidecareforseverelyimmunocompromisedpatients(i.e.,facilitiesthatdonothaveHSCTor
solidorgantransplantprograms)(seeAppendix)(27,189,190).CategoryIB
1.EstablishasurveillanceprocesstodetecthealthcareassociatedLegionnairesdisease
(27,189,190).CategoryIB
2.Informhealthcarepersonnel(e.g.,infectioncontrol,physicians,patientcarestaff,engineering)
regardingthepotentialforLegionnairesdiseasetooccurandmeasurestopreventand
controlhealthcareassociatedlegionellosis(166,191).CategoryIB
3.Establishmechanismstoprovideclinicianswithlaboratorytests(e.g.,culture,urineantigen,direct
fluorescenceassay[DFA],andserology)forthediagnosisofLegionnairesdisease
(27,189).CategoryIB

C.MaintainahighindexofsuspicionforhealthcareassociatedLegionnairesdisease,andperform
laboratorydiagnostictestsforlegionellosisonsuspectedcases,especiallyinpatientsatriskwhodo
notrequireaPEforcare(e.g.,patientsreceivingsystemicsteroidspatientsaged>65yearsor
patientswithchronicunderlyingdisease(e.g.,diabetesmellitus,congestiveheartfailure,orchronic
obstructivelungdisease)(27,166,190,192198).CategoryIA
D.Periodicallyreviewtheavailabilityandclinicians'useoflaboratorydiagnostictestsforLegionnaires
diseaseinthefacilityifclinicians'useofthetestsonpatientswithdiagnosedorsuspected
pneumoniaislimited,implementmeasures(e.g.,aneducationalcampaign)toenhanceclinicians'use
ofthetest(s)(193).CategoryIB
E.Ifonecaseoflaboratoryconfirmed,healthcareassociatedLegionnairesdiseaseisidentified,orif
twoormorecasesoflaboratorysuspected,healthcareassociatedLegionnairesdiseaseoccurduring
a6monthperiod,certainactivitiesshouldbeinitiated(181,189,191,193,199,200).CategoryIB
1.Reportthecasestostateandlocalhealthdepartmentswhererequired.CategoryIC(States)
2.Ifthefacilitydoesnottreatseverelyimmunocompromisedpatients,conductanepidemiologic
investigation,includingretrospectivereviewofmicrobiologic,serologic,andpostmortem
datatolookforpreviouslyunidentifiedcasesofhealthcareassociatedLegionnairesdisease,and
beginintensiveprospectivesurveillanceforadditionalcases
(27,181,189,191,193,199,200).CategoryIB
3.Ifnoevidenceofcontinuedhealthcareassociatedtransmissionexists,continueintensive
prospectivesurveillancefor>2monthsaftertheinitiationofsurveillance(27,181,
189,191,193,199,200).CategoryIB

F.Ifthereisevidenceofcontinuedhealthcareassociatedtransmission(i.e.,anoutbreak),conductan
environmentalassessmenttodeterminethesourceofLegionellaspp.(199207).CategoryIB
1.Collectwatersamplesfrompotentialaerosolizedwatersources(Box1andBox2)(208).Category
IB
2.SaveandsubtypeisolatesofLegionellaspp.obtainedfrompatientsandtheenvironment(163,199
207,209).CategoryIB
3.Ifasourceisidentified,promptlyinstitutewatersystemdecontaminationmeasuresper
recommendations(seeWaterIV)(164,210).CategoryIB
4.IfLegionellaspp.aredetectedin>1culture(e.g.,conductedat2weekintervalsduring3months),
reassessthecontrolmeasures,modifythemaccordingly,andrepeatthe
decontaminationproceduresconsiderintensiveuseoftechniquesusedintheinitial
decontamination,oracombinationofsuperheatingandhyperchlorination(27,210,211).Category
IB

G.IfanenvironmentalsourceisnotidentifiedduringaLegionnairesdiseaseoutbreak,continue
surveillancefornewcasesfor>2months.Eitherdeferdecontaminationpendingidentificationofthe
sourceofLegionellaspp.orproceedwithdecontaminationofthehospital'swaterdistributionsystem,
withspecialattentiontoareasinvolvedintheoutbreak.CategoryII
H.Norecommendationisofferedregardingroutineculturingofwatersystemsinhealthcarefacilities
thatdonothavepatientcareareas(i.e.,PEortransplantunits)forpersonsathighriskforLegionella
spp.infection(seeAppendix)(161,165,167,198,212214).Unresolvedissue
I.Norecommendationisofferedregardingtheremovaloffaucetaeratorsinareasfor
immunocompetentpatients.Unresolvedissue
J.Keepadequaterecordsofallinfectioncontrolmeasuresandenvironmentaltestresultsforpotable
watersystems.CategoryII
VI.PreventingLegionnairesDiseaseinProtectiveEnvironmentsandTransplantUnits
A.WhenimplementingstrategiesforpreventingLegionnairesdiseaseamongseverely
immunocompromisedpatientshousedinfacilitieswithHSCTorsolidorgantransplantprograms,
incorporatethesespecificsurveillanceandepidemiologicmeasuresinadditiontothestepsoutlined
previously(seeAppendix).
1.Maintainahighindexofsuspicionforlegionellosisintransplantpatientsevenwhen
environmentalsurveillanceculturesdonotyieldlegionellae(189,215).CategoryIB
2.Ifacaseoccursinaseverelyimmunocompromisedpatient,orifseverelyimmunocompromised
patientsarepresentinhighriskareasofthehospital(e.g.,PEortransplantunits)and
casesareidentifiedelsewhereinthefacility,conductacombinedepidemiologicandenvironmental
investigationtodeterminethesourceofLegionellaspp.(189,210).CategoryIB

B.Implementculturestrategiesandpotablewaterandfixturetreatmentmeasuresinadditiontothose
previousoutlined(Water:V).CategoryII
1.Dependingonstateregulationsonpotablewatertemperatureinpublicbuildings(216),hospitals
housingpatientsathighriskforhealthcareassociatedlegionellosisshouldeither
maintainheatedwaterwithaminimumreturntemperatureof>124F(>51C)andcoldwaterat
<68F(<20C),orchlorinateheatedwatertoachieve12mg/L(12ppm)offree
residualchlorineatthetap(153155,165,167169,217).CategoryII
2.PeriodicculturingforlegionellaeinpotablewatersamplesfromHSCTorsolidorgantransplant
unitscanbeperformedaspartofacomprehensivestrategytopreventLegionnaires
diseaseintheseunits(37,154,189,218).CategoryII
3.Norecommendationisofferedregardingtheoptimalmethodology(i.e.,frequencyornumberof
sites)forenvironmentalsurveillanceculturesinHSCTorsolidorgantransplantunits.
Unresolvedissue
4.Inareaswithpatientsatrisk,whenLegionellaspp.arenotdetectableinunitwater,remove,clean,
anddisinfectshowerheadsandtapaeratorsmonthlybyusingachlorinebased,
EPAregisteredproduct.IfanEPAregisteredchlorinedisinfectantisnotavailable,useachlorine
bleachsolution(500615ppm[1:100v/vdilution])(153,187).CategoryII

C.IfLegionellaspp.aredeterminedtobepresentinthewaterofatransplantunit,implementcertain
measuresuntilLegionellaspp.arenolongerdetectedbyculture.
1.Decontaminatethewatersupplyasoutlinedpreviously(Water:IV)(27,37,153,164,210).Category
IB
2.Donotusewaterfromthefaucetsinpatientcareroomstoavoidcreatinginfectiousaerosols
(37,219).CategoryIB
3.Restrictseverelyimmunocompromisedpatientsfromtakingshowers(37,219).CategoryIB
4.UsewaterthatisnotcontaminatedwithLegionellaspp.forHSCTpatients'spongebaths(37,219).
CategoryIB
5.Providepatientswithsterilewaterfortoothbrushing,drinking,andforflushingnasogastrictubing
duringlegionellosisoutbreaks(37,219).CategoryIB

D.Donotuselargevolumeroomairhumidifiersthatcreateaerosols(e.g.,byVenturiprinciple,
ultrasound,orspinningdisk)unlesstheyaresubjectedtohighleveldisinfectionandfilledonlywith
sterilewater(27,37,201,220).CategoryIB
VII.CoolingTowersandEvaporativeCondensers
A.Whenplanningconstructionofnewhealthcarefacilities,locatecoolingtowerssothatthedriftis
directedawayfromtheairintakesystem,anddesignthetowerstominimizethevolumeofaerosol
drift(153,203,221).CategoryIC(ASHRAE122000)
B.Implementinfectioncontrolproceduresforoperationalcoolingtowers(153,203,222).CategoryIC
(ASHRAE122000)
1.Installdrifteliminators(153,203,222).CategoryIC(ASHRAE122000)
2.UseaneffectiveEPAregisteredbiocideonaregularbasis(153).CategoryIC(ASHRAE122000)
3.Maintaintowersaccordingtomanufacturers'recommendations,andkeepdetailedmaintenanceand
infectioncontrolrecords,includingenvironmentaltestresultsfromlegionellosis
outbreakinvestigations(153).CategoryIC(ASHRAE122000)

C.Ifcoolingtowersorevaporativecondensersareimplicatedinhealthcareassociatedlegionellosis,
decontaminatethecoolingtowersystem(199,203,221,223).CategoryIB
VIII.DialysisWaterQualityandDialysate
A.AdheretocurrentAAMIstandardsforqualityassuranceperformanceofdevicesandequipmentused
totreat,store,anddistributewaterinhemodialysiscenters(bothacuteandmaintenance[chronic]
settings)andforthepreparationofconcentratesanddialysate(224235).CategoryIA,IC(AAMI:
AmericanNationalStandardsInstitute[ANSI]/AAMIRD5:1992,ANSI/AAMIRD47:1993)
B.Norecommendationisofferedregardingwhethermorestringentrequirementsforwaterquality
shouldbeimposedinhemofiltrationandhemodiafiltration.Unresolvedissue
C.Conductmicrobiologictestingspecifictowaterindialysissettings(229,230,236238).CategoryIA,
IC(AAMI:ANSI/AAMIRD5:1992,ANSI/AAMIRD47:1993,RD62:2001)
1.Performbacteriologicassaysofwateranddialysisfluidsatleastonceamonthandduring
outbreaksbyusingstandardquantitativemethods(236238).CategoryIA,IC(AAMI:
ANSI/AAMIRD62:2001)
a.Assayforheterotrophic,mesophilicbacteria(e.g.,Pseudomonasspp).
b.Donotusenutrientrichmedia(e.g.,bloodagarorchocolateagar).
2.Inconjunctionwithmicrobiologictesting,performendotoxintestingonproductwaterusedto
reprocessdialyzersformultipleuse(229,230,239242).CategoryIA,IC(AAMI:
ANSI/AAMIRD5:1992,ANSI/AAMIRD47:1993)
3.Ensurethatwaterdoesnotexceedthelimitsformicrobialcountsandendotoxinconcentrations
(Table2)(229231).CategoryIA,IC(AAMI:ANSI/AAMIRD5:1992,
ANSI/AAMIRD47:1993)

D.Disinfectwaterdistributionsystemsindialysissettingsatleastweekly(226228,231,236).Category
IA,IC(AAMI:ANSI/AAMIRD62:2001)
E.Whereverpractical,designandengineerwatersystemsindialysissettingstoavoidincorporating
joints,deadendpipes,andunusedbranchesandtapsthatcanharborbacteria(226228,231,236).
CategoryIA,IC(AAMI:ANSI/AAMIRD62:2001)
F.Whenstoragetanksareusedindialysissystems,theyshouldberoutinelydrained,disinfectedwithan
EPAregisteredproduct,andfittedwithanultrafilterorpyrogenicfilter(membranefilterwithapore
sizesufficienttoremoveparticlesandmolecules>1kilodalton)installedinthewaterlinedistaltothe
storagetank(236).CategoryIC(AAMI:ANSI/AAMIRD62:2001)
IX.IceMachinesandIce
A.Donothandleicedirectlybyhand,andwashhandsbeforeobtainingice.CategoryII
B.Useasmoothsurfaceicescooptodispenseice(243,244).CategoryII
1.Keeptheicescooponachainshortenoughthatthescoopcannottouchthefloororkeepthescoop
onaclean,hardsurfacewhennotinuse(243,244).CategoryII
2.Donotstoretheicescoopintheicebin.CategoryII

C.Donotstorepharmaceuticalsormedicalsolutionsoniceintendedforconsumptionusesterileiceto
keepmedicalsolutionscold,oruseequipmentspecificallymanufacturedforthispurpose(244,245).
CategoryIB
D.Machinesthatdispenseicearepreferredtothosethatrequireicetoberemovedfrombinsorchests
withascoop(246,247).CategoryII
E.Limitaccesstoicestoragechests,andkeepcontainerdoorsclosedexceptwhenremovingice(244).
CategoryII
F.Clean,disinfect,andmaintainicestoragechestsonaregularbasis.CategoryII
1.Followthemanufacturer'sinstructionsforcleaning.CategoryII
2.UseanEPAregistereddisinfectantsuitableforuseonicemachines,dispensers,orstoragechests
inaccordancewithlabelinstructions.CategoryII
3.IfinstructionsandEPAregistereddisinfectantssuitableforuseonicemachinesarenotavailable,
useageneralcleaning/disinfectingregimen(Box3)(244).CategoryII
4.Flushandcleanicemachinesanddispensersiftheyhavenotbeendisconnectedbeforeanticipated
lengthywaterdisruptions.CategoryII

G.Installproperairgapswherethecondensatelinesmeetthewastelines.CategoryII.
H.Conductmicrobiologicsamplingofice,icechests,andicemakingmachinesanddispenserswhere
indicatedduringanepidemiologicinvestigation(244,248,249).CategoryIB
X.HydrotherapyTanksandPools
A.Drainandcleanhydrotherapyequipment(e.g.,Hubbardtanks,tubs,whirlpools,whirlpoolspas,or
birthingtanks)aftereachpatient'suse,anddisinfectequipmentsurfacesandcomponentsbyusingan
EPAregisteredproductinaccordancewiththemanufacturer'sinstructions.CategoryII
B.IntheabsenceofanEPAregisteredproductforwatertreatment,addsodiumhypochloritetothe
water:
1.Maintaina15ppmchlorineresidualinthewaterofsmallhydrotherapytanks,Hubbardtanks,and
tubs(250).CategoryII
2.Maintaina25ppmchlorineresidualinthewaterofwhirlpoolsandwhirlpoolspas(251).
CategoryII
3.IfthepHofthemunicipalwaterisinthebasicrange(e.g.,whenchloramineisusedastheprimary
drinkingwaterdisinfectantinthecommunity),consultthefacilityengineerregarding
thepossibleneedtoadjustthepHofthewatertoamoreacidiclevelbeforedisinfection,to
enhancethebiocidalactivityofthechlorine(252).CategoryII

C.Cleananddisinfecthydrotherapyequipmentafterusingtubliners.CategoryII
D.Cleananddisinfectinflatabletubsunlesstheyaresingleuseequipment.CategoryII
E.Norecommendationisofferedregardingtheuseofantisepticchemicals(e.g.,chloramineT)inthe
waterduringhydrotherapysessions.Unresolvedissue
F.Conductariskassessmentofpatientsbeforetheiruseoflargehydrotherapypools,deferringpatients
withdrainingwoundsorfecalincontinencefrompooluseuntiltheirconditionresolves.CategoryII
G.Forlargehydrotherapypools,usepHandchlorineresiduallevelsappropriateforanindoorpoolas
providedbylocalandstatehealthagencies.CategoryIC(States)
H.Norecommendationisofferedregardingtheuseinhealthcaresettingsofwhirlpoolorspaequipment
manufacturedforhomeorrecreationaluse.Unresolvedissue
XI.MiscellaneousMedicalEquipmentConnectedtoWaterSystems
A.Clean,disinfect,andmaintainAERequipmentaccordingtothemanufacturer'sinstructionsand
relevantscientificliteraturetopreventinadvertentcontaminationofendoscopesandbronchoscopes
withwaterbornemicroorganisms(253257).CategoryIB
1.Torinsedisinfectedendoscopesandbronchoscopes,usewaterofthehighestqualitypracticalfor
thesystem'sengineeringanddesign(e.g.,sterilewaterorbacteriologicallyfiltered
water[waterfilteredthrough0.10.2mfilters])(254,256258).CategoryIB
2.Drytheinternalchannelsofthereprocessedendoscopeorbronchoscopebyusingaprovenmethod
(e.g.,70%alcoholfollowedbyforcedairtreatment)tolessenthepotentialfor
proliferationofwaterbornemicroorganismsandtohelppreventbiofilmformation(259263).
CategoryIB

B.UsewaterthatmeetsnationallyrecognizedstandardssetbytheEPAfordrinkingwater(<500
CFU/mLforheterotrophicplatecount)forroutinedentaltreatmentoutputwater(264267).
CategoryIC(EPA:40CFR1Part141,SubpartG)
C.Takeprecautionstopreventwaterbornecontaminationofdentalunitwaterlinesandinstruments.
1.Aftereachpatient,dischargewaterandairforaminimumof2030secondsfromanydental
deviceconnectedtothedentalwatersystemthatentersapatient'smouth(e.g.,
handpieces,ultrasonicscalers,orair/watersyringes)(265,268).CategoryII
2.Consultwithdentalwaterlinemanufacturersto1)determinesuitablemethodsandequipmentto
obtaintherecommendedwaterqualityand2)determineappropriatemethodsfor
monitoringthewatertoensurequalityismaintained(265,269).CategoryII
3.Consultwiththedentalunitmanufacturerregardingtheneedforperiodicmaintenanceof
antiretractionmechanisms(268,269).CategoryIB
RecommendationsEnvironmentalServices
I.CleaningandDisinfectingStrategiesforEnvironmentalSurfacesinPatientCareAreas
A.SelectEPAregistereddisinfectants,ifavailable,andusetheminaccordancewiththemanufacturer's
instructions(270272).CategoryIC(EPA:7UnitedStatesCode[USC]136etseq.)
B.Donotusehighleveldisinfectants/liquidchemicalsterilantsfordisinfectionofeithernoncritical
instrumentsanddevicesoranyenvironmentalsurfacessuchuseiscountertolabelinstructionsfor
thesetoxicchemicals(273278).CategoryIC(FoodandDrugAdministration[FDA]:21CFR
801.5,807.87.e)
C.Followmanufacturers'instructionsforcleaningandmaintainingnoncriticalmedicalequipment.
CategoryII
D.Intheabsenceofamanufacturer'scleaninginstructions,followcertainprocedures.
1.Cleannoncriticalmedicalequipmentsurfaceswithadetergent/disinfectant.Thismaybefollowed
byanapplicationofanEPAregisteredhospitaldisinfectantwithorwithouta
tuberculocidalclaim(dependingonthenatureofthesurfaceandthedegreeofcontamination),in
accordancewithgermicidelabelinstructions(274).CategoryII
2.Donotusealcoholtodisinfectlargeenvironmentalsurfaces(273).CategoryII
3.Usebarrierprotectivecoveringsasappropriatefornoncriticalsurfacesthatare1)touched
frequentlywithglovedhandsduringthedeliveryofpatientcare2)likelytobecome
contaminatedwithbloodorbodysubstancesor3)difficulttoclean(e.g.,computerkeyboards)
(265).CategoryII

E.Keephousekeepingsurfaces(e.g.,floors,walls,tabletops)visiblycleanonaregularbasisandclean
upspillspromptly(279).CategoryII
1.UseaonestepprocessandanEPAregisteredhospitaldetergent/disinfectantdesignedforgeneral
housekeepingpurposesinpatientcareareaswhere1)uncertaintyexistsastothe
natureofthesoilonthesurfaces(e.g.,bloodorbodyfluidcontaminationversusroutinedustor
dirt)or2)uncertaintyexistsregardingthepresenceofmultidrugresistantorganisums
onsuchsurfaces(272,274,280,281).CategoryII
2.Detergentandwaterareadequateforcleaningsurfacesinnonpatientcareareas(e.g.,
administrativeoffices).CategoryII
3.Cleananddisinfecthightouchsurfaces(e.g.,doorknobs,bedrails,lightswitches,andsurfacesin
andaroundtoiletsinpatients'rooms)onamorefrequentschedulethanminimal
touchhousekeepingsurfaces.CategoryII
4.Cleanwalls,blinds,andwindowcurtainsinpatientcareareaswhentheyarevisiblydustyorsoiled
(270,282284).CategoryII

F.Donotperformdisinfectantfogginginpatientcareareas(270,285).CategoryIB
G.Avoidlargesurfacecleaningmethodsthatproducemistsoraerosols,ordispersedustinpatientcare
areas(37,48,51,73).CategoryIB
H.Followproperproceduresforeffectiveusesofmops,cloths,andsolutions.CategoryII
1.Preparecleaningsolutionsdailyorasneeded,andreplacewithfreshsolutionfrequentlyaccording
tofacilitypoliciesandprocedures(280,281).CategoryII
2.Changethemopheadatthebeginningofeachdayandalsoasrequiredbyfacilitypolicy,orafter
cleaninguplargespillsofbloodorotherbodysubstances.CategoryII
3.Cleanmopsandclothsafteruseandallowtodrybeforereuseorusesingleuse,disposablemop
headsandcloths(282,286288).CategoryII

I.Afterthelastsurgicalprocedureofthedayornight,wetvacuumormopoperatingroomfloorswitha
singleusemopandanEPAregisteredhospitaldisinfectant(114).CategoryIB
J.Donotusematswithtackysurfacesattheentrancestooperatingroomsorinfectioncontrolsuites
(114).CategoryIB
K.Useappropriatedustingmethodsforpatientcareareasdesignatedforimmunocompromisedpatients
(e.g.,HSCTpatients)(37,40,280).CategoryIB
1.WetdusthorizontalsurfacesdailybymoisteningaclothwithasmallamountofanEPAregistered
hospitaldetergent/disinfectant(37,40,280).CategoryIB
2.Avoiddustingmethodsthatdispersedust(e.g.,featherdusting)(40).CategoryIB

L.KeepvacuumsingoodrepairandequipvacuumswithHEPAfiltersforuseareaswithpatientsatrisk
(37,40,280,289).CategoryIB
M.Closethedoorsofimmunocompromisedpatients'roomswhenvacuuming,waxing,orbuffing
corridorfloorstominimizeexposuretoairbornedust(37,40,289).CategoryIB
N.Whenperformingloworintermediateleveldisinfectionofenvironmentalsurfacesinnurseriesand
neonatalunits,avoidunnecessaryexposureofneonatestodisinfectantresiduesonthesesurfacesby
usingEPAregisteredgermicidesinaccordancewithmanufacturers'instructionsandsafetyadvisories
(271,290292).CategoryIB,IC(EPA:7USC136etseq.)
1.Donotusephenolicsoranyotherchemicalgermicidetodisinfectbassinetsorincubatorsduringan
infant'sstay(271,290292).CategoryIB
2.Rinsedisinfectanttreatedsurfaces,especiallythosetreatedwithphenolics,withwater(290292).
CategoryIB

O.Whenusingphenolicdisinfectantsinneonatalunits,preparesolutionstocorrectconcentrationsin
accordancewithmanufacturers'instructions,orusepremixedformulations(271,290292).Category
IB,IC(EPA:7USC136etseq.)
II.CleaningSpillsofBloodandBodySubstances
A.Promptlycleananddecontaminatespillsofbloodorotherpotentiallyinfectiousmaterials(293300).
CategoryIB,IC(OSHA:29CFR1910.1030d.4.ii.A)
B.Followproperproceduresforsitedecontaminationofspillsofbloodorbloodcontainingbodyfluids
(293300).CategoryIC(OSHA:29CFR1910.1030d.4.ii.A)
1.UseprotectiveglovesandotherPPEappropriateforthistask(293).CategoryIC(OSHA:29CFR
1910.1030d.3.i,ii)
2.Ifthespillcontainslargeamountsofbloodorbodyfluids,cleanthevisiblematterwithdisposable
absorbentmaterial,anddiscardtheusedcleaningmaterialsinappropriate,labeled
containers(293,298,299,301,302).CategoryIC(OSHA:29CFR1910.1030d.4.iii.B)
3.Swabtheareawithaclothorpapertowelsmoderatelywettedwithdisinfectant,andallowthe
surfacetodry(293,301).CategoryIC(OSHA:29CFR1910.1030d.4.ii.A)

C.UsegermicidesregisteredbytheEPAforuseashospitaldisinfectantsandlabeledtuberculocidalor
registeredgermicidesontheEPAListsDandE(i.e.,productswithspecificlabelclaimsforHIVor
hepatitisBvirus[HBV])inaccordancewithlabelinstructionstodecontaminatespillsofbloodand
otherbodyfluids(293,301,303).CategoryIC(OSHA29CFR1910.1030d.4.ii.Amemorandum
2/28/97compliancedocument[CPL]22.44D[11/99])
D.AnEPAregisteredsodiumhypochloriteproductispreferred,butifsuchproductsarenotavailable,
genericsodiumhypochloritesolutions(e.g.,householdchlorinebleach)maybeused.
1.Usea1:100dilution(500615ppmavailablechlorine)todecontaminatenonporoussurfacesafter
cleaningaspillofeitherbloodorbodyfluidsinpatientcaresettings(301,304).
CategoryIB
2.Ifaspillinvolveslargeamountsofbloodorbodyfluids,orifabloodorculturespilloccursinthe
laboratory,usea1:10dilution(5,0006,150ppmavailablechlorine)forthefirst
applicationofgermicidebeforecleaning(279,301).CategoryIB
III.CarpetingandClothFurnishings
A.Vacuumcarpetinginpublicareasofhealthcarefacilitiesandingeneralpatientcareareasregularly
withwellmaintainedequipmentdesignedtominimizedustdispersion(280).CategoryII
B.Periodicallyperformathorough,deepcleaningofcarpetingasdeterminedbyfacilitypolicybyusing
amethodthatminimizestheproductionofaerosolsandleaveslittleornoresidue(44).CategoryII
C.Avoiduseofcarpetinginhightrafficzonesinpatientcareareasorwherespillsarelikely(e.g.,burn
therapyunits,operatingrooms,laboratories,orintensivecareunits)(44,305,306).CategoryIB
D.Followappropriateproceduresformanagingspillsoncarpeting.
1.Spotcleanbloodorbodysubstancespillspromptly(293,301,304,307).CategoryIC(OSHA:29
CFR1910.1030d.4.ii.A,interpretation)
2.Ifaspilloccursoncarpettiles,replaceanytilescontaminatedbybloodandbodyfluidsorbody
substances(307).CategoryIC(OSHA29CFR1910.1030d.4.iiinterpretation)

E.Thoroughlydrywetcarpetingtopreventthegrowthoffungireplacecarpetingthatremainswetafter
72hours(37,160).CategoryIB
F.Norecommendationisofferedregardingtheroutineuseoffungicidalorbactericidaltreatmentsfor
carpetinginpublicareasofahealthcarefacilityoringeneralpatientcareareas.Unresolvedissue
G.Donotusecarpetinginhallwaysandpatientroomsinareashousingimmunosuppressedpatients
(e.g.,PEareas)(37,44).CategoryIB
H.Avoidusingupholsteredfurnitureandfurnishingsinhighriskpatientcareareasandinareaswith
increasedpotentialforbodysubstancecontamination(e.g.,pediatricsunits)(37).CategoryII
I.Norecommendationisofferedregardingwhetherupholsteredfurnitureandfurnishingsshouldbe
avoidedingeneralpatientcareareas.Unresolvedissue
1.Maintainupholsteredfurnitureingoodrepair.CategoryII
2.Maintainthesurfaceintegrityoftheupholsterybyrepairingtearsandholes.CategoryII
3.Ifupholsteredfurnitureinapatient'sroomrequirescleaningtoremovevisiblesoilorbody
substancecontamination,movethatitemtoamaintenanceareawhereitcanbeadequately
cleanedwithaprocessappropriateforthetypeofupholsteryandnatureofthesoil.CategoryII
IV.FlowersandPlantsinPatientCareAreas
A.Flowersandpottedplantsneednotberestrictedfromareasforimmunocompetentpatients(308
311).CategoryII
B.Designatecareandmaintenanceofflowersandpottedplantstostaffnotdirectlyinvolvedwith
patientcare(309).CategoryII
C.Ifplantorflowercarebypatientcarestaffisunavoidable,instructthestafftoweargloveswhen
handlingplantsandflowersandperformhandhygieneaftergloveremoval(309).CategoryII
D.Donotallowfreshordriedflowers,orpottedplants,inpatientcareareasforimmunosuppressed
patients(37,51,308,312).CategoryII
V.PestControl
A.Developpestcontrolstrategies,withemphasisonkitchens,cafeterias,laundries,centralsterile
supplyareas,operatingrooms,loadingdocks,constructionactivities,andotherareasproneto
infestations(313315).CategoryII
B.Installscreensonallwindowsthatopentotheoutsidekeepscreensingoodrepair(314).Category
IB
C.Contractforroutinepestcontrolservicebyacredentialedpestcontrolspecialistwhowilltailorthe
applicationtotheneedsofahealthcarefacility(315).CategoryII
D.Placelaboratoryspecimens(e.g.,fixedsputumsmears)incoveredcontainersforovernightstorage
(316,317).CategoryII
VI.SpecialPathogens
A.Useappropriatehandhygiene,PPE(e.g.,gloves),andisolationprecautionsduringcleaningand
disinfectingprocedures(146,274,318,319).CategoryIB
B.Usestandardcleaninganddisinfectionprotocolstocontrolenvironmentalcontaminationwith
antibioticresistant,grampositivecocci(e.g.,methicillinresistantStaphylococcusaureus,
vancomycinintermediatesensitiveStaphylococcusaureus,orvancomycinresistantEnterococcus
[VRE])(318,320322).CategoryIB
1.Paycloseattentiontocleaninganddisinfectionofhightouchsurfacesinpatientcareareas(e.g.,
bedrails,carts,charts,bedsidecommodes,bedrails,doorknobs,orfaucethandles)
(318,320322).CategoryIB
2.Ensurecompliancebyhousekeepingstaffwithcleaninganddisinfectionprocedures(318,320
322).CategoryIB
3.UseEPAregisteredchemicalgermicidesappropriateforthesurfacetobedisinfected(e.g.,either
loworintermediateleveldisinfection)asspecifiedbythemanufacturer's
instructions(271,322327).CategoryIB,IC(EPA:7USC136etseq.)
4.Whencontactprecautionsareindicatedforpatientcare,usedisposablepatientcareitems(e.g.,
bloodpressurecuffs)whereverpossibletominimizecrosscontaminationwith
multipleresistantmicroorganisms(328).CategoryIB
5.Followthesesamesurfacecleaninganddisinfectingmeasuresformanagingtheenvironmentof
VRSApatients(320322,327).CategoryII

C.Environmentalsurfaceculturingcanbeusedtoverifytheefficacyofhospitalpoliciesandprocedures
beforeandaftercleaninganddisinfectingroomsthathousepatientswithVRE(318,329333).
CategoryII
1.Obtainpriorapprovalfrominfectioncontrolstaffandtheclinicallaboratorybeforeperforming
environmentalsurfaceculturing.CategoryII
2.Infectioncontrolstaff,withclinicallaboratorystaffconsultation,mustsuperviseallenvironmental
culturing.CategoryII

D.Thoroughlycleananddisinfectenvironmentalandmedicalequipmentsurfacesonaregularbasisby
usingEPAregistereddisinfectantsinaccordancewithmanufacturers'instructions(271,274,319,
334).CategoryIB,IC(EPA:7USC136etseq.)
E.Advisefamilies,visitors,andpatientsregardingtheimportanceofhandhygienetominimizethe
spreadofbodysubstancecontamination(e.g.,respiratorysecretionsorfecalmatter)tosurfaces
(274).CategoryII
F.Donotusehighleveldisinfectants(i.e.,liquidchemicalsterilants)onenvironmentalsurfacessuch
useisinconsistentwithlabelinstructionsbecauseofthetoxicityofthechemicals(270,273,274,278).
CategoryIC(FDA:21CFR801.5,807.87.e)
G.BecausenoEPAregisteredproductsarespecificforinactivatingClostridiumdifficilespores,use
hypochloritebasedproductsfordisinfectionofenvironmentalsurfacesinaccordancewithguidance
fromthescientificliteratureinthosepatientcareareaswheresurveillanceandepidemiologyindicate
ongoingtransmissionofC.difficile(274,319,334).CategoryII
H.NorecommendationisofferedregardingtheuseofspecificEPAregisteredhospitaldisinfectants
withrespecttoenvironmentalcontrolofC.difficile.Unresolvedissue
I.Applystandardcleaninganddisinfectionprocedurestocontrolenvironmentalcontaminationwith
respiratoryandentericvirusesinpediatriccareunitsandcareareasforimmunocompromised
patients(280,335).CategoryIC(EPA:7USC136etseq.)
J.Cleansurfacesthathavebeencontaminatedwithbodysubstancesperformlowtointermediatelevel
disinfectiononcleanedsurfaceswithanEPAregistereddisinfectantinaccordancewiththe
manufacturer'sinstructions(271,293,335).CategoryIC(OSHA:29CFR1910.1030d.4.ii.AEPA:
7USC136etseq.)
K.Usedisposablebarriercoveringsasappropriatetominimizesurfacecontamination.CategoryII
L.Developandmaintaincleaninganddisinfectionproceduresinpatientcareareastocontrol
environmentalcontaminationwithagentsofCreutzfeldtJakobdisease(CJD),forwhichnoEPA
registeredproductexists.CategoryII
1.Intheabsenceofcontaminationwithcentralnervoussystemtissue,extraordinarymeasures(e.g.,
useof2Nsodiumhydroxide[NaOH]orapplyingfullstrengthsodiumhypochlorite)
arenotneededforroutinecleaningorterminaldisinfectionofaroomhousingaconfirmedor
suspectedCJDpatient(273,336).CategoryII
2.Afterremovinggrosstissuefromthesurface,useeither1NNaOHorasodiumhypochlorite
solutioncontainingapproximately10,00020,000ppmavailablechlorine(dilutionsof
1:5to1:3v/v,respectively,ofU.S.householdchlorinebleachcontactthemanufacturersof
commerciallyavailablesodiumhypochloriteproductsforadvice)todecontaminate
operatingroomorautopsysurfaceswithcentralnervoussystemorcerebralspinalfluid
contaminationfromadiagnosedorsuspectedCJDpatient(273,337342).CategoryII
a.Thecontacttimeforthechemicalusedduringthisprocessshouldbe30min1hour
(339,340,342).
b.Blotupthechemicalwithabsorbentmaterialandrinsethetreatedsurfacethoroughlywith
water.
c.Discardtheused,absorbentmaterialintoappropriatewastecontainers.
3.Usedisposable,imperviouscoverstominimizebodysubstancecontaminationtoautopsytables
andsurfaces(340,342).CategoryII

M.Usestandardproceduresforcontainment,cleaning,anddecontaminationofbloodspillsonsurfaces
aspreviouslydescribed(EnvironmentalServices:II)(293).CategoryIC(OSHA:29CFR1910.1030
d.4.ii.A)
1.WearPPEappropriateforasurfacedecontaminationandcleaningtask(293,336).CategoryIC
(OSHA29CFR1910.1030d.3.i,ii)
2.DiscardusedPPEbyusingroutinedisposalproceduresordecontaminatereusablePPEas
appropriate(293,336).CategoryIC(OSHA29CFR1910.1030d.3.viii)
RecommendationsEnvironmentalSampling
I.GeneralInformation
A.Donotconductrandom,undirected,microbiologicsamplingofair,water,andenvironmentalsurfaces
inhealthcarefacilities(270,343).CategoryIB
B.Whenindicated,conductmicrobiologicsamplingaspartofanepidemiologicinvestigationorduring
assessmentofhazardousenvironmentalconditionstodetectcontaminationorverifyabatementofa
hazard(270,343).CategoryIB
C.Limitmicrobiologicsamplingforqualityassurancepurposesto1)biologicmonitoringof
sterilizationprocesses2)monthlyculturesofwateranddialysateinhemodialysisunitsand3)short
termevaluationoftheimpactofinfectioncontrolmeasuresorchangesininfectioncontrolprotocols
II.Air,Water,andEnvironmentalSurfaceSampling
A.Whenconductinganyformofenvironmentalsampling,identifyexistingcomparativestandardsand
fullydocumentdeparturesfromstandardmethods(343347).CategoryII
B.Selectahighvolumeairsamplingdeviceifanticipatedlevelsofmicrobialairbornecontamination
areexpectedtobelow(345,346,348,349).CategoryII
C.Donotusesettleplatestoquantifytheconcentrationofairbornefungalspores(348).CategoryII
D.Whensamplingwater,choosegrowthmediaandincubationconditionsthatwillfacilitaterecoveryof
waterborneorganisms(344).CategoryII
E.Whenusingasample/rinsemethodforsamplinganenvironmentalsurface,developanddocumenta
procedureformanipulatingtheswab,gauze,orspongeinareproduciblemannersothatresultsare
comparable(347).CategoryII
F.Whenenvironmentalsamplesandpatientspecimensareavailableforcomparison,performthe
laboratoryanalysisontherecoveredmicroorganismsdowntothespecieslevelataminimum,and
beyondthespecieslevelifpossible(343).CategoryII
RecommendationsLaundryandBedding
I.EmployerResponsibilities
A.Employersmustlaunderworkers'personalprotectivegarmentsoruniformsthatarecontaminated
withbloodorotherpotentiallyinfectiousmaterials(293).CategoryIC(OSHA:29CFR1910.1030
d.3.iv)
II.LaundryFacilitiesandEquipment
A.Maintainthereceivingareaforcontaminatedtextilesatnegativepressurecomparedwiththeclean
areasofthelaundryinaccordancewithAIAconstructionstandardsineffectduringthetimeof
facilityconstruction(1,350352).CategoryIC(AIA:7.23.B1,B2)
B.EnsurethatlaundryareashavehandwashingfacilitiesandproductsandappropriatePPEavailablefor
workers(1,293).CategoryIC(AIA:7.23.D4OSHA:29CFR1910.1030d.2.iii)
C.Useandmaintainlaundryequipmentaccordingtomanufacturers'instructions(353,354).CategoryII
D.Donotleavedamptextilesorfabricsinmachinesovernight(353).CategoryII
E.Disinfectionofwashinganddryingmachinesinresidentialcareisnotneededaslongasgrosssoilis
removedfromitemsbeforewashingandproperwashinganddryingproceduresareused.CategoryII
III.RoutineHandlingofContaminatedLaundry
A.Handlecontaminatedtextilesandfabricswithminimumagitationtoavoidcontaminationofair,
surfaces,andpersons(36,293,355,356).CategoryIC(OSHA:29CFR1910.1030d.4.iv)
B.Bagorotherwisecontaincontaminatedtextilesandfabricsatthepointofuse(293).CategoryIC
(OSHA:29CFR1910.1030d.4.iv)
1.Donotsortorprerinsecontaminatedtextilesorfabricsinpatientcareareas(293).CategoryIC
(OSHA:29CFR1910.1030d.4.iv)
2.Useleakresistantcontainmentfortextilesandfabricscontaminatedwithbloodorbodysubstances
(293,355).CategoryIC(OSHA:29CFR1910.1030d.4.iv)
3.Identifybagsorcontainersforcontaminatedtextileswithlabels,colorcoding,orotheralternative
meansofcommunicationasappropriate(293).CategoryIC(OSHA:29CFR
1910.1030d.4.iv)

C.Coversarenotneededoncontaminatedtextilehampersinpatientcareareas.CategoryII
D.Iflaundrychutesareused,ensurethattheyareproperlydesigned,maintained,andusedinamanner
tominimizedispersionofaerosolsfromcontaminatedlaundry(357361).CategoryIC(AAMI:
ANSI/AAMIST65:2000)
1.Ensurethatlaundrybagsareclosedbeforetossingthefilledbagintothechute.CategoryII
2.Donotplacelooseitemsinthelaundrychute.CategoryII

E.Establishafacilitypolicytodeterminewhentextilesorfabricsshouldbesortedinthelaundry
facility(i.e.,beforeorafterwashing)(362,363).CategoryII
IV.LaundryProcess
A.Ifhotwaterlaundrycyclesareused,washwithdetergentinwater>160F(>71C)for>25minutes
(1,270).CategoryIC(AIA:7.31.E3)
B.Norecommendationisofferedregardingahotwatertemperaturesettingandcycledurationforitems
launderedinresidencestylehealthcarefacilities.Unresolvedissue
C.Followfabriccareinstructionsandspeciallaunderingrequirementsforitemsusedinthefacility
(364).CategoryII
D.Choosechemicalssuitableforlowtemperaturewashingatproperuseconcentrationiflow
temperature(<160F[<70C])laundrycyclesareused(365370).CategoryII
E.Package,transport,andstorecleantextilesandfabricsbymethodsthatwillensuretheircleanliness
andprotectthemfromdustandsoilduringinterfacilityloading,transport,andunloading(270).
CategoryII
V.MicrobiologicSamplingofTextiles
A.Donotconductroutinemicrobiologicsamplingofcleantextiles(270,371).CategoryIB
B.Usemicrobiologicsamplingduringoutbreakinvestigationsifepidemiologicevidenceindicatesarole
forhealthcaretextilesandclothingindiseasetransmission(371).CategoryIB
VI.SpecialLaundrySituations
A.Usesterilizedtextiles,surgicaldrapes,andgownsforsituationsrequiringsterilityinpatientcare
(114).CategoryIB
B.Usehygienicallycleantextiles(i.e.,laundered,butnotsterilized)inneonatalintensivecareunits
C.Followmanufacturers'recommendationsforcleaningfabricproducts,includingthosewithcoatedor
laminatedsurfaces.CategoryII
D.Donotusedrycleaningforroutinelaunderinginhealthcarefacilities(373375).CategoryII
E.Usecautionwhenconsideringuseofantimicrobialmattresses,textiles,andclothingasreplacements
forstandardbeddingandotherfabricitemsEPAhasnotapprovedpublichealthclaimsasserting
protectionagainsthumanpathogensforsuchtreateditems(376).CategoryII
F.Norecommendationisofferedregardingusingdisposablefabricsandtextilesversusdurablegoods.
Unresolvedissue
VII.MattressesandPillows
A.Keepmattressesdrydiscardthemiftheyremainwetorstained,particularlyinburnunits(377382).
CategoryIB
B.CleananddisinfectmattresscoversbyusingEPAregistereddisinfectantsthatarecompatiblewith
thematerialstopreventthedevelopmentoftears,cracks,orholesinthecovers(377382).Category
IB
C.Maintaintheintegrityofmattressandpillowcovers.CategoryII
1.Replacemattressandpillowcoversiftheybecometornorotherwiseinneedofrepair.CategoryII
2.Donotstickneedlesintoamattressthroughthecover.CategoryII

D.CleananddisinfectmoistureresistantmattresscoversbetweenpatientusebyusinganEPA
registeredproduct(377382).CategoryIB
E.Ifusingamattresscovercompletelymadeoffabric,changethesecoversandlaunderbetweenpatient
use(377382).CategoryIB
F.Launderpillowcoversandwashablepillowsinthehotwatercyclebetweenpatientsorwhenthey
becomecontaminatedwithbodysubstances(382).CategoryIB
VIII.AirFluidizedBeds
A.Followmanufacturers'instructionsforairfluidizedbedmaintenanceanddecontamination.Category
II
B.Changethepolyesterfiltersheetatleastweeklyorasindicatedbythemanufacturer(383386).
CategoryII
C.Cleananddisinfectthepolyesterfiltersheetthoroughly,especiallybetweenpatients,usinganEPA
registeredproduct(383386).CategoryIB
D.Consultthefacilityengineertodeterminetheproperplacementofairfluidizedbedsinnegative
pressurerooms(387).CategoryII
RecommendationsAnimalsinHealthCareFacilities
I.GeneralInfectionControlMeasuresforAnimalEncounters
A.Minimizecontactwithanimalsaliva,dander,urine,andfeces(388390).CategoryII
B.Practicehandhygieneafteranyanimalcontact(146,270).CategoryII
1.Washhandswithsoapandwater,especiallyifhandsarevisiblysoiledorcontaminatedwith
proteinaceousmaterial(146).CategoryII
2.Useeithersoapandwateroralcoholbasedhandrubswhenhandsarenotvisiblysoiledor
contaminated(146).CategoryII
II.AnimalAssistedActivitiesandResidentAnimalPrograms
A.Avoidselectionofnonhumanprimatesandreptilesinanimalassistedactivities,animalassisted
therapy,orresidentanimalprograms(391393).CategoryIB
B.Enrollanimalsthatarefullyvaccinatedforzoonoticdiseasesandthatarehealthy,clean,well
groomed,andnegativeforentericparasitesorotherwisehavecompletedrecentanthelmintic
treatmentundertheregularcareofaveterinarian(391,394).CategoryII
C.Enrollanimalsthataretrainedwiththeassistanceorunderthedirectionofpersonswhoare
experiencedinthisfield(391).CategoryII
D.Ensurethatanimalsarecontrolledbypersonstrainedinprovidingactivitiesortherapiessafely,and
whoknowtheanimal'shealthstatusandbehaviortraits(391,394).CategoryII
E.Takepromptactionwhenanincidentofbitingorscratchingbyananimaloccursduringananimal
assistedactivityortherapy.
1.Removetheanimalpermanentlyfromtheseprograms(391).CategoryII
2.Reporttheincidentpromptlytoappropriateauthorities(e.g.,infectioncontrolstaff,animal
programcoordinator,orlocalanimalcontrolpersonnel)(391).CategoryII
3.Promptlycleanandtreatscratches,bites,orotherbreaksintheskin.CategoryII

F.PerformanICRAandworkactivelywiththeanimalhandlerbeforeconductingananimalassisted
activityortherapytodeterminewhetherthesessionshouldbeheldinapublicareaofthefacilityor
inindividualpatientrooms(391,394).CategoryII
G.Takeprecautionstomitigateallergicresponsestoanimals.CategoryII
1.Minimizesheddingofanimaldanderbybathinganimals<24hoursbeforeavisit(391).Category
II
2.Groomanimalstoremoveloosehairbeforeavisit,oruseatherapyanimalcape(395).CategoryII

H.Useroutinecleaningprotocolsforhousekeepingsurfacesaftertherapysessions.CategoryII
I.Restrictresidentanimals,includingfishintanks,fromaccesstopatientcareareas,foodpreparation
areas,diningareas,laundry,centralsterilesupplyareas,sterileandcleansupplystorageareas,
medicationpreparationareas,operatingrooms,isolationareas,andPEareas.CategoryII
J.Establishafacilitypolicyforregularcleaningoffishtanks,rodentcages,andbirdcages,andany
otheranimaldwellingsandassignthiscleaningtasktoanonpatientcarestaffmemberavoid
splashingtankwaterorcontaminatingenvironmentalsurfaceswithanimalbedding.CategoryII
III.ProtectiveMeasuresforImmunocompromisedPatients
A.Advisepatientstoavoidcontactwithanimalfeces,saliva,urine,orsolidlitterboxmaterial(396).
CategoryII
B.Promptlycleanandtreatscratches,bites,orotherwoundsthatbreaktheskin(396).CategoryII
C.Advisepatientstoavoiddirectorindirectcontactwithreptiles(397).CategoryIB
D.Conductacasebycaseassessmenttodetermineifanimalassistedactivitiesoranimalassisted
therapyprogramsareappropriateforimmunocompromisedpatients(394).CategoryII
E.Norecommendationisofferedregardingpermittingpetvisitstoterminallyillimmunocompromised
patientsoutsidetheirPEunits.Unresolvedissue.
IV.ServiceAnimals
A.Avoidprovidingfacilityaccesstononhumanprimatesandreptilesasserviceanimals(393,397).
CategoryIB
B.AllowserviceanimalsaccesstothefacilityinaccordancewiththeAmericanswithDisabilitiesAct
of1990,unlessthepresenceoftheanimalcreatesadirectthreattootherpersonsorafundamental
alterationinthenatureofservices(389,398).CategoryIC(U.S.DepartmentofJustice:28CFR
36.302)
C.Whenadecisionmustbemaderegardingaserviceanimal'saccesstoanyparticularareaofthe
healthcarefacility,evaluatetheserviceanimal,patient,andhealthcaresituationonacasebycase
basistodeterminewhethersignificantriskofharmexistsandwhetherreasonablemodificationsin
policiesandprocedureswillmitigatethisrisk(398).CategoryIC(U.S.DepartmentofJustice:28
CFR36.208)
D.Ifapatientmustbeseparatedfromhisorherserviceanimalwhileinthehealthcarefacility1)
ascertainfromthepersonwhatarrangementshavebeenmadeforsupervisionorcareoftheanimal
duringthisperiodofseparationand2)makeappropriatearrangementstoaddressthepatient'sneeds
intheabsenceoftheserviceanimal.CategoryII
V.AnimalsasPatientsinHumanHealthCareFacilities
A.Develophealthcarefacilitypoliciestoaddressthetreatmentofanimalsinhumanhealthcare
facilities.
1.Usethemultidisciplinaryteamapproachtopolicydevelopment,includingpublicmediarelations
effortstodiscloseanddiscusstheseactivities.CategoryII
2.Exhaustallveterinaryfacility,equipment,andinstrumentoptionsbeforeundertakingthe
procedure.CategoryII
3.Ensurethatthecareoftheanimalissupervisedbyalicensedveterinarian.CategoryII

B.Whenanimalsaretreatedinhumanhealthcarefacilities,avoidtreatinganimalsinoperatingrooms
orotherpatientcareareaswhereinvasiveproceduresareperformed(e.g.,cardiaccatheterization
laboratoriesorinvasivenuclearmedicineareas).CategoryII
C.Scheduletheanimalprocedureforthelastprocedureofthedayinthearea,atatimewhenhuman
patientsarenotscheduledtobeinthevicinity.CategoryII
D.Adherestrictlytostandardprecautions.CategoryII
E.CleananddisinfectenvironmentalsurfacesthoroughlybyusinganEPAregisteredproductinthe
roomaftertheanimalhasbeenremoved.CategoryII
F.AllowsufficientACHtocleantheairandhelpremoveairbornedander,microorganisms,and
allergens(Table1).CategoryII
G.CleananddisinfectusingEPAregisteredproductsorsterilizeequipmentthathasbeenincontact
withtheanimalorusedisposableequipment.CategoryII
H.Ifreusablemedicalorsurgicalinstrumentsareusedinananimalprocedure,restrictfutureuseof
theseinstrumentstoanimalsonly.CategoryII
VI.ResearchAnimalsinHealthCareFacilities
A.Useanimalsobtainedfromqualitystock,orquarantineincominganimalstodetectzoonoticdiseases.
CategoryII
B.Treatsickanimalsorremovethemfromthefacility.CategoryII
C.Provideprophylacticvaccinations,asavailable,toanimalhandlersandcontactsathighrisk.
CategoryII
D.Ensureproperventilationthroughappropriatefacilitydesignandlocation(399).CategoryIC(U.S.
DepartmentofAgriculture[USDA]:7USC2131)
1.Keepanimalroomsatnegativepressurerelativetocorridors(399).CategoryIC(USDA:7USC
2131)
2.Preventairinanimalroomsfromrecirculatingelsewhereinthehealthcarefacility(399).Category
IC(USDA:7USC2131)

E.Keepdoorstoanimalresearchroomsclosed.CategoryII
F.Restrictaccesstoanimalfacilitiestoessentialpersonnel.CategoryII
G.Establishemployeeoccupationalhealthprogramsspecifictotheanimalresearchfacility,and
coordinatemanagementofpostexposureproceduresspecifictozoonoseswithoccupationalhealth
clinicsinthehealthcarefacility(400,401).CategoryIC(U.S.DepartmentofHealthandHuman
Services[DHHS]:BiosafetyinMicrobiologicalandBiomedicalLaboratories[BMBL]OSHA:29
CFR1910.1030.132139)
H.Documentstandardoperatingproceduresfortheunit(400).CategoryIC(DHHS:BMBL)
I.Conductroutineemployeetrainingonworkersafetyconcernsrelevanttotheanimalresearchfacility
(e.g.,workingsafelywithanimals,animalhandling)(400,401).CategoryIC(DHHS:BMBLOSHA:
29CFR1910.1030.132139)
J.Useprecautionstopreventdevelopmentofanimalinducedasthmainanimalworkers(400).
CategoryIC(DHHS:BMBL)
RecommendationsRegulatedMedicalWastes
I.CategoriesofRegulatedMedicalWaste
A.Designatethefollowingasmajorcategoriesofmedicalwastethatrequirespecialhandlingand
disposalprecautions:1)microbiologylaboratorywastes[e.g.,culturesandstocksof
microorganisms]2)bulkblood,bloodproducts,blood,andbloodybodyfluidspecimens3)
pathologyandanatomywasteand4)sharps[e.g.,needlesandscalpels](270).CategoryII
B.Consultfederal,state,andlocalregulationstodetermineifotherwasteitemsareconsideredregulated
medicalwastes(293,402,403).CategoryIC(StatesOSHA:29CFR1910.1030g.2.1Department
ofTransportation[DOT]:49CFR171180U.S.PostalService:CO23.8)
II.DisposalPlanforRegulatedMedicalWastes
A.Developaplanforthecollection,handling,predisposaltreatment,andterminaldisposalofregulated
medicalwastes(293,404).CategoryIC(StatesOSHA:29CFR1910.1030g.2.i)
B.Designateapersonorpersonsasresponsibleforestablishing,monitoring,reviewing,and
administeringtheplan.CategoryII
III.Handling,Transporting,andStoringRegulatedMedicalWastes
A.Informpersonnelinvolvedinhandlinganddisposalofpotentiallyinfectivewasteofpossiblehealth
andsafetyhazardsensurethattheyaretrainedinappropriatehandlinganddisposalmethods(293).
CategoryIC(OSHA:29CFR1910.1030g.2.i)
B.Managethehandlinganddisposalofregulatedmedicalwastesgeneratedinisolationareasbyusing
thesamemethodsusedforregulatedmedicalwastesfromotherpatientcareareas(270).CategoryII
C.Usepropersharpsdisposalstrategies(293).CategoryIC(OSHA:29CFR1910.1030d.4.iii.A)
1.Useasharpscontainercapableofmaintainingitsimpermeabilityafterwastetreatmenttoavoid
subsequentphysicalinjuriesduringfinaldisposal(293).CategoryIC(OSHA:29CFR
1910.1030d.4.iii.A)
2.Placedisposablesyringeswithneedles,includingsterilesharpsthatarebeingdiscarded,scalpel
blades,andothersharpitemsintopunctureresistantcontainerslocatedascloseas
practicaltothepointofuse(293).CategoryIC(OSHA:29CFR1910.1030d.4.iii.A)
3.Donotbend,recap,orbreakusedsyringeneedlesbeforediscardingthemintoacontainer
(36,293,405).CategoryIC(OSHA:29CFR1910.1030d.2.viiandd.2.vii.A)

D.Storeregulatedmedicalwastesawaitingtreatmentinaproperlyventilatedareainaccessibleto
vertebratepestsusewastecontainersthatpreventdevelopmentofnoxiousodors.CategoryIC
(States)
E.Iftreatmentoptionsarenotavailableatthesitewherethemedicalwasteisgenerated,transport
regulatedmedicalwastesinclosed,imperviouscontainerstotheonsitetreatmentlocationorto
anotherfacilityfortreatmentasappropriate.CategoryIC(States)
IV.TreatmentandDisposalofRegulatedMedicalWastes
A.Treatregulatedmedicalwastesbyusingamethod(e.g.,steamsterilization,incineration,interment,
oranalternativetreatmenttechnology)approvedbytheappropriateauthorityhavingjurisdiction
(AHJ)(e.g.,state,IndianHealthService,orVeteransAdministration)beforedisposalinasanitary
landfill.CategoryIC(States,AHJ)
B.Followprecautionsfortreatingmicrobiologicwastes(e.g.,amplifiedculturesandstocksof
microorganisms)(400).CategoryIC(DHHS:BMBL)
1.Biosafetylevel4laboratoriesmustinactivatemicrobiologicwastesinthelaboratorybyusingan
approvedinactivationmethod(e.g.,autoclaving)beforetransporttoanddisposalina
sanitarylandfill(400).CategoryIC(DHHS:BMBL)
2.Biosafetylevel3laboratoriesmustinactivatemicrobiologicwastesinthelaboratorybyusingan
approvedinactivationmethod(e.g.,autoclaving)orincineratethematthefacility
beforetransporttoanddisposalinasanitarylandfill(400).CategoryIC(DHHS:BMBL)

C.Biosafetylevels1and2laboratoriesshoulddevelopstrategiestoinactivateamplifiedmicrobial
culturesandstocksonsitebyusinganapprovedinactivationmethod(e.g.,autoclaving)insteadof
packagingandshippinguntreatedwastestoanoffsitefacilityfortreatmentanddisposal(400,406
408).CategoryII
D.Laboratoriesthatisolateselectagentsfromclinicalspecimensmustcomplywithfederalregulations
forreceipt,transfer,management,andappropriatedisposaloftheseagents(409).CategoryIC
(DHHS:42CFR7272.6.i.1.iii)
E.Sanitarysewersmaybeusedforsafedisposalofblood,suctionedfluids,groundtissues,excretions,
andsecretions,providedthatlocalsewagedischargerequirementsaremetandthatthestatehas
declaredthistobeanacceptablemethodofdisposal(410).CategoryII
V.SpecialPrecautionsforWastesGeneratedDuringCareofPatientswithRareDiseases
A.WhendiscardingitemscontaminatedwithbloodandbodyfluidsfromVHFpatients,containthese
regulatedmedicalwasteswithminimalagitationduringhandling(36,109).CategoryII
B.ManageproperlycontainedwastesfromareasprovidingcaretoVHFpatientsinaccordancewith
recommendationsforotherisolationareas(RegulatedMedicalWaste:IIIB)(36,109,270).Category
II
C.DecontaminatebulkbloodandbodyfluidsfromVHFpatientsbyusingapprovedinactivation
methods(e.g.,autoclavingorchemicaltreatment)beforedisposal(36,109).CategoryIC,II(States)
D.Whendiscardingregulatedmedicalwastegeneratedduringtheroutine(i.e.,nonsurgical)careofCJD
patients,containthesewastesanddecontaminatethembyusingapprovedinactivationmethods(e.g.,
autoclavingorincineration)appropriateforthemedicalwastecategory(e.g.,blood,sharps,or
pathologicalwaste)(36,270,273,336).CategoryIC,II(States)
E.Incineratemedicalwastes(e.g.,centralnervoussystemtissuesorcontaminateddisposablematerials)
frombrainautopsyorbiopsyproceduresofdiagnosedorsuspectedCJDpatients(340,342).Category
IB
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