衛福部 疾病管制署 中區傳染病防治醫療網 王任賢 指揮官 呼吸道傳染病的感染管制 衛福部 疾病管制署 中區傳染病防治醫療網 王任賢 指揮官

呼吸道傳染病的感染管制 良好的病例偵測系統 發現病例後完整的收治系統 病例與接觸者追蹤系統 呼吸道衛生及咳嗽禮節 硬體設備 醫療行為 個人防護與防疫物資 疫苗注射

良好的傳染病例偵測系統 傳染病與感染症 相同處 均由微生物感染所造成 均會發燒 相異處 是否出現傳染的事實？

何謂 “傳染的事實” ？ 人對人傳染之事實 出現群聚現象 動物對人傳染之事實 接觸過罹病或死亡的動物 最近剛由WHO設定的旅遊警示區回來

何種人必須詢問傳染的事實 醫院的留滯人員 新住院病人 急診病患 醫院發燒或缺席的員工

傳染的事實為強迫要問的病史 應用於所有醫、護、檢傷人員、及救護車救護員 應用於每一個病人，不是只有發燒的人才問 在醫院中應有強制之作為及稽核的機制

有傳染事實之病患該如何處置？ 立即進行個案隔離 立即以症候群通報之方式向衛生單位通報 照顧者進行個人防護(PPE)

急診檢傷人員 人員必須固定 必須充分了解何謂症候群聚集現象？ 必須具備發出biothreat containment alert之能力 聚集現象之通報 有限度containment alert之發布 Lockdown containment area 配合部門內containment alert而該有配套措 施之checklist 檢傷人員該有完善的訓練，並應設立“檢傷司令”

“Lockdown” Containment Area 這是檢傷部門發出containment alert後立即要做的配套措施，意謂： 打開獨立負壓系統 人員進出進行動線管制 謝絕訪客，並以門禁管制 點收防疫物資是否符合需求

疑似或確認病例之收治動線 病例必須戴外科口罩，傳送人員必須戴N95口罩及著防護衣、戴手套 病患可以步行、輪椅、或推床執行運送，運送期間應準備垃圾袋、衛生紙、及酒精消毒劑 經過的動線必須進行人員管制，病患運送期間動線上不得有人員進出 動線不需額外的消毒與通風，但動線中之停留點需要通風或消毒(例如電梯內)

病例追蹤系統 隔離的病例應有行動與訪客的限制 解除隔離應以微生物學陰轉為依據，若無微生物資料可供參考，也可以退燒為指標

接觸者追蹤系統 醫院內必須追蹤的為院內接觸者，院外接觸者由公共衛生體系負責追蹤 接觸者必須造冊追蹤，追蹤的期間為一個潛伏期 追蹤期間必須每日回報體溫兩次，一出現發燒立即視同病例處理，依據2009年WHO對H1N1流感的研究認為潛伏期並不具有傳染力，因此二級接觸者不必追蹤

呼吸道衛生及咳嗽禮節之平時作為：I 民眾通視教育: 所有具呼吸道症狀的人 咳嗽時用衛生紙遮住口鼻，然後將紙丟進垃圾桶。 如果可以，咳嗽時應戴口罩 如果有接觸到呼吸道分泌物，之後要洗手 盡可能保持與別人距離1公尺以上

呼吸道衛生及咳嗽禮節之平時作為：II 醫療機構要推行呼吸道衛生及咳嗽禮節： 教育所有HCW、病人、家屬及訪客，避免散布呼吸道飛沫以預防流感或其他呼吸道病毒的重要性。 張貼告示要求病人及家屬主動通報呼吸道症狀，並遵守呼吸道衛生及咳嗽禮節. 張貼告示要求有呼吸道症狀的人不要到機構探病 在院內公共區及門診區提供口罩給有呼吸道症狀者 在院內公共區及門診區提供衛生紙及揮發性洗手劑

呼吸道衛生及咳嗽禮節之提升作為：I 民眾通視教育: 所有具呼吸道症狀或發燒的人，以門禁管理禁止進入醫療院所探病 來醫院探病的人，每次每床以一人為限，需配戴探病證，並應全程配戴外科口罩 咳嗽時用衛生紙遮住口鼻，然後將紙丟進垃圾桶。 如果可以，咳嗽時應戴口罩 如果有接觸到呼吸道分泌物，之後要洗手 盡可能保持與別人距離1公尺以上

呼吸道衛生及咳嗽禮節之提升作為：II 醫療機構要推行呼吸道衛生及咳嗽禮節： 管制執行呼吸道侵襲性醫療行為 醫療機構全面口罩政策 張貼告示要求有呼吸道症狀的人不要到機構探病 在院內公共區及門診區提供口罩給有呼吸道症狀者 在院內公共區及門診區提供衛生紙及揮發性洗手劑

硬體設備 Ventilation system 每個病房或病室應設立負壓咳痰區 醫院的waiting area必須保持通風 醫院要有負壓隔離病房，每小時空氣交換12次以上 執行呼吸道介入行為時，必須要在有負壓的空間並著個人防護 一般病房必須通風良好 每個病房或病室應設立負壓咳痰區 醫院的waiting area必須保持通風 診間的風向設計必須由醫師的頭後方吹向病患

Key concepts for Influenza Prevention (1) Is Influenza Airborne?

Transmission of influenza A in human beings Search of 2012 citations “We are able to conclude that transmission occurs at close range rather then over long distance, suggesting that airborne transmission, traditional defined, is unlikely to be of significance in most clinical setting.” Brankston et al. Lancet ID 2007(7):257-65

人工產生的aerosols能否感染人畜 人工的aerosols: <10%大於8 m 自然咳嗽: 99.9%大於8 m “沒有任何循證證明人類感染來自於空氣”

aerosol

Aircraft observation Alaskan airline Naval base aircraft Non functional ventilation system Free movement of passengers 72% infected Naval base aircraft Klontz reported outbreak (56%) in functional ventilation planes Am J Epidemiol 1979:110:1-6 Am J Epidemiol 1989:129:341-48

2009 pH1N1 virus transmission WHO – 29th April 2009 “Human-to-human transmission of the pandemic (H1N1) 2009 virus appears to be primarily through droplets. ” WHO – 16 December 2009 “primarily….through unprotected contact with large respiratory droplets.”

CDC’s Transmission Based Precaution Airborne Nuclei of < 5µm Pulm. TB Measles Varicella Zoster Droplet Nuclei of > 5µm Influenza Meningococcal Pertussis Contact Transmission by MR organisms direct or indirect Enteric RSV contact Blood Exposure to blood HIV, HBV inoculation

Key concepts for Influenza Prevention (2) What isolation precautions is needed for Influenza?

Key concepts for Influenza Prevention (3) Respiratory protection is needed for aerosol generating procedures. Intubation and related procedures Cardiopulmonary resuscitation Bronchoscopy Surgery and autopsy

Recent classification for airborne transmission Obligate airborne: initiate solely through aerosols: TB Preferential airborne: initiate through multiple routes but predominately by aerosols: Chicken pox and measles Opportunistic airborne: typically through other routes but by aerosols in favorable conditions (as high-risk procedures such as intubation): Influenza and SARS

呼吸道介入行為 Intubation and related procedures Cardiopulmonary resuscitation Bronchoscopy Surgery and autopsy

醫療行為 建立症候群防護的概念 (Transmission based precaution)，並確實執行 疫情期間所有的呼吸道插管均由麻醉科醫師執行，並停止其他非插管的呼吸道介入行為 取痰一定在取痰區或通風良好處 醫療單位禁用窗簾、地毯 清潔禁用掃把、乾抹、雞毛撢子、電扇，外溢處理時以覆蓋為最高處理原則 用過的衣物被褥禁止抖動，一律以打包處理

基本防護觀念在平時就應該落實 微生物千變萬化，但是傳播方式卻只有寥寥幾種，日常之醫療行為若能稍加改變就可免去一場災難 處理每個病人都應遵守標準防護措施 處理呼吸道症狀的病人要外加呼吸道防護 處理不明皮疹的病人要外加接觸防護 處理皮膚膿瘍的病人要外加接觸防護

個人防護 個人防護的使用原則 醫院有責任訂定任務導向及症候群導向之個人防護使用原則之明文規定，並有強制落實之機制存在 任務導向，MOPP (mission oriented personal protection)，而非職務導向 症候群導向，而非診斷導向 醫院有責任訂定任務導向及症候群導向之個人防護使用原則之明文規定，並有強制落實之機制存在 醫院防疫物資之存量必須視可能疫情的持續時間、國內物資之供給性、及國內運輸狀況而定

A key controversy regarding H1N1 prevention Surgical mask or N95 ?

SHEA recommendations “At the start of the 2009 outbreak, there was uncertainty regarding the transmission dynamics of the novel H1N1 virus. While seasonal influenza is spread by large respiratory droplets, a concern at the onset of any potential influenza pandemic is whether the pathogen will have a different dynamics or methods of spread.” 13th May – CDC recommends N95 to be used in all situations SHEA: Society of Healthcare Epidemiology of America

SHEA recommendations (10th June 2009) Mode of transmission “available data and clinical experiences suggest that H1N1 transmission occurs like seasonal influenza via droplets spread”. “SHEA endorses implementing the same practices recommended to prevent the transmission of seasonal influenza for the novel H1N1”. Isolation Measures: “Negative pressure rooms are not needed for the routine care of such patients.” “The N95 is not recommended as part of standard precautions”. This applies even for “preventing seasonal influenza transmission.”

High risk aerosol-generating procedures Enhance respiratory protection including the N95 is recommended for such procedures. The procedures should include “open suctioning of airway secretions, resuscitation involving emergency incubation or cardiac pulmonary resuscitation and endotracheal intubation”. However the following should not be included: “collection of nasopharyngeal specimens, close suctioning of airway secretions and administration of nebulized medications”.

HICPIC advisory committee 23rd July to vote on the latest recommendation “endorse the use of surgical masks for the routine care of patients with confirmed or suspected, novel influenza A (H1N1)” “it is appropriate at this time to recommend the use of N95 or higher respiratory protection for procedures that are likely to generate small particle aerosols.” The procedures are then listed to include “bronchoscopy, intubation under controlled or emergent situations, cardiopulmonary resuscitation, open airway suctioning and airway induction.” HICPIC: Healthcare Infection Control Practices Advisory Committee

Surgical Mask vs N95 Respirator for Preventing Influenza Among HCW A Randomized Trail A randomized controlled trail of 446 nurses in 8 tertiary care hospitals – Ontario Surgical masks N95 n 225 221 Influenza infected 50 (23.6%) 48 (22.9%) p = 0.086 (meet criteria for non-inferiority) Mark Loeb et al, JAMA,, 2009;302(17)

Preventing Influenza in the community Can Hand Hygiene make a difference

58% reduction of transmission w HH Hands play a role in flu transmission Cowling et al, Annuals of Internal Medicine – 2009 Vol.151 No.7 p.437-446

WHO guidance for infection prevention and control for H1N1 Standard precaution Hand hygiene (HH) Use of PPE does not eliminate hand hygiene when procedures include relevant risk: medical mask and PPE for eye protection a gown and clean gloves Droplet Precautions medical mask if < 1m of patient HH before and after patient contact and after removal of mask

Performing aerosol-generating procedures Wear a particulate respirator Adequately ventilated room, min of 6-12 ACH Limit only to those with patient care HH before & after patient contact and PPE removal Special considerations (eg. BiPAP, Nebulization) above measures also for open suctioning system

Duration of isolation precautions All patients on Droplet (DP) for seven days after s/s onset. DP maintained 24 hrs after resolution of s/s, especially fever DP in immunosuppressed maintained for full duration of ILI.

CDC Infection Control Guidance for Influenza: Adhere to droplet precautions Droplet precautions for 7 days after symptom onset or 24 hours after resolution of fever and resp symptoms Airborne precautions (fit tested N95 or equivalent) during aerosol generating procedures Bronchoscopy, sputum induction, intubation and extubation, autopsies, cardiopulmonary resuscitation, and open suctioning of airways http://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm

Collection of laboratory specimens Upper respiratory tract (above larynx) Standard and Droplet Precaution Lower respiratory tract specimens Aerosol-generating procedures IPC measures

醫療人員疫苗注射 為所有呼吸道傳染病防治政策中，最有效也是最重要的一項 疫苗注射之標的為呼吸道傳染病，注射之前之流行病學調查很重要

http://www. cdc. gov/mmwr/pdf/wk/mm5641-Immunization http://www.cdc.gov/mmwr/pdf/wk/mm5641-Immunization.pdf-accessed March 14, 2008

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