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PocketGuide for Family Planning Service Providers

Infection Prevention

Introduction (continued)

How to Withdraw Medication from a Sterile Multidose Vial

Wipe the top of the vial with a cotton swab soaked in 60–90% alcohol or other locally available disinfectant. Allow to dry.
If using a new disposable needle and syringe, open the sterile pack.
If using a sterile or high-level disinfected needle and syringe, remove from covered container using dry, sterile or high-level disinfected forceps.

Never use a syringe for more than one injection. Studies have shown that changing only the needle, not the syringe, between clients can result in transmission of hepatitis B virus, and presumably HIV/AIDS.

Attach needle to syringe by holding the hub (base) of the needle and the barrel of the syringe.
Turn the vial containing the drug upside-down and draw the fluid into syringe using the same needle you will use for the injection.
Withdraw needle from vial.

Do not leave a needle inserted in the rubber stopper of a multiple dose vial. This practice is dangerous because it provides a direct route for bacteria to enter the drug vial and contaminate the fluid between each use.

Figure 1. One-Handed Recap Method³

Figure 11. One-Handed Recap Method

Decontamination

Decontamination makes objects safer to be handled by staff before cleaning. It is the first step in processing soiled surgical instruments and other items.

Immediately after use, place instruments and other items in 0.5% chlorine solution for 10 minutes. This step rapidly inactivates HBV and HIV.
After decontamination, instruments should be rinsed immediately with cool water to prevent corrosion and to remove visible organic material before being thoroughly cleaned.
Surfaces (especially procedure tables) that may have come in contact with body fluids also should be decontaminated. Wiping with a suitable disinfectant, such as 0.5% chlorine solution, before reuse, when visibly contaminated or at least daily, is an easy-to-do, inexpensive way to decontaminate large surfaces.

Instructions for Preparing Dilute Chlorine Solutions

Formula for Making a Dilute Solution from a Concentrated Solution

Total Parts (TP) (H₂O) =

[

% Concentrate
% Dilute

]

-1

Example: Make a dilute solution (0.1%) from 5% concentrated solution.

1. Calculate TP(H₂O) =	[	5.0% 0.1%	]	-1 =	50-1= 49
2. Take 1 part concentrated solution and add to 49 parts boiled (filtered if necessary) water.

Formula for Making a Chlorine-Releasing Solution from a Dry Powder

Grams/Liter =

[

% Dilute
% Concentrate

]

x 1000

Example: Make a dilute chlorine-releasing solution (0.5%) from a concentrated powder (35%).

1. Calculate Grams/liter =	[	0.5% 35%	]	x 1000 =	14.2 g/l
2. Add 14.2 grams ( approximately14 g) to 1 liter of water.

Cleaning Instruments and Other Items

Cleaning is important because:

It is the most effective way to reduce the number of microorganisms on soiled instruments and equipment. (It reduces up to 80% of contaminating microorganisms—see Table 2.)
Neither sterilization nor high-level disinfection procedures are effective without prior cleaning.

Cleaning is also the best way to reduce the numbers of endospores which cause tetanus and gangrene. When sterilization equipment is not available, thorough cleaning is the only way to reduce the number of endospores effectively.

Table 2. Effectiveness of Methods for Processing Instruments

	EFFECTIVENESS (removal or inactivation of microbes)	END POINT
Decontamination	Kills HBV and HIV	10 minute soak
Cleaning (water only)	Up to 50%	Until visibly clean
Cleaning (detergent and rinsing with water)	Up to 80%	Until visibly clean
Sterilization^a	100%	High-pressure steam (autoclave), dry heat or chemical (see below)
High-level disinfection^a	95% (does not inactivate some endospores)	Boiling, steaming or chemical (see below)

^a Prior decontamination and thorough cleaning required.

Standard Conditions for Sterilization

Steam Sterilization

121� C (250� F)
106 kPa (15 lb/in²) pressure
20 minutes for unwrapped items; 30 minutes for wrapped items

Note: Pressure settings (kPa or lb/in²) may vary slightly depending on the sterilizer used. When possible, follow manufacturers' recommendations.

Do not overload the sterilizer. (Leave at least 7.5 cm—3 inches—between the packs and walls of sterilizer. Overloading alters heat convection and increases time required to sterilize.)

Allow all items to dry before removing.

Dry Heat Sterilization

170� C (340� F)
1 hour (total cycle time—placing instruments in oven, heating to 170� C, timing for 1 hour, and then cooling—is from 2–2� hours)

160� C (320� F)
2 hours (total cycle time is from 3–3� hours)
Ideal for instruments with cutting edges and other sharps (e.g., scissors, scalpel blades, needles)

Exposure time begins only after the oven has reached the specified temperature.

Endoscopes (laparoscopes) and other instruments that would be damaged by heat can only be sterilized or high-level disinfected (see next section) using chemicals.

Chemical Sterilization

An alternative to steam or dry-heat sterilization is chemical sterilization by soaking for 8 to 10 hours in a glutaraldehyde or at least 24 hours in an 8% formaldehyde⁴ solution. Glutaraldehydes, such as Cidex^�, often are in short supply and expensive, but they and formaldehyde are the only practical liquid sterilants usable for instruments, such as laparoscopes, that cannot be heated. Because glutaraldehydes and formaldehyde require special handling and leave a residue on treated instruments, rinsing with sterile water (which can be prepared only by autoclaving) is preferable. (Because boiling does not inactivate some endospores reliably, using boiled water can contaminate sterile instruments.)

Although formaldehyde is less expensive than glutaraldehyde, it is very irritating to the skin, eyes and respiratory tract. When using either formaldehyde or glutaraldehyde, wear gloves, protect eyes from splashes, limit exposure time and use only in a well-ventilated area.

High-Level Disinfection of Instruments and Other Items

High-Level Disinfection by Boiling

Timing should begin once the water is at a rolling (bubbling) boil. Use instruments and other items immediately or place them in a covered, dry high-level disinfected container. Store for up to 1 week.

Boiling Tips

Always boil for 20 minutes in a pot with a lid.
Start timing when the water begins to boil.
Items should be completely covered with water during boiling.
Do not add anything to the pot after boiling begins.
Air dry in a high-level disinfected container before use or storage

High-Level Disinfection by Steaming

Place only clean, dry items (e.g., surgical gloves) in the steamer pans. Start timing when steam begins to come out from between the pans and lid. Air dry high-level disinfected items in a clean area of the room. Use instruments and other items immediately or place them in a covered, dry, high-level disinfected container. Store for up to 1 week.

Steaming Tips

Always steam for 20 minutes in a steamer with a lid.
Reduce heat so that water continues to boil at a rolling boil.
Start timing when the steam begins to come out from between the pans and lid.
Do not use more than 3 steamer pans.
Air dry in the covered steamer pans or a high-level disinfected container before use or storage.

Figure 3. Steamer Used for HLD

Figure 13. Steamer Used for HLD

Chemical High-Level Disinfection

A variety of chemical high-level disinfectants are available worldwide including:

0.1% chlorine (sodium hypochlorite)⁵
8% Formaldehyde (Formalin)⁶
2% Glutaraldehydes

Although alcohols (60–90%), iodine and iodophors are inexpensive and readily available, they are no longer classified as high-level disinfectants. They should be used for disinfection only when high-level disinfectants are not available or appropriate.

Key Steps in Chemical HLD

Following decontamination, thoroughly clean and dry all equipment and instruments.
Cover all items completely with correct dilution of properly stored disinfectant.
Soak for 20 minutes.
Rinse well with boiled water and air dry.
Store for up to 1 week in a high-level disinfected, covered container or use promptly.
To prepare a high-level disinfected container, boil (if small) or fill it with 0.5% chlorine solution and soak for 20 minutes. (The chlorine solution can then be transferred to a plastic container and reused.) Rinse the inside thoroughly with boiled water. Air dry before use.

Waste Disposal

The purpose of waste disposal is:

to prevent the spread of infection to clinic personnel who handle the waste,
to prevent the spread of infection to the local community, and
to protect those who handle wastes from accidental injury.

Medical waste may be noncontaminated or contaminated. Noncontaminated waste (e.g., paper from offices, boxes) poses no infectious risk and can be disposed of according to local guidelines. Proper handling of contaminated waste (blood- or body fluid-contaminated items) is required to minimize the spread of infection to clinic personnel and to the local community. Proper handling means:

Wearing utility gloves
Transporting solid contaminated waste to the disposal site in covered containers
Disposing of all sharp items in puncture-resistant containers
Carefully pouring liquid waste down a utility drain or flushable toilet
Burning or burying contaminated solid waste
Washing hands, gloves and containers after disposal of infectious waste

³ Where disposable needles are not available and recapping is practiced, use the “one-handed” recap method: First, place the cap on a hard, flat surface; then remove hand. Next, with one hand, hold the syringe and use the needle to “scoop-up” the cap. Finally, when the cap covers the needle completely, hold the needle at the base near the hub and use the other hand to secure the cap on the needle.
⁴ Use formaldehyde with extreme caution because it is an agent that is reasonably anticipated to be a human carcinogen.
⁵ Use concentrated liquid bleach (sodium hypochlorite) diluted with boiled water (filtered if necessary) to make 0.1% solution.
⁶ Use of boiled water (filtered if necessary) is recommended to make a dilute solution (8%) from a concentrated one.

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