PM2ch40.pdf

Principles of Infection Control and Prevention During Military Deployment

Chapter 40

PRINCIPLES OF INFECTION CONTROL

AND PREVENTION DURING MILITARY

DEPLOYMENT

BRENDA ROUP, RN, P H D AND PATRICK W. KELLEY, MD, D R PH

INTRODUCTION

ELEMENTS OF AN INFECTION CONTROL PROGRAM

THE INFECTION CONTROL COMMITTEE

SURVEILLANCE

OCCUPATIONAL HEALTH FOR DEPLOYED HEALTH CARE WORKERS

THREE LEVELS OF INFECTION CONTROL

Control Level 1: Sanitary Practices

Control Level 2: Disinfection and Sterilization

Control Level 3: Isolation Procedures

MOVING PATIENTS

VECTOR-BORNE DISEASE CONTAINMENT

HANDLING OF LINEN, SHARPS, SPECIMENS, AND TERMINAL CLEANING

HANDLING OF CADAVERS

FUTURE RESEARCH

SUMMARY

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Military Preventive Medicine: Mobilization and Deployment, Volume 2

B. Roup , RN, PhD, Lieutenant Colonel, Nurse Corps, US Army (retired); Nurse Consultant in Infection Control, Maryland Depart-

ment of Health and Mental Hygiene, Baltimore, Maryland 21201; Formerly: Chief, Infection Control Service, Walter Reed Army

Medical Center, Nurse Consultant in Infection Control, Office of the Army Surgeon General, 5109 Leesburg Pike, Falls Church, VA

22041

P. W. Kelley , MD, D R PH, Colonel, Medical Corps, US Army; Director, Division of Preventive Medicine and the Department of

Defense Global Emerging Infections Surveillance and Response System, Walter Reed Army Institute of Research, Silver Spring, MD

20910-7500

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Principles of Infection Control and Prevention During Military Deployment

INTRODUCTION

Long-established concepts of infection control,

plus those that have achieved prominence since rec-

ognition of the bloodborne human immunodefi-

ciency virus (HIV), pose challenges even to fixed

health care facilities in peacetime. Medical care un-

der deployed conditions, especially in combat,

stretches the feasibility of infection control ap-

proaches, yet patients and their providers still deserve

the best care that the circumstances allow. During

deployments, uncommon and unique infection con-

trol hazards must be appreciated by providers who

normally work in well-equipped and well-staffed

fixed facilities. On the battlefield, infection control

must extend from semi-fixed facilities through

rapidly mobile units to the warfighter. Medical per-

sonnel must recognize that mass casualty situations

under fire, biological warfare, challenging logistics,

care of non-US patients, natural environmental hazards,

and exotic infectious diseases call for innovative ad-

aptations of the US fixed-facility model of infection

control. Though much research remains to be done

and doctrine to be written, prudent and creative ap-

plication of basic principles can help achieve success-

ful infection control in the field setting.

Prevention and control of infection in military

medical settings is in some respects more impor-

tant during deployment than it is during more

stable operations, such as occur in military hospi-

tals in the United States. Infections that not only

cause needless morbidity and mortality and

threaten the well-being of other warfighter-patients

also put a drain on what may be an already over-

taxed health care and medical evacuation system.

If key health care providers must be placed under

isolation because they have been exposed to dis-

eases such as Crimean-Congo hemorrhagic fever or

Lassa fever, health care can be compromised for

many current and future patients. Provider anxiety

over potential exposure to bloodborne pathogens

can also affect performance.

Infection control challenges in the deployed set-

ting may be compounded by higher rates of antibi-

otic resistance in many overseas settings; greater

susceptibility to common infectious diseases such

as rubella, mumps, and varicella among some pa-

tients from allied forces; the greater possibility of

transmissible infections such as tuberculosis among

local-hire workers; logistic delays; and bloodborne

pathogens. Biological warfare involving a transmis-

sible agent such as smallpox would dwarf any pre-

vious infection control concern. These scenarios

may be well beyond those envisioned by current

US occupational safety standards. Infection control

problems arising on deployments may reach back

to US-based fixed facilities. The growing emphasis

on rapid medical evacuation may result in the im-

portation into the United States of infection control

problems, such as previously unknown drug-resis-

tant organisms or exotic emerging infections.

In the civilian sector, the amount of attention paid

to controlling the spread of infection in medical fa-

cilities is related broadly to the level of general

health care. This, in turn, depends on the country’s

degree of development. At one end of the spectrum,

infection control and prevention practices may be

ignored by the lower-echelon health care worker;

the practices are simply left up to the initiative and

concern of individual physicians and nurses. At the

other end of the spectrum are facilities that prac-

tice all of the Northern American or European mod-

els of infection control, complete with surveillance

activities and outcome measures.

Since deployment may occur anywhere in the

world and since other cultures and geographic ar-

eas pose different challenges in infectious disease

prevention, general concepts will be the focus of this

chapter. Instituting infection control and prevention

practices during deployment will present varying

levels of difficulty and require varying levels of cre-

ativity, depending on the mission, geographic area,

logistical support, and beliefs of the local people about

health and medicine. Local people who are hired to

work for the military medical unit may not under-

stand why certain practices are mandated; they may

also be a source of infection or contribute to transmis-

sion themselves if, for example, they have undetec-

ted tuberculosis or continue to work (to produce

income) while they have an enteric illness. Major edu-

cational efforts may be necessary for such personnel,

with particular attention paid to cultural misunder-

standings concerning the transmission of infectious

diseases. The challenge to the military medical sys-

tem while under deployment conditions is not only

to improvise in incorporating practices familiar to the

US-based practitioner but also to bridge this gap be-

tween those practices and local circumstances.

ELEMENTS OF AN INFECTION CONTROL PROGRAM

An effective infection control and prevention

program for military and nonmilitary personnel in

a deployed environment should be based as much

as possible on the same elements and principles that

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Military Preventive Medicine: Mobilization and Deployment, Volume 2

guide such programs in garrison. Because of the

austerity of the deployed environment, though,

common sense and creativity may be needed to

adjust to the situation at hand. Health care work-

ers must first understand that while infection con-

trol principles remain the same, the infection

control threat under deployed conditions may be

different and more complicated than normal. Health

care workers at all levels need to be educated con-

cerning how a deployment scenario may call for

particular and even unfamiliar infection control

emphases. For example, patient-to-patient transmis-

sion of a vector-borne infection such as dengue

would not typically be an issue in the controlled

environments of a US hospital, but bednets may be

essential to protect staff and patients if mosquitoes

are present in a deployed hospital with viremic

dengue patients.

Infection control encompasses those policies,

procedures, and concepts necessary to minimize the

transmission of infectious diseases in the health care

setting. Successful infection control programs usually

have an active multidisciplinary infection control com-

mittee; proactive surveillance; effective methods for

isolating patients and specimens that pose a risk to

others; an occupational health program; policies re-

garding antibiotic use, aseptic technique, and facility

sanitation; and access to at least basic microbiological

laboratory support. The underpinning of a success-

ful program is regular education and communication.

Infection control must be given emphasis and respon-

sible personnel to be successful.

Infection control policies have to address both

facility-acquired and community-acquired infec-

tions. Facility-acquired infections, also known as

nosocomial infections, are generally defined as

those infections that are neither present nor incu-

bating at the time of admission to a facility but de-

velop 48 to 72 hours afterward, unless the infection

is clearly related to a procedure or exposure that

occurred within the first 48 to 72 hours of hospital-

ization. Criteria for defining such infections have

been outlined by the Centers for Disease Control

and Prevention (CDC) and should be used by mili-

tary personnel. 1 Community-acquired infections are

generally considered to be all infections that arise

from exposures outside the facility. In this chapter,

“facility” refers to any setting in which patients are

treated, including hospitals, clinics, or forward

treatment areas.

According to Meers, 2 the problems of facility-trans-

mitted infections in developing or war-ravaged

countries are 2-fold. The first is communication

between the medical personnel and patients. The

second is the spectrum of diseases. Some commu-

nity-acquired infections that are viewed as major

problems in the United States are seen as minor

problems or everyday occurrences in other nations

and cultures (eg, tuberculosis, hepatitis). This can

also be true of infections that are transmitted within

the facility. An understanding of local attitudes to-

wards infections and infectious diseases may be

crucial to the successful prevention of infections in

a deployed environment.

THE INFECTION CONTROL COMMITTEE

While most infection control committees are fo-

cused on and based in hospitals, on deployment

infection control must be addressed at levels extend-

ing from the warfighter to supporting hospitals in

the United States. This requires layers of infection

control management tailored to the size and circum-

stances of the deployment. For this reason, there is

no single model for how to manage infection control

efforts in the deployed setting. Individuals should be

formally appointed to manage this function.

The committee has several key functions; it formu-

lates theater-specific infection control policies, over-

sees surveillance activities, develops appropriate

medical education, and evaluates the program. This

group should also, recognizing resource limitations,

advise medical commanders on what infection con-

trol programs and settings deserve the highest pri-

ority. The frequency of meetings will depend on the

maturity of the theater and the complexity of the

medical care system being put into place. Efficiency

may require meetings by individuals responsible for

specific parts of the health care continuum. Mem-

bership on the infection control committee, and any

subcommittees, should reflect the expertise of cli-

nicians (to include medics), clinical nurses, preven-

tive medicine and environmental science officers,

an epidemiologist or a surveillance nurse, the phar-

macist, medical regulators involved with moving

patients, and laboratorians.

The committee should develop appropriate

medical education for all medical personnel, but

special emphasis should be placed on education for

nurses because of their intense contact with patients

and implementation of standard procedures. The

committee can also help clinicians in the theater by

researching and reporting local antibiotic-resistance

patterns. Another important educational focus

should be the avoidance of occupational injuries

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Principles of Infection Control and Prevention During Military Deployment

from contaminated sharps and medical waste.

Nonclinicians who may find themselves involved

in patient care (eg, first aid and triage personnel,

litter carriers) should be taught how to protect

themselves from bloodborne infections. Regular

feedback of infection control information, includ-

ing surveillance data, to supported facilities is

desirable.

SURVEILLANCE

If a military unit will be stationary for some pe-

riod of time, a program for nosocomial infection

surveillance should be instituted. Ideally, the de-

ployed unit will already have in place policies and

procedures for such a program and will only need to

implement them. Since microbiological laboratory

support may be minimal, if it is present at all, other

information about patients (eg, unexplained fevers,

new rashes, purulent drainage from wounds) will

need to serve as markers for the possible spread of

nosocomial infection. Considering that resources

are often constrained in the deployment setting, a

role of the infection control committee will likely

be to prioritize surveillance efforts. This may in-

volve targeting specific high-risk facilities or wards,

rotating surveillance of lower-risk wards, and fo-

cusing on infections associated with the highest

mortality (eg, bacteremia, pneumonia).

One individual should be designated to perform

surveillance “rounds” of the patients in the medi-

cal treatment facility at least once a week, using

patient records, written or oral nursing reports, and

pharmacy and laboratory records as primary

sources of data and clues as to which patients have

nosocomial infections. For example, more scrutiny

might be given to those whose records show sug-

gestive antibiotic prescriptions, intravenous cath-

eter sites, wound dressing changes, or abnormal

EXHIBIT 40-1

CASE DEFINITION FOR SUSPECTED EBOLA HEMORRHAGIC FEVER

The following case definition may be useful for surveillance in an area at recognized risk for the emergence

of Ebola hemorrhagic fever.

Anyone presenting with fever and signs of bleeding

such as:

• Bleeding of the gums

• Bleeding from the nose

• Red eyes

• Bleeding into the skin

• Bloody or dark stools

•Vomiting blood

• Other unexplained signs of bleeding

Whether or not there is a history of contact

with a suspected case of Ebola

Anyone living or deceased with:

• Contact with a suspected case of Ebola

AND

•A history of fever, with or without signs of

bleeding

Anyone living or deceased with a history of fever

AND

three of the following symptoms:

• Headache

•Vomiting

• Loss of appetite

• Diarrhea

•Weakness of severe fatigue

• Abdominal pain

• Generalized muscle or joint pain

• Difficulty swallowing

• Difficulty breathing

• Hiccups

Any unexplained death in an area with suspected

cases of Ebola

Source: Centers for Disease Control and Prevention. Infection Control for Viral Hemorrhagic Fevers in the African Health Care

Setting . Atlanta: CDC; 1999.

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