MANUAL OF APPLIED INFECTION PREVENTION AND CONTROL

2021-2022

1 Table of Contents

OVERVIEW: APPLIED INFECTION PREVENTION AND CONTROL ...... 5 Introduction ...... 5 Rationale ...... 5 How does infection occur ...... 5 Contact transmission ...... 5 i. Direct ...... 5 ii. Indirect ...... 5 Droplets ...... 5 Aerosols ...... 5 Infection Control Protocol: Standard Precautions ...... 7  Hand hygiene ...... 7  Use of personal protective equipment (PPE) ...... 7  Proper management of patient care equipment ...... 7  Environmental surfaces ...... 7  Injury prevention ...... 7 WORK RESTRICTION GUIDELINES1 IN THE OHC FOR STUDENTS, FACULTY AND CLINICAL STAFF INFECTED WITH OR EXPOSED TO THE FOLLOWING INFECTIOUS DISEASES ...... 8 APPLIED INFECTION PREVENTION AND CONTROL IN THE NOBEL BIOCARE ORAL HEALTH CENTRE ...... 12 1. Basic Dress Code (patient care or simulation): ...... 12 2. Hand Hygiene (for routine dental procedures): ...... 16 a. Hand washing ...... 16 b. Alcohol-based preparations (hand sanitizers) ...... 17 3. Personal Protective Equipment (PPE)...... 18 The Sequence of donning PPE ...... 18 2. SURGICAL CAP/ BOUFFANT ...... 18 4. GOWN ...... 19 5. MASK ...... 19 6. PROTECTIVE EYEWEAR / LOUPES & FACE SHIELD ...... 19 8. GLOVES ...... 19 The sequence of removing PPE ...... 19 1. GLOVES ...... 19 3. GOWN ...... 19 5. FACE SHIELS & PROTECTIVE EYEWEAR / LOUPES ...... 20 6. SURGICAL CAP/ BOUFFANT ...... 20 8. MASK ...... 20 4. Environmental Surfaces and Infection Control: ...... 20 a. Housekeeping surfaces...... 21 b. Clinical contact surfaces ...... 21 c. Barriers ...... 21 OPERATORY ASEPSIS AND SET-UP PROCEDURES ...... 23 Preparation for patient care ...... 23 Asepsis and Set-up Procedures ...... 23 DURING PATIENT CARE ...... 30 RETURNING CONTAMINATED INSTRUMENTS TO CSD CUBBY ...... 31

2 END-OF-SESSION’ OPERATORY ASEPSIS PROCEDURE ...... 32 Tear Down Procedures ...... 32 BEFORE COMMENCING TREATMENT ...... 35 PROPER DISINFECTION OF IMPRESSIONS, FACEBOW/OCCLUSAL REGISTRATION, CUSTOM TRAYS, APPLIANCES, PRDPs, CRDPSs, CROWNS &FDPs ...... 37 INSTRUMENT REPROCESSING AND STERILIZATION ...... 38 Critical patient care equipment/device: ...... 38 Semi-critical patient care device: ...... 38 Noncritical device: ...... 38 Disinfection: ...... 38 High level disinfection: ...... 38 Steam sterilization ...... 39 Flash Sterilization ...... 39 AIR TURBINE AND HANDPIECES ...... 40 INFECTION CONTROL FOR DIGITAL RADIOLOGY ...... 41 1. PPE for RAD ROOM ...... 41 2. RAD ROOM PREPARATION ...... 41 3. EQUIPMENT ...... 42 a. For bagged supplies ...... 42 b. For PSPs ...... 42 c. For CCDs ...... 42 4. EXPOSURE OF RADIOGRAPHS ...... 43 5. ROOM CLEAN UP ...... 44 6. SCANNER ROOM FOR PSPs ...... 44 ORAL SURGERY AND SPECIAL CONSIDERATIONS IN INFECTION CONTROL...... 46 ORAL SURGERY: ...... 46 Environmental and engineering controls: ...... 46 Personal Protective Equipment PPE: ...... 46 Surgical hand asepsis: ...... 46 Barriers and surgical drapes: ...... 46 Irrigation of surgical sites: ...... 46 Return and reprocessing of clinical use items: ...... 47 CPR/AED Certification: ...... 47 DENTAL UNIT WATERLINES ...... 48 WASTE MANAGEMENT ...... 49 Biomedical wastes ...... 49 Sharps and Needles ...... 49 Amalgam ...... 49 Mercury ...... 50 Battery ...... 50 Butane Canisters and Endo Ice Canisters ...... 50 Gypsum ...... 50 A GUIDE FOR CRITICAL EXPOSURE TO BLOODBORNE PATHOGENS ...... 51 POLICY AND GUIDELINES ON INFECTIOUS DISEASES ...... 54

3 UBC immunization protocol: ...... 55 TETANUS/DIPHTHERIA AND ADACEL ...... 55 POLIO VACCINATION ...... 55 MEASLES, MUMPS AND RUBELLA ...... 55 TB SKIN TESTING ...... 55 VARICELLA ( CHICKENPOX ) ...... 55 Bloodborne Pathogens ...... 56 HEPATITIS B ...... 56 HEPATITIS C ...... 56 HUMAN IMMUNODEFICIENCY VIRUS (HIV) ...... 56 Communicable Disease Status ...... 57 British Columbia Guidelines for Control of Antibiotic Resistant Organisms (AROs) [Methicillin-Resistant Staphylococcus aureus (MRSA) and Vancomycin-Resistant Enterococci (VRE)] ...... 58 MRSA METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS ...... 58 Introduction ...... 58 Who is at risk for CA-MRSA? ...... 59 MRSA Carriers ...... 60 CA-MRSA-related morbidity ...... 60 Skin Infections ...... 60 Treatment and Management of CA-MRSA SSTIs ...... 61 Measles Cluster in Fraser East ...... 62 Influenza ...... 62 Vaccination ...... 62 Hand hygiene ...... 63 Respiratory etiquette ...... 63 Routine cleaning ...... 63 7. COVID-19 ...... 63 Infection Prevention and Control Principles and Strategies ...... 64 Infection prevention and control (IPAC) principles include: ...... 64 IPAC strategies to reduce the possibility of disease transmission include: ...... 64 Routine practices ...... 64 REFERENCES ...... 65

4

OVERVIEW: APPLIED INFECTION PREVENTION AND CONTROL

Introduction

Rationale

This manual on infection prevention and control is based upon current guidelines and recommendations published by the College of Dental Surgeons of British Columbia (CDSBC)1, Centers for Disease Control and Prevention (CDC)2 in the United States, recommendations of the Organization for Safety and Asepsis Procedures (OSAP), and the Recommendations for Infection Prevention and Control in the Dental Office of the Canadian Dental Association, as well as local laws and statutes.

The underlying premise that necessitates infection control practice is that dental patients, dental healthcare personnel (DHCP), (dentist, assistant, hygienist, and receptionist), as well as laboratory technicians, can be exposed to pathogenic microorganisms. These pathogens can be transmitted in dental settings through:

How does infection occur Contact transmission Where pathogens enter a person’s body through contact with a mucous membrane or breaks (i.e., cuts, abrasions) in the skin. It is divided into:

i. Direct Direct contact; contact with blood, oral fluids or other patient body fluids (except sweat);

ii. Indirect Indirect contact; contact with contaminated objects (e.g., instruments, equipment or environmental surfaces; Droplets Contact of mucosa (conjunctival, nasal or oral) with droplets (e.g. spray or splatter) containing pathogens generated from an infected person and propelled a short distance (e.g. by sneezing or coughing); and Aerosols Inhalation of airborne pathogens (aerosol). 3

5 For the risk of infection to be present, whether real or theoretical, through any of the 4 transmission routes, the "chain of infection" needs to be closed i.e. requires that all of the following conditions, or "links" be present:

 Pathogenic organism of sufficient virulence and in adequate numbers to cause disease;

 Reservoir or source (e.g. blood) that allows the pathogen to survive and multiply;

 Mode of transmission from the source to the host;

 Portal of entry through which the pathogen can enter the host;

 Susceptible host (i.e., one who is not immune).

Exposure may be insufficient to cause replication in the host and not lead to transmission or be sufficient for replication (transmission) in the new host; and may or may not lead to symptoms, which may/may not lead to a diagnosis.

Effective infection control strategies prevent disease transmission by interrupting one or more of the above "links" in the chain, i.e. breaking the chain.

6 Infection Control Protocol: Standard Precautions

CDC first introduced the term "standard precautions" in 1996 to refer to a standard of care designed to protect health care professionals and patients from pathogens that can be spread by blood or any other body fluids. That was reinforced again in 2007.4 Standard precautions apply to contact with blood, body fluids (except sweat), non-intact skin, and mucous membranes. In the dental setting, saliva is considered potentially infectious. While a thorough medical history is mandatory to help identify individuals who pose a risk of infection to the DHCP. Some infections have a latent or prodromal stage of infection (where the disease is not yet clinically manifested). Therefore, standard precautions need to be applied to everyone i.e. treat all patients as a potential source of infection. Basic elements of standard precautions include:

 Hand hygiene 5

 Use of personal protective equipment (PPE) Namely: gloves, mask, protective eyewear, and long-sleeved protective gown.

 Proper management of patient care equipment

 Environmental surfaces

 Injury prevention Actions to stay healthy including immunizations as well as safe injection practices.

In some cases, (e.g. TB, influenza, varicella, COVID-19), expanded or transmission-based precautions (e.g. isolation, respiratory protection, postponement of non-emergency treatment) might be necessary. 6

7 WORK RESTRICTION GUIDELINES1 IN THE OHC FOR STUDENTS, FACULTY AND CLINICAL STAFF INFECTED WITH OR EXPOSED TO THE FOLLOWING INFECTIOUS DISEASES

Disease/Condition Clinical Restriction Duration of Restriction SARS-CoV-2 (COVID-19) Restrict from patient clinical If you’ve been diagnosed with care contact (should not come to COVID-19, public health will UBC) tell you when you can end isolation.

Conjunctivitis Restrict from patient clinical Until discharge ceases care contact and contact with patient's environment

Cytomegalovirus infection No restriction

Diarrheal disease Acute stage (with other Restrict from patient clinical Until symptoms subside symptoms) care contact

Convalescence Restrict from care of high-risk Until symptoms resolve stage (Salmonella patients (negative stool sample may be species) necessary)

Enteroviral infection Restrict from care of Until symptoms resolve immunocompromised patients

Hepatitis A Restrict from patient clinical Until 7 days after onset of care contact Jaundice

Hepatitis B* HBsAg-positive No restriction - Consult with personnel who do not provincial authorities. (standard perform exposure-prone precautions always must be procedures followed) HBeAg-positive Should not perform exposure- prone or invasive procedures – Until HBeAg is negative and consult with provincial viral DNA <103 copies/mL authorities

*In 2012, the CDC issued revised guidelines for students and healthcare workers infected with Hepatitis B. These guidelines are still in effect. 8 Hepatitis C No restrictions – always follow aseptic technique and standard precautions

Human Immunodeficiency Restrict from invasive exposure- Virus (HIV) prone procedures until consultation with provincial authorities. Always follow standard precautions

Herpes simplex Genital No restrictions

Hands (herpetic Restrict from patient clinical Until lesions heal whitlow) care contact

Orofacial Evaluate the need to restrict the Lesions are contagious at both the vesicular and crusted stage. treatment of patients at high risk Patients identified with HSV infections should be rescheduled (decision to treat is left to the discretion of student)

Influenza Exclude from clinical activity Infectious from 2 days prior to symptoms and up to 7 days after

Measles Active Exclude from clinical activity Until 7 days after rash appears

Post exposure susceptible Exclude from patient clinical From 5th day after first Personnel activity exposure through twenty-first day after last exposure, or 4 days after rash appears

Meningococcal infection Exclude from clinical care Until 24 hours after start of activity effective therapy

Mumps Active Exclude from clinical activity Until 9 days after onset of parotitis

9 Post exposure (susceptible Exclude from clinical activity personnel) From 12th day after first exposure through 26th day after last exposure, or until 9 days after onset of parotitis.

Pediculosis (head lice) Exclude from clinical activity Exclude from clinical activity until treated and observed to be free of adult and immature lice.

Pertussis (whooping cough) Active Exclude from clinical activity From beginning of catarrhal stage through third week after

onset of paroxysms or until 5 days after start of effective antibiotic therapy.

Post exposure (asymptomatic No restriction, prophylaxis personnel) recommended

Post exposure (symptomatic Exclude from clinical activity Until 5 days after start of personnel) effective antibiotic therapy.

Rubella Active Exclude from clinical activity Until 5 days after rash appears

Post exposure (susceptible Exclude from clinical activity From 7th day after first personnel) exposure through 21st day after last exposure.

Streptococcal Infection, Exclude from clinical activity Until 24 hours after adequate group A treatment is started.

Tuberculosis Active disease Exclude from clinical activity Until proven non-infectious

PPD converter No restrictions

Staphylococcus aureus infection Active, draining skin Exclude from clinical patient Until lesions have resolved lesions care activity

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Carrier state No restriction unless personnel are epidemiologically linked to transmission of the organism.

Varicella (Chicken pox) Active disease Exclude from clinical activity Until all lesions dry and crust

Post exposure (susceptible Exclude from clinical activity From 10th day after first st th personnel) exposure through 21 day (28 day if varicella- zoster immune globulin [VZIG] administered) after last exposure.

Zoster (shingles) Localized, in a healthy Cover lesions, restrict from care Until all lesions dry and crust. Person of patients at high risk

Generalized or localized in Exclude from clinical activity Until all lesions dry and crust. immunosuppressed person

Post exposure (susceptible Exclude from clinical patient From 10th day after first personnel) care activity exposure through 21st day (28th day if varicella-zoster immune

globulin [VZIG] administered) after last exposure or if varicella occurs when lesions crust and dry.

Viral respiratory infection, Consider excluding from clinical Until acute symptoms resolve. acute febrile care patients at high risk, or contact with such patients' environment during community outbreak of respiratory syncytial virus and influenza.

11 APPLIED INFECTION PREVENTION AND CONTROL IN THE NOBEL BIOCARE ORAL HEALTH CENTRE

1. Basic Dress Code (patient care or simulation):

 Hygiene and grooming

o Face should be clean and well groomed.

o Males: clean shaven, unless growing a permanent beard or moustache. Beards and moustaches to be well-groomed.

o Makeup to be worn in moderation.

o Good principles of personal hygiene, including control of body odors, strongly scented colognes/perfumes should not be used.  Hair

o Hair should be clean, well-groomed and worn in such a manner that it will not interfere with patient care or laboratory activity and presents a professional image.

o If hair is long, it must be worn in a surgical cap or tied back behind the neck and securely pulled back for the full length of the clinical session. Bangs should be held back as to not touch the protective eyewear. (To minimize its contamination by droplets and aerosols)  Nails

o Fingernails clean and trimmed to surgical working length. Artificial nails or nail jewelry are prohibited.

o No nail polish; colored or clear. Always remember that once nail polish starts to breakdown, it will act as a harbor for microorganisms to breed and thrive.

o The picture shows how the length of nails will be checked in the clinic. The instructor should not feel nails when they keep their fingers perpendicular to students’ fingers.

 Skin/Mucosal Alterations

o No visible tattoos. Any visible tattoo must be covered with a bandage or clothing.

12 o All facial jewelry/piercings, such as those in the nose, lips, and eyebrows need to be removed. If they do not come out the area needs to be covered by a bandage.

 Protective personal equipment (PPE)

o A surgical mask, eye protection (goggles and a face shield that covers the front and sides of the face), a gown or protective clothing, and gloves during procedures likely to generate splashing or spattering of blood or other body fluids.

o Protective eyewear (e.g., safety glasses, trauma glasses) with gaps between glasses and the face likely do not protect eyes from all splashes and sprays.

o Long sleeved disposable gowns must be worn in all patient care, ICC and all satellite clinics where splatter and spray are anticipated, as the case with handpiece and/or power instrumentation unit use (including ultrasonic instruments). Also during acrylic denture, custom tray adjustments and prophylaxis use. Likewise, when invasive oral surgery procedures are undertaken.

 Cloth mask

o Wearing a cloth mask is strongly recommended when arriving the clinic

o Cloth mask should be replaced by a surgical mask when putting on PPE

 Clinic scrubs

o Scrubs should be cleaned and changed daily. Always remember that if you are not using a long sleeved protective gown, most of the droplets and aerosols generated during the clinical session, land on your scrubs even though it may seem clean.

o If pant legs are too long do not roll them up as they can harbour soil and debris. You need to get them properly hemmed and fitted, or you can use rubber bands to tighten them if they are too loose.

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 Attire

o No jewelry; that includes rings, wrist-watches, neck pendants, multiple chains, drop earrings and all facial jewelry. The exception is religious bracelets which must be covered during clinic procedures

o No sweaters or jackets over the scrubs, a white t-shirt or tank may be worn under the scrubs if needed, however, such clothes need to be handled and changed the exact same manner as the scrubs (not to be worn back and forth from home, needs to be changed daily)

o o Identification badge worn, with name visible to others. Note: name tag must be in accordance with the design, lettering and wording mutually agreed upon by the Clinic Director and the DUS executive.

 Shoes

o Clean, white athletic runners (in good condition) with white socks. To avoid injury in the incidence of a dropped sharp instrument; - Runners must be solid leather (not fabric, no holes and no large logos) without mesh parts - Socks must extend mid-calf.

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Please note:

 Students will be issued scrubs and lab coats when they first get to the school. They are responsible to buy proper shoes before the first clinic day.

 Clinical scrubs are intended for wear only in the OHC clinic and off-site clinics of the Faculty of Dentistry. To access other areas of the UBC Health Sciences Complex, scrubs must be covered with a buttoned-up, clean lab coat.

 The UBC Health Sciences Complex (HSC) is considered to comprise the following: 1. JB Macdonald Dentistry Building and the Nobel Biocare Oral Health Centre 2. IRC and related Woodward Health Sciences Library 3. UBC Hospital, including cafeteria 4. Detwiler Pavilion

 Scrubs (even if covered by a lab coat) are not to be worn beyond the UBC Health Sciences Complex area or off-site clinical areas. That includes:

- The remaining commercial, retail and office spaces of the Strangway Building (Shopper’s Drug Mart, Scotiabank, Coffee Barista) as well as the east side of Wesbrook Mall (the Village), these areas are at a higher level

15 of general public access and therefore are NOT considered part of the UBC Health Sciences Complex. - Traveling to-and-from home to HSC or off-site Clinics

 Wearing scrubs in undesignated areas is considered a breach of infection control protocol and subject to an Unsatisfactory Professionalism assessment and/or suspension of Clinic privileges.

 It is important to note, many individuals get offended by the sight of operating scrubs being worn outside clinical areas, period. In addition to the obvious infection control purpose, wearing disposable operating gowns in the presence of splatter and spray will reduce the potential for unsightly staining and soiling of scrubs.

 No bags or backpacks are allowed in the clinic. The valuables are to be placed in the small bag already present under the counter in the operatory.

2. Hand Hygiene (for routine dental procedures): 7 Hand hygiene is a term that encompasses hand washing and hand sanitizing. It is the single most critical measure for reducing the risk of pathogen transmission by removing soil and transient microorganisms. Hand and wrist jewelry must be removed before hand hygiene.

In the clinical setting hand hygiene is indicated  when in the patient care environment,  before and after direct contact with a patient,  before procedures,  before donning gloves and immediately after removing gloves,  before and after mask use,  after risk of body fluid exposure,  after touching inanimate objects likely to have been contaminated by blood or saliva  after contact with environmental surfaces, instruments or other equipment in the dental operatory;  after contact with dental laboratory materials or equipment;  when hands are visibly soiled  Before leaving the dental operatory or the dental laboratory

Good hand hygiene, whether hand-washing with soap and water or hand sanitizing using an alcohol-based hand rub, is critical to reduce the risk of spreading infections in patient care settings.

a. Hand washing When hands are visibly soiled, hand washing with soap and water should be performed.

16 Hand washing using plain soap for a minimum of 20 seconds (lathering), followed by thoroughly rinsing with cool or tepid water and careful drying with disposable paper towels. A thorough hand wash is essential  At the beginning of the day  Upon entering the operatory for a clinical session  After washroom use  At the end of the clinical session

A routine hand wash using plain soap and water should be performed as follows:  Wet hands,  Dispense soap,  Rub hands together to generate lather,  Scrub all surface of your hands for a minimum of 20 seconds,  Rinse with cool or tepid water,  Thoroughly dry with a disposable paper towel.

b. Alcohol-based preparations (hand sanitizers) Alcohol-based hand rubs may also be used if hands are not visibly soiled. The antimicrobial activity of alcohols can be attributed to their ability to denature proteins. Alcohol solutions containing 60% - 95% alcohol are most effective, reducing bacterial counts on the hands, however, do not eliminate soil, only soap and water does.

Limitations Advantages

 Cannot be used when  Rapid; less time hands are visibly soiled consuming than hand washing & drying  Need to store away from high temperatures or  Effective against a wide flames range of microorganisms  Builds-up after a number  Less irritating to skin than of uses requiring hand soap and water washing

17 3. Personal Protective Equipment (PPE) To be worn at all times during patient care procedures. PPE is designed to protect the skin and mucous membranes of the eyes, nose and mouth of the DHCP from exposure to blood and other potentially infectious material (notably saliva). Primary PPE in dentistry includes:  Gloves,  Surgical masks,  Protective eyewear/loupes and face shields,  Protective clothing  Surgical caps/ Bouffant  Gown

Long sleeved disposable protective gowns and surgical caps/ bouffant are required when splatter/spray and debris is anticipated as is the case with handpiece and/or power instrumentation unit use (including ultrasonic instruments). Also during acrylic denture, custom tray adjustments and prophylaxis use. Likewise, when invasive oral surgery procedures are undertaken.

Protective eyewear for patients must also be used at all time during the clinical session. The Sequence of donning PPE8 1. HAND HYGIENE  Remove hand and wrist jewelry  Clean all surfaces of hands and wrists

2. SURGICAL CAP/ BOUFFANT

3. HAND HYGIENE

18 4. GOWN  Fully cover torso from neck to knees, arms to the end of wrists, and wrap around the back  Fasten at the back of the neck and waist 5. MASK  Must effectively cover the nose and mouth, and must be changed between patients or when visibly soiled or wet  Secure ties or elastic bands at the middle of head and neck (elastic bands go around the ears)  Fit flexible band to the nose bridge  Fit snug to face and below the chin 6. PROTECTIVE EYEWEAR / LOUPES & FACE SHIELD  Place over face and eyes and adjust to fit

7. HAND HYGIENE 8. GLOVES  Extend to cover cuff of isolation gown

SAFE WORK PRACTICES TO PROTECT YOURSELF AND LIMIT THE SPREAD OF CONTAMINATION  Keep hands away from the face  Limit surfaces touched  Change gloves when torn or heavily contaminated  Perform hand hygiene before donning and after removing gloves  Clean overgloves to be used on patient care gloves to adjust mask and eyewear during patient care sessions

The sequence of removing PPE

1. GLOVES  Outside of gloves are contaminated!  Grasp outside of glove with an opposite gloved hand; peel off  Hold removed glove in the gloved hand  Slide fingers of ungloved hand under remaining glove at the wrist  Peel glove off over first glove  Discard gloves in a waste container

2. HAND HYGIENE 3. GOWN  Gown front and sleeves are contaminated!  Unfasten ties  Pull away from neck and shoulders, touching inside of gown only  Turn gown inside out

19  Fold or roll into a bundle and discard

4. HAND HYGIENE 5. FACE SHIELS & PROTECTIVE EYEWEAR / LOUPES  Outside of goggles or face shield is contaminated!  To remove, handle by a headband or earpieces  Place in a designated spot for later cleaning and disinfecting 6. SURGICAL CAP/ BOUFFANT

7. HAND HYGIENE 8. MASK  Front of the mask is contaminated —DO NOT TOUCH!  Grasp bottom, then top ties or elastics and remove  Discard in a waste container

9. HAND HYGIENE

NOTE: Patient care gloves and gowns are not to be worn outside the operatory unless covered by overgloves/ clean white coats

4. Environmental Surfaces and Infection Control:

Environmental surfaces are inanimate surfaces that do not directly come into direct contact with a patient. These surfaces may become contaminated with pathogens during patient care although they have not been associated directly with transmission of infection. These surfaces can be divided into two categories: housekeeping surfaces and clinical contact surfaces.

20 a. Housekeeping surfaces (e.g. floors, walls and doors) have limited risk of disease transmission and can be decontaminated by less stringent means. Transfer of pathogens is primarily via hand contact. b. Clinical contact surfaces can be directly contaminated from direct contact, splatter or spray and pose a theoretical risk of cross contamination. Clinical contact surfaces include bracket tables, countertops, overhead lights and reusable containers of dental materials.

Cleaning is the first step in decontaminating clinical contact surfaces. Following the cleaning process, clinical contact surfaces should be disinfected with a hospital grade tuberculocidal intermediate-level disinfectant.

OptIM 33 wipes are used in the OHC

c. Barriers  When used appropriately, are an effective tool to reduce the spread of infection, through creating an interruption in the chain of infection;  Reduce bio-burden i.e. reduces the number of micro-organisms contaminating the underlying clinical surface;  Are effective on surfaces that are difficult to clean and disinfect thoroughly and are likely to become contaminated with oral fluids during treatment procedures. Typically; permanently attached components to the dental unit, e.g. handles / dental unit attachments of saliva ejector, high volume suction, air/water syringe;  Should be impervious to moisture;  Are single-use;  Must be changed after each use;  Are not substitutes for disinfection, therefore, the area to be protected should be appropriately cleaned and disinfected before placing the barrier.

There are several barriers utilized in the clinic:

Sleeve Sticky Headrest Overgloves barriers barriers covers

21 Overgloves are  Like other barriers; “single-use”;  Must be used (over patient care gloves / clean bare hands) when accessing ‘community-based’ supplies from the bay end trolleys;  Must be set-up (cuffs crunched up and propped open) for easy donning without contaminating its outside;  Once putting on the set-up pair, a new pair needs to be set-up for the following use;  With patient care gloves on, must be used when handling items not directly involved in the patient care procedure, e.g. chart, adjusting protective masks and eyewear, accessing the computer keyboard and mouse, picking dropped items off of the floor to safely clean and disinfect/dispose of them.

22 UBC Faculty of Dentistry PPE table for Students and Instructors

Procedure Gloves Surgical Eyewear/loupes Surgical cap** Gown* Scrubs masks & Face shields SIM session: working on mannequins (students/instructors)  Level 1   Student to student partner practice (Students)  Level 3     Obtain Blood pressure/pulse/Resp Level 3 (Students)     Patient care session (Students)  Level 3     (Instructors: If they are involved in AGPs) ** Level 3 Patient care session/ Student to      student partner practice (Instructors: If they are NOT involved in AGPs) **

DRAFT Patient care session/ Student to  Level 3    student partner practice

Plaster Lab & Mini-Lab Level 1    Or Lab coat

Aerosols generating procedures (AGP): When splatter and spray are anticipated, using air-water syringes, handpieces (high-speed, low-speed and other rotary handpieces) and/or power instrumentation unit (including ultrasonic/power instruments). Includes: acrylic denture, custom tray adjustments, prophylaxis and invasive oral surgery procedures. Faculty will replace PPE during patient care depending on the interaction and procedure performed. For AGPs when replacing gloves, consider replacing the gown and clean/disinfect your face shield. Donning and doffing during these times to be performed in vacant operatories #4 & #8.

*Gowns – Gowns are to worn as noted above. Students are not to leave the bay with a gown as it is considered contaminated.

** Surgical caps/ bouffant must be worn BEFORE entering the clinics. Disposable surgical caps are available on the cart at the entrance. The whole hair must be covered by the caps. Students should avoid touching their hair as soon as they are in the clinics. They need to adjust their hair or change caps outside the clinic at any time if required.

23 FOD February 2021 PREPARATION FOR PATIENT CARE

Asepsis and Set-up Procedures Attire and presentation (before entering the clinic area): Hair, including bangs, back covered with a surgical cap; NO hand/wrist jewelry, dangling earrings, exposed neck pendant, religious bracelets covered during clinical procedures. Nails – trimmed; no artificial nails or nail polish. Personal mask. White solid runners and hose/white Stage 1 Stage socks extended mid-calf. No tattoos are visible. Beards/mustaches well-groomed. No bag pack

Etc. SECTION 1: Cleaning and Disinfecting the operatory Arrive at the clinic with the following items: • Clean clinician’s protective eyewear or surgical telescopes (when purchased, could be worn around one’s neck or brought in its box). • Patient protective eyewear • Face shield • Metal bib chain • Simulation toolbox (for Restorative only): For Resto 1 simulation, you will be bringing the plastic instrument tray from your locker. It will be labelled “SIM” and is never to be used for working on people. - On the way to the assigned operatory, pick up a plastic instrument tray from the instrument cart located against the clinic wall. In the operatory, place the plastic instrument tray, with the patient’s protective eyewear and metal bib chain onto the Assistant’s table. - The toolbox needs to be placed on a disposable barrier (bib) - The clinician’s protective eyewear (and its box) and Face shield are placed on top of the

Stage 2 Stage cubicle partition. - Hang lab coat and your personal mask on the designated hook on the operatory partition by the foot of the patient’s chair or uner the counter Perform hand washing as per proper technique: a) Wet hands and dispense soap b) Scrub hands with soap for at least 20 seconds away from water c) rinse and dry well Don Personal Protective Equipment (PPE) – in the correct order: 1. UBC Level 1 or Level 3 Mask 2. Clinician’s protective eyewear/surgical telescopes and face shield 3. Perform hand hygiene (washing or sanitizing) 4. Don patient care gloves to clean the operatory Don Overgloves (overtop patient care gloves). Inspect your operatory to determine if clean-up is required. If so, • Clean off everything from the partition that you do not need. • Check the remainder of the partition wall top, working surfaces and floor. Stage 3 Stage • Remove clutter or debris on working surfaces, floor, and partition wall tops Place rheostat on the floor and discard paper towel that was underneath

24 Turn on operatory Remove overgloves appropriately and discard

With patient care gloves still on (FLUSHING MUST BE DONE AT THIS STAGE): FLUSH all appropriate hoses (the light cure hose is not flushed) in the prescribed manner: • Press and hold the water spray key for 3 seconds until ‘the long beep’ is heard, this flushes the lines for 120 seconds

• When flushing is complete, return hoses to their appropriate positions and wipe the end of each triplex syringe hose using an OPTIM wipe then attach the triplex syringe handles (operator’s and assistant’s) to be cleaned and disinfected later • Discard wipe Flushing the suction lines;

Stage 4 – FlushStage • With a new disinfectant wipe, wipe the 500 mL cup present in the cabinet under the sink. • Fill the designated cup with water • Alternate suctioning the water with the low-volume and the high-volume suction making sure to incorporate air in the process to ensure biofilm disruption. • Refill the cup and repeat once • Wipe the cup and return in the cabinet When CLEANING and DISINFECTING; • Remember to change the wipe whenever you feel it is getting dry. • Do not touch wiped surfaces with your scrubs, hair, or skin as this will contaminate them.

With patient care gloves still on: Wipe to Clean all clinical contact surfaces and one housekeeping surface (backsplash) using OPTIM wipes. With a new wipe : 1. Backsplash All of the backsplash, including mirror and its frame, metal dispensers of paper cups, paper towels, gloves, masks, overgloves, and hand sanitizer, as well as chart holder)

With a new wipe: 2. Countertop  a. Inner strip against the backsplash, and its facing b. The entire countertop surface and all items on top  kidney dish, soap dispenser, sink rim, faucet, OPTIM container, mouse and its cord, signature pad and cord, swiping machine

Stage 5 – CleanStage and its cord, countertop facing edge. c. All items underneath the countertop: cabinet side, doors, and handles, keyboard and keyboard tray (top, facing edge, and underneath for both). With a new wipe: 3. Operator’s chair ALL surfaces of seat, back support, white connector between back and seat and adjustment handles.

With a new wipe: 4. Items on top of the assistant’s table (kidney shaped) (Dirty): a) patient glasses b) metal bib chain (all surfaces)

25 c) the plastic instrument tray (all surfaces and all nooks/crannies) Place each cleaned item onto cleaned counter after thorough wiping (“clean on clean”)

5. Assistant’s table  top, edges, and underneath the table top

With a new wipe: 6. Assistant bar  All surfaces of bar; its supporting arm up to the second joint, holders (removable support of triplex syringe: remove and wipe), the high volume suction, low volume suction, triplex syringe, as well as an arm’s length of their hoses

With a new wipe: 7. Hose flushing receptacle top and 2 sides closest to the patient (down to patient seat level) plus hoses With a new wipe: 8. Vertical Pole & Attachments  Patient’s side computer monitor handle and its supporting arm; overhead light, light handle and full extent of light arm; full extent of the delivery unit arm; the vertical pole attaching all arms. Push the overhead light away from the patient chair.

With a new wipe: 9. Delivery unit All surfaces of control panel, instrument bracket table (remove, wipe both sides & all edges), Right and Left bracket table holder and arm, full length of all hoses, all surfaces of the struts, top side of rubber mat, and plastic surface underneath rubber mat. Push the delivery unit away from the patient chair.

10. Patient chair  All surfaces of head rest and chair arms, white metal back support and top and side surfaces of the full extent of the seat cushion.

With patient care gloves still on: Wipe to DISINFECT all clinical contact surfaces (as previously detailed):

With a new wipe: 1. The Assistant’s table top, edges, and underneath

2. From the top of the countertop: a) Patient glasses b) Metal bib chain (all surfaces)

Stage 6 - Disinfect 6 - Stage c) Plastic instrument tray, Place each disinfected item onto disinfected assistant’s table (“disinfected on disinfected”)

26 With a new wipe: 3. Countertop  a. Inner strip against the backsplash, and its facing b. The entire countertop surface and all items on top  kidney dish, soap dispenser, sink rim, faucet, OPTIM container, mouse and its cord, signature pad and cord, swiping machine and its cord, countertop facing edge c. All items underneath the countertop: cabinet doors, and handles, keyboard and keyboard tray (top, facing edge, and underneath for both).

With a new wipe: 4. Operator’s chair; All surfaces of seat, back support, white connector between back and seat and adjustment handles With a new wipe: 5. Assistant bar  All surfaces of bar; its supporting arm up to the second joint, holders (removable support of triplex syringe: remove and wipe), the high volume suction, low volume suction, triplex syringe, as well as an arm’s length of their hoses

With a new wipe: 6. Hose flushing receptacle top and 2 sides closest to the patient (down to patient seat level), plus hoses With a new wipe: 7. Vertical Pole & Attachments  Patient’s side computer monitor handle and its supporting arm; overhead light, light handle, and full extent of light arm; full extent of the delivery unit arm; the vertical pole attaching all arms. Make sure overhead light is pushed away from patient chair.

With a new wipe: 8. Delivery unit  All surfaces of the struts, full length of all hoses, Right and Left bracket table holders, and arm, instrument bracket table (wipe both sides & all edges), all surfaces of control panel, top side of rubber mat, and plastic surface underneath rubber mat. Make sure delivery unit is pushed away from patient chair. With a new wipe: 9. Patient chair  All surfaces of head rest and chair arms, white metal back support and top and side surfaces of the full extent of the seat cushion.

27 SECTION 2: Retrieval of Supplies from Bay End Trolley

1) REMOVE ALL GLOVES 2) Perform hand hygiene (wash /sanitize) 3) With cleaned bare hands: From the instrument cart located against the clinic wall pick up Exam pack and Instrument cassette and carefully place them on top of the cubicle partition.

a) Unpackaging cassette: • OPEN carefully the sterilization bag which contains the instrument cassette (peel like a banana) • EMPTY the cassette from the sterilization bag onto the disinfected counter without touching the cassette and ensuring the “contaminated” sterilization bag does not touch Stage 7 Stage the disinfected countertop. • DISCARD the sterilization bag.

b) OPEN package of barriers: • TOUCH only outer plastic bag of exam pack • EMPTY contents onto disinfected counter without touching counter with plastic bag. • DISCARD outer plastic bag and piece of paper from inside.

4) Move to barrier application

SECTION 3: BARRIER PLACEMENT & TRAY SET UP 1) Perform hand hygiene (wash/sanitize) 2) Don new Patient care gloves 3) Attach Operator’s Triplex syringe tip (from exam pack) 4) Barrier Placement: a) Headrest cover • Place headrest cover on head rest of patient chair b) 3 Bibs: • Place 1 bib on Assistant’s table under the plastic instrument tray • Place the 2nd bib (‘overglove’ bib) next to computer • The 3rd bib is the patient’s bib and can remain on the counter Stage 8 Stage c) Overgloves • Set-up 1 pair of overgloves on top of disinfected countertop – have them open and ready to slip on

d) 7 Sleeve barriers: Place 1 sleeve barrier extended fully on each of the following, sleeve barriers have a small slit at their end to allow the passage of various tips (e.g. saliva ejector and triplex syringe tip): • Overhead light handle (making sure to cover the ON/OFF button on the handle)

28 • Right operator’s chair handle • Left operator’s chair handle • Operator’s triplex syringe • Assistant’s triplex syringe • High volume suction • Low volume suction (saliva ejector)* (place this last sleeve barrier on top of the kidney table and place it on the saliva ejector after you attach saliva ejector tip)

RULE: To obtain sundries from the bay end trolleys students must always wear overgloves (NOTE: overgloves are worn either overtop of cleaned bare hands or patient care gloves. At this stage, you still have your patient care gloves on from putting on the barriers.) Don overgloves overtop of patient care gloves. WITH OVERGLOVES ON: 5) Obtain from the bay end trolley: • 1 sticky barrier • 1 saliva ejector tip (utilizing the cotton pliers in the drawer)

a) Apply sticky barrier on disinfected control panel b) Remove overgloves c) Attach saliva ejector tip to the saliva ejector hose (*place the barrier at this stage) d) Set up a new pair of overgloves on the designated bib (#2)

6) Tray set up: • Doff patient care gloves • Hand hygiene • Don a new pair of patient care gloves • Transfer Instruments from the cassette to the plastic instrument tray on the disinfected counter.

SECTION 4a: To meet and greet the patient Remove PPE in the correct order: • Gloves • Hand hygiene • Face shield & Protective eyewear /surgical telescopes (leave them on the top of pices of paper towel on the counter) Stage 9 Stage Perform hand hygiene  WASH hands.

Don white lab coat

29 DURING PATIENT CARE Escort patient from reception area to cubicle Seat patient Remove white lab coat and hang on hook underneath counter Sanitize hands With clean bare hands, place the patient’s bib and offer safety glasses Don Personal Protective Equipment (PPE) – in correct order: 1. Hand hygiene 2. MASK AND SURGICAL CAP SHOULD STILL BE ON 3. Protective eyewear & face shield; 4. Perform Hand Hygiene (as described above); 5. Don patient care gloves ** Use overgloves if you need to adjust • Mask, • Surgical caps • Face shield • Loupes/eyewear When donning the set-up overgloves, you need to set up a new pair on the designated bib (#2), make sure to prop it open to facilitate putting it on without contaminating its outside

For computer access during patient care There are 2 options

Don Overgloves over patient care Remove patient care gloves gloves being careful not to OR Hand wash / sanitize contaminate the outside of Use computer with clean bare overgloves hands

At the end of the appointment: Remove PPE in correct order: • Gloves • Hand hygiene • Face shield and Protective eyewear /surgical telescopes and place on a paper towel Perform hand hygiene  WASH hands.

30 RETURNING CONTAMINATED INSTRUMENTS TO CSD CUBBY

Don PPE Dismantle local anesthetic syringes (use sharps container for used needles and carpules) Return instruments into cassettes making sure to remove any materials or debris on any of the instruments. With a disinfectant wipe Clean the assistant table Put instruments tray, cassettes, sundries and materials* on the assistant table Don overgloves Take the assistant table to the return dispensary window Return the assistant table to the cubicle Doff and discard all gloves Hand sanitize

*Common sundries and materials that are shared in the clinic e.g. acid etchant, retraction cord, IRM, alginate, kromopan…. etc, these containers need to be disinfected before returning them for further use by someone else. Amalgam capsules should be disposed of appropriately and any scrap amalgam needs to be picked up by the appropriate mercon wipe not the disinfecting wipe.

31 ‘END-OF-SESSION’ OPERATORY ASEPSIS PROCEDURE Tear Down Procedures SECTION 1: Operatory clean-up After dismissing your patient, return to clean and disinfect the operatory Because your protective eyewear / surgical telescopes and face shields have been soiled during your clinical exercise, you will need to clean and disinfect it before donning it again Don PPE (as described above) 1. MASK AND SURGICAL CAP SHOULD STILL BE ON 2. Perform Hand Hygiene 3. Patient care gloves Clean protective eyewear/surgical telescopes with disinfectant wipes: Prepare a clean paper towel on the paper towel dispenser. Using OPTIM wipe, thoroughly wipe eyewear and place it on paper towel, after 3 mins wipe eyewear again and place on a new clean paper towel for another 3 mins. Once dry, don eyewear with clean bare hands or overgloves on top of patient care gloves. OR

Stage 1 Stage Wash thoroughly with soap and water, dry thoroughly. Don eyewear when dry with clean bare hands or with overgloves on top of patient care gloves. 4. Clean face shield with disinfectant wipes: Discard overgloves, OR don new patient care gloves. Prepare a new, clean paper towel on the paper towel dispenser. Using OPTIM wipe thoroughly wipe the interior followed by the exterior of the facial protection as well as headband and strap and place it on paper towel. Ensure all surfaces remain wet with disinfectant for at least 3 minute. After 3 mins wipe again and place on a new clean paper towel for another 3 mins. Face shield may be rinsed with tap water if visibility is compromised by residual disinfectant. Allow to dry (air dry or use clean absorbent towel). Don face shield with clean bare hands or overgloves on top of patient care gloves PS: you cannot continue with the tear down procedures without the protective eyewear & face shield on. With patient care gloves on: Pack all instruments back in the instrument cassette. Don Overgloves (overtop patient care gloves). Return the exam cassette and instrument plastic tray to the return trolley In the operatory,

Stage 2 Stage • Remove and discard triplex syringe tip, saliva ejector, and all barriers. • Remove and discard clutter or debris on working surfaces, floor, and partition walls. • Place the bib chain and patient protective glasses on the assistant table. Discard all gloves Perform hand hygiene Don new patient care gloves Flush in the prescribed manner all appropriate hoses (the light cure hose is not flushed) Stage 3 Stage • for 90 seconds in between patients (press flush key for until ‘one beep’ is heard) or

32 • for 120 seconds at the end of the clinical session (press flush key for 3 seconds until a long beep is heard). Flush suction lines

SECTION 2: Cleaning the operatory

With patient care gloves still on: CLEAN – all clinical contact surfaces and some housekeeping surface (backsplash) using OPTIM wipes. With a new wipe: 1. The top of the Cubicle Partition 2. Backsplash All of the backsplash, including mirror and its frame, metal dispensers of paper cups, paper towels, gloves, masks, overgloves, and hand sanitizer, as well as chart holder) With a new wipe: 3. Countertop  a. Inner strip against the backsplash, and its facing b. The entire countertop surface and all items on top  kidney dish, soap dispenser, sink rim, faucet, OPTIM container, mouse and its cord, signature pad and cord, swiping machine and its cord, countertop facing edge. c. All items underneath the countertop: cabinet side, doors, and handles, keyboard and keyboard tray (top, facing edge, and underneath for both).

With a new wipe: 4. Operator’s chair ALL surfaces of seat, back support, white connector between back and seat, and adjustment handles. With a new wipe: 5. Items on top of the assistant’s table (kidney shaped): a) patient glasses b) metal bib chain (all surfaces) Place each cleaned item onto cleaned counter after thorough wiping (“clean on clean”) 6. The Assistant’s table itself top, edges, and underneath 7. Assistant bar  all surfaces of bar; its supporting arm up to the second joint, holders (and removable support for the triplex syringe), the high volume suction, saliva ejector, triplex syringe, as well as an arm’s length of their hoses With a new wipe: 8. Hose flushing receptacle top and the 2 sides closest to the patient (down to patient seat level) plus hoses With a new wipe: 9. Vertical Pole & Attachments  Patient’s side computer monitor handle and supporting arm; overhead light, light handle and full extent of light arm; full extent of the delivery unit arm; the vertical pole attaching all arms

33 With a new wipe: 10. Delivery unit All surfaces of control panel, instrument bracket table (remove, wipe both sides & all edges), Right and Left bracket table holder and arm, full length of all hoses, all surfaces of the struts, top side of rubber mat, and plastic surface underneath rubber mat With a new wipe: 11. Patient chair All surfaces of head rest and chair arms, white metal back support and top and side surfaces of the full extent of the seat cushion

Clean floor rheostat (with an OPTIM wipe) and place on paper towel on top of flushing unit. Ensure rheostat cord is not tangled. Inspect operatory for tidiness. Stage 7 Stage Turn off the Unit at the end of the day Remove PPE - in correct order: 1. Gloves 2. Hand hygiene 3. Shield and Eyewear

Stage 8 Stage 4. Surgical Cap 5. Mask

Perform hand washing Don lab coat and personal mask to leave the clinic

34 BEFORE COMMENCING TREATMENT

Escort patient from reception area to cubicle Seat patient A thorough medical history must be reviewed and should include questions about:  New cough or shortness of breath  New fever or chills in the last 24 hours  New onset diarrhea  New undiagnosed rash, lesion, or break in skin  Recent exposure to communicable infectious disease (e.g. measles, chicken pox, or tuberculosis)  History of cardiac surgery or joint prostheses procedures in the past two years  History of antimicrobial therapy  Recent travel to areas where endemic diseases are present  Immunization history  Patients with Latent Tuberculosis (CDC, 2011) Patients who present with a history of Latent Tuberculosis:  Have TB bacteria in their body that are alive, but inactive  Cannot spread TB bacteria to others  Do not feel sick and do not have any symptoms  Have a positive reaction to a tuberculin skin test or blood test  Have a normal chest x-ray and negative sputum test  May develop TB in the future Such individuals require medical evaluation  Patients with Methicillin-Resistant Staphylococcus aureus (MRSA) (Public Health Agency of Canada, 2008) Staphylococcus aureus is bacteria that are commonly present on the skin and in the nose of healthy people. Staph bacteria that are resistant to the antibiotic methicillin are known as MRSA. Read on the disease later on page 50.  Hands are to be washed with soap and water or an alcohol hand sanitizer before and after patient treatment.  All common patient equipment that has direct contact with a patient’s skin (e.g. BP cuff, stethoscope, wheelchair) is to be disinfected after each use.  Environmental cleaning of clinical areas is to be carried out on a regular basis.  Medically compromised patients Students should carry out the following activities for all patients receiving treatment for a significant medical problem:  Identify the problem from the Health Questionnaire.  Review the history of the problem with the patient.  Document the problem in the chart.  Investigate dental implications of the problem.  Communicate with the patient’s physician prior to treatment.

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Failure to comply with the infection control protocol will result in an unsatisfactory clinical and/or professional grade, and/or suspension of clinic privileges.

Three things to always remember  Food and Drinks are strictly prohibited in OHC Clinic  Cell phones are known to be highly contaminated and are not to be left anywhere in the operatory  Overgloves are to be worn on gloves/clean bare hands when accessing the bay end trolleys

36 PROPER DISINFECTION OF IMPRESSIONS, FACEBOW/OCCLUSAL REGISTRATION, CUSTOM TRAYS, APPLIANCES, PRDPs, CRDPSs, CROWNS &FDPs

ALL IMPRESSIONS MUST BE DISINFECTED before being poured up or sent to the laboratory.

 Thoroughly rinse the impression under running water.  Drain the water out of the impression.  Inspect the impression for visible debris and bioburden, repeat rinse if necessary.  Squirt/wet the impression with the Optim 33 liquid surface disinfectant.  Wait three minutes, then rinse well.

After disinfection, alginate impressions should be wrapped in wet (use water only) paper towel. Place impression securely in zip lock bag (if being poured immediately, wrapped alginate impressions can be transported inside a sealed overglove).

Any RDPs, FDPs, crowns, or appliances leaving the clinic whether to be sent out to a commercial lab for reline or repair, adding porcelain on coping(s)….etc or needing adjustment in the dry lab, same applies for face bow and occlusal registrations before being taken to the wet lab. all need to be disinfected in the same manner:  Rinse.  Disinfect.  Rinse again.

Do not forget to disinfect the rubber mixing bowl and plastic spatula using disinfectant wipes

37 INSTRUMENT REPROCESSING AND STERILIZATION

First, some definitions:

Critical patient care equipment/device: Medical and dental equipment/device, including dental handpiece burs that penetrate normally sterile tissue. Such devices present a high risk of infection if they are contaminated with any microorganisms, including bacterial spores. Reprocessing involves meticulous cleaning followed by complete sterilization and proper storage.

Semi-critical patient care device: Any device that comes in contact with non-intact skin or mucous membranes but does not penetrate them. Reprocessing involves meticulous cleaning and, at a minimum, high- level disinfection. (Sterilization is preferred).

Noncritical device: A device that touches only intact skin (but not mucous membranes) or does not directly touch the patient. Reprocessing involves cleaning and may also require low-level disinfection (e.g. blood pressure cuffs and stethoscopes).

Disinfection: The process of inactivation of disease-producing microorganisms, not including bacterial spores. Items must be cleaned (the physical removal of foreign material) before effective disinfection takes place.

High level disinfection: The level of disinfection required when processing semi-critical devices, which destroys vegetative bacteria, mycobacteria, fungi, viruses (enveloped and non-enveloped). Devices must be thoroughly cleaned by vigorously removing foreign material.

Critical and semi-critical devices labeled as single use; must not be reprocessed and reused, e.g. Endodontic files, scalpel blades.

When reusable patient care items are being reprocessed, the following steps are taken:  Collection at point of use containment and  Transport  Cleaning  Inspection  Disinfection/sterilization  Rinsing (for items that are immersed in disinfectant, wiped items are not rinsed)  Drying/aeration  Clean transportation  Storage

38 Disposable sharps such as needles and blades must be removed and disposed of in an appropriate sharps container at the point of use, before transportation to the return side of the instrument reprocessing area.

At the return side of the instrument reprocessing area, Instruments are  Collected, disassembled as necessary, and sorted  Hand or mechanically cleaned (washer/disinfector)  Rinsed, dried, and inspected  Wrapped or packaged in an appropriate material before sterilization.

Steam sterilization OHC’s steam sterilization processes are monitored in several ways:  Biologic spore tests are conducted daily  Every sterilization cycle contains a “Class V” chemical indicator in a challenge pack  Chemical indicators (in the form of tape, strips, tabs, and special markings on packaging material) indicate exposure to heat. Heat-sensitive chemical indicators that change color after exposure to heat do not guarantee sterilization but should be placed inside each pack, and on the outside of each pack when the internal indicator is not visible from the outside, to identify packs that have been processed through the heating cycle. Chemical indicators also should be placed in the center of a load of unwrapped instruments.  Every wrapped or packaged device has a Class I chemical indicator externally in the form of an autoclave tape and a Class I internal chemical indicator strip

 When opening an instrument pack, ensure the chemical indicator is appropriately challenged.  If not, return it and report it IMMEDIATELY to the dispensary staff.

Flash Sterilization  May be used in an emergency where the reprocessed item is to be used immediately.  Short cycles for unwrapped instruments. Only in case of emergency.

Boiling, ultraviolet radiation, glass beads, and microwave ovens are inappropriate for sterilization.

39 AIR TURBINE AND HANDPIECES

Maintenance of air turbines and dental handpieces requires special attention. All rotating instruments are very delicate and complicated devices. Clinically, cleaning, lubrication, and sterilization have been demonstrated to be the most critical factors in determining performance and durability. Manufacturer's instructions for cleaning, lubrication, and sterilization should be followed closely to ensure both the effectiveness of the process and the longevity of handpieces.

Over time, the internal channels of turbines and handpieces will become coated with biofilm, consisting of organic material and different types of microorganisms. The biofilm will also harbour particles that have been retracted into the internal parts of the instruments from the oral cavity. If flushing, lubrication, and sterilization are not carried out regularly between every patient when the rotary handpiece has been used, it becomes a source of cross-contamination and the deposits accumulated inside it will have a devastating effect on the function of all internal moving parts.

There are devices available to specifically flush and lubricate handpieces before their sterilization.

40 INFECTION CONTROL FOR DIGITAL RADIOLOGY

Tips: Overgloves are “single-use” only. To obtain materials from drawers; overgloves and cotton pliers must be used. Do not touch the door! Close door with the foot, open door with barriered handle.

1. PPE for RAD ROOM  Doff patient care gown in the operatory,  Discard it,  Go to the rad room and Set-up rad room,  Escort patient to rad room,  Don a clean gown and patient care gloves,  Take the radiographs  Doff patient care gloves and gown,  Escort patient back to the operatory,  Return to the rad room  Tear down rad room,  Go to the scanner room,  Return to the operatory  Don a new gown and patient care gloves, and  Resume patient care

2. RAD ROOM PREPARATION

With bare hands: Turn radiographic unit “on”  Turn “on” computer - Log onto Romexis - select patient file - choose icon and template of radiographs to be used  Don mask, and a protective eyewear  Wash and dry hands  Don gloves to disinfect room (not to be used intraorally)  Clean and disinfect rad room with disinfecting wipes: choose a starting point (always from the outside in) - X-ray control panel outside by the door - Door; rim, handles and outside shelf - Lead apron (both surfaces) - Inside shelf - Keyboard, mouse and underlying shelf

41

- Entire arm and tube head - Patient’s chair - The portable trolley  Doff gloves used in disinfection  Hand hygiene (wash / sanitize)  Don patient care gloves or overgloves on clean bare hands  Obtain barriers - Sleeve barriers for . door handles (inside and outside) - Sticky barriers for . control panel . edge of shelf (rolled with sticky surface out to attach overgloves) - Sticky barrier on mouse - Large bag for keyboard and mouse - A bib for the patient and a disposable bib chain - A pair of overgloves (propped open and “stuck” to edge of shelf)  Obtain strip of bitewing tabs and place strip on shelf  Apply other barriers (paper towel for inside/outside shelf)

3. EQUIPMENT

Remove gloves, leaving eyewear and mask on. Hand wash/sanitize, With overgloves on clean bare hands obtain equipment (sensors and holders, cotton rolls package) from dispensary.

a. For bagged supplies  i.e. RINN holders and cotton rolls  Place bags behind sink faucet  Empty bag contents onto disinfected operatory shelf  (being careful not to touch and contaminate its contents)  dispose of sterilization bags b. For PSPs  Place PSPs on paper towel on the outside shelf  Place cup in cup holder c. For CCDs  Place CCD case on the door side of operatory shelf  Open CCD case and put lid underneath  Being careful not to touch (contaminate) its contents  Make sure cassette contains protective CCD/CMOC sleeve

Doff overgloves Hand sanitize

42 4. EXPOSURE OF RADIOGRAPHS  Escort patient to rad room  Seat patient  Place lead apron (with clean, bare hands)  Place a new patient bib using the disposable bib chain (available in trolley in Rad room)  Wash and dry your hands  Hand hygiene  Don gloves  Select and assemble RINN holder and sensor  On outside shelf, arrange PSPs in the order of template used as a guideline  Select exposure setting on control panel  Position sensor in patient’s mouth  Press exposure key until 2 beeps are heard  View radiograph on screen (CCD)  Select next exposure setting

When changing from size 1 CCD sensor to size 2 CCD sensor: Don OVERGLOVES Unplug the sensor, The sensor’s computer connector side of sensor must be treated as contaminated at all times

 Place CCD in its case making sure the connector remains outside the case  Discard overgloves  If changing to PSPs; leave CCD inside rad room  Select PSP and holder  Press “MODE” button 2 seconds while it changes from d. (CCD) to P. (PSP) If “MODE” changes to “O” (film) press again for 2 seconds  Select exposure setting on control panel  Place PSP intraorally  Leave room and close door  Press exposure key until 2 beeps are heard  Place exposed PSP in the paper cup outside  Continue as necessary  Upon completion, remove gloves, eyewear, mask and wash hands  Bring patient chair down  Dipose of patient bib  Remove lead apron  Doff PPE and leave the mask on  Escort patient to operatory

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5. ROOM CLEAN UP  Clean eyewear and wear it  Hand wash / sanitize  Don gloves  Obtain basket from drawer  Place any unused PSPs in clean cup, place cup in basket – return to allocated containers on the dispensary return window counter  Place all used RINN holders and CCDs (in its case) in basket (make sure not to contaminate the outside of the basket)  Remove all barriers  Clean and Disinfect rad room with disinfecting wipes in same order as set up  Remove gloves, eyewear and mask and wash / sanitize hands  Take exposed PSPs in the cup outside to scanner room  Return CCDs to “Returns/CDSR” dispensary and put basket in your “return” cubby

ROOM NEEDS TO BE LEFT CLEAN, TIDY AND DISINFECTED. Patient’s chair down / tube arm against wall.

6. SCANNER ROOM FOR PSPs  With bare hands take PSPs to scanner room  Upon entering the scanner room:  Don mask, eyewear (the posted video does not demonstrate eyewear, which is part of proper PPE)  Sanitize hands  Don gloves  Clean counter, scanning machine, keyboard and mouse using disinfectant wipes  Doff gloves and sanitize hands  Obtain 3 paper towels and a new paper cup  Place the new paper cup beside the scanner and line up the 3 paper towels across the counter in front of the scanner.  Empty the PSP’s onto the first paper towel  Discard the ‘contaminated’ paper cup  Switch computer and scanner “on” - Turn “off” the lights - Log onto Romexis - Open Romexis patient’s chart - Choose template to import images if applicable - Select adequate PSP guide (sizes 0,1,2) (no guide for size 4 occlusals)  Don gloves  Take out one disinfecting wipe  Remove bitewing tabs if used  One by one, wipe each PSP barrier and place on second paper towel

44  Then again- one by one, open barrier envelope (without touching plates) and place on third paper towel (sensitive side facing down is preferred - BUT do NOT touch if they fall with sensitive side up as this would ‘contaminate’ the sensor)  After all barrier envelopes are removed, discard all used envelopes  Discard the first and second paper towels  Doff and discard gloves  Sanitize hands  With bare hands place PSP into scanner slots  Import images and allocate relevant teeth for every image  Place scanned plates into the new clean paper cup  If you come across a scratched or damaged PSP plate, ensure to place a red dot sticker so that it would be taken out of circulation  Sanitize hands  Leave the scanner room clean and tidy  Doff eyewear  Make sure to hand sanitize before leaving the scanner room  Immediately, take PSP sensors to “Return” dispensary to be properly disinfected, erased and re-barriered (to facilitate the ‘turn-around’ of the PSP’s, ensuring that there will be no shortage of PSP’s available for subsequent clinical sessions).

45 ORAL SURGERY AND SPECIAL CONSIDERATIONS IN INFECTION CONTROL

ORAL SURGERY:

As oral surgery involves the incision, excision or reflection of normally sterile body tissue, exposing it to an oral environment colonized with numerous microorganisms, an increased potential exists for local or systemic infection. To reduce the risk of such infections, special additional steps for infection control are undertaken in the clinic.

Environmental and engineering controls: Currently, the operatories that are designated for oral surgery use have a separate vacuum suction apparatus to reduce the chances of cross contamination.

Personal Protective Equipment PPE: Students must wear the appropriate personal protective equipment, in addition to mask, protective eyewear and gloves, a long sleeved gown, disposable cap and a disposable face shield (which covers the mask) should be used.

Surgical hand asepsis: The purpose of surgical hand asepsis is to reduce, with persistent effect, transient and resident hand microflora thus preventing contamination of the surgical site in case surgical gloves get punctured or torn. We are presently using Manorapid, an alcohol based surgical antimicrobial alcohol rub. When performing surgical hand asepsis the protocol is to  First handwash with soap and water  Use Manorapid according to the manufacturer’s instructions (90 seconds) for a surgical hand disinfection.  Don sterile surgical gloves.

Barriers and surgical drapes: The certified dental assistant (CDA) assigned to oral surgery will open the surgical tray which contains the sterilized drape, patient bib, the foil which is to be placed on the light and bracket table handles. The CDA will also attach the sterilized surgical handpiece to its connection and place it on top of the sterilized drape on the bracket arm.

Irrigation of surgical sites: Sterile saline only is used for the irrigation of surgical sites. The method of delivery can be through the electric handpiece via sterile disposable tubing or by drawing up the saline with a sterile disposable syringe.

46 Return and reprocessing of clinical use items:

At the conclusion of a patient treatment session, all reusable instruments, items and trays are returned to the dispensary for reprocessing, which includes disinfection and/or sterilization.

Students are responsible for removing gross debris and paper products at chair-side prior to returning the instruments on trays to their ‘return cubbies’, or in the case of larger items, to the return side of the dispensary. The trained dispensary staff then inspects the items, removes any remaining debris, and where appropriate places the instruments through the thermal washer/disinfector. These instruments and then placed in instrument cassettes and are autoclaved. Some critical care instruments that cannot be autoclaved are placed in a dry heat sterilizer for the appropriate length of time.

Handpieces that are returned are first cleaned and surface disinfected, then placed in an automated handpiece cleaner/lubricator. Following that, the handpieces are placed in cassettes and autoclaved.

CPR/AED Certification:

Students are required to receive CPR Level C certification with training for AED yearly during their course of study at the faculty. Students Services verifies the certification for all students.

Clinical faculty and staff are required to be re-certified for CPR Level C with training for AED. Copies of the re-certification are collected by the departmental assistant annually. Re-certification courses are provided at the Faculty to facilitate the process.

47 DENTAL UNIT WATERLINES

The US EPA’s standard (upper limit) for the presence of heterotrophic bacteria in drinking water is 500 colony forming units (CFU’s) per milliliter. Studies have shown that waterlines within the dental unit can become colonized with microorganisms, mostly common heterotrophic water bacteria. Although research has not demonstrated a measurable risk of adverse health effects among dental healthcare workers or patients from exposure to water from dental units, every effort should be made to ensure that dental unit water at least meets the drinking water standard of 500 cfu’s/ ml.9

In the Nobel Biocare Oral Healthcare Clinic, water that enters the dental units is first filtered and then treated by reverse osmosis and ultra violet disinfection. Dental unit waterlines are flushed for 2 minutes at the beginning and end of the clinical day, and for 90 seconds before and after every patient. Further, our staff treats the waterlines with the water line disinfectant recommended by the dental unit manufacturer every two weeks. Dental unit water is cultured for heterotrophic bacteria four times a year.

Suction lines are flushed before and after patient care with plain water making sure to incorporate air during flushing to disrupt the biofilm. Further, our staff treats the waterlines with the suction line disinfectant recommended by the dental unit manufacturer every two weeks.

48 WASTE MANAGEMENT

Biomedical wastes

The biomedical waste bin is located by the Return Window at the CSD. There is a label on its lid indicating its content. All biomedical waste should be double-bagged and disposed in red plastic bags bearing the biohazard symbol, and the bag should be checked and changed at least twice a week. Once the bag is ¾ full, it is affixed with an Environmental Services Facility Waste Generator tag. This tag should contain a bar code indicating where to place the department bar code sticker on the tag and check off the box for anatomical human. In case of any question, contact the Environmental Programs Officer (604-822-9280)

Sharps and Needles

All sharps and needles must be disposed in the proper container located in each cubicle under the sink. A staff member checks the containers for replacement periodically. Once container is full, it is taken to the CSD. The container is affixed with an Environmental Services Facility Waste Generator tag. A department bar code sticker is attached to the tag and the box for sharps is checked off. In case of any question, contact the Environmental Programs Officer (604- 822-9280).

Amalgam

Students are responsible for disposing of all spent amalgam capsules and scrap amalgam in appropriate marked containers. A Merconvap wipe should be used on the amalgam well, amalgam carrier, condensers, carvers, burnishers, tray and mobile top. Merconvap wipe can be disposed of in the garbage as long as there are no visible traces of mercury on it. Our central suction unit has an amalgam separator which precludes the possibility of amalgam waste entering the municipal sewer system.

49 Mercury

The only mercury-containing devices in the Clinic are the amalgam capsules. In the unlikely case of mercury spill, contact the CSD Supervisor. A spill cart is located in the CSD, and the directions of how to contain the spill are in the red book in the top drawer of the cart. In case of any question, contact the Environmental Programs Officer (604-822-9280).

Battery

All work-related batteries must be collected and disposed in labeled containers in Stores. When necessary, contact Environmental Safety Facility (ESF) to collect used batteries for safe disposal (604-822-6306).

Butane Canisters and Endo Ice Canisters

All empty pressurized butane canisters and Endo Ice canisters must be collected and placed in a box in the CSD. The box must be labeled “empty butane canisters and empty pressurized canisters” and ESF should be contacted for pick up (604-822-6306).

Gypsum

All gypsum waste (old models, left-over of mixed plaster) must be disposed in the labeled containers placed in the Plaster Room. The waste is labeled and collected by UBC Waste Management (604-822-9619)

50 A GUIDE FOR CRITICAL EXPOSURE TO BLOODBORNE PATHOGENS Prepared with information from Student Health Services, UBC.

A critical exposure should be recognized as any event where blood or body fluid contacts non- intact skin, mucous membranes, eyes or tissue via percutaneous injury i.e. needlestick. A critical exposure can expose you to a risk of blood borne pathogens such as Hepatitis B, Hepatitis C and HIV.

THE MOST EFFECTIVE WAY TO PREVENT A CRITICAL EXPOSURE IS TO CONSISTENTLY PRACTISE STANDARD PRECAUTIONS AND USE THE “SCOOP AND LIFT” METHOD (SEE INTRANET VIDEO) https://secure.dentistry.ubc.ca/intranet/infectioncontrol/video/ScoopAndLift_ref.mov

OR USE A NEEDLE CAP HOLDER (BELOW)

There is a needle cap holder in every instrument cassette.

If you experience an exposure to blood or body fluid, treat it as an infectious exposure. Do not deny it or assume that it isn’t infectious. Follow the following protocol:

1. Stop the clinical procedure. 2. Politely excuse yourself from the patient. 3. Apply routine first aid procedures: a. If you have a needle-stick or other sharps injury, allow it to bleed freely. If it is not bleeding, DO NOT squeeze it (that would create negative pressure sucking possible pathogens on the skin surface into the tissues upon release). Wash wounds thoroughly with soap and warm water. Use antiseptic soap if available and bandage all wounds appropriately.

51 b. In the event of a splash to the eye or mucous membranes flush the area continuously for ten minutes using a normal saline solution. There are 7 eyewash stations located throughout the OHC clinic:  2 in Dispensary  1 in each dry lab  1 outside each dry lab  1 on the eastside of clinic by the enclosed Ops  1 in wet lab in JBM

4. Notify your supervisor / Faculty member, to assist you with the clinical procedure completion and /or with presenting the situation to the patient. 5. There is a requirement to document incidents of accidental exposure. All the documents are available at dispensary. You can take them along and fill them while you are at the hospital. 6. It is appropriate to get as much information as possible about the source’s (patient) risk for blood borne disease. Either you or your supervising clinical instructor may undertake this process, by explaining to the patient what just happened and politely request the patient to join you in getting screened for blood borne disease and consent to you knowing the results. However, this is completely on voluntary basis, i.e. the individual may refuse to provide their history or to be tested or the release of the results and if that is the case, they are under no legal obligation to do so. 7. Go immediately to the nearest Emergency Department. For us at the OHC, go the UBC Hospital just east of our building. You will be counseled, have the appropriate screening blood tests ordered, and, on consultation with you, may be prescribed medication to diminish your risk of disease transmission (if so, these should be commenced within 72 hours of your exposure). 8. The source patient may choose to go with you and this response should be encouraged. This will facilitate the results being available earlier. 9. When the patient has all of their questions answered, they usually are very cooperative with this process. Please be sensitive to their concerns and take the time to thoroughly answer their questions.

Alternatively, the source (patient) may choose to consult directly with his or her own personal Physician. It is their choice. They should be advised to have their Physician order screening tests for Hepatitis B, Hepatitis C and HIV.

Keep your immunizations card in your wallet at all times so you are aware of your immunization history. You will readily be able to provide this information to the treating Physician. The Emergency Physician will order the appropriate screening tests based on your history of immunizations. They will counsel you about risk.

Results of your screening tests for Hepatitis B, Hepatitis C and HIV will be available to you through Student Health Service. These may be available in 24 hrs. In order to access your results and your source results, there needs to be two pieces of identifying documents for the source so

52 that the information can be released at Student Health Services. You should contact SHS as soon as possible after the exposure to make arrangements for follow up screening. This may be done as early as 6 weeks and later at 3, 6, and 12 months. It is your responsibility to initiate your treatment and follow up at the appropriate intervals.

ALWAYS PRACTISE STANDARD PRECAUTIONS, AND THE SAFE HANDLING OF NEEDLES AND ALL SHARPS.

Be certain you have completed your series of Hepatitis B immunizations. A blood test after your third vaccine for Hepatitis B will ensure you have an adequate antibody level to protect you from Hepatitis B infection. If you have not had this test, please see your health care provider or student health service.

IF YOU EXPERIENCE A CRITICAL EXPOSURE, BE SURE TO RECOGNIZE IT! THEN REPORT IT IMMEDIATELY. DO NOT IGNORE IT OR DELAY TREATMENT. IF YOU DO, YOUR HEALTH MAY BE COMPROMISED.

If you have any difficulty or concerns about how to arrange source testing or you require more information, please contact Student Health Service at (604) 822-7011 and ask to speak to the Nursing staff. We are committed to assisting you in this process.

53 POLICY AND GUIDELINES ON INFECTIOUS DISEASES Developed from the AFCD Guidelines on Infectious Diseases and Health Care Workers 2009 document10

Entry into and working in the healthcare professions, and in particular Dentistry, is a privilege that carries a responsibility to do no harm. As students will more than likely be treating patients with infectious diseases during direct patient care, and especially when performing invasive procedures, patients and dental healthcare workers are placed at an increased risk of transmission of infection from various airborne and blood-borne (e.g. HIV/AIDS, hepatitis B, and C virus) diseases. To mitigate the risks of transmission of an infectious disease, strict infection prevention, and control protocol is implemented and enforced in clinical activities.

All health care workers, including those in dentistry, who perform invasive procedures, have an ethical obligation to know their own infectious disease status and to be medically assessed for risk of transmission of any infection. The Faculty of Dentistry has adopted the “Infected- Affected Registrants” policy of the College of Dental Surgeons of BC (CDSBC) for Faculty and Staff. The policy of the College is that at time of registration, the College requires the applicants to disclose their overall health status. As well, the policy relates to those who acquire bloodborne infection diseases and the mandatory reporting of such conditions. The policy was designed to protect the public while being fair and not unduly restrictive to the individual practitioner involved. As of April 3, 2009, the College of Dental Surgeons of BC became legislated under the Health Professions Act (HPA), and as such, the Faculty will review and update any change to the policy as it becomes available.

Being a carrier of any serious communicable disease may restrict students’ educational opportunity to attain competency for graduation and subsequent practice as a dentist or dental hygienist. While the UBC Faculty of Dentistry does not currently take hepatitis status into account when admitting students, students who are hepatitis B antigen positive may pose a risk of passing infection to others. Counseling is available to individuals who have, or to those who are carriers of communicable diseases.

In order to participate in Dentistry or Dental Hygiene at UBC, certain immunizations are mandatory, and supporting documentation confirming immunizations must be available. You should ensure that you receive yearly immunization against influenza. It is also strongly recommended that all clinical instructors and staff have their immunizations current.

Students are required to report to UBC Student Health for an Immunization Review and TB testing at the beginning of their first year of study. Student Health follows up with UBC Dentistry Student Services for any students who require additional vaccinations during the course of study.

Faculty and Staff members are informed of the need to be immunized in an effort to minimize the risk to patients and themselves. The information is provided at the start of the academic year and available throughout the year.

Also, University full-time employees are eligible to enrol in the Medical Surveillance Program that assesses risks and provides vaccination. The Faculty of Dentistry is one of the units

54 participating in the program. In addition, the Faculty holds Flu Shot Clinics to facilitate immunization.

UBC immunization protocol: TETANUS/DIPHTHERIA AND ADACEL

A primary series of five doses of vaccine in childhood (four if the 4th dose of vaccine is given after the child’s fourth birthday) Boosters should be updated every 10 years. Adacel vaccine (Td & Pertussis combined ) is recommended. A single dose of Tdap is recommended and can be given w/o waiting the usual 10 years between Td boosters.

POLIO VACCINATION

A primary vaccination series (5 doses) of polio with the last dose given at 5 or 6 years of age is sufficient providing there are records. If no records are located a polio booster is required. Please include the vaccination record if booster given.

MEASLES, MUMPS AND RUBELLA

Minimum requirement: 2 MMR vaccinations with documentation or titres to prove immunity. If the individual is not immune to one or more of MMR components, then an MMR booster must be given. Records must be included.

TB SKIN TESTING

A one step TB skin test is required. It must be current to within 6 months of the start date of the program. This should be done irrespective of previous BCG vaccine given. If a previous skin test has been positive and where repeat skin testing has not been recommended a Chest X-ray should be done and a copy of the report of this screening CXR must be included with the immunization documentation. In all cases where skin tests are positive (>10 mm induration), referral to BCCDC is recommended and the report of the BCCDC recommendations is required. Generally please provide as much documentation around the TB history and screening tests done. This greatly assists us in streamlining our process.

VARICELLA ( CHICKENPOX )

A history of Chickenpox disease is required. Where uncertainty exists about disease history or if not know to have had the disease, a VZ IgG test for immunity is recommended. If not immune, adults should receive two doses of vaccine given 4-8 weeks apart.

55 Bloodborne Pathogens

Compared with HCV (Hepatitis C Virus) or HIV (Human Immunodeficiency Virus), transmission of HBV (Hepatitis B Virus) is the greatest hazard in healthcare settings to those who are not immune. The presence of HBeAg indicates a high risk of infectivity. Among HCPs (Health Care Personnel) who sustained injuries from needles contaminated with blood containing HBV, the risk of developing clinical hepatitis if the blood was both HBsAg-positive (Hepatitis B surface antigen) and HBeAg-positive (Hepatitis B core antigen) was 22%-31%. By comparison, the risk of developing clinical hepatitis from a needle contaminated with HBsAg-positive, HBeAg-negative blood was 1%-6%. Estimates of the risk of disease transmission after needlestick injuries contaminated with HCV or HIV are approximately 2% and 0.3% respectively. Healthcare workers, including students who are infected with HCV, HIV, or HBV - with no evidence of HBe antigen or a high viral load (>103 genome equivalents/mL) are considered low risk for transmission.

Applicants to our programs who are HBsAg-positive and HBeAg-positive or who have a viral load greater than 103 genome equivalents/mL should NOT be accepted into clinical programs. Applicants who are HBsAg-positive but HBeAg-negative can be accepted, but should receive counseling before beginning the clinical program. Non-responders (non-immune) to the hepatitis B vaccine should be tested on a regular basis for the presence of HBeAg and viral DNA and be removed from direct patient care activities if found to be positive for HBeAg or if they exceed a viral load greater than 103 genome equivalents/ml. Current recommendations should be followed in the event of exposure to a non-responder.

HEPATITIS B

Immunization of adults is a series of three vaccines.

A Hepatitis B screen for previous disease is mandatory. (Hepatitis B surface antigen and Ab (Antibody) to Hepatitis B core total tests should be ordered). Additionally, Hepatitis B post vaccination Antibody titre test is required Acceptance into a DMD/DHDP or clinical graduate program must be contingent upon completion of appropriate immunization and screening.

HEPATITIS C

Applicants who are carriers of Hepatitis C can be accepted, but should receive counseling before beginning the clinical program

HUMAN IMMUNODEFICIENCY VIRUS (HIV)

Applicants who are HIV positive can be accepted but should be counseled before admission to clinical programs. Students with risk factors for HIV should be counseled to seek HIV testing on a volunteer basis.

56 Communicable Disease Status

Any student or student applicant with an infectious disease has a moral and ethical obligation to inform the appropriate authority in their educational institution to receive appropriate counseling and recommendations. This is consistent with the Canadian Dental Association’s Code of Ethics. In addition, there may be further specific reporting requirements in the various provincial jurisdictions.

HCPs exposed to HIV, HBV or HCV should be advised to follow current recommendations for post-exposure prophylaxis. (see page 36).

IMMUNIZE!!!

57 British Columbia Guidelines for Control of Antibiotic Resistant Organisms (AROs) [Methicillin-Resistant Staphylococcus aureus (MRSA) and Vancomycin-Resistant Enterococci (VRE)]

7.7 Doctors’ Offices/Outpatient Clinics/Dental Offices/Travel Clinics • Handwashing and the consistent use of Routine/Standard Precautions with all patients are considered essential infection prevention practices for all office/clinic settings. • Following the visit of any patient, clean soiled surfaces (e.g. examination tables or chairs with a low-level detergent disinfectant product and the contact surface of any equipment used on the patient (e.g. Stethoscopes). • The following detergent disinfectants are suggested for use in the daily cleaning and disinfection of office surfaces/equipment; phenolic, iodophor, quaternary ammonium compound or a 10% fresh solution of sodium hypochlorite. Follow manufactures recommendations for contact time. • It should be noted that antibiotic resistance does not infer disinfectant resistance, therefore extraordinary measures beyond routine disinfection practices are not warranted. • It is recommended that an antimicrobial handwashing product be used before and after patient contact.

MRSA METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS Managing MRSA in the Community Practice Setting

George A. Pankey, MD Clinical Professor of Medicine, Tulane University School of Medicine, New Orleans, Louisiana; Director, Infectious Disease Research, Ochsner Clinic Foundation, New Orleans, Louisiana

Introduction When MRSA is acquired in a healthcare setting it is referred to as healthcare-associated MRSA (HA-MRSA) and when it is acquired in the community in someone not recently exposed to a healthcare setting it is referred to as community-associated MRSA (CA-MRSA). Management of CA-MRSA by primary care clinicians is the focus of this column because this group is more likely to encounter MRSA infections than any other group of healthcare providers. Recent data show that Americans visit a doctor approximately 12 million times each year to get checked for suspected S aureus or MRSA skin infection. Methicillin was introduced into clinical practice in 1959. By 1961, the first case of infection due to MRSA was reported in the United Kingdom. The first case of MRSA infection was reported in the United States in 1968 and by 1990, MRSA had disseminated worldwide. MRSA has historically been considered a nosocomial pathogen confined to healthcare facilities and early recognition of its ability to spread within and between hospitals earned it the name "epidemic MRSA." During the past decade however, CA-MRSA has emerged as a problematic

58 pathogen in individuals who have had no contact with healthcare facilities in at least the 6 months prior to infection. The global epidemiology of MRSA continues to change. Two MRSA strains -- HA-MRSA and CA-MRSA -- have emerged. HA-MRSA has more antibiotic resistance genes than CA-MRSA. CA-MRSA may be more virulent, sometimes causing serious and fatal infections in healthy individuals. The clinical distinctions between HA-MRSA (USA100) and CA-MRSA (USA 300) are becoming blurred, with both strains causing disease in both community and healthcare settings. Currently, up to 25% of MRSA with onset in the hospital or community is due to CA- MRSA USA300. Differences in antibiotic susceptibility patterns are also diminishing. Initially, CA-MRSA was known to be resistant only to β-lactams, but is now also resistant to quinolones, macrolides, and other antibiotics. A Word or Two About Methicillin-sensitive S aureus In contrast to MRSA, methicillin-sensitive S aureus (MSSA) refers to all oxacillin-sensitive strains of S aureus. MSSA and MRSA are equally prevalent in the community. Both MRSA and MSSA can cause life-threatening infections, including bacteremia, endocarditis, and pneumonia, as well as uncomplicated and complicated Skin and Soft Tissue (ligaments, tendons, fat, and muscle) Infections (SSTIs). There are more cases of pneumonia and bacteremia due to MSSA, but MRSA pneumonia is associated with higher mortality rates, longer hospital stays, and increased cost. Outcomes of CA-MRSA infections, especially in neonates, are worse compared with outcomes of MSSA infections.

Who is at risk for CA-MRSA? Humans serve as the main reservoir of MRSA, but furred animals and pigs can acquire MRSA from humans and possibly the environment. It is likely that humans (especially veterinarians, farm workers, and children) can become infected from animals. In the United States, CA-MRSA colonization is more common in blacks, Native Americans, Alaskan natives, and Pacific Islanders in Hawaii. In general, CA-MRSA infections are associated with crowded living conditions or institutional contacts (daycare centers, long-term care residences, military trainee facilities, prisons). Other risk behaviors include intravenous drug abuse; playing contact sports; men having sex with men; sharing razors, clothing, linens or soap; living with someone who is infected with CA-MRSA; previous antimicrobial use; and exposure to furred animals. In addition, healthcare workers are especially at risk. CA-MRSA is responsible for more infections in healthcare workers than HA- MRSA, perhaps because many more persons have USA300 disease and it is very easily transmitted. CA-MRSA is spread primarily by direct contact with a carrier or infected person. The main mode of transmission of MRSA is via hands, which may become contaminated by contact with:  Colonized or infected individuals;  Colonized or infected body sites of other persons; or  Devices, items, or environmental surfaces contaminated with body fluids containing MRSA.

59 MRSA Carriers Much of the transmission of S aureus occurs through cross-infection by spread from patient to patient. Healthy individuals, on the other hand, are at low risk of contracting an invasive S aureus infection, but they can be carriers. The primary habitat of S aureus appears to be moist squamous epithelium of the anterior nares, but widespread cutaneous colonization is common. Population-based estimates of nasal carriage of S aureus and MRSA, and associated risk factors were made using the National Health and Nutrition Examination Survey (NHANES) 2001-2002. Nearly one third of the population was found to be colonized by S aureus, and more than 2.2 million are colonized by MRSA. Individuals who have been MRSA carriers for longer than a year are more likely to develop MRSA disease. There is no gold standard screening detection method for CA-MRSA carriers. Combined nasal, throat, axillary, and groin skin testing has the highest yield, but this approach is not practical.

CA-MRSA-related morbidity The spectrum of MRSA-related disease in the community is similar to that of non-MRSA S aureus; rapidly progressive, severe infection develops in a minority of cases. Skin and soft tissue infections (SSTIs) are the most frequently reported clinical manifestations of CA-MRSA.

Skin Infections SSTIs, the most common manifestations of CA-MRSA infections, are commonly encountered in the primary care and emergency department settings are described in Table below. Common CA-MRSA Skin and Soft Tissue Infections Infection Description Abscess A localized collection of pus in any part of the body, surrounded by inflammation and swelling, sometimes referred to as a common boil Boil A collection of pus localized deep in the skin; usually starts as a reddened, tender area and in time becomes firm; eventually, the center of the boil softens and becomes filled with pus Furuncle Abscessed hair follicles or boils; the simultaneous occurrence of a number of furuncles or the persistent sequential occurrence of furuncles over a period of weeks or months is referred to as furunculosis Carbuncle A coalesced mass of furuncles; the infected material forms a lump or mass, which occurs deep in the skin; more than 1 carbuncle is referred to as carbunculosis Folliculitis Inflammation or infection (bacterial or fungal) of 1 or more hair follicles, characterized by small, yellowish-white, blister-like lumps (pustules) surrounded by narrow red rings; can cause boils and serious skin infections Impetigo A bacterial skin infection caused by S aureus or Streptococcus; pustules develop, forming crusty, yellow-brown sores that can spread to cover entire areas of the face, arms, and other body parts Cellulitis An acute spreading bacterial infection below the subcutaneous tissue characterized by erythema, warmth, swelling, and pain

60

CA-MRSA is the most common cause of SSTIs in patients presenting to emergency departments in the United States. Risk factors for SSTIs caused by CA-MRSA include poor hygiene, skin trauma (i.e. sports injuries), and the 6 "Cs":

 Crowding;  Compromised skin or systemic defenses;  Contact with an active lesion (by contact or auto-inoculation);  Contaminated items (especially towels);  Corpulence (obesity); and  Colonization (personal or in direct contact with the nares, throat, gastrointestinal tract, vagina, and/or skin).

More invasive disease (i.e. necrotizing fasciitis, septic thrombophlebitis of the extremities, pelvic infections, Waterhouse-Friderichsen syndrome, and rapidly progressive necrotizing pneumonia) can occur in children and adults, but is less common. Approximately one-third of all invasive MRSA-related disease is caused by CA-MRSA. MRSA should always be considered in the differential diagnosis of SSTIs when the clinical presentation and history are suggestive of a S aureus infection, especially when purulence is present (fluctuant or palpable fluid-filled cavity, yellow or white center, central point or "head," draining pus, or if it is possible to aspirate pus with needle and syringe). The involved site will also be red, swollen, and painful. Pain and systemic symptoms out of proportion to findings on physical exam are associated with necrotizing fasciitis, a rare but potentially lethal condition sometimes associated with CA-MRSA infection. Patients with necrotizing fasciitis require prompt surgical intervention.

Treatment and Management of CA-MRSA SSTIs Incision and drainage, which is the primary treatment for furuncles and other abscesses, should be performed routinely for initial management. Clinicians are encouraged to collect specimens for culture and antimicrobial susceptibility testing from all patients with abscesses or purulent skin lesions, particularly those with severe local infections, systemic signs of infection, or history suggesting connection to a cluster or outbreak of infections among epidemiologically linked individuals. Some patients with purulent skin lesions may require empiric antimicrobial therapy in addition to incision and drainage. Factors that influence the decision to supplement with antimicrobial therapy include: 1. Severity and rapidity of progression of the SSTI or the presence of associated cellulitis, 2. Signs and symptoms of systemic illness, 3. Associated patient comorbidities or immunosuppression, 4. Extremes of patient age, 5. Location of the abscess in an area that may be difficult to drain completely or that can be associated with septic phlebitis of major vessels (e.g. central face), and 6. Lack of response to initial treatment with incision and drainage alone.

61 Infection control measures in healthcare facilities may include patient screening for colonization, cohorting and isolation of infected and colonized patients, decolonization protocols, and increased emphasis on appropriate hand hygiene. Despite efforts to reduce spread of MRSA, the current and future burden of colonization and infection is formidable. In the absence of effective decolonization regimens, ongoing education activities for both the public and clinicians will be vital to recognizing and controlling disease.

Measles Cluster in Fraser East From Fraser Health11

Measles is a highly contagious disease caused by the measles virus. Complications and death can result from a measles infection, most commonly in infants less than 12 months old and in adults. Since the introduction of the measles vaccine, rates of measles infections have dropped greatly.

There were 17 confirmed measles cases among BC residents in 2013. 2014 has seen a measles outbreak occur in the Fraser Valley with several hundred cases being reported.

For more information about cases of measles in British Columbia see the most recent Annual Summary of Reportable Diseases. The most effective protection against the virus is two doses of the vaccine which is free to all those born after 1957.

Influenza12

Influenza is a respiratory infection caused primarily by influenza A and B viruses. In Canada, influenza generally occurs each year in the late fall and winter months. Symptoms typically include the sudden onset of high fever, chills, sore throat, cough and myalgia. Other common symptoms include headache, loss of appetite, fatigue, and coryza. Nausea, vomiting and diarrhea may also occur, especially in children. Most people will recover within a week or ten days, but some are at greater risk of more severe complications, such as pneumonia.

Vaccination

The World Health Organization’s (WHO) recommendations on the composition of influenza virus vaccines are typically available in February of each year for the upcoming season. The WHO recommends that, where available, seasonal quadrivalent influenza vaccines contain the recommended three viruses for the trivalent vaccine as well as the influenza B virus lineage that is not included in the trivalent vaccine.

Annual influenza vaccine recommendations for use in Canada are developed by the Influenza Working Group (IWG) for consideration by NACI. Yearly vaccination is recommended for all individuals aged 6 months and older (noting product-specific age indications and contraindications), with particular focus on: people at high risk of influenza-related complications or hospitalization, including all pregnant women, people capable of transmitting influenza to those at high risk, and others.

62 Both inactivated and live attenuated influenza vaccines are authorized for use in Canada; some are trivalent formulations and some are quadrivalent formulations.

TIV (Trivalent inactivated influenza vaccine) and QIV (Quadrivalent inactivated influenza vaccine), instead of LAIV (Live attenuated influenza vaccine), are recommended for health care workers.

Hand hygiene

Influenza may spread via contaminated hands or inanimate objects that become contaminated with influenza viruses. CDC recommends that students and staff be encouraged to wash their hands often with soap and water, especially after coughing or sneezing. Alcohol-based hand cleaners are also effective at killing flu germs, but may not be allowed in all schools. If soap and water are not available, and alcohol-based products are not allowed in the school, other hand sanitizers that do not contain alcohol may be useful however, there is less evidence on their effectiveness compared to that on hand washing and alcohol-based sanitizers.

Respiratory etiquette

Influenza viruses are thought to spread mainly from person to person in respiratory droplets of coughs and sneezes. This can happen when droplets from a cough or sneeze of an infected person are propelled through the air and deposited on the mouth or nose or are inhaled by people nearby. CDC recommends covering the nose and mouth with a tissue when coughing or sneezing and throwing the tissue in the trash after use. Wash hands promptly after coughing or sneezing. If a tissue is not immediately available, coughing or sneezing into one’s arm or sleeve (not into one’s hand) is recommended. To encourage respiratory etiquette, students and staff should have access to tissues and must be educated about the importance of respiratory etiquette, including keeping hands away from the face.

Routine cleaning

CDC does not believe any additional disinfection of environmental surfaces beyond the recommended routine cleaning is required.

7. COVID-1913

The causative agent of COVID-19 is Severe Acute Respiratory Syndrome Coronavirus 2 (SARS- CoV-2). The incubation period, the time between exposure and potentially becoming infected, is on average 5-6 days, but can be up to 14 days with or without symptoms. COVID-19 is understood to be highly infective and easily transmissible, primarily as a result of close contact with infected persons through respiratory droplets. This evidence comes from data found in published epidemiological and virologic studies.

63 Infection Prevention and Control Principles and Strategies

The risk of transmission of an infection as a result of an oral health procedure represents an important patient safety consideration.In the context of low incidence and prevalence of COVID- 19 in British Columbia, a comprehensive approach includes maintaining routine practices, physical adaptations within the facility, hand hygiene and risk assessment with focus on aerosol and dropletmanagement and appropriate contact precautions.

Infection prevention and control (IPAC) principles include:

 Patient assessment;  Implementation of routine procedures;  Use of barrier techniques to protect patients, OHCPs and staff;  Application of the principles of cleaning, disinfection, sterilization and storage of dental instruments;  Environmental surface protection/cleaning;  Care of overall office setting; and  Safe handling and disposal of waste.

IPAC strategies to reduce the possibility of disease transmission include:

 Setting specific policies and procedures to identify, communicate and implement effective standards and guidelines;  Written office policies and programs for effective occupational health and safety;  Educating OHCPs, staff and patients about their roles in infection prevention; and  Ongoing review and evaluation of IPAC policies and procedures.

Routine practices

Routine IPAC practices (standard precautions) protect patients, OHCPs, and staff. OHCPs must maintain routine practices, including risk assessment, hand hygiene, use of PPE, and safe handling and disposal of waste.

“COVID 19 Patient Care and Simulation Guidelines Fall Term” provides more detailed information about Oral Health Care During COVID-19 at OHC. The document is based on the latest available best practices and scientific evidence about this emerging disease and may change as new information becomes available.

64 REFERENCES

1. The College of Dental Surgeons of British Columbia; The infection Prevention and Control Guidelines, July 2012. http://www.cdsbc.org/~ASSETS/DOCUMENT/CDSBC_Infection_Prevention_and_Control_Gu idelines_Interactive_PDF.pdf

2. CDC. Guidelines for Infection Control in Dental Health-Care Settings, 2003. MMWR 2003; 52(17): 1-76 www.cdc.gov/oralhealth/infectioncontrol/guidelines/index.htm

3. Hall CB. Nosocomial respiratory syncytial virus infections: the "Cold War" has not ended. Clin Infect Dis 2000;31(2):590-6.

4. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings http://www.cdc.gov/hicpac/2007IP/2007ip_ExecSummary.html

5. Boyce JM, Pittet D. Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep 2002;51(RR-16):1-45, quiz CE1-4. http://www.cdc.gov/HAI/settings/outpatient/outpatient-care-gl-standared-precautions.html#hh

6. CDC. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health- care settings, 2005. MMWR Recomm Rep 2005;54(17):1-141.

7. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm

8. http://www.cdc.gov/hai/pdfs/ppe/PPE-Sequence.pdf

9. Kohn WG et al. Guidelines for infection control in dental health care settings, JADA 2004; 135: 33-47.

10. http://acfd.ca/about-acfd/publications/acfd-guidelines-for-infectious-diseases-and-health- care-workers/

11 . http://www.fraserhealth.ca/professionals/student-practice-education/news/measles-outbreak- in-fraser-health

12. http://www.phac-aspc.gc.ca/naci-ccni/assets/pdf/flu-2016-grippe-eng.pdf

13- https://www.cdsbc.org/Documents/covid-19/COVID-19-oral-healthcare-Aug18.pdf

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