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Guidelines for Environmental Infection Control in Health-Care Facilities

Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC)
Prepared by Lynne Sehulster, Ph.D.1 Raymond Y.W. Chinn, M.D.2 1 Division of Healthcare Quality Promotion National Center for Infectious Diseases 2 HICPAC member Sharp Memorial Hospital San Die o! California
The material in this report ori inated in the !ational Center "or #n"e$tious Diseases, %ames M. &u hes, M.D., Dire$tor' and the Di(ision o" &ealth$are )uality Promotion, Ste(en L. Solomon, M.D., *$tin Dire$tor.

"he health#care facility environment is rarely implicate$ in $isease transmission! e%cept amon patients &ho are immunocompromise$' Nonetheless! ina$vertent e%posures to environmental patho ens (e' '! *sper illus spp' an$ Le ionella spp') or airborne patho ens (e' '! My$oba$terium tuber$ulosis an$ varicella#*oster virus) can result in a$verse patient outcomes an$ cause illness amon health#care &or+ers' ,nvironmental infection#control strate ies an$ en ineerin controls can effectively prevent these infections' "he inci$ence of health#care##associate$ infections an$ pseu$o#outbrea+s can be minimi*e$ by 1) appropriate use of cleaners an$ $isinfectants- 2) appropriate maintenance of me$ical e.uipment (e' '! automate$ en$oscope reprocessors or hy$rotherapy e.uipment)- /) a$herence to &ater#.uality stan$ar$s for hemo$ialysis! an$ to ventilation stan$ar$s for speciali*e$ care environments (e' '! airborne infection isolation rooms! protective environments! or operatin rooms)- an$ 0) prompt mana ement of &ater intrusion into the facility' 1outine environmental samplin is not usually a$vise$! e%cept for &ater .uality $eterminations in hemo$ialysis settin s an$ other situations &here samplin is $irecte$ by epi$emiolo ic principles! an$ results can be applie$ $irectly to infection# control $ecisions' "his report revie&s previous ui$elines an$ strate ies for preventin environment# associate$ infections in health#care facilities an$ offers recommen$ations' "hese inclu$e 1) evi$ence#base$ recommen$ations supporte$ by stu$ies- 2) re.uirements of

fe$eral a encies (e' '! 2oo$ an$ Dru A$ministration! 3'S' ,nvironmental Protection A ency! 3'S' Department of 4abor! 5ccupational Safety an$ Health A$ministration! an$ 3'S' Department of 6ustice)- /) ui$elines an$ stan$ar$s from buil$in an$ e.uipment professional or ani*ations (e' '! American Institute of Architects! Association for the A$vancement of Me$ical Instrumentation! an$ American Society of Heatin ! 1efri eration! an$ Air#Con$itionin ,n ineers)- 0) recommen$ations $erive$ from scientific theory or rationale- an$ 7) e%perience$ opinions base$ upon infection#control an$ en ineerin practices' "he report also su ests a series of performance measurements as a means to evaluate infection#control efforts'

Parameters of the Re ort This report, +hi$h $ontains the $omplete list o" re$ommendations +ith pertinent re"eren$es, is Part ## o" 8ui$elines for ,nvironmental Infection Control in Health# Care 2acilities' The "ull "our,part uidelines +ill be a(ailable on CDC-s Di(ision o" &ealth$are )uality Promotion .D&)P/ +ebsite. Relati(e to pre(ious CDC uidelines, this report

re(ises multiple se$tions .e. ., $leanin and disin"e$tion o" en(ironmental sur"a$es, en(ironmental samplin , laundry and beddin , and re ulated medi$al +aste/ "rom pre(ious editions o" CDC-s 8ui$eline for Han$&ashin an$ Hospital ,nvironmental Control' in$orporates dis$ussions o" air and +ater en(ironmental $on$erns "rom CDC-s 8ui$eline for Prevention of Nosocomial Pneumonia' $onsolidates rele(ant en(ironmental in"e$tion,$ontrol measures "rom other CDC uidelines' and in$ludes t+o topi$s not addressed in pre(ious CDC uidelines ,,, in"e$tion, $ontrol $on$erns related to animals in health,$are "a$ilities and +ater 0uality in hemodialysis settin s.

#n the "ull uidelines, Part #, 1a$2 round #n"ormation3 4n(ironmental #n"e$tion Control in &ealth,Care 5a$ilities, pro(ides a $omprehensi(e re(ie+ o" the rele(ant s$ienti"i$ literature. *ttention is i(en to en ineerin and in"e$tion,$ontrol $on$erns durin $onstru$tion, demolition, reno(ation, and repair o" health,$are "a$ilities. 6se o" an in"e$tion,$ontrol ris2 assessment is stron ly supported be"ore the start o" these or any other a$ti(ities e7pe$ted to enerate dust or +ater aerosols. *lso re(ie+ed in Part # are in"e$tion,$ontrol measures used to re$o(er "rom $atastrophi$ e(ents .e. ., "loodin , se+a e spills, loss o" ele$tri$ity and (entilation, or disruption o" +ater supply/ and the limited e""e$ts o" en(ironmental sur"a$es, laundry, plants, animals, medi$al +astes, $loth "urnishin s, and $arpetin on disease transmission in health, $are "a$ilities. Part ### and Part #8 o" the "ull uidelines pro(ide re"eren$es ."or the $omplete uideline/ and appendi$es, respe$ti(ely.

Part ## .this report/ $ontains re$ommendations "or en(ironmental in"e$tion $ontrol in health,$are "a$ilities, des$ribin $ontrol measures "or pre(entin in"e$tions asso$iated +ith air, +ater, or other elements o" the en(ironment. These re$ommendations represent the (ie+s o" di""erent di(isions +ithin CDC-s !ational Center "or #n"e$tious Diseases and the &ealth$are #n"e$tion Control Pra$ti$es *d(isory Committee .&#CP*C/, a 12,member roup that ad(ises CDC on $on$erns related to the sur(eillan$e, pre(ention, and $ontrol o" health,$are,,asso$iated in"e$tions, primarily in 6.S. health,$are "a$ilities. #n 1999, &#CP*C-s in"e$tion,$ontrol "o$us +as e7panded "rom a$ute,$are hospitals to all (enues +here health $are is pro(ided .e. ., outpatient sur i$al $enters, ur ent $are $enters, $lini$s, outpatient dialysis $enters, physi$ians- o""i$es, and s2illed nursin "a$ilities/. The topi$s addressed in this report are appli$able to the ma:ority o" health,$are "a$ilities in the 6nited States. This report is intended "or use primarily by in"e$tion,$ontrol pra$titioners, epidemiolo ists, employee health and sa"ety personnel, en ineers, "a$ility mana ers, in"ormation systems pro"essionals, administrators, en(ironmental ser(i$e pro"essionals, and ar$hite$ts. ;ey re$ommendations in$lude

in"e$tion,$ontrol impa$t o" (entilation system and +ater system per"orman$e' establishment o" a multidis$iplinary team to $ondu$t in"e$tion,$ontrol ris2 assessment' use o" dust,$ontrol pro$edures and barriers durin $onstru$tion, repair, reno(ation, or demolition' en(ironmental in"e$tion,$ontrol measures "or spe$ial areas +ith patients at hi h ris2' use o" airborne,parti$le samplin to monitor the e""e$ti(eness o" air "iltration and dust,$ontrol measures' pro$edures to pre(ent airborne $ontamination in operatin rooms +hen in"e$tious tuber$ulosis .T1/ patients re0uire sur ery' uidan$e re ardin appropriate indi$ations "or routine $ulturin o" +ater as part o" a $omprehensi(e $ontrol pro ram "or le ionellae' uidan$e "or re$o(erin "rom +ater,system disruptions, +ater lea2s, and natural disasters .e. ., "loodin /' in"e$tion,$ontrol $on$epts "or e0uipment usin +ater "rom main lines .e. ., +ater systems "or hemodialysis, i$e ma$hines, hydrotherapy e0uipment, dental unit +ater lines, and automated endos$ope repro$essors/' en(ironmental sur"a$e $leanin and disin"e$tion strate ies +ith respe$t to antibioti$,resistant mi$roor anisms' in"e$tion,$ontrol pro$edures "or health,$are laundry' use o" animals in health $are "or a$ti(ities and therapy' mana in the presen$e o" ser(i$e animals in health,$are "a$ilities' in"e$tion,$ontrol strate ies "or +hen animals re$ei(e treatment in human health,$are "a$ilities' and a $all to reinstate the pra$ti$e o" ina$ti(atin ampli"ied $ultures and sto$2s o" mi$roor anisms onsite durin medi$al +aste treatment.

Topi$s outside the s$ope o" this report in$lude 1/ nonin"e$tious ad(erse e(ents .e. ., si$2 buildin syndrome/, 2/ en(ironmental $on$erns in the home, </ home health $are, =/ terrorism, and >/ health,$are,,asso$iated "oodborne illness. Where(er possible, the re$ommendations in this report are based on data "rom +ell, desi ned s$ienti"i$ studies. &o+e(er, $ertain o" these studies +ere $ondu$ted by usin narro+ly de"ined patient populations or spe$i"i$ health,$are settin s .e. ., hospitals (ersus lon ,term $are "a$ilities/, ma2in enerali?ation o" "indin s potentially problemati$. Constru$tion standards "or hospitals or other health,$are "a$ilities may not apply to residential home,$are units. Similarly, in"e$tion,$ontrol measures indi$ated "or immunosuppressed patient $are are usually not ne$essary in those "a$ilities +here su$h patients are not present. @ther re$ommendations +ere deri(ed "rom 2no+led e ained durin in"e$tious disease in(esti ations in health,$are "a$ilities, +here su$$ess"ul termination o" the outbrea2 +as o"ten the result o" multiple inter(entions, the ma:ority o" +hi$h $annot be independently and ri orously e(aluated. This is espe$ially true "or $onstru$tion situations in(ol(in air or +ater. @ther re$ommendations +ere deri(ed "rom empiri$ en ineerin $on$epts and may re"le$t industry standards rather than e(iden$e,based $on$lusions. Where re$ommendations re"er to uidan$e "rom the *meri$an #nstitute o" *r$hite$ts .*#*/, the statements re"le$t standards intended "or ne+ $onstru$tion or reno(ation. 47istin stru$tures and en ineered systems are e7pe$ted to be in $ontinued $omplian$e +ith those standards in e""e$t at the time o" $onstru$tion or reno(ation. *lso, in the absen$e o" s$ienti"i$ $on"irmation, $ertain in"e$tion,$ontrol re$ommendations that $annot be ri orously e(aluated are based on stron theoreti$ rationale and su esti(e e(iden$e. 5inally, $ertain re$ommendations are deri(ed "rom e7istin "ederal re ulations. Performance !easurements #n"e$tions $aused by the mi$roor anisms des$ribed in this uideline are rare e(ents, and the e""e$t o" these re$ommendations on in"e$tion rates in a "a$ility may not be readily measurable. There"ore, the "ollo+in steps to measure per"orman$e are su ested to e(aluate these re$ommendations3 1. Do$ument +hether in"e$tion,$ontrol personnel are a$ti(ely in(ol(ed in all phases o" a health,$are "a$ility-s demolition, $onstru$tion, and reno(ation. *$ti(ities should in$lude per"ormin a ris2 assessment o" the ne$essary types o" $onstru$tion barriers, and daily monitorin and do$umentin o" the presen$e o" ne ati(e air"lo+ +ithin the $onstru$tion ?one or reno(ation area.

2. Monitor and do$ument daily the ne ati(e air"lo+ in *## rooms and positi(e air"lo+ in P4 rooms, espe$ially +hen patients are in these rooms. <. Per"orm assays at least on$e a month by usin standard 0uantitati(e methods "or endoto7in in +ater used to repro$ess hemodialy?ers, and "or heterotrophi$ and mesophili$ ba$teria in +ater used to prepare dialysate and "or hemodialy?er repro$essin . =. 4(aluate possible en(ironmental sour$es .e. ., +ater, laboratory solutions, or rea ents/ o" spe$imen $ontamination +hen nontuber$ulous my$oba$teria .!TM/ o" unli2ely $lini$al importan$e are isolated "rom $lini$al $ultures. #" en(ironmental $ontamination is "ound, eliminate the probable me$hanisms. >. Do$ument poli$ies to identi"y and respond to +ater dama e. Su$h poli$ies should result in either repair and dryin o" +et stru$tural or porous materials +ithin A2 hours, or remo(al o" the +et material i" dryin is unli2ely +ithin A2 hours. " dates to Previous Recommendations Contributors to this report re(ie+ed primarily 4n lish,lan ua e manus$ripts identi"ied "rom re"eren$e sear$hes usin the !ational Library o" Medi$ine-s M4DL#!4, biblio raphies o" published arti$les, and in"e$tion,$ontrol te7tboo2s. *ll the re$ommendations may not re"le$t the opinions o" all re(ie+ers. This report updates the "ollo+in published uidelines and re$ommendations3 CDC. Buideline "or hand+ashin and hospital en(ironmental $ontrol. MMWR 199C'<A.!o. 2=/. Repla$es se$tions on mi$robiolo i$ samplin , laundry, in"e$ti(e +aste, and house2eepin . Tablan @C, *nderson L%, *rden !&, et al., &ospital #n"e$tion Control Pra$ti$es *d(isory Committee. Buideline "or pre(ention o" noso$omial pneumonia. #n"e$t Control &osp 4pidemiol 199='1>3>CA,,D2A. 6pdates and e7pands en(ironmental in"e$tion,$ontrol in"ormation "or asper illosis and Le ionnaires disease' online (ersion in$orporates *ppendi$es 1, C, and D addressin en(ironmental $ontrol and dete$tion o" Le ionella spp. CDC. Buidelines "or pre(entin the transmission o" mycobacterium tuberculosis in health,$are "a$ilities. MMWR 199='=<.!o. RR1</. Pro(ides supplemental in"ormation on en ineerin $ontrols. CDC. Re$ommendations "or pre(entin the spread o" (an$omy$in resistan$e3 re$ommendations o" the &ospital #n"e$tion Control Pra$ti$es *d(isory Committee .&#CP*C/. MMWR 199>'==.!o. RR12/. Supplements en(ironmental in"e$tion, $ontrol in"ormation "rom the se$tion, &ospitals +ith 4ndemi$ 8R4 or Continued 8R4 Transmission.

Barner %S, &ospital #n"e$tion Control Pra$ti$es *d(isory Committee. Buideline "or isolation pre$autions in hospitals. #n"e$t Control &osp 4pidemiol 199D'1A3><,,CE. Supplements and updates topi$s in Part ## ,,, Re$ommendations "or #solation Pre$autions in &ospitals .linen and laundry, routine and terminal $leanin , airborne pre$autions/. Man ram *%, &oran TC, Pearson ML, Sil(er LC, %ar(is WR, &ospital #n"e$tion Control Pra$ti$es *d(isory Committee. Buideline "or pre(ention o" sur i$al site in"e$tion. #n"e$t Control &osp 4pidemiol 1999'=32>E,,AC. 6pdates operatin room (entilation and sur"a$e $leanin Fdisin"e$tion re$ommendations "rom the se$tion, #ntraoperati(e #ssues3 @peratin Room 4n(ironment. 6.S. Publi$ &ealth Ser(i$e, #n"e$tious Diseases So$iety o" *meri$a, Pre(ention o" @pportunisti$ #n"e$tions Wor2in Broup. 6SP&SF#DS* uidelines "or the pre(ention o" opportunisti$ in"e$tions in persons in"e$ted +ith human immunode"i$ien$y (irus. #n"e$t Dis @bstet Byne$ol 2EE2' 1E3<,,D=. Supplements in"ormation re ardin patient intera$tion +ith pets and animals in the home. CDC, #n"e$tious Diseases So$iety o" *meri$a, *meri$an So$iety o" 1lood and Marro+ Transplantation. Buidelines "or pre(entin opportunisti$ in"e$tions amon hematopoieti$ stem $ell transplant re$ipients. Cytotherapy 2EE1'<3=1,,>=. Supplements and updates the se$tion, &ospital #n"e$tion Control. #ey $erms Air%orne infection isolation (AII) re"ers to the isolation o" patients in"e$ted +ith or anisms spread (ia airborne droplet nu$lei G> Hm in diameter. This isolation area re$ei(es numerous air $han es per hour .*C&/ .I12 *C& "or ne+ $onstru$tion as o" 2EE1' ID *C& "or $onstru$tion be"ore 2EE1/, and is under ne ati(e pressure, su$h that the dire$tion o" the air "lo+ is "rom the outside ad:a$ent spa$e .e. ., the $orridor/ into the room. The air in an *## room is pre"erably e7hausted to the outside, but may be re$ir$ulated pro(ided that the return air is "iltered throu h a hi h,e""i$ien$y parti$ulate air .&4P*/ "ilter. The use o" personal respiratory prote$tion is also indi$ated "or persons enterin these rooms +hen $arin "or T1 or smallpo7 patients and "or sta"" +ho la$2 immunity to airborne (iral diseases .e. ., measles or (ari$ella ?oster (irus J8K8L in"e$tion/. Protective environment (PE) is a spe$iali?ed patient,$are area, usually in a hospital, +ith a positi(e air "lo+ relati(e to the $orridor .i.e., air "lo+s "rom the room to the outside ad:a$ent spa$e/. The $ombination o" &4P* "iltration, hi h numbers o" air $han es per hour .I12 *C&/, and minimal lea2a e o" air into the room $reates an en(ironment that $an sa"ely a$$ommodate patients +ho ha(e under one allo enei$ hematopoieti$ stem $ell transplant .&SCT/.

Immunocom romised atients are those patients +hose immune me$hanisms are de"i$ient be$ause o" immunolo i$ disorders .e. ., human immunode"i$ien$y (irus J&#8L in"e$tion or $on enital immune de"i$ien$y syndrome/, $hroni$ diseases .e. ., diabetes, $an$er, emphysema, or $ardia$ "ailure/, or immunosuppressi(e therapy .e. ., radiation, $ytoto7i$ $hemotherapy, anti,re:e$tion medi$ation, or steroids/. #mmuno$ompromised patients +ho are identi"ied as hi h,ris2 patients ha(e the reatest ris2 o" in"e$tion $aused by airborne or +aterborne mi$roor anisms. Patients in this subset in$lude persons +ho are se(erely neutropeni$ "or prolon ed periods o" time .i.e., an absolute neutrophil $ount J*!CL o" G>EE $ellsFmL/, allo enei$ &SCT patients, and those +ho ha(e re$ei(ed the most intensi(e $hemotherapy .e. ., $hildhood a$ute myelo enous leu2emia patients/. A%%reviations **M# *sso$iation "or the *d(an$ement o" Medi$al #nstrumentation *C& air $han es per hour *4R automated endos$ope repro$essor *&% authority ha(in :urisdi$tion *#* *meri$an #nstitute o" *r$hite$ts *## airborne in"e$tion isolation *!S# *meri$an !ational Standards #nstitute *S&R*4 *meri$an So$iety o" &eatin , Re"ri eration, and *ir,Conditionin 4n ineers 1M1L 1iosa"ety in Mi$robiolo i$al and 1iomedi$al Laboratories .CDCF!ational #nstitutes o" &ealth/ C5R Code o" 5ederal Re ulations C%D Creut?"eldt,%a2ob disease CPL $omplian$e do$ument .@S&*/ D5* dire$t "luores$en$e assay D&&S 6.S. Department o" &ealth and &uman Ser(i$es D@T 6.S. Department o" Transportation

4C en(ironment o" $are 4P* 6. S. 4n(ironmental Prote$tion * en$y 5D* 6.S. 5ood and Dru *dministration &18 hepatitis 1 (irus &4P* hi h e""i$ien$y parti$ulate air &#8 human immunode"i$ien$y (irus &SCT hematopoieti$ stem $ell transplant &8*C heatin , (entilation, air $onditionin #CR* in"e$tion,$ontrol ris2 assessment %C*&@ %oint Commission on *$$reditation o" &ealth$are @r ani?ations !a@& sodium hydro7ide !TM nontuber$ulous my$oba$teria @S&* @$$upational Sa"ety and &ealth *dministration P4 prote$ti(e en(ironment PP4 personal prote$ti(e e0uipment T1 tuber$ulosis 6SC 6nited States Code 6SD* 6.S. Department o" * ri$ulture 68 ultra(iolet 68B# ultra(iolet ermi$idal irradiation 8&5 (iral hemorrha i$ "e(er 8R4 (an$omy$in,resistant ,nterococcus 8RS* (an$omy$in,resistant Staphylococcus aureus

8K8 (ari$ella ?oster (irus

Recommendations for Environmental Infection Control in Health-Care Facilities

Rationale for Recommendations *s in pre(ious CDC uidelines, ea$h re$ommendation is $ate ori?ed on the basis o" e7istin s$ienti"i$ data, theoreti$ rationale, appli$ability, and possible e$onomi$ e""e$t. The re$ommendations are e(iden$e,based +here(er possible. &o+e(er, $ertain re$ommendations are deri(ed "rom empiri$ in"e$tion,$ontrol or en ineerin prin$iples, theoreti$ rationale, or "rom e7perien$e ained "rom e(ents that $annot be readily studied .e. ., "loods/. The &#CP*C system "or $ate ori?in re$ommendations has been modi"ied to in$lude a $ate ory "or en ineerin standards and a$tions re0uired by state or "ederal re ulations. Buidelines and standards published by the *#*, *meri$an So$iety o" &eatin , Re"ri eration, and *ir,Conditionin 4n ineers .*S&R*4/, and the *sso$iation "or the *d(an$ement o" Medi$al #nstrumentation .**M#/ "orm the basis o" $ertain re$ommendations. These standards re"le$t a $onsensus o" e7pert opinions and e7tensi(e $onsultation +ith a en$ies o" the 6.S. Department o" &ealth and &uman Ser(i$es. Complian$e +ith these standards is usually (oluntary. &o+e(er, state and "ederal o(ernments o"ten adopt these standards as re ulations. 5or e7ample, the standards "rom *#* re ardin $onstru$tion and desi n o" ne+ or reno(ated health,$are "a$ilities, ha(e been adopted by re"eren$e by I=E states. Certain re$ommendations ha(e t+o $ate ory ratin s .e. ., Cate ories #* and #C or Cate ories #1 and #C/, indi$atin the re$ommendation is e(iden$e,based as +ell as a standard or re ulation. Ratin& Cate&ories Re$ommendations are rated a$$ordin to the "ollo+in $ate ories3 Cate&ory IA' Stron ly re$ommended "or implementation and stron ly supported by +ell,desi ned e7perimental, $lini$al, or epidemiolo i$ studies. Cate&ory I(' Stron ly re$ommended "or implementation and supported by $ertain e7perimental, $lini$al, or epidemiolo i$ studies and a stron theoreti$ rationale. Cate&ory IC' Re0uired by state or "ederal re ulation, or representin an established asso$iation standard. .!ote3 *bbre(iations "or o(ernin a en$ies and re ulatory $itations are listed +here appropriate. Re$ommendations "rom re ulations adopted at state le(els are also noted. Re$ommendations "rom *#* uidelines $ite the appropriate se$tions o" the standards./

Cate&ory II' Su ested "or implementation and supported by su epidemiolo i$ studies, or a theoreti$ rationale.

esti(e $lini$al or

"nresolved issue' !o re$ommendation is o""ered. !o $onsensus or insu""i$ient e(iden$e e7ists re ardin e""i$a$y.

Recommendations --- Air

I' Air-Handlin& )ystems in Health-Care Facilities *. 6se *#* uidelines as minimum standards +here state or lo$al re ulations are not in pla$e "or desi n and $onstru$tion o" (entilation systems in ne+ or reno(ated health,$are "a$ilities. 4nsure that e7istin stru$tures $ontinue to meet the spe$i"i$ations in e""e$t at the time o" $onstru$tion .1/. Cate ory #C .*#*3 1.1.*, >.=/ 1. Monitor (entilation systems in a$$ordan$e +ith en ineers- and manu"a$turersre$ommendations to ensure pre(enti(e en ineerin , optimal per"orman$e "or remo(al o" parti$ulates, and elimination o" e7$ess moisture .1##9/. Cate ory #1, #C .*#*3 A.2, A.<1.D, C.<1.D, 9.<1.D, 1E.<1.D, 11.<1.D, 4n(ironmental Prote$tion * en$y J4P*L uidan$e/ 1. 4nsure that heatin , (entilation, air $onditionin .&8*C/ "ilters are properly installed and maintained to pre(ent air lea2a es and dust o(erloads .2!0!:!;/. Cate ory #1 2. Monitor areas +ith spe$ial (entilation re0uirements .e. ., *## or P4/ "or *C&, "iltration, and pressure di""erentials .1!<!9!1=##2:/. Cate ory #1, #C .*#*3 A.2.CA, A.2.DD/ a. De(elop and implement a maintenan$e s$hedule "or *C&, pressure di""erentials, and "iltration e""i$ien$ies by usin "a$ility,spe$i"i$ data as part o" the multidis$iplinary ris2 assessment. Ta2e into a$$ount the a e and reliability o" the system. b. Do$ument these parameters, espe$ially the pressure di""erentials. <. 4n ineer humidity $ontrols into the &8*C system and monitor the $ontrols to ensure ade0uate moisture remo(al .1/. Cate ory #C .*#*3 A.<1.D9/ a. Lo$ate du$t humidi"iers upstream "rom the "inal "ilters. b. #n$orporate a +ater,remo(al me$hanism into the system. $. Lo$ate all du$t ta2eo""s su""i$iently do+nstream "rom the humidi"ier so that moisture is $ompletely absorbed. =. #n$orporate steam humidi"iers, i" possible, to redu$e potential "or mi$robial proli"eration +ithin the system, and a(oid use o" $ool,mist humidi"iers.

Cate ory ## >. 4nsure that air inta2es and e7haust outlets are lo$ated properly in $onstru$tion o" ne+ "a$ilities and reno(ation o" e7istin "a$ilities .1!2</. Cate ory #C .*#*3 A.<1.D<, C.<1.D<, 9.<1.D<, 1E.<1.D<, 11.<1.D</ a. Lo$ate e7haust outlets I2> "t "rom air,inta2e systems. b. Lo$ate outdoor air inta2es ID "t abo(e round or I< "t abo(e roo" le(el. $. Lo$ate e7haust outlets "rom $ontaminated areas abo(e roo" le(el to minimi?e re$ir$ulation o" e7hausted air. D. Maintain air inta2es and inspe$t "ilters periodi$ally to ensure proper operation .1!11##1:!2</. Cate ory #C .*#*3 A.<1.DC/ A. 1a dust,"illed "ilters immediately upon remo(al to pre(ent dispersion o" dust and "un al spores durin transport +ithin the "a$ility .0!29/. Cate ory #1 a. Seal or $lose the ba $ontainin the dis$arded "ilter. b. Dis$ard spent "ilters as re ular solid +aste, re ardless o" the area "rom +hi$h they +ere remo(ed .29/. C. Remo(e bird roosts and nests near air inta2es to pre(ent mites and "un al spores "rom enterin the (entilation system .2<!2;!/=/. Cate ory #1 9. Pre(ent dust a$$umulation by $leanin air,du$t rilles in a$$ordan$e +ith "a$ility,spe$i"i$ pro$edures and s$hedules and +hen rooms are not o$$upied by patients .1!1=##1:/. Cate ory #C, ## .*#*3 A.<1.D1E/ 1E. Periodi$ally measure output to monitor system "un$tion' $lean (entilation du$ts as part o" routine &8*C maintenan$e to ensure optimum per"orman$e .1!/1!/2/. Cate ory #C, ## .*#*3 A.<1.D1E/
C. 6se portable, industrial, rade &4P* "ilter units $apable o" "iltration rates in

the ran e o" <EE,,CEE "t<Fmin to au ment remo(al o" respirable parti$les as needed .///. Cate ory ## 1. Sele$t portable &4P* "ilters that $an re$ir$ulate all or nearly all o" the room air and pro(ide the e0ui(alent o" I12 *C& ./0/. Cate ory ## 2. Portable &4P* "ilter units pla$ed in $onstru$tion ?ones $an be used later in patient,$are areas, pro(ided all internal and e7ternal sur"a$es are $leaned, and the "ilter repla$ed or its per"orman$e (eri"ied by appropriate parti$le testin . Cate ory ## <. Situate portable &4P* units +ith the ad(i$e o" "a$ility en ineers to ensure that all room air is "iltered ./0/. Cate ory ##

=. 4nsure that "resh,air re0uirements "or the area are met .//!/7/. Cate ory ##
D. 5ollo+ appropriate pro$edures "or use o" areas +ith throu h,the,+all

(entilation units .1/. Cate ory #C .*#*3 C.<1.D1, C.<1.DC, 9.<1.D2<, 1E.<1.D1C, 11.<1.D1>/ 1. Do not use su$h areas as P4 rooms .1/. Cate ory #C .*#*3 A.2.D</ 2. Do not use a room +ith a throu h,the,+all (entilation unit as an *## room unless it $an be demonstrated that all re0uired *## en ineerin $ontrols are met .1!/0/. Cate ory #C .*#*3 A.2.C</
4. Condu$t an in"e$tion,$ontrol ris2 assessment .#CR*/ and pro(ide an ade0uate


B. &. #.

number o" *## and P4 rooms .i" re0uired/ or other areas to meet the needs o" the patient population .1!2!<!9!1<!1;! 2=!/0!/:##0//. Cate ory #*, #C .*#*3 A.2.C, A.2.D/ When ultra(iolet ermi$idal irradiation .68B#/ is used as a supplemental en ineerin $ontrol, install "i7tures 1/ on the +all near the $eilin or suspended "rom the $eilin as an upper air unit' 2/ in the air,return du$t o" an *## area' or </ in desi nated en$losed areas or booths "or sputum indu$tion ./0/. Cate ory ## Seal +indo+s in buildin s +ith $entrali?ed &8*C systems, in$ludin P4 areas .1!/!00/. Cate ory #1, #C .*#*3 A.2.D</ ;eep emer en$y doors and e7its "rom P4 rooms $losed e7$ept durin an emer en$y' e0uip emer en$y doors and e7its +ith alarms. Cate ory ## De(elop a $ontin en$y plan "or ba$2up $apa$ity in the e(ent o" a eneral po+er "ailure .07/. Cate ory #C .%oint Commission on *$$reditation o" &ealth$are @r ani?ations J%C*&@L3 4n(ironment o" Care J4CL 1.=/ 1. 4mphasi?e restoration o" appropriate air 0uality and (entilation $onditions in *## rooms, P4 rooms, operatin rooms, emer en$y departments, and intensi(e $are units .1!07/. Cate ory #C .*#*3 1.>.*1' %C*&@3 4C 1.=/ 2. Deploy in"e$tion,$ontrol pro$edures to prote$t o$$upants until po+er and systems "un$tions are restored .1!/:!07/. Cate ory #C .*#*3 >.1, >.2' %C*&@3 4C 1.=/


Do not shut do+n &8*C systems in patient,$are areas e7ept "or maintenan$e, repair, testin o" emer en$y ba$2up $apa$ity, or ne+ $onstru$tion .1!0:/. Cate ory #1, #C .*#*3 >.1, >.2.1, C/ 1. Coordinate &8*C system maintenan$e +ith in"e$tion,$ontrol sta"" and relo$ate immuno$ompromised patients i" ne$essary .1/. Cate ory #C .*#*3 >.1, >.2/

2. Pro(ide ba$2up emer en$y po+er and air,handlin and pressuri?ation systems to maintain "iltration, $onstant *C&, and pressure di""erentials in P4 rooms, *## rooms, operatin rooms, and other $riti$al,$are areas .1!/<!0</. Cate ory #C .*#*3 >.1, >.2/ <. 5or areas not ser(ed by installed emer en$y (entilation and ba$2up systems, use portable units and monitor (entilation parameters and patients in those areas .///. Cate ory ## =. Coordinate system startups +ith in"e$tion,$ontrol sta"" to prote$t patients in P4 rooms "rom bursts o" "un al spores .1!/!/<!0</. Cate ory #C .*#*3 >.1, >.2/ >. *llo+ su""i$ient time "or *C& to $lean the air on$e the system is operational .Table 1/ .1!///. Cate ory #C .*#*3 >.1, >.2/ ;. &8*C systems ser(in o""i$es and administrati(e areas may be shut do+n "or ener y $onser(ation purposes, but the shutdo+n must not alter or ad(ersely a""e$t pressure di""erentials maintained in laboratories or $riti$al,$are areas +ith spe$i"i$ (entilation re0uirements .i.e., P4 rooms, *## rooms, operatin rooms/. Cate ory ## L. Whene(er possible, a(oid ina$ti(atin or shuttin do+n the entire &8*C system, espe$ially in a$ute,$are "a$ilities. Cate ory ## M. Whene(er "easible, desi n and install "i7ed ba$2up (entilation systems "or ne+ or reno(ated $onstru$tion o" P4 rooms, *## rooms, operatin rooms, and other $riti$al,$are areas identi"ied by #CR* .1/. Cate ory #C .*#*3 1.>.*1/ II' Construction* Renovation* Remediation* Re air* and Demolition *. 4stablish a multidis$iplinary team that in$ludes in"e$tion,$ontrol sta"" to $oordinate demolition, $onstru$tion, and reno(ation pro:e$ts and $onsider proa$ti(e pre(enti(e measures at the in$eption' produ$e and maintain summary statements o" the team-s a$ti(ities .1!;!11##1:!/9!09##71/. Cate ory #1, #C .*#*3 >.1/ 1. 4du$ate both the $onstru$tion team and health,$are sta"" in immuno$ompromised patient,$are areas re ardin the airborne in"e$tion ris2s asso$iated +ith $onstru$tion pro:e$ts, dispersal o" "un al spores durin su$h a$ti(ities, and methods to $ontrol the dissemination o" "un al spores .11## 1:!2<!7=!72##7:/. Cate ory #1 C. #n$orporate mandatory adheren$e a reements "or in"e$tion $ontrol into $onstru$tion $ontra$ts, +ith penalties "or non$omplian$e and me$hanisms to ensure timely $orre$tion o" problems .1!11!1/##1:!2<!7=/. Cate ory #C .*#*3 >.1/ D. 4stablish and maintain sur(eillan$e "or airborne en(ironmental disease .e. ., asper illosis/ as appropriate durin $onstru$tion, reno(ation, repair, and demolition a$ti(ities to ensure the health and sa"ety o" immuno$ompromised patients .2<!7<##7;/. Cate ory #1

1. 6sin a$ti(e sur(eillan$e, monitor "or airborne in"e$tions in immuno$ompromised patients .2<!/<!7<!79/. Cate ory #1 2. Periodi$ally re(ie+ the "a$ility-s mi$robiolo i$, histopatholo i$, and postmortem data to identi"y additional $ases .2<!/<!7<!79/. Cate ory #1 <. #" $ases o" asper illosis or other health,$are,,asso$iated airborne "un al in"e$tions o$$ur, a ressi(ely pursue the dia nosis +ith tissue biopsies and $ultures as "easible .11!1/## 1:!2<!7=!7<##7;/. Cate ory #1 4. #mplement in"e$tion,$ontrol measures rele(ant to $onstru$tion, reno(ation, maintenan$e, demolition, and repair .1!1:!0;!7=!:=/. Cate ory #1, #C .*#*3 >.1, >.2/ 1. 1e"ore the pro:e$t ets under +ay, per"orm an #CR* to de"ine the s$ope o" the a$ti(ity and the need "or barrier measures .1!11!1/##1:!09##71!:=/. Cate ory #1, #C .*#*3 >.1/ a. Determine i" immuno$ompromised patients may be at ris2 "or e7posure to "un al spores "rom dust enerated durin the pro:e$t .1/##1:!09!71/. b. De(elop a $ontin en$y plan to pre(ent su$h e7posures .1/##1:!09!71/. 2. #mplement in"e$tion,$ontrol measures "or e7ternal demolition and $onstru$tion a$ti(ities .11!1/##1:!7=!:1!:2/. Cate ory #1 a. Determine i" the "a$ility $an operate temporarily on re$ir$ulated air' i" "easible, seal o"" ad:a$ent air inta2es. b. #" this is not possible or pra$ti$al, $he$2 the lo+,e""i$ien$y .rou hin / "ilter ban2s "re0uently and repla$e as needed to a(oid buildup o" parti$ulates. $. Seal +indo+s and redu$e +here(er possible other sour$es o" outside air intrusion .e. ., open doors in stair+ells and $orridors/, espe$ially in P4 areas. <. *(oid dama in the under round +ater system .i.e., buried pipes/ to pre(ent soil and dust $ontamination o" the +ater .1!://. Cate ory #1, #C .*#*3 >.1/ =. #mplement in"e$tion,$ontrol measures "or internal $onstru$tion a$ti(ities .1!11!1/##1:!09## 7=!:0/. Cate ory #1, #C .*#*3 >.1, >.2/ a. Constru$t barriers to pre(ent dust "rom $onstru$tion areas "rom enterin patient,$are areas' ensure that barriers are impermeable to "un al spores and in $omplian$e +ith lo$al "ire $odes .1!07!09!0;!77!:0##::/. b. Seal o"" and blo$2 return air (ents i" ri id barriers are used "or $ontainment .1!1:!7=/.

$. #mplement dust,$ontrol measures on sur"a$es and di(ert pedestrian tra""i$ a+ay "rom +or2 ?ones .1!09!0;!:0/. d. Relo$ate patients +hose rooms are ad:a$ent to +or2 ?ones, dependin on their immune status, the s$ope o" the pro:e$t, the potential "or eneration o" dust or +ater aerosols, and the methods used to $ontrol these aerosols .1!:0!:7/. >. Per"orm those en ineerin and +or2,site related in"e$tion,$ontrol measures as needed "or internal $onstru$tion, repairs, and reno(ations .1!09!0;!71!:0!::/. Cate ory #1, #C .*#*3 >.1, >.2/ a. 4nsure proper operation o" the air,handlin system in the a""e$ted area a"ter ere$tion o" barriers and be"ore the room or area is set to ne ati(e pressure ./;!0<!7=!:0/. Cate ory #1 b. Create and maintain ne ati(e air pressure in +or2 ?ones ad:a$ent to patient,$are areas and ensure that re0uired en ineerin $ontrols are maintained .1!09!0;!71!:0!::/. $. Monitor ne ati(e air"lo+ inside ri id barriers .1!:</. d. Monitor barriers and ensure inte rity o" the $onstru$tion barriers' repair aps or brea2s in barrier :oints .1!:7!::!:9/. e. Seal +indo+s in +or2 ?ones i" pra$ti$al' use +indo+ $hutes "or disposal o" lar e pie$es o" debris as needed, but ensure that the ne ati(e pressure di""erential "or the area is maintained .1!1/!09/. ". Dire$t pedestrian tra""i$ "rom $onstru$tion ?ones a+ay "rom patient,$are areas to minimi?e dispersion o" dust .1!1/##1:!00!09##71!:0/. . Pro(ide $onstru$tion $re+s +ith 1/ desi nated entran$es, $orridors, and ele(ators +here(er pra$ti$al' 2/ essential ser(i$es .e. ., toilet "a$ilities/ and $on(enien$e ser(i$es .e. ., (endin ma$hines/' </ prote$ti(e $lothin .e. ., $o(eralls, "oot ear, and head ear/ "or tra(el to patient,$are areas' and =/ a spa$e or anteroom "or $han in $lothin and storin e0uipment .1!11!1/##1:!7=/. h. Clean +or2 ?ones and their entran$es daily by 1/ +et,+ipin tools and tool $arts be"ore their remo(al "rom the +or2 ?one' 2/ pla$in mats +ith ta$2y sur"a$es inside the entran$e' and </ $o(erin debris and se$urin this $o(erin be"ore remo(in debris "rom the +or2 ?one .1!11!1/##1:!7=/. i. #n patient,$are areas, "or ma:or repairs that in$lude remo(al o" $eilin tiles and disruption o" the spa$e abo(e the "alse $eilin , use plasti$ sheets or pre"abri$ated plasti$ units to $ontain dust' use a ne ati(e pressure system +ithin this en$losure to

remo(e dust' and either pass air throu h an industrial, rade, portable &4P* "ilter $apable o" "iltration rates o" <EE,,CEE "t<Fmin., or e7haust air dire$tly to the outside .1:!7=!:0!:<!:;/. :. 6pon $ompletion o" the pro:e$t, $lean the +or2 ?one a$$ordin to "a$ility pro$edures, and install barrier $urtains to $ontain dust and debris be"ore remo(in ri id barriers .1!11!1/# #1:!09##7=/. 2. 5lush the +ater system to $lear sediment "rom pipes to minimi?e +aterborne mi$roor anism proli"eration .1!://. l. Restore appropriate *C&, humidity, and pressure di""erential' $lean or repla$e air "ilters' dispose o" spent "ilters ./!0!29!0</. 5. 6se airborne,parti$le samplin as a tool to e(aluate barrier inte rity ./!<=/. Cate ory ## B. Commission the &8*C system "or ne+ly $onstru$ted health,$are "a$ilities and reno(ated spa$es be"ore o$$upan$y and use, +ith emphasis on ensurin proper (entilation "or operatin rooms, *## rooms, and P4 areas .1!<=##<2/. Cate ory #C .*#*3 >.1' *S&R*43 1,199D/ &. !o re$ommendation is o""ered re ardin routine mi$robiolo i$ air samplin be"ore, durin , or a"ter $onstru$tion, or be"ore or durin o$$upan$y o" areas housin immuno$ompromised patients .;!09!0;!71!:0!</!<0/. 6nresol(ed issue #. #" a $ase o" health,$are,,a$0uired asper illosis or other opportunisti$ en(ironmental airborne "un al disease o$$urs durin or immediately a"ter $onstru$tion, implement appropriate "ollo+,up measures .0=!09!<7##<9/. Cate ory #1 1. Re(ie+ pressure,di""erential monitorin do$umentation to (eri"y that pressure di""erentials in the $onstru$tion ?one and in P4 rooms are appropriate "or their settin s .1!0=!<9/. Cate ory #1, #C .*#*3 >.1/ 2. #mplement $orre$ti(e en ineerin measures to restore proper pressure di""erentials as needed .1!0=!<9/. Cate ory #1, #C .*#*3 >.1/ <. Condu$t a prospe$ti(e sear$h "or additional $ases and intensi"y retrospe$ti(e epidemiolo i$ re(ie+ o" the hospital-s medi$al and laboratory re$ords .2<!09!<:!<;!9=/. Cate ory #1 =. #" no epidemiolo i$ e(iden$e o" on oin transmission e7ists, $ontinue routine maintenan$e in the area to pre(ent health,$are,,a$0uired "un al disease .2<!<7/. Cate ory #1

#" no epidemiolo i$ e(iden$e e7ists o" on oin transmission o" "un al disease, $ondu$t an en(ironmental assessment to "ind and eliminate the sour$e .11!1/## 1:!2<!00!0;##71!:=!91/. Cate ory #1

1. Colle$t en(ironmental samples "rom potential sour$es o" airborne "un al spores, pre"erably by usin a hi h,(olume air sampler rather than settle plates .2!0!11!1/## 1:!2<!00!0;!7=!:0!:7!91##9:/. Cate ory #1 2. #" either an en(ironmental sour$e o" airborne "un i or an en ineerin problem +ith "iltration or pressure di""erentials is identi"ied, promptly per"orm $orre$ti(e measures to eliminate the sour$e and route o" entry .0;!:=/. Cate ory #1 <. 6se an 4P*,re istered anti"un al bio$ide .e. ., $opper,C,0uinolinolate/ "or de$ontaminatin stru$tural materials .1:!:1!::!9</. Cate ory #1 =. #" an en(ironmental sour$e o" airborne "un i is not identi"ied, re(ie+ in"e$tion,$ontrol measures, in$ludin en ineerin $ontrols, to identi"y potential areas "or $orre$tion or impro(ement .99!9;/. Cate ory #1 >. #" possible, per"orm mole$ular subtypin o" Asper illus spp. isolated "rom patients and the en(ironment to $ompare their strain identities .;=##;0/. Cate ory ## ;. #" air,supply systems to hi h,ris2 areas .e. ., P4 rooms/ are not optimal, use portable, industrial, rade &4P* "ilters on a temporary basis until rooms +ith optimal air,handlin systems be$ome a(ailable .1!1/##1:!2<!7=/. Cate ory ## III' Infection Control and +entilation Re,uirements for PE rooms
*. Minimi?e e7posures o" se(erely immuno$ompromised patients .e. ., solid,

or an transplant patients or allo enei$ neutropeni$ patients/ to a$ti(ities that mi ht $ause aerosoli?ation o" "un al spores .e. ., (a$uumin or disruption o" $eilin tiles/ ./<!09!71!<//. Cate ory #1 1. Minimi?e the len th o" time that immuno$ompromised patients in P4 are outside their rooms "or dia nosti$ pro$edures and other a$ti(ities ./<!:2/. Cate ory #1 C. Pro(ide respiratory prote$tion "or se(erely immuno$ompromised patients +hen they must lea(e P4 "or dia nosti$ pro$edures and other a$ti(ities' $onsult the most re$ent re(ision o" CDC-s 8ui$eline for Prevention of Health# Care##Associate$ Pneumonia "or in"ormation re ardin the appropriate type o" respiratory prote$tion. .2<!/</. Cate ory ## D. #n$orporate (entilation en ineerin spe$i"i$ations and dust,$ontrollin pro$esses into the plannin and $onstru$tion o" ne+ P4 units .5i ure 1/. Cate ory #1, #C 1. #nstall $entral or point,o",use &4P* "ilters "or supply .in$omin / air .1!2!2<!09!7:!<=! 9=!92!97!;7##1=2/. Cate ory #1, #C .*#*3 >.1, >.2, A.2.D/ 2. 4nsure that rooms are +ell,sealed by 1/ properly $onstru$tin +indo+s,

doors, and inta2e and e7haust ports' 2/ maintainin $eilin s that are smooth and "ree o" "issures, open :oints, and $re(i$es' </ sealin +alls abo(e and belo+ the $eilin ' and =/ monitorin "or lea2a e and ma2in any ne$essary repairs .1!2<!00!1==!1=1/. Cate ory #1, #C .*#*3 A.2.D</ <. 8entilate the room to maintain I12 *C& .1!2<!/<!1==!1=1!1=//. Cate ory #C .*#*3 A.2.D/ =. Lo$ate air supply and e7haust rilles so that $lean, "iltered air enters "rom one side o" the room, "lo+s a$ross the patient-s bed, and e7its "rom the opposite side o" the room .1!2<!1==!1=1/. Cate ory #C .*#*3 A.<1.D1/ >. Maintain positi(e room air pressure .I2.> Pa JE.E1,in$h +ater au eL/ in relation to the $orridor .1!/!2<!1==!1=1/. Cate ory #1, #C .*#*3 Table A.2/ D. Maintain air"lo+ patterns and monitor these on a daily basis by usin permanently installed (isual means o" dete$tin air"lo+ in ne+ or reno(ated $onstru$tion, or by usin other (isual methods .e. ., "lutter strips or smo2e tubes/ in e7istin P4 units. Do$ument the monitorin results .1!1//. Cate ory #C .*#*3 A.2.DD/ A. #nstall sel",$losin de(i$es on all room e7it doors in P4 rooms .1/. Cate ory #C .*#*3 A.2.D=/ 4. Do not use laminar air "lo+ systems in ne+ly $onstru$ted P4 rooms .;;!1=1/. Cate ory ## 5. Ta2e measures to prote$t immuno$ompromised patients +ho +ould bene"it "rom a P4 room and +ho also ha(e an airborne in"e$tious disease .e. ., a$ute 8K8 in"e$tion or tuber$ulosis/. 1. 4nsure that the patient-s room is desi ned to maintain positi(e pressure. 2. 6se an anteroom to ensure appropriate air,balan$e relationships and pro(ide independent e7haust o" $ontaminated air to the outside, or pla$e a &4P* "ilter in the e7haust du$t i" the return air must be re$ir$ulated .1!1==/ .5i ure 2/. Cate ory #C .*#*3 A.2.D1, *A.2.D/ <. #" an anteroom is not a(ailable, pla$e the patient in *## and use portable, industrial, rade &4P* "ilters to enhan$e "iltration o" spores in the room .///. Cate ory ## B. Maintain ba$2up (entilation e0uipment .e. ., portable units "or "ans or "ilters/ "or emer en$y pro(ision o" re0uired (entilation "or P4 areas and ta2e immediate steps to restore the "i7ed (entilation system .1!/<!0</. Cate ory #C .*#*3 >.1/ I+' Infection-Control and +entilation Re,uirements for AII Rooms

*. #n$orporate $ertain spe$i"i$ations into the plannin and $onstru$tion or

reno(ation o" *## units .1!/0!1==!1=1!1=0/ .5i ure </. Cate ory #1, #C 1. Maintain $ontinuous ne ati(e air pressure .2.> Pa JE.E1 in$h +ater au eL/ in relation to the air pressure in the $orridor' monitor air pressure periodi$ally, pre"erably daily, +ith audible manometers or smo2e tubes at the door ."or e7istin *## rooms/, or +ith a permanently installed (isual monitorin me$hanism. Do$ument the results o" monitorin .1!1==!1=1/. Cate ory #C .*#*3 A.2.CA, Table A.2/ 2. 4nsure that rooms are +ell,sealed by properly $onstru$tin +indo+s, doors, and air,inta2e and e7haust ports' +hen monitorin indi$ates air lea2a e, lo$ate the lea2 and ma2e ne$essary repairs .1!;;!1==/. Cate ory #1, #C .*#*3 A.2.C</ <. #nstall sel",$losin de(i$es on all *## room e7it doors .1/. Cate ory #C .*#*3 A.2.C=/ =. Pro(ide (entilation to ensure I12 *C& "or reno(ated rooms and ne+ rooms, and ID *C& "or e7istin *## rooms .1!/0!1=0/. Cate ory #1, #C .*#*3 Table A.2/ >. Dire$t e7haust air to the outside, a+ay "rom air,inta2e and populated areas. #" this is not pra$ti$al, air "rom the room $an be re$ir$ulated a"ter passin throu h a &4P* "ilter .1!/0/. Cate ory #C .*#*3 Table A.2/
1. Where supplemental en ineerin $ontrols "or air $leanin are indi$ated "rom a

ris2 assessment o" the *## area, install 68B# units in the e7haust air du$ts o" the &8*C system to supplement &4P* "iltration or install 68B# "i7tures on or near the $eilin to irradiate upper room air ./0/. Cate ory ## C. #mplement en(ironmental in"e$tion,$ontrol measures "or persons +ith dia nosed or suspe$ted airborne in"e$tious diseases. 1. 6se *## rooms "or patients +ith or suspe$ted o" ha(in an airborne in"e$tion +ho also re0uire $ou h,indu$in pro$edures, or use an en$losed booth that is en ineered to pro(ide 1/ I12 *C&' 2/ air supply and e7haust rate su""i$ient to maintain a 2.> Pa .E.E1,in$h +ater au e/ ne ati(e pressure di""eren$e +ith respe$t to all surroundin spa$es +ith an e7haust rate o" I>E "t<Fmin' and </ air e7hausted dire$tly outside a+ay "rom air inta2es and tra""i$ or e7hausted a"ter &4P* "iltration be"ore re$ir$ulation .1!/0!1=7##1=</. Cate ory #1, #C .*#*3 A.1>.4, A.<1.D2<, 9.1E, Table A.2/ 2. *lthou h airborne spread o" (iral hemorrha i$ "e(er .8&5/ has not been do$umented in a health,$are settin , pruden$e di$tates pla$in a 8&5 patient in an *## room, pre"erably

+ith an anteroom, to redu$e the ris2 o" o$$upational e7posure to aerosoli?ed in"e$tious material in blood, (omitus, li0uid stool, and respiratory se$retions present in lar e amounts durin the end sta e o" a patient-s illness .1=9##11=/. Cate ory ## a. #" an anteroom is not a(ailable, use portable, industrial, rade &4P* "ilters in the patient-s room to pro(ide additional *C& e0ui(alents "or remo(in airborne parti$ulates. b. 4nsure that health,$are +or2ers +ear "a$e shields or o les +ith appropriate respirators +hen enterin the rooms o" 8&5 patients +ith prominent $ou h, (omitin , diarrhea, or hemorrha e .1=;/. <. Pla$e smallpo7 patients in ne ati(e pressure rooms at the onset o" their illness, pre"erably usin a room +ith an anteroom, i" a(ailable ./:/. Cate ory ## D. !o re$ommendation is o""ered re ardin ne ati(e pressure or isolation "or patients +ith Pneumocystis carinii pneumonia .111##11//. 6nresol(ed issue. 4. Maintain ba$2up (entilation e0uipment .e. ., portable units "or "ans or "ilters/ "or emer en$y pro(ision o" (entilation re0uirements "or *## rooms, and ta2e immediate steps to restore the "i7ed (entilation system .1!/0!0</. Cate ory #C .*#*3 >.1/ +' Infection-Control and +entilation Re,uirements for - eratin& Rooms *. #mplement en(ironmental in"e$tion,$ontrol and (entilation measures "or operatin rooms. 1. Maintain positi(e,pressure (entilation +ith respe$t to $orridors and ad:a$ent areas .1!110!117/. Cate ory #1, #C .*#*3 Table A.2/ 2. Maintain I1> *C&, o" +hi$h I< *C& should be "resh air .1!11:!11</. Cate ory #C .*#*3 Table A.2/ <. 5ilter all re$ir$ulated and "resh air throu h the appropriate "ilters, pro(idin 9EM e""i$ien$y .dust,spot testin / at a minimum .1!119/. Cate ory #C .*#*3 Table A.</ =. #n rooms not en ineered "or hori?ontal laminar air"lo+, introdu$e air at the $eilin and e7haust air near the "loor .1!117!11;/. Cate ory #C .*#*3 A.<1.D=/ >. Do not use ultra(iolet .68/ li hts to pre(ent sur i$al,site in"e$tions .117!12=##12:/. Cate ory #1 D. ;eep operatin room doors $losed e7$ept "or the passa e o" e0uipment, personnel, and patients, and limit entry to essential personnel .12<!129/. Cate ory #1

1. 5ollo+ pre$autionary pro$edures "or in"e$tious T1 patients +ho also re0uire

emer en$y sur ery ./0!12;!1/=/. Cate ory #1, #C 1. 6se an !9> respirator appro(ed by the !ational #nstitute "or @$$upational Sa"ety and &ealth +ithout e7halation (al(es in the operatin room .12;!1/1/. Cate ory #C .@$$upational Sa"ety and &ealth *dministration J@S&*L' 29 Code o" 5ederal Re ulations JC5RL 191E.1<=,1<9/ 2. #ntubate the patient in either the *## room or the operatin room' i" intubatin the patient in the operatin room, do not allo+ the doors to open until 99M o" the airborne $ontaminants are remo(ed .Table 1/ ./0!11</. Cate ory #1 <. When anestheti?in a patient +ith $on"irmed or suspe$ted T1, pla$e a ba$terial "ilter bet+een the anesthesia $ir$uit and patient-s air+ay to pre(ent $ontamination o" anesthesia e0uipment or dis$har e o" tuber$le ba$illi into the ambient air .1/=!1/2/. Cate ory #1 =. 47tubate and allo+ the patient to re$o(er in an *## room ./0!11</. Cate ory #1 >. #" the patient has to be e7tubated in the operatin room, allo+ ade0uate time "or *C& to $lean 99M o" airborne parti$les "rom the air .Table 1/, be$ause e7tubation is a $ou h, produ$in pro$edure ./0!11</. Cate ory #1
C. 6se portable, industrial, rade &4P* "ilters temporarily "or supplemental air

$leanin durin intubation and e7tubation "or T1 patients +ho re0uire sur ery .//!/0!11</. Cate ory ## 1. Position the units appropriately so that all room air passes throu h the "ilter' obtain en ineerin $onsultation to determine the appropriate pla$ements ./0/. Cate ory ## 2. S+it$h the portable unit o"" durin the sur i$al pro$edure. Cate ory ## <. Pro(ide "resh air as per (entilation standards "or operatin rooms' portable units do not meet the re0uirements "or the number o" "resh *C& .1!//!1///. Cate ory ## D. #" possible, s$hedule T1 patients as the last sur i$al $ases o" the day to ma7imi?e the time a(ailable "or remo(al o" airborne $ontamination. Cate ory ## 4. !o re$ommendation is o""ered "or per"ormin orthopedi$ implant operations in rooms supplied +ith laminar air"lo+ .119!12=/. 6nresol(ed issue 5. Maintain ba$2up (entilation e0uipment .e. ., portable units "or "ans or "ilters/ "or emer en$y (entilation o" operatin rooms, and ta2e immediate steps to restore the "i7ed (entilation system .1!0<!1/1!1/0/. Cate ory #1, #C .*#*3 >.1/

+I' -ther Potential Infectious Aerosol Ha.ards in Health-Care Facilities *. #n settin s +here sur i$al lasers are used, +ear appropriate personal prote$ti(e e0uipment .PP4/, in$ludin !9> or !1EE respirators, to minimi?e e7posure to laser plumes .12;!1/7!1/:/. Cate ory #C .@S&*' 29 C5R 191E.1<=,1<9/ 1. 6se $entral +all su$tion units +ith in,line "ilters to e(a$uate minimal laser plumes .1/7##1/9/. Cate ory ## C. 6se a me$hani$al smo2e e(a$uation system +ith a hi h,e""i$ien$y "ilter to mana e the eneration o" lar e amounts o" laser plume, +hen ablatin tissue in"e$ted +ith human papilloma (irus .&P8/ or per"ormin pro$edures on a patient +ith e7trapulmonary T1 ./0!1/:!1/<!1/;##101/. Cate ory ##

Recommendations --- /ater

I' Controllin& the ) read of /ater%orne !icroor&anisms *. Pra$ti$e hand hy iene to pre(ent the hand trans"er o" +aterborne patho ens, and use barrier pre$autions .e. ., lo(es/ as de"ined by other uidelines ./:!102##10:/. Cate ory #* 1. 4liminate $ontaminated +ater or "luid en(ironmental reser(oirs .e. ., in e0uipment or solutions/ +here(er possible .102!10</. Cate ory #1 C. Clean and disin"e$t sin2s and +ash basins on a re ular basis by usin an 4P*, re istered produ$t as set by "a$ility poli$ies. Cate ory ## D. 4(aluate "or possible en(ironmental sour$es .e. ., potable +ater/ o" spe$imen $ontamination +hen +aterborne mi$roor anisms .e. ., !TM/ o" unli2ely $lini$al importan$e are isolated "rom $lini$al $ultures .e. ., spe$imens $olle$ted asepti$ally "rom sterile sites or, i" postpro$edural, $oloni?ation a"ter use o" tap +ater in patient $are/ .109##171/. Cate ory #1 4. *(oid pla$in de$orati(e "ountains and "ish tan2s in patient,$are areas' ensure disin"e$tion and "ountain maintenan$e i" de$orati(e "ountains are used in publi$ areas o" the health,$are "a$ility .172/. Cate ory #1 II' Routine Prevention of /ater%orne !icro%ial Contamination /ithin the Distri%ution )ystem
*. Maintain hot +ater temperature at the return at the hi hest temperature

allo+able by state re ulations or $odes, pre"erably I12=N5 .I>1NC/, and maintain $old +ater temperature at GDCN5 .G2ENC/ .2<!17//. Cate ory #C .States' *S&R*43 1232EEE/ 1. #" the hot +ater temperature $an be maintained at I12=N5 .I>1NC/, e7plore en ineerin options .e. ., installin preset thermostati$ (al(es in point,o",use "i7tures/ to help minimi?e the ris2 o" s$aldin .17/). Cate ory ## C. When state re ulations or $odes do not allo+ hot +ater temperatures abo(e the ran e o" 1E>N5,,12EN5 .=E.DNC,,=9NC/ "or hospitals or 9>N5,,11EN5 .<>NC,,

=<.<NC/ "or nursin $are "a$ilities or +hen buildin s $annot be retro"itted "or thermostati$ mi7in (al(es, "ollo+ either o" these alternati(e pre(enti(e measures to minimi?e the ro+th o" 4e ionella spp. in +ater systems. Cate ory ## 1. Periodi$ally in$rease the hot +ater temperature to I1>EN5 .IDDNC/ at the point o" use .17//. Cate ory ## 2. *lternati(ely, $hlorinate the +ater and then "lush it throu h the system .17/##177/. Cate ory ## D. Maintain $onstant re$ir$ulation in hot,+ater distribution systems ser(in patient,$are areas .1/. Cate ory #C .*#*3 A.<1.4.</ III' Remediation )trate&ies for Distri%ution )ystem Re air or Emer&encies *. Whene(er possible, dis$onne$t the i$e ma$hine be"ore planned +ater disruptions. Cate ory ## 1. Prepare a $ontin en$y plan to estimate +ater demands "or the entire "a$ility in ad(an$e o" si ni"i$ant +ater disruptions .i.e., those e7pe$ted to result in e7tensi(e and hea(y mi$robial or $hemi$al $ontamination o" the potable +ater/, se+a e intrusion, or "loodin .07!17:/. Cate ory #C .%C*&@3 4C 1.=/ C. When a si ni"i$ant +ater disruption or an emer en$y o$$urs, adhere to any ad(isory to boil +ater issued by the muni$ipal +ater utility .17</. Cate ory #1, #C .Muni$ipal order/ 1. *lert patients, "amilies, sta"", and (isitors not to $onsume +ater "rom drin2in "ountains, i$e, or drin2s made "rom muni$ipal tap +ater, +hile the ad(isory is in e""e$t, unless the +ater has been disin"e$ted .e. ., by brin in to a rollin boil "or I1 minute/ .17</. Cate ory #1, #C .Muni$ipal order/ 2. *"ter the ad(isory is li"ted, run "au$ets and drin2in "ountains at "ull "lo+ "or I>minutes, or use hi h,temperature +ater "lushin or $hlorination .17/!17</. Cate ory #C, ## .Muni$ipal order' *S&R*43 1232EEE/ D. Maintain a hi h le(el o" sur(eillan$e "or +aterborne disease amon patients a"ter a boil +ater ad(isory is li"ted. Cate ory ## 4. Corre$ti(e de$ontamination o" the hot +ater system mi ht be ne$essary a"ter a disruption in ser(i$e or a $ross,$onne$tion +ith se+er lines has o$$urred. 1. De$ontaminate the system +hen the "e+est o$$upants are present in the buildin .e. ., ni hts or +ee2ends/ .2<!17//. Cate ory #C .*S&R*43 1232EEE/ 2. #" usin hi h,temperature de$ontamination, raise the hot,+ater temperature

to 1DEN5,,1AEN5 .A1NC,,AANC/ and maintain that le(el +hile pro ressi(ely "lushin ea$h outlet around the system "or I> minutes .2<!17//. Cate ory #C .*S&R*43 1232EEE/ <. #" usin $hlorination, add enou h $hlorine, pre"erably o(erni ht, to a$hie(e a "ree $hlorine residual o" I2 m FL .I2 ppm/ throu hout the system .17//. Cate ory #C .*S&R*43 1232EEE/ a. 5lush ea$h outlet until $hlorine odor is dete$ted. b. Maintain the ele(ated $hlorine $on$entration in the system "or I2 .but G2= hrs/. =. 6se a thorou h "lushin o" the +ater system instead o" $hlorination i" a hi hly $hlorine,resistant mi$roor anism .e. ., Cryptospori$ium spp./ is suspe$ted as the +ater $ontaminant. Cate ory ## 5. 5lush and restart e0uipment and "i7tures a$$ordin to manu"a$turer-s instru$tions. Cate ory ## B. Chan e the pretreatment "ilter and disin"e$t the dialysis +ater system +ith an 4P*,re istered produ$t to pre(ent $oloni?ation o" the re(erse osmosis membrane and do+nstream mi$robial $ontamination .179/. Cate ory ## &. Run +ater so"teners throu h a re eneration $y$le to restore their $apa$ity and "un$tion. Cate ory ## #. #" the "a$ility has a +ater,holdin reser(oir or +ater,stora e tan2, $onsult the "a$ility en ineer or lo$al health department to determine +hether this e0uipment needs to be drained, disin"e$ted +ith an 4P*,re istered produ$t, and re"illed. Cate ory ## %. #mplement "a$ility pro$edures to mana e a se+a e system "ailure or "loodin .e. ., arran in +ith other health,$are "a$ilities "or temporary trans"er o" patients or pro(ision o" ser(i$es/, and establish $ommuni$ations +ith the lo$al muni$ipal +ater utility and the lo$al health department to ensure that ad(isories are re$ei(ed in a timely manner a"ter release .07!17:/. Cate ory #C .%C*&@3 4C 1.=' Muni$ipal order/ ;. #mplement in"e$tion,$ontrol measures durin se+a e intrusion, "loodin , or other +ater,related emer en$ies. 1. Relo$ate patients and $lean or sterili?e supplies "rom a""e$ted areas. Cate ory ## 2. #" hands are not (isibly soiled or $ontaminated +ith proteina$eous material, in$lude an al$ohol,based hand rub in the hand hy iene pro$ess 1/ be"ore per"ormin in(asi(e pro$edures' 2/ be"ore and a"ter ea$h patient $onta$t' and </ +hene(er hand hy iene is indi$ated .10:/. Cate ory ##

<. #" hands are (isibly soiled or $ontaminated +ith proteina$eous material, use soap and bottled +ater "or hand+ashin .10:/. Cate ory ## =. #" the potable +ater system is not a""e$ted by "loodin or se+a e $ontamination, pro$ess sur i$al instruments "or sterili?ation a$$ordin to standard pro$edures. Cate ory ## >. Conta$t the manu"a$turer o" the automated endos$ope repro$essor .*4R/ "or spe$i"i$ instru$tions on the use o" this e0uipment durin a +ater ad(isory. Cate ory ## L. Remediate the "a$ility a"ter se+a e intrusion, "loodin , or other +ater,related emer en$ies. 1. Close o"" a""e$ted areas durin $leanup pro$edures. Cate ory ## 2. 4nsure that the se+a e system is "ully "un$tional be"ore be innin remediation so $ontaminated solids and standin +ater $an be remo(ed. Cate ory ## <. #" hard,sur"a$ed e0uipment, "loors, and +alls remain in ood repair, ensure that these are dry +ithin A2 hours' $lean +ith deter ent a$$ordin to standard $leanin pro$edures. Cate ory ## =. Clean +ood "urniture and materials .i" still in ood repair/' allo+ them to dry thorou hly be"ore restorin (arnish or other sur"a$e $oatin s. Cate ory ## >. Contain dust and debris durin remediation and repair as outlined in air re$ommendations .*ir3 ##B =, >/. Cate ory ## M. Re ardless o" the ori inal sour$e o" +ater dama e .e. ., "loodin (ersus +ater lea2s "rom point,o",use "i7tures or roo"s/, remo(e +et, absorbent stru$tural items .e. ., $arpetin , +allboard, and +allpaper/ and $loth "urnishin s i" they $annot be easily and thorou hly $leaned and dried +ithin A2 hours .e. ., moisture $ontent G2EM as determined by moisture meter readin s/' repla$e +ith ne+ materials as soon as the underlyin stru$ture is de$lared by the "a$ility en ineer to be thorou hly dry .2!0<!17;!1:=/. Cate ory #1 I+' Additional En&ineerin& !easures as Indicated %y E idemiolo&ic Investi&ation for Controllin& /ater%orne* Health-Care--Associated 0e&ionnaires Disease *. When usin a pulse or one,time de$ontamination method, superheat the +ater by "lushin ea$h outlet "or I> minutes +ith +ater at 1DEN5,,1AEN5 .A1NC,,AANC/ or hyper$hlorinate the system by "lushin all outlets "or I> minutes +ith +ater $ontainin I2 m FL .I2 ppm/ "ree residual $hlorine usin a $hlorine,based produ$t re istered by the 4P* "or +ater treatment .e. ., sodium hypo$hlorite J$hlorine blea$hL/ .17/!177!1:1##1:0/. Cate ory #1

1. *"ter a pulse treatment, maintain both the heated +ater temperature at the return and the $old +ater temperature per the re$ommendation .Water3 ## */ +here(er pra$ti$al and permitted by state $odes, or $hlorinate heated +ater to a$hie(e 1,,2 m FL .1,,2 ppm/ "ree residual $hlorine at the tap by usin a $hlorine,based produ$t re istered by the 4P* "or +ater treatment .e. ., sodium hypo$hlorite Jblea$hL/ .17/!1:7##1:;/. Cate ory #C .States' *S&R*43 1232EEE/ C. 47plore en ineerin or edu$ational options .e. ., install preset thermostati$ mi7in (al(es in point,o",use "i7tures or post +arnin si ns at ea$h outlet/ to minimi?e the ris2 o" s$aldin "or patients, (isitors, and sta"". Cate ory ## D. !o re$ommendation is o""ered "or treatin +ater in the "a$ility-s distribution system +ith $hlorine dio7ide, hea(y,metal ions .e. ., $opper or sil(er/, mono$hloramines, o?one, or 68 li ht .1<=##199/. 6nresol(ed issue +' General Infection-Control )trate&ies for Preventin& 0e&ionnaires Disease
*. Condu$t an in"e$tion,$ontrol ris2 assessment o" the "a$ility to determine i"

patients at ris2 or se(erely immuno$ompromised patients are present .2<!19;!1;=/. Cate ory #1 1. #mplement eneral strate ies "or dete$tin and pre(entin Le ionnaires disease in "a$ilities that do not pro(ide $are "or se(erely immuno$ompromised patients .i.e., "a$ilities that do not ha(e &SCT or solid,or an transplant pro rams/ .see *ppendi7/ .2<!19;!1;=/. Cate ory #1 1. 4stablish a sur(eillan$e pro$ess to dete$t health,$are,,asso$iated Le ionnaires disease .2<!19;!1;=/. Cate ory #1 2. #n"orm health,$are personnel .e. ., in"e$tion $ontrol, physi$ians, patient, $are sta"", en ineerin / re ardin the potential "or Le ionnaires disease to o$$ur and measures to pre(ent and $ontrol health,$are,,asso$iated le ionellosis .1::!1;1/. Cate ory #1 <. 4stablish me$hanisms to pro(ide $lini$ians +ith laboratory tests .e. ., $ulture, urine anti en, dire$t "luores$en$e assay JD5*L, and serolo y/ "or the dia nosis o" Le ionnaires disease .2<!19;/. Cate ory #1
C. Maintain a hi h inde7 o" suspi$ion "or health,$are,,asso$iated Le ionnaires

disease, and per"orm laboratory dia nosti$ tests "or le ionellosis on suspe$ted $ases, espe$ially in patients at ris2 +ho do not re0uire a P4 "or $are .e. ., patients re$ei(in systemi$ steroids' patients a ed ID> years' or patients +ith $hroni$ underlyin disease .e. ., diabetes mellitus, $on esti(e heart "ailure, or $hroni$ obstru$ti(e lun disease/ .2<!1::!1;=!1;2##1;9/. Cate ory #* D. Periodi$ally re(ie+ the a(ailability and $lini$ians- use o" laboratory dia nosti$ tests "or Le ionnaires disease in the "a$ility' i" $lini$ians- use o" the tests on patients +ith dia nosed or suspe$ted pneumonia is limited, implement

measures .e. ., an edu$ational $ampai n/ to enhan$e $lini$ians- use o" the test.s/ .1;//. Cate ory #1 4. #" one $ase o" laboratory,$on"irmed, health,$are,,asso$iated Le ionnaires disease is identi"ied, or i" t+o or more $ases o" laboratory,suspe$ted, health, $are,asso$iated Le ionnaires disease o$$ur durin a D,month period, $ertain a$ti(ities should be initiated .191!19;!1;1!1;/!1;;!2==/. Cate ory #1 1. Report the $ases to state and lo$al health departments +here re0uired. Cate ory #C .States/ 2. #" the "a$ility does not treat se(erely immuno$ompromised patients, $ondu$t an epidemiolo i$ in(esti ation, in$ludin retrospe$ti(e re(ie+ o" mi$robiolo i$, serolo i$, and postmortem data to loo2 "or pre(iously unidenti"ied $ases o" health,$are,,asso$iated Le ionnaires disease, and be in intensi(e prospe$ti(e sur(eillan$e "or additional $ases .2<!191!19;!1;1!1;/!1;;!2==/. Cate ory #1 <. #" no e(iden$e o" $ontinued health,$are,,asso$iated transmission e7ists, $ontinue intensi(e prospe$ti(e sur(eillan$e "or I2 months a"ter the initiation o" sur(eillan$e .2<!191! 19;!1;1!1;/!1;;!2==/. Cate ory #1
5. #" there is e(iden$e o" $ontinued health,$are,,asso$iated transmission .i.e., an

outbrea2/, $ondu$t an en(ironmental assessment to determine the sour$e o" 4e ionella spp. .1;;##2=</. Cate ory #1 1. Colle$t +ater samples "rom potential aerosoli?ed +ater sour$es .1o7 1 and 1o7 2/ .2=9/. Cate ory #1 2. Sa(e and subtype isolates o" 4e ionella spp. obtained "rom patients and the en(ironment .1:/!1;;##2=<!2=;/. Cate ory #1 <. #" a sour$e is identi"ied, promptly institute +ater system de$ontamination measures per re$ommendations .see Water #8/ .1:0!21=/. Cate ory #1 =. #" 4e ionella spp. are dete$ted in I1 $ulture .e. ., $ondu$ted at 2,+ee2 inter(als durin < months/, reassess the $ontrol measures, modi"y them a$$ordin ly, and repeat the de$ontamination pro$edures' $onsider intensi(e use o" te$hni0ues used in the initial de$ontamination, or a $ombination o" superheatin and hyper$hlorination .2<!21=!211/. Cate ory #1 B. #" an en(ironmental sour$e is not identi"ied durin a Le ionnaires disease outbrea2, $ontinue sur(eillan$e "or ne+ $ases "or I2 months. 4ither de"er de$ontamination pendin identi"i$ation o" the sour$e o" 4e ionella spp. or pro$eed +ith de$ontamination o" the hospital-s +ater distribution system, +ith spe$ial attention to areas in(ol(ed in the outbrea2. Cate ory ##

&. !o re$ommendation is o""ered re ardin routine $ulturin o" +ater systems in health,$are "a$ilities that do not ha(e patient,$are areas .i.e., P4 or transplant units/ "or persons at hi h ris2 "or 4e ionella spp. in"e$tion .see *ppendi7/ .1:1!1:7!1:<! 1;9!212##210/. 6nresol(ed issue #. !o re$ommendation is o""ered re ardin the remo(al o" "au$et aerators in areas "or immuno$ompetent patients. 6nresol(ed issue %. ;eep ade0uate re$ords o" all in"e$tion,$ontrol measures and en(ironmental test results "or potable +ater systems. Cate ory ## +I' Preventin& 0e&ionnaires Disease in Protective Environments and $rans lant "nits *. When implementin strate ies "or pre(entin Le ionnaires disease amon se(erely immuno$ompromised patients housed in "a$ilities +ith &SCT or solid,or an transplant pro rams, in$orporate these spe$i"i$ sur(eillan$e and epidemiolo i$ measures in addition to the steps outlined pre(iously .see *ppendi7/. 1. Maintain a hi h inde7 o" suspi$ion "or le ionellosis in transplant patients e(en +hen en(ironmental sur(eillan$e $ultures do not yield le ionellae .19;!217/. Cate ory #1 2. #" a $ase o$$urs in a se(erely immuno$ompromised patient, or i" se(erely immuno$ompromised patients are present in hi h,ris2 areas o" the hospital .e. ., P4 or transplant units/ and $ases are identi"ied else+here in the "a$ility, $ondu$t a $ombined epidemiolo i$ and en(ironmental in(esti ation to determine the sour$e o" 4e ionella spp. .19;!21=/. Cate ory #1
1. #mplement $ulture strate ies and potable +ater and "i7ture treatment measures

in addition to those pre(ious outlined .Water3 8/. Cate ory ## 1. Dependin on state re ulations on potable +ater temperature in publi$ buildin s .21:/, hospitals housin patients at hi h ris2 "or health,$are,, asso$iated le ionellosis should either maintain heated +ater +ith a minimum return temperature o" I12=N5 .I>1NC/ and $old +ater at GDCN5 .G2ENC/, or $hlorinate heated +ater to a$hie(e 1,,2 m FL .1,,2 ppm/ o" "ree residual $hlorine at the tap .17/##177!1:7!1:<##1:;!21</. Cate ory ## 2. Periodi$ $ulturin "or le ionellae in potable +ater samples "rom &SCT or solid,or an transplant units $an be per"ormed as part o" a $omprehensi(e strate y to pre(ent Le ionnaires disease in these units ./<!170!19;!219/. Cate ory ## <. !o re$ommendation is o""ered re ardin the optimal methodolo y .i.e., "re0uen$y or number o" sites/ "or en(ironmental sur(eillan$e $ultures in &SCT

or solid,or an transplant units. 6nresol(ed issue =. #n areas +ith patients at ris2, +hen 4e ionella spp. are not dete$table in unit +ater, remo(e, $lean, and disin"e$t sho+er heads and tap aerators monthly by usin a $hlorine,based, 4P*,re istered produ$t. #" an 4P*,re istered $hlorine disin"e$tant is not a(ailable, use a $hlorine blea$h solution .>EE,,D1> ppm J131EE (F( dilutionL/ .17/!19</. Cate ory ##
C. #" 4e ionella spp. are determined to be present in the +ater o" a transplant

unit, implement $ertain measures until 4e ionella spp. are no lon er dete$ted by $ulture. 1. De$ontaminate the +ater supply as outlined pre(iously .Water3 #8/ .2<!/<!17/!1:0!21=/. Cate ory #1 2. Do not use +ater "rom the "au$ets in patient,$are rooms to a(oid $reatin in"e$tious aerosols ./<!21;/. Cate ory #1 <. Restri$t se(erely immuno$ompromised patients "rom ta2in sho+ers ./<!21;/. Cate ory #1 =. 6se +ater that is not $ontaminated +ith 4e ionella spp. "or &SCT patientsspon e baths ./<!21;/. Cate ory #1 >. Pro(ide patients +ith sterile +ater "or tooth brushin , drin2in , and "or "lushin naso astri$ tubin durin le ionellosis outbrea2s ./<!21;/. Cate ory #1 D. Do not use lar e,(olume room air humidi"iers that $reate aerosols .e. ., by 8enturi prin$iple, ultrasound, or spinnin dis2/ unless they are sub:e$ted to hi h,le(el disin"e$tion and "illed only +ith sterile +ater .2<!/<!2=1!22=/. Cate ory #1 +II' Coolin& $o1ers and Eva orative Condensers *. When plannin $onstru$tion o" ne+ health,$are "a$ilities, lo$ate $oolin to+ers so that the dri"t is dire$ted a+ay "rom the air,inta2e system, and desi n the to+ers to minimi?e the (olume o" aerosol dri"t .17/!2=/!221/. Cate ory #C .*S&R*4 12,2EEE/ 1. #mplement in"e$tion,$ontrol pro$edures "or operational $oolin to+ers .17/!2=/!222/. Cate ory #C .*S&R*4 12,2EEE/ 1. #nstall dri"t eliminators .17/!2=/!222/. Cate ory #C .*S&R*4 12,2EEE/ 2. 6se an e""e$ti(e 4P*,re istered bio$ide on a re ular basis .17//. Cate ory #C .*S&R*4 12,2EEE/ <. Maintain to+ers a$$ordin to manu"a$turers- re$ommendations, and 2eep detailed maintenan$e and in"e$tion,$ontrol re$ords, in$ludin en(ironmental

test results "rom le ionellosis outbrea2 in(esti ations .17//. Cate ory #C .*S&R*4 12,2EEE/ C. #" $oolin to+ers or e(aporati(e $ondensers are impli$ated in health,$are,, asso$iated le ionellosis, de$ontaminate the $oolin ,to+er system .1;;!2=/!221!22//. Cate ory #1 +III' Dialysis /ater 2uality and Dialysate *. *dhere to $urrent **M# standards "or 0uality,assuran$e per"orman$e o" de(i$es and e0uipment used to treat, store, and distribute +ater in hemodialysis $enters .both a$ute and maintenan$e J$hroni$L settin s/ and "or the preparation o" $on$entrates and dialysate .220##2/7/. Cate ory #*, #C .**M#3 *meri$an !ational Standards #nstitute J*!S#LF**M# RD>31992, *!S#F**M# RD=A3199</ 1. !o re$ommendation is o""ered re ardin +hether more strin ent re0uirements "or +ater 0uality should be imposed in hemo"iltration and hemodia"iltration. 6nresol(ed issue C. Condu$t mi$robiolo i$ testin spe$i"i$ to +ater in dialysis settin s .22;!2/=!2/:##2/9/. Cate ory #*, #C .**M#3 *!S#F**M# RD>31992, *!S#F**M# RD=A3199<, RDD232EE1/ 1. Per"orm ba$teriolo i$ assays o" +ater and dialysis "luids at least on$e a month and durin outbrea2s by usin standard 0uantitati(e methods .2/:## 2/9/. Cate ory #*, #C .**M#3 *!S#F**M# RDD232EE1/ a. *ssay "or heterotrophi$, mesophili$ ba$teria .e. ., Pseu$omonas spp/. b. Do not use nutrient,ri$h media .e. ., blood a ar or $ho$olate a ar/. 2. #n $on:un$tion +ith mi$robiolo i$ testin , per"orm endoto7in testin on produ$t +ater used to repro$ess dialy?ers "or multiple use .22;!2/=!2/;##202/. Cate ory #*, #C .**M#3 *!S#F**M# RD>31992, *!S#F**M# RD=A3199</ <. 4nsure that +ater does not e7$eed the limits "or mi$robial $ounts and endoto7in $on$entrations .Table 2/ .22;##2/1/. Cate ory #*, #C .**M#3 *!S#F**M# RD>31992, *!S#F**M# RD=A3199</ D. Disin"e$t +ater distribution systems in dialysis settin s at least +ee2ly .22:## 229!2/1!2/:/. Cate ory #*, #C .**M#3 *!S#F**M# RDD232EE1/ 4. Where(er pra$ti$al, desi n and en ineer +ater systems in dialysis settin s to a(oid in$orporatin :oints, dead,end pipes, and unused bran$hes and taps that

$an harbor ba$teria .22:## 229!2/1!2/:/. Cate ory #*, #C .**M#3 *!S#F**M# RDD232EE1/ 5. When stora e tan2s are used in dialysis systems, they should be routinely drained, disin"e$ted +ith an 4P*,re istered produ$t, and "itted +ith an ultra"ilter or pyro eni$ "ilter .membrane "ilter +ith a pore si?e su""i$ient to remo(e parti$les and mole$ules I1 2ilodalton/ installed in the +ater line distal to the stora e tan2 .2/:/. Cate ory #C .**M#3 *!S#F**M# RDD232EE1/ I3' Ice !achines and Ice *. Do not handle i$e dire$tly by hand, and +ash hands be"ore obtainin i$e. Cate ory ## 1. 6se a smooth,sur"a$e i$e s$oop to dispense i$e .20/!200/. Cate ory ## 1. ;eep the i$e s$oop on a $hain short enou h that the s$oop $annot tou$h the "loor or 2eep the s$oop on a $lean, hard sur"a$e +hen not in use .20/!200/. Cate ory ## 2. Do not store the i$e s$oop in the i$e bin. Cate ory ## C. Do not store pharma$euti$als or medi$al solutions on i$e intended "or $onsumption' use sterile i$e to 2eep medi$al solutions $old, or use e0uipment spe$i"i$ally manu"a$tured "or this purpose .200!207/. Cate ory #1 D. Ma$hines that dispense i$e are pre"erred to those that re0uire i$e to be remo(ed "rom bins or $hests +ith a s$oop .20:!20</. Cate ory ## 4. Limit a$$ess to i$e,stora e $hests, and 2eep $ontainer doors $losed e7$ept +hen remo(in i$e .200/. Cate ory ## 5. Clean, disin"e$t, and maintain i$e,stora e $hests on a re ular basis. Cate ory ## 1. 5ollo+ the manu"a$turer-s instru$tions "or $leanin . Cate ory ## 2. 6se an 4P*,re istered disin"e$tant suitable "or use on i$e ma$hines, dispensers, or stora e $hests in a$$ordan$e +ith label instru$tions. Cate ory ## <. #" instru$tions and 4P*,re istered disin"e$tants suitable "or use on i$e ma$hines are not a(ailable, use a eneral $leanin Fdisin"e$tin re imen .1o7 </ .200/. Cate ory ## =. 5lush and $lean i$e ma$hines and dispensers i" they ha(e not been dis$onne$ted be"ore anti$ipated len thy +ater disruptions. Cate ory ## B. #nstall proper air aps +here the $ondensate lines meet the +aste lines. Cate ory ##. &. Condu$t mi$robiolo i$ samplin o" i$e, i$e $hests, and i$e,ma2in ma$hines and dispensers +here indi$ated durin an epidemiolo i$ in(esti ation .200!209!20;/. Cate ory #1

3' Hydrothera y $an4s and Pools *. Drain and $lean hydrotherapy e0uipment .e. ., &ubbard tan2s, tubs, +hirlpools, +hirlpool spas, or birthin tan2s/ a"ter ea$h patient-s use, and disin"e$t e0uipment sur"a$es and $omponents by usin an 4P*,re istered produ$t in a$$ordan$e +ith the manu"a$turer-s instru$tions. Cate ory ## 1. #n the absen$e o" an 4P*,re istered produ$t "or +ater treatment, add sodium hypo$hlorite to the +ater3 1. Maintain a 1>,ppm $hlorine residual in the +ater o" small hydrotherapy tan2s, &ubbard tan2s, and tubs .27=/. Cate ory ## 2. Maintain a 2,,>,ppm $hlorine residual in the +ater o" +hirlpools and +hirlpool spas .271/. Cate ory ## <. #" the p& o" the muni$ipal +ater is in the basi$ ran e .e. ., +hen $hloramine is used as the primary drin2in +ater disin"e$tant in the $ommunity/, $onsult the "a$ility en ineer re ardin the possible need to ad:ust the p& o" the +ater to a more a$idi$ le(el be"ore disin"e$tion, to enhan$e the bio$idal a$ti(ity o" the $hlorine .272/. Cate ory ## C. Clean and disin"e$t hydrotherapy e0uipment a"ter usin tub liners. Cate ory ## D. Clean and disin"e$t in"latable tubs unless they are sin le,use e0uipment. Cate ory ## 4. !o re$ommendation is o""ered re ardin the use o" antisepti$ $hemi$als .e. ., $hloramine,T/ in the +ater durin hydrotherapy sessions. 6nresol(ed issue 5. Condu$t a ris2 assessment o" patients be"ore their use o" lar e hydrotherapy pools, de"errin patients +ith drainin +ounds or "e$al in$ontinen$e "rom pool use until their $ondition resol(es. Cate ory ## B. 5or lar e hydrotherapy pools, use p& and $hlorine residual le(els appropriate "or an indoor pool as pro(ided by lo$al and state health a en$ies. Cate ory #C .States/ &. !o re$ommendation is o""ered re ardin the use in health,$are settin s o" +hirlpool or spa e0uipment manu"a$tured "or home or re$reational use. 6nresol(ed issue 3I' !iscellaneous !edical E,ui ment Connected to /ater )ystems *. Clean, disin"e$t, and maintain *4R e0uipment a$$ordin to the manu"a$turer-s instru$tions and rele(ant s$ienti"i$ literature to pre(ent inad(ertent $ontamination o" endos$opes and bron$hos$opes +ith +aterborne mi$roor anisms .27/##27</. Cate ory #1 1. To rinse disin"e$ted endos$opes and bron$hos$opes, use +ater o" the hi hest 0uality pra$ti$al "or the system-s en ineerin and desi n .e. ., sterile +ater or ba$teriolo i$ally "iltered

+ater J+ater "iltered throu h E.1,,E.2,Hm "iltersL/ .270!27:##279/. Cate ory #1 2. Dry the internal $hannels o" the repro$essed endos$ope or bron$hos$ope by usin a pro(en method .e. ., AEM al$ohol "ollo+ed by "or$ed,air treatment/ to lessen the potential "or proli"eration o" +aterborne mi$roor anisms and to help pre(ent bio"ilm "ormation .27;##2://. Cate ory #1 1. 6se +ater that meets nationally re$o ni?ed standards set by the 4P* "or drin2in +ater .G>EE C56FmL "or heterotrophi$ plate $ount/ "or routine dental treatment output +ater .2:0##2:</. Cate ory #C .4P*3 =E C5R 1 Part 1=1, Subpart B/ C. Ta2e pre$autions to pre(ent +aterborne $ontamination o" dental unit +ater lines and instruments. 1. *"ter ea$h patient, dis$har e +ater and air "or a minimum o" 2E,,<E se$onds "rom any dental de(i$e $onne$ted to the dental +ater system that enters a patient-s mouth .e. ., handpie$es, ultrasoni$ s$alers, or airF+ater syrin es/ .2:7!2:9/. Cate ory ## 2. Consult +ith dental +ater,line manu"a$turers to 1/ determine suitable methods and e0uipment to obtain the re$ommended +ater 0uality' and 2/ determine appropriate methods "or monitorin the +ater to ensure 0uality is maintained .2:7!2:;/. Cate ory ## <. Consult +ith the dental unit manu"a$turer re ardin the need "or periodi$ maintenan$e o" antiretra$tion me$hanisms .2:9!2:;/. Cate ory #1

Recommendations ---Environmental )ervices

I' Cleanin& and Disinfectin& )trate&ies for Environmental )urfaces in PatientCare Areas *. Sele$t 4P*,re istered disin"e$tants, i" a(ailable, and use them in a$$ordan$e +ith the manu"a$turer-s instru$tions .2<=##2<2/. Cate ory #C .4P*3 A 6nited States Code J6SCL O 1<D et se0./ 1. Do not use hi h,le(el disin"e$tantsFli0uid $hemi$al sterilants "or disin"e$tion o" either non$riti$al instruments and de(i$es or any en(ironmental sur"a$es' su$h use is $ounter to label instru$tions "or these to7i$ $hemi$als .2</##2<9/. Cate ory #C .5ood and Dru *dministration J5D*L3 21 C5R CE1.>, CEA.CA.e/ C. 5ollo+ manu"a$turers- instru$tions "or $leanin and maintainin non$riti$al medi$al e0uipment. Cate ory ## D. #n the absen$e o" a manu"a$turer-s $leanin instru$tions, "ollo+ $ertain pro$edures. 1. Clean non$riti$al medi$al e0uipment sur"a$es +ith a deter entFdisin"e$tant.

This may be "ollo+ed by an appli$ation o" an 4P*,re istered hospital disin"e$tant +ith or +ithout a tuber$ulo$idal $laim .dependin on the nature o" the sur"a$e and the de ree o" $ontamination/, in a$$ordan$e +ith ermi$ide label instru$tions .2<0/. Cate ory ## 2. Do not use al$ohol to disin"e$t lar e en(ironmental sur"a$es .2<//. Cate ory ## <. 6se barrier prote$ti(e $o(erin s as appropriate "or non$riti$al sur"a$es that are 1/ tou$hed "re0uently +ith lo(ed hands durin the deli(ery o" patient $are' 2/ li2ely to be$ome $ontaminated +ith blood or body substan$es' or </ di""i$ult to $lean .e. ., $omputer 2eyboards/ .2:7/. Cate ory ## 4. ;eep house2eepin sur"a$es .e. ., "loors, +alls, tabletops/ (isibly $lean on a re ular basis and $lean up spills promptly .2<;/. Cate ory ## 1. 6se a one,step pro$ess and an 4P*,re istered hospital deter entFdisin"e$tant desi ned "or eneral house2eepin purposes in patient, $are areas +here 1/ un$ertainty e7ists as to the nature o" the soil on the sur"a$es .e. ., blood or body "luid $ontamination (ersus routine dust or dirt/' or 2/ un$ertainty e7ists re ardin the presen$e o" multidru resistant or anisums on su$h sur"a$es .2<2!2<0!29=!291/. Cate ory ## 2. Deter ent and +ater are ade0uate "or $leanin sur"a$es in nonpatient,$are areas .e. ., administrati(e o""i$es/. Cate ory ## <. Clean and disin"e$t hi h,tou$h sur"a$es .e. ., door2nobs, bed rails, li ht s+it$hes, and sur"a$es in and around toilets in patients- rooms/ on a more "re0uent s$hedule than minimal, tou$h house2eepin sur"a$es. Cate ory ## =. Clean +alls, blinds, and +indo+ $urtains in patient,$are areas +hen they are (isibly dusty or soiled .2<=!292##290/. Cate ory ## 5. Do not per"orm disin"e$tant "o in in patient,$are areas .2<=!297/. Cate ory #1 B. *(oid lar e,sur"a$e $leanin methods that produ$e mists or aerosols, or disperse dust in patient,$are areas ./<!09!71!<//. Cate ory #1 &. 5ollo+ proper pro$edures "or e""e$ti(e uses o" mops, $loths, and solutions. Cate ory ## 1. Prepare $leanin solutions daily or as needed, and repla$e +ith "resh solution "re0uently a$$ordin to "a$ility poli$ies and pro$edures .29=!291/. Cate ory ## 2. Chan e the mop head at the be innin o" ea$h day and also as re0uired by "a$ility poli$y, or a"ter $leanin up lar e spills o" blood or other body

substan$es. Cate ory ## <. Clean mops and $loths a"ter use and allo+ to dry be"ore reuse' or use sin le, use, disposable mop heads and $loths .292!29:##299/. Cate ory ## #. *"ter the last sur i$al pro$edure o" the day or ni ht, +et (a$uum or mop operatin room "loors +ith a sin le,use mop and an 4P*,re istered hospital disin"e$tant .110/. Cate ory #1 %. Do not use mats +ith ta$2y sur"a$es at the entran$es to operatin rooms or in"e$tion,$ontrol suites .110/. Cate ory #1 ;. 6se appropriate dustin methods "or patient,$are areas desi nated "or immuno$ompromised patients .e. ., &SCT patients/ ./<!0=!29=/. Cate ory #1 1. Wet,dust hori?ontal sur"a$es daily by moistenin a $loth +ith a small amount o" an 4P*,re istered hospital deter entFdisin"e$tant ./<!0=!29=/. Cate ory #1 2. *(oid dustin methods that disperse dust .e. ., "eather,dustin / .0=/. Cate ory #1
L. ;eep (a$uums in ood repair and e0uip (a$uums +ith &4P* "ilters "or use

areas +ith patients at ris2 ./<!0=!29=!29;/. Cate ory #1 M. Close the doors o" immuno$ompromised patients- rooms +hen (a$uumin , +a7in , or bu""in $orridor "loors to minimi?e e7posure to airborne dust ./<!0=!29;/. Cate ory #1 !. When per"ormin lo+, or intermediate,le(el disin"e$tion o" en(ironmental sur"a$es in nurseries and neonatal units, a(oid unne$essary e7posure o" neonates to disin"e$tant residues on these sur"a$es by usin 4P*,re istered ermi$ides in a$$ordan$e +ith manu"a$turers- instru$tions and sa"ety ad(isories .2<1!2;=##2;2/. Cate ory #1, #C .4P*3 A 6SC O 1<D et se0./ 1. Do not use phenoli$s or any other $hemi$al ermi$ide to disin"e$t bassinets or in$ubators durin an in"ant-s stay .2<1!2;=##2;2/. Cate ory #1 2. Rinse disin"e$tant,treated sur"a$es, espe$ially those treated +ith phenoli$s, +ith +ater .2;=##2;2/. Cate ory #1 @. When usin phenoli$ disin"e$tants in neonatal units, prepare solutions to $orre$t $on$entrations in a$$ordan$e +ith manu"a$turers- instru$tions, or use premi7ed "ormulations .2<1!2;=##2;2/. Cate ory #1, #C .4P*3 A 6SC O 1<D et se0./ II' Cleanin& ) ills of (lood and (ody )u%stances *. Promptly $lean and de$ontaminate spills o" blood or other potentially in"e$tious materials .2;/##/==/. Cate ory #1, #C .@S&*3 29 C5R 191E.1E<E O d.=.ii.*/

1. 5ollo+ proper pro$edures "or site de$ontamination o" spills o" blood or blood, $ontainin body "luids .2;/##/==/. Cate ory #C .@S&*3 29 C5R 191E.1E<E O d.=.ii.*/ 1. 6se prote$ti(e lo(es and other PP4 appropriate "or this tas2 .2;//. Cate ory #C .@S&*3 29 C5R 191E.1E<E O d.<.i, ii/ 2. #" the spill $ontains lar e amounts o" blood or body "luids, $lean the (isible matter +ith disposable absorbent material, and dis$ard the used $leanin materials in appropriate, labeled $ontainers .2;/!2;9!2;;!/=1!/=2/. Cate ory #C .@S&*3 29 C5R 191E.1E<E O d.=.iii.1/ <. S+ab the area +ith a $loth or paper to+els moderately +etted +ith disin"e$tant, and allo+ the sur"a$e to dry .2;/!/=1/. Cate ory #C .@S&*3 29 C5R 191E.1E<E O d.=.ii.*/ C. 6se ermi$ides re istered by the 4P* "or use as hospital disin"e$tants and labeled tuber$ulo$idal or re istered ermi$ides on the 4P* Lists D and 4 .i.e., produ$ts +ith spe$i"i$ label $laims "or &#8 or hepatitis 1 (irus J&18L/ in a$$ordan$e +ith label instru$tions to de$ontaminate spills o" blood and other body "luids .2;/!/=1!/=//. Cate ory #C .@S&* 29 C5R 191E.1E<E O d.=.ii. * memorandum 2F2CF9A' $omplian$e do$ument JCPLL 2,2.==D J11F99L/ D. *n 4P*,re istered sodium hypo$hlorite produ$t is pre"erred, but i" su$h produ$ts are not a(ailable, eneri$ sodium hypo$hlorite solutions .e. ., household $hlorine blea$h/ may be used. 1. 6se a 131EE dilution .>EE,,D1> ppm a(ailable $hlorine/ to de$ontaminate nonporous sur"a$es a"ter $leanin a spill o" either blood or body "luids in patient,$are settin s ./=1!/=0/. Cate ory #1 2. #" a spill in(ol(es lar e amounts o" blood or body "luids, or i" a blood or $ulture spill o$$urs in the laboratory, use a 131E dilution .>,EEE,,D,1>E ppm a(ailable $hlorine/ "or the "irst appli$ation o" ermi$ide be"ore $leanin .2<;!/=1/. Cate ory #1 III' Car etin& and Cloth Furnishin&s *. 8a$uum $arpetin in publi$ areas o" health,$are "a$ilities and in eneral patient,$are areas re ularly +ith +ell,maintained e0uipment desi ned to minimi?e dust dispersion .29=/. Cate ory ## 1. Periodi$ally per"orm a thorou h, deep $leanin o" $arpetin as determined by "a$ility poli$y by usin a method that minimi?es the produ$tion o" aerosols and lea(es little or no residue .00/. Cate ory ##

C. *(oid use o" $arpetin in hi h,tra""i$ ?ones in patient,$are areas or +here spills are li2ely .e. ., burn therapy units, operatin rooms, laboratories, or intensi(e $are units/ .00!/=7!/=:/. Cate ory #1 D. 5ollo+ appropriate pro$edures "or mana in spills on $arpetin . 1. Spot,$lean blood or body substan$e spills promptly .2;/!/=1!/=0!/=</. Cate ory #C .@S&*3 29 C5R 191E.1E<E O d.=.ii.*, interpretation/ 2. #" a spill o$$urs on $arpet tiles, repla$e any tiles $ontaminated by blood and body "luids or body substan$es ./=</. Cate ory #C .@S&* 29 C5R 191E.1E<E O d.=.ii interpretation/
4. Thorou hly dry +et $arpetin to pre(ent the ro+th o" "un i' repla$e


B. &.


$arpetin that remains +et a"ter A2 hours ./<!1:=/. Cate ory #1 !o re$ommendation is o""ered re ardin the routine use o" "un i$idal or ba$teri$idal treatments "or $arpetin in publi$ areas o" a health,$are "a$ility or in eneral patient,$are areas. 6nresol(ed issue Do not use $arpetin in hall+ays and patient rooms in areas housin immunosuppressed patients .e. ., P4 areas/ ./<!00/. Cate ory #1 *(oid usin upholstered "urniture and "urnishin s in hi h,ris2 patient,$are areas and in areas +ith in$reased potential "or body substan$e $ontamination .e. ., pediatri$s units/ ./</. Cate ory ## !o re$ommendation is o""ered re ardin +hether upholstered "urniture and "urnishin s should be a(oided in eneral patient,$are areas. 6nresol(ed issue 1. Maintain upholstered "urniture in ood repair. Cate ory ## 2. Maintain the sur"a$e inte rity o" the upholstery by repairin tears and holes. Cate ory ## <. #" upholstered "urniture in a patient-s room re0uires $leanin to remo(e (isible soil or body substan$e $ontamination, mo(e that item to a maintenan$e area +here it $an be ade0uately $leaned +ith a pro$ess appropriate "or the type o" upholstery and nature o" the soil. Cate ory ##

I+' Flo1ers and Plants in Patient-Care Areas *. 5lo+ers and potted plants need not be restri$ted "rom areas "or immuno$ompetent patients ./=9##/11/. Cate ory ## 1. Desi nate $are and maintenan$e o" "lo+ers and potted plants to sta"" not dire$tly in(ol(ed +ith patient $are ./=;/. Cate ory ## C. #" plant or "lo+er $are by patient,$are sta"" is una(oidable, instru$t the sta"" to +ear lo(es +hen handlin plants and "lo+ers and per"orm hand hy iene a"ter lo(e remo(al ./=;/. Cate ory ## D. Do not allo+ "resh or dried "lo+ers, or potted plants, in patient,$are areas "or immunosuppressed patients ./<!71!/=9!/12/. Cate ory ##

+' Pest Control *. De(elop pest,$ontrol strate ies, +ith emphasis on 2it$hens, $a"eterias, laundries, $entral sterile supply areas, operatin rooms, loadin do$2s, $onstru$tion a$ti(ities, and other areas prone to in"estations ./1/##/17/. Cate ory ## 1. #nstall s$reens on all +indo+s that open to the outside' 2eep s$reens in ood repair ./10/. Cate ory #1 C. Contra$t "or routine pest $ontrol ser(i$e by a $redentialed pest,$ontrol spe$ialist +ho +ill tailor the appli$ation to the needs o" a health,$are "a$ility ./17/. Cate ory ## D. Pla$e laboratory spe$imens .e. ., "i7ed sputum smears/ in $o(ered $ontainers "or o(erni ht stora e ./1:!/1</. Cate ory ## +I' ) ecial Patho&ens
*. 6se appropriate hand hy iene, PP4 .e. ., lo(es/, and isolation pre$autions

durin $leanin and disin"e$tin pro$edures .10:!2<0!/19!/1;/. Cate ory #1 1. 6se standard $leanin and disin"e$tion proto$ols to $ontrol en(ironmental $ontamination +ith antibioti$,resistant, ram,positi(e $o$$i .e. ., methi$illin, resistant Staphylococcus aureus, (an$omy$in intermediate sensiti(e Staphylococcus aureus, or (an$omy$in,resistant ,nterococcus J8R4L/ ./19!/2=##/22/. Cate ory #1 1. Pay $lose attention to $leanin and disin"e$tion o" hi h,tou$h sur"a$es in patient,$are areas .e. ., bed rails, $arts, $harts, bedside $ommodes, bed rails, door2nobs, or "au$et handles/ ./19!/2=##/22/. Cate ory #1 2. 4nsure $omplian$e by house2eepin sta"" +ith $leanin and disin"e$tion pro$edures ./19!/2=##/22/. Cate ory #1 <. 6se 4P*,re istered $hemi$al ermi$ides appropriate "or the sur"a$e to be disin"e$ted .e. ., either lo+, or intermediate,le(el disin"e$tion/ as spe$i"ied by the manu"a$turer-s instru$tions .2<1!/22##/2</. Cate ory #1, #C .4P*3 A 6SC O 1<D et se0./ =. When $onta$t pre$autions are indi$ated "or patient $are, use disposable patient,$are items .e. ., blood pressure $u""s/ +here(er possible to minimi?e $ross,$ontamination +ith multiple,resistant mi$roor anisms ./29/. Cate ory #1 >. 5ollo+ these same sur"a$e,$leanin and disin"e$tin measures "or mana in the en(ironment o" 8RS* patients ./2=##/22!/2</. Cate ory ##
C. 4n(ironmental,sur"a$e $ulturin $an be used to (eri"y the e""i$a$y o" hospital

poli$ies and pro$edures be"ore and a"ter $leanin and disin"e$tin rooms that house patients +ith 8R4 ./19!/2;##////. Cate ory ##

1. @btain prior appro(al "rom in"e$tion,$ontrol sta"" and the $lini$al laboratory be"ore per"ormin en(ironmental,sur"a$e $ulturin . Cate ory ## 2. #n"e$tion,$ontrol sta"", +ith $lini$al laboratory sta"" $onsultation, must super(ise all en(ironmental $ulturin . Cate ory ## D. Thorou hly $lean and disin"e$t en(ironmental and medi$al e0uipment sur"a$es on a re ular basis by usin 4P*,re istered disin"e$tants in a$$ordan$e +ith manu"a$turers- instru$tions .2<1!2<0!/1;! //0/. Cate ory #1, #C .4P*3 A 6SC O 1<D et se0./ 4. *d(ise "amilies, (isitors, and patients re ardin the importan$e o" hand hy iene to minimi?e the spread o" body substan$e $ontamination .e. ., respiratory se$retions or "e$al matter/ to sur"a$es .2<0/. Cate ory ## 5. Do not use hi h,le(el disin"e$tants .i.e., li0uid $hemi$al sterilants/ on en(ironmental sur"a$es' su$h use is in$onsistent +ith label instru$tions be$ause o" the to7i$ity o" the $hemi$als .2<=!2</!2<0!2<9/. Cate ory #C .5D*3 21 C5R CE1.>, CEA.CA.e/ B. 1e$ause no 4P*,re istered produ$ts are spe$i"i$ "or ina$ti(atin Clostri$ium $ifficile spores, use hypo$hlorite,based produ$ts "or disin"e$tion o" en(ironmental sur"a$es in a$$ordan$e +ith uidan$e "rom the s$ienti"i$ literature in those patient,$are areas +here sur(eillan$e and epidemiolo y indi$ate on oin transmission o" C' $ifficile .2<0!/1;!//0/. Cate ory ## &. !o re$ommendation is o""ered re ardin the use o" spe$i"i$ 4P*,re istered hospital disin"e$tants +ith respe$t to en(ironmental $ontrol o" C' $ifficile. 6nresol(ed issue #. *pply standard $leanin and disin"e$tion pro$edures to $ontrol en(ironmental $ontamination +ith respiratory and enteri$ (iruses in pediatri$,$are units and $are areas "or immuno$ompromised patients .29=!//7/. Cate ory #C .4P*3 A 6SC O 1<D et se0./ %. Clean sur"a$es that ha(e been $ontaminated +ith body substan$es' per"orm lo+, to intermediate,le(el disin"e$tion on $leaned sur"a$es +ith an 4P*, re istered disin"e$tant in a$$ordan$e +ith the manu"a$turer-s instru$tions .2<1!2;/!//7/. Cate ory #C .@S&*3 29 C5R 191E.1E<E O d.=.ii.*' 4P*3 A 6SC O 1<D et se0./ ;. 6se disposable barrier $o(erin s as appropriate to minimi?e sur"a$e $ontamination. Cate ory ## L. De(elop and maintain $leanin and disin"e$tion pro$edures in patient,$are areas to $ontrol en(ironmental $ontamination +ith a ents o" Creut?"eldt,%a2ob disease .C%D/, "or +hi$h no 4P*,re istered produ$t e7ists. Cate ory ## 1. #n the absen$e o" $ontamination +ith $entral ner(ous system tissue, e7traordinary measures .e. ., use o" 2! sodium hydro7ide J!a@&L or applyin "ull,stren th sodium hypo$hlorite/ are not needed "or routine $leanin or terminal disin"e$tion o" a room

housin a $on"irmed or suspe$ted C%D patient .2</!//:/. Cate ory ## 2. *"ter remo(in ross tissue "rom the sur"a$e, use either 1! !a@& or a sodium hypo$hlorite solution $ontainin appro7imately 1E,EEE,,2E,EEE ppm a(ailable $hlorine .dilutions o" 13> to 13< (F(, respe$ti(ely, o" 6.S. household $hlorine blea$h' $onta$t the manu"a$turers o" $ommer$ially a(ailable sodium hypo$hlorite produ$ts "or ad(i$e/ to de$ontaminate operatin room or autopsy sur"a$es +ith $entral ner(ous system or $erebral spinal "luid $ontamination "rom a dia nosed or suspe$ted C%D patient .2</!//<##/02/. Cate ory ## a. The $onta$t time "or the $hemi$al used durin this pro$ess should be <E min,,1 hour .//;!/0=!/02/. b. 1lot up the $hemi$al +ith absorbent material and rinse the treated sur"a$e thorou hly +ith +ater. $. Dis$ard the used, absorbent material into appropriate +aste $ontainers. <. 6se disposable, imper(ious $o(ers to minimi?e body substan$e $ontamination to autopsy tables and sur"a$es ./0=!/02/. Cate ory ## M. 6se standard pro$edures "or $ontainment, $leanin , and de$ontamination o" blood spills on sur"a$es as pre(iously des$ribed .4n(ironmental Ser(i$es3 ##/ .2;//. Cate ory #C .@S&*3 29 C5R 191E.1E<E O d.=.ii.*/ 1. Wear PP4 appropriate "or a sur"a$e de$ontamination and $leanin tas2 .2;/!//:/. Cate ory #C .@S&* 29 C5R 191E.1E<E O d.<.i, ii/ 2. Dis$ard used PP4 by usin routine disposal pro$edures or de$ontaminate reusable PP4 as appropriate .2;/!//:/. Cate ory #C .@S&* 29 C5R 191E.1E<E O d.<.(iii/

Recommendations ---Environmental )am lin&

I' General Information *. Do not $ondu$t random, undire$ted, mi$robiolo i$ samplin o" air, +ater, and en(ironmental sur"a$es in health,$are "a$ilities .2<=!/0//. Cate ory #1 1. When indi$ated, $ondu$t mi$robiolo i$ samplin as part o" an epidemiolo i$ in(esti ation or durin assessment o" ha?ardous en(ironmental $onditions to dete$t $ontamination or (eri"y abatement o" a ha?ard .2<=!/0//. Cate ory #1 C. Limit mi$robiolo i$ samplin "or 0uality assuran$e purposes to 1/ biolo i$ monitorin o" sterili?ation pro$esses' 2/ monthly $ultures o" +ater and dialysate in hemodialysis units' and </ short,term e(aluation o" the impa$t o" in"e$tion,$ontrol measures or $han es in in"e$tion,$ontrol proto$ols .2<=!/0//. Cate ory #1

II' Air* /ater* and Environmental )urface )am lin& *. When $ondu$tin any "orm o" en(ironmental samplin , identi"y e7istin $omparati(e standards and "ully do$ument departures "rom standard methods ./0/##/0</. Cate ory ## 1. Sele$t a hi h,(olume air samplin de(i$e i" anti$ipated le(els o" mi$robial airborne $ontamination are e7pe$ted to be lo+ ./07!/0:!/09!/0;/. Cate ory ## C. Do not use settle plates to 0uanti"y the $on$entration o" airborne "un al spores ./09/. Cate ory ## D. When samplin +ater, $hoose ro+th media and in$ubation $onditions that +ill "a$ilitate re$o(ery o" +aterborne or anisms ./00/. Cate ory ## 4. When usin a sampleFrinse method "or samplin an en(ironmental sur"a$e, de(elop and do$ument a pro$edure "or manipulatin the s+ab, au?e, or spon e in a reprodu$ible manner so that results are $omparable ./0</. Cate ory ## 5. When en(ironmental samples and patient spe$imens are a(ailable "or $omparison, per"orm the laboratory analysis on the re$o(ered mi$roor anisms do+n to the spe$ies le(el at a minimum, and beyond the spe$ies le(el i" possible ./0//. Cate ory ##

Recommendations ---0aundry and (eddin&

I' Em loyer Res onsi%ilities *. 4mployers must launder +or2ers- personal prote$ti(e arments or uni"orms that are $ontaminated +ith blood or other potentially in"e$tious materials .2;//. Cate ory #C .@S&*3 29 C5R 191E.1E<E O d.<.i(/ II' 0aundry Facilities and E,ui ment *. Maintain the re$ei(in area "or $ontaminated te7tiles at ne ati(e pressure $ompared +ith the $lean areas o" the laundry in a$$ordan$e +ith *#* $onstru$tion standards in e""e$t durin the time o" "a$ility $onstru$tion .1!/7=##/72/. Cate ory #C .*#*3 A.2<.11, 12/ 1. 4nsure that laundry areas ha(e hand+ashin "a$ilities and produ$ts and appropriate PP4 a(ailable "or +or2ers .1!2;//. Cate ory #C .*#*3 A.2<.D=' @S&*3 29 C5R 191E.1E<E O d.2.iii/ C. 6se and maintain laundry e0uipment a$$ordin to manu"a$turers- instru$tions ./7/!/70/. Cate ory ## D. Do not lea(e damp te7tiles or "abri$s in ma$hines o(erni ht ./7//. Cate ory ## 4. Disin"e$tion o" +ashin and dryin ma$hines in residential $are is not needed as lon as ross soil is remo(ed "rom items be"ore +ashin and proper +ashin and dryin pro$edures are used. Cate ory ##

III' Routine Handlin& of Contaminated 0aundry *. &andle $ontaminated te7tiles and "abri$s +ith minimum a itation to a(oid $ontamination o" air, sur"a$es, and persons ./:!2;/!/77!/7:/. Cate ory #C .@S&*3 29 C5R 191E.1E<E O d.=.i(/ 1. 1a or other+ise $ontain $ontaminated te7tiles and "abri$s at the point o" use .2;//. Cate ory #C .@S&*3 29 C5R 191E.1E<E O d.=.i(/ 1. Do not sort or prerinse $ontaminated te7tiles or "abri$s in patient,$are areas .2;//. Cate ory #C .@S&*3 29 C5R 191E.1E<E O d.=.i(/ 2. 6se lea2,resistant $ontainment "or te7tiles and "abri$s $ontaminated +ith blood or body substan$es .2;/!/77/. Cate ory #C .@S&*3 29 C5R 191E.1E<E O d.=.i(/ <. #denti"y ba s or $ontainers "or $ontaminated te7tiles +ith labels, $olor $odin , or other alternati(e means o" $ommuni$ation as appropriate .2;//. Cate ory #C .@S&*3 29 C5R 191E.1E<E O d.=.i(/ C. Co(ers are not needed on $ontaminated te7tile hampers in patient,$are areas. Cate ory ## D. #" laundry $hutes are used, ensure that they are properly desi ned, maintained, and used in a manner to minimi?e dispersion o" aerosols "rom $ontaminated laundry ./7<##/:1/. Cate ory #C .**M#3 *!S#F**M# STD>32EEE/ 1. 4nsure that laundry ba s are $losed be"ore tossin the "illed ba into the $hute. Cate ory ## 2. Do not pla$e loose items in the laundry $hute. Cate ory ## 4. 4stablish a "a$ility poli$y to determine +hen te7tiles or "abri$s should be sorted in the laundry "a$ility .i.e., be"ore or a"ter +ashin / ./:2!/://. Cate ory ## I+' 0aundry Process *. #" hot,+ater laundry $y$les are used, +ash +ith deter ent in +ater I1DEN5 .IA1NC/ "or I2> minutes .1!2<=/. Cate ory #C .*#*3 A.<1.4</ 1. !o re$ommendation is o""ered re ardin a hot,+ater temperature settin and $y$le duration "or items laundered in residen$e,style health,$are "a$ilities. 6nresol(ed issue C. 5ollo+ "abri$,$are instru$tions and spe$ial launderin re0uirements "or items used in the "a$ility ./:0/. Cate ory ## D. Choose $hemi$als suitable "or lo+,temperature +ashin at proper use $on$entration i" lo+,temperature .G1DEN5 JGAENC L/ laundry $y$les are used ./:7##/<=/. Cate ory ##

4. Pa$2a e, transport, and store $lean te7tiles and "abri$s by methods that +ill ensure their $leanliness and prote$t them "rom dust and soil durin inter"a$ility loadin , transport, and unloadin .2<=/. Cate ory ## +' !icro%iolo&ic )am lin& of $e5tiles *. Do not $ondu$t routine mi$robiolo i$ samplin o" $lean te7tiles .2<=!/<1/. Cate ory #1 1. 6se mi$robiolo i$ samplin durin outbrea2 in(esti ations i" epidemiolo i$ e(iden$e indi$ates a role "or health,$are te7tiles and $lothin in disease transmission ./<1/. Cate ory #1 +I' ) ecial 0aundry )ituations *. 6se sterili?ed te7tiles, sur i$al drapes, and o+ns "or situations re0uirin sterility in patient $are .110/. Cate ory #1 1. 6se hy ieni$ally $lean te7tiles .i.e., laundered, but not sterili?ed/ in neonatal intensi(e $are units .2;2!/<2/. Cate ory #1 C. 5ollo+ manu"a$turers- re$ommendations "or $leanin "abri$ produ$ts, in$ludin those +ith $oated or laminated sur"a$es. Cate ory ## D. Do not use dry $leanin "or routine launderin in health,$are "a$ilities ./</## /<7/. Cate ory ## 4. 6se $aution +hen $onsiderin use o" antimi$robial mattresses, te7tiles, and $lothin as repla$ements "or standard beddin and other "abri$ items' 4P* has not appro(ed publi$ health $laims assertin prote$tion a ainst human patho ens "or su$h treated items ./<:/. Cate ory ## 5. !o re$ommendation is o""ered re ardin usin disposable "abri$s and te7tiles (ersus durable oods. 6nresol(ed issue +II' !attresses and Pillo1s *. ;eep mattresses dry' dis$ard them i" they remain +et or stained, parti$ularly in burn units ./<<##/92/. Cate ory #1 1. Clean and disin"e$t mattress $o(ers by usin 4P*,re istered disin"e$tants that are $ompatible +ith the materials to pre(ent the de(elopment o" tears, $ra$2s, or holes in the $o(ers ./<<##/92/. Cate ory #1 C. Maintain the inte rity o" mattress and pillo+ $o(ers. Cate ory ## 1. Repla$e mattress and pillo+ $o(ers i" they be$ome torn or other+ise in need o" repair. Cate ory ## 2. Do not sti$2 needles into a mattress throu h the $o(er. Cate ory ## D. Clean and disin"e$t moisture,resistant mattress $o(ers bet+een patient use by usin an 4P*,re istered produ$t ./<<##/92/. Cate ory #1

4. #" usin a mattress $o(er $ompletely made o" "abri$, $han e these $o(ers and launder bet+een patient use ./<<##/92/. Cate ory #1 5. Launder pillo+ $o(ers and +ashable pillo+s in the hot,+ater $y$le bet+een patients or +hen they be$ome $ontaminated +ith body substan$es ./92/. Cate ory #1 +III' Air-Fluidi.ed (eds *. 5ollo+ manu"a$turers- instru$tions "or air,"luidi?ed bed maintenan$e and de$ontamination. Cate ory ## 1. Chan e the polyester "ilter sheet at least +ee2ly or as indi$ated by the manu"a$turer ./9/##/9:/. Cate ory ## C. Clean and disin"e$t the polyester "ilter sheet thorou hly, espe$ially bet+een patients, usin an 4P*,re istered produ$t ./9/##/9:/. Cate ory #1 D. Consult the "a$ility en ineer to determine the proper pla$ement o" air,"luidi?ed beds in ne ati(e,pressure rooms ./9</. Cate ory ##

Recommendations --- Animals in Health-Care Facilities

I' General Infection-Control !easures for Animal Encounters *. Minimi?e $onta$t +ith animal sali(a, dander, urine, and "e$es ./99##/;=/. Cate ory ## 1. Pra$ti$e hand hy iene a"ter any animal $onta$t .10:!2<=/. Cate ory ## 1. Wash hands +ith soap and +ater, espe$ially i" hands are (isibly soiled or $ontaminated +ith proteina$eous material .10:/. Cate ory ## 2. 6se either soap and +ater or al$ohol,based hand rubs +hen hands are not (isibly soiled or $ontaminated .10:/. Cate ory ## II' Animal-Assisted Activities and Resident Animal Pro&rams *. *(oid sele$tion o" nonhuman primates and reptiles in animal,assisted a$ti(ities, animal,assisted therapy, or resident animal pro rams ./;1##/;//. Cate ory #1 1. 4nroll animals that are "ully (a$$inated "or ?oonoti$ diseases and that are healthy, $lean, +ell, roomed, and ne ati(e "or enteri$ parasites or other+ise ha(e $ompleted re$ent anthelminti$ treatment under the re ular $are o" a (eterinarian ./;1!/;0/. Cate ory ## C. 4nroll animals that are trained +ith the assistan$e or under the dire$tion o" persons +ho are e7perien$ed in this "ield ./;1/. Cate ory ## D. 4nsure that animals are $ontrolled by persons trained in pro(idin a$ti(ities or therapies sa"ely, and +ho 2no+ the animal-s health status and beha(ior traits ./;1!/;0/. Cate ory ##

4. Ta2e prompt a$tion +hen an in$ident o" bitin or s$rat$hin by an animal o$$urs durin an animal,assisted a$ti(ity or therapy. 1. Remo(e the animal permanently "rom these pro rams ./;1/. Cate ory ## 2. Report the in$ident promptly to appropriate authorities .e. ., in"e$tion, $ontrol sta"", animal pro ram $oordinator, or lo$al animal $ontrol personnel/ ./;1/. Cate ory ## <. Promptly $lean and treat s$rat$hes, bites, or other brea2s in the s2in. Cate ory ## 5. Per"orm an #CR* and +or2 a$ti(ely +ith the animal handler be"ore $ondu$tin an animal,assisted a$ti(ity or therapy to determine +hether the session should be held in a publi$ area o" the "a$ility or in indi(idual patient rooms ./;1!/;0/. Cate ory ## B. Ta2e pre$autions to miti ate aller i$ responses to animals. Cate ory ## 1. Minimi?e sheddin o" animal dander by bathin animals G2= hours be"ore a (isit ./;1/. Cate ory ## 2. Broom animals to remo(e loose hair be"ore a (isit, or use a therapy animal $ape ./;7/. Cate ory ## &. 6se routine $leanin proto$ols "or house2eepin sur"a$es a"ter therapy sessions. Cate ory ## #. Restri$t resident animals, in$ludin "ish in tan2s, "rom a$$ess to patient,$are areas, "ood,preparation areas, dinin areas, laundry, $entral sterile supply areas, sterile and $lean supply stora e areas, medi$ation preparation areas, operatin rooms, isolation areas, and P4 areas. Cate ory ## %. 4stablish a "a$ility poli$y "or re ular $leanin o" "ish tan2s, rodent $a es, and bird $a es, and any other animal d+ellin s and assi n this $leanin tas2 to a nonpatient,$are sta"" member' a(oid splashin tan2 +ater or $ontaminatin en(ironmental sur"a$es +ith animal beddin . Cate ory ## III' Protective !easures for Immunocom romised Patients
*. *d(ise patients to a(oid $onta$t +ith animal "e$es, sali(a, urine, or solid litter

bo7 material ./;:/. Cate ory ##

1. Promptly $lean and treat s$rat$hes, bites, or other +ounds that brea2 the s2in

./;:/. Cate ory ## C. *d(ise patients to a(oid dire$t or indire$t $onta$t +ith reptiles ./;</. Cate ory #1 D. Condu$t a $ase,by,$ase assessment to determine i" animal,assisted a$ti(ities or animal,assisted therapy pro rams are appropriate "or immuno$ompromised patients ./;0/. Cate ory ##

4. !o re$ommendation is o""ered re ardin permittin pet (isits to terminally ill immuno$ompromised patients outside their P4 units. 6nresol(ed issue. I+' )ervice Animals
*. *(oid pro(idin "a$ility a$$ess to nonhuman primates and reptiles as ser(i$e

animals ./;/!/;</. Cate ory #1 1. *llo+ ser(i$e animals a$$ess to the "a$ility in a$$ordan$e +ith the *meri$ans +ith Disabilities *$t o" 199E, unless the presen$e o" the animal $reates a dire$t threat to other persons or a "undamental alteration in the nature o" ser(i$es ./9;!/;9/. Cate ory #C .6.S. Department o" %usti$e3 2C C5R O <D.<E2/ C. When a de$ision must be made re ardin a ser(i$e animal-s a$$ess to any parti$ular area o" the health,$are "a$ility, e(aluate the ser(i$e animal, patient, and health,$are situation on a $ase,by,$ase basis to determine +hether si ni"i$ant ris2 o" harm e7ists and +hether reasonable modi"i$ations in poli$ies and pro$edures +ill miti ate this ris2 ./;9/. Cate ory #C .6.S. Department o" %usti$e3 2C C5R O <D.2EC/ D. #" a patient must be separated "rom his or her ser(i$e animal +hile in the health,$are "a$ility 1/ as$ertain "rom the person +hat arran ements ha(e been made "or super(ision or $are o" the animal durin this period o" separation' and 2/ ma2e appropriate arran ements to address the patient-s needs in the absen$e o" the ser(i$e animal. Cate ory ## +' Animals as Patients in Human Health-Care Facilities *. De(elop health,$are "a$ility poli$ies to address the treatment o" animals in human health,$are "a$ilities. 1. 6se the multidis$iplinary team approa$h to poli$y de(elopment, in$ludin publi$ media relations e""orts to dis$lose and dis$uss these a$ti(ities. Cate ory ## 2. 47haust all (eterinary "a$ility, e0uipment, and instrument options be"ore underta2in the pro$edure. Cate ory ## <. 4nsure that the $are o" the animal is super(ised by a li$ensed (eterinarian. Cate ory ## 1. When animals are treated in human health,$are "a$ilities, a(oid treatin animals in operatin rooms or other patient,$are areas +here in(asi(e pro$edures are per"ormed .e. ., $ardia$ $atheteri?ation laboratories or in(asi(e nu$lear medi$ine areas/. Cate ory ## C. S$hedule the animal pro$edure "or the last pro$edure o" the day in the area, at a time +hen human patients are not s$heduled to be in the (i$inity. Cate ory ## D. *dhere stri$tly to standard pre$autions. Cate ory ##

4. Clean and disin"e$t en(ironmental sur"a$es thorou hly by usin an 4P*, re istered produ$t in the room a"ter the animal has been remo(ed. Cate ory ## 5. *llo+ su""i$ient *C& to $lean the air and help remo(e airborne dander, mi$roor anisms, and aller ens .Table 1/. Cate ory ## B. Clean and disin"e$t usin 4P*,re istered produ$ts or sterili?e e0uipment that has been in $onta$t +ith the animal' or use disposable e0uipment. Cate ory ## &. #" reusable medi$al or sur i$al instruments are used in an animal pro$edure, restri$t "uture use o" these instruments to animals only. Cate ory ## +I' Research Animals in Health-Care Facilities *. 6se animals obtained "rom 0uality sto$2, or 0uarantine in$omin animals to dete$t ?oonoti$ diseases. Cate ory ## 1. Treat si$2 animals or remo(e them "rom the "a$ility. Cate ory ## C. Pro(ide prophyla$ti$ (a$$inations, as a(ailable, to animal handlers and $onta$ts at hi h ris2. Cate ory ## D. 4nsure proper (entilation throu h appropriate "a$ility desi n and lo$ation ./;;/. Cate ory #C .6.S. Department o" * ri$ulture J6SD*L3 A 6SC 21<1/ 1. ;eep animal rooms at ne ati(e pressure relati(e to $orridors ./;;/. Cate ory #C .6SD*3 A 6SC 21<1/ 2. Pre(ent air in animal rooms "rom re$ir$ulatin else+here in the health,$are "a$ility ./;;/. Cate ory #C .6SD*3 A 6SC 21<1/ 4. ;eep doors to animal resear$h rooms $losed. Cate ory ## 5. Restri$t a$$ess to animal "a$ilities to essential personnel. Cate ory ## B. 4stablish employee o$$upational health pro rams spe$i"i$ to the animal resear$h "a$ility, and $oordinate mana ement o" poste7posure pro$edures spe$i"i$ to ?oonoses +ith o$$upational health $lini$s in the health,$are "a$ility .0==!0=1/. Cate ory #C .6.S. Department o" &ealth and &uman Ser(i$es JD&&SL3 1iosa"ety in Mi$robiolo i$al and 1iomedi$al Laboratories J1M1LL' @S&*3 29 C5R 191E.1E<E.1<2,1<9/ &. Do$ument standard operatin pro$edures "or the unit .0==/. Cate ory #C .D&&S3 1M1L/ #. Condu$t routine employee trainin on +or2er sa"ety $on$erns rele(ant to the animal resear$h "a$ility .e. ., +or2in sa"ely +ith animals, animal handlin / .0==!0=1/. Cate ory #C .D&&S3 1M1L' @S&*3 29 C5R 191E.1E<E.1<2,, 1<9/ %. 6se pre$autions to pre(ent de(elopment o" animal,indu$ed asthma in animal +or2ers .0==/. Cate ory #C .D&&S3 1M1L/

Recommendations --- Re&ulated !edical /astes

I' Cate&ories of Re&ulated !edical /aste

*. Desi nate the "ollo+in as ma:or $ate ories o" medi$al +aste that re0uire spe$ial handlin and disposal pre$autions3 1/ mi$robiolo y laboratory +astes Je. ., $ultures and sto$2s o" mi$roor anismsL' 2/ bul2 blood, blood produ$ts, blood, and bloody body "luid spe$imens' </ patholo y and anatomy +aste' and =/ sharps Je. ., needles and s$alpelsL .2<=/. Cate ory ## 1. Consult "ederal, state, and lo$al re ulations to determine i" other +aste items are $onsidered re ulated medi$al +astes .2;/!0=2!0=//. Cate ory #C .States' @S&*3 29 C5R 191E.1E<E O .2.1' Department o" Transportation JD@TL3 =9 C5R 1A1,1CE' 6.S. Postal Ser(i$e3 C@2<.C/ II' Dis osal Plan for Re&ulated !edical /astes *. De(elop a plan "or the $olle$tion, handlin , predisposal treatment, and terminal disposal o" re ulated medi$al +astes .2;/!0=0/. Cate ory #C .States' @S&*3 29 C5R 191E.1E<E O .2.i/ 1. Desi nate a person or persons as responsible "or establishin , monitorin , re(ie+in , and administerin the plan. Cate ory ## III' Handlin&* $rans ortin&* and )torin& Re&ulated !edical /astes *. #n"orm personnel in(ol(ed in handlin and disposal o" potentially in"e$ti(e +aste o" possible health and sa"ety ha?ards' ensure that they are trained in appropriate handlin and disposal methods .2;//. Cate ory #C .@S&*3 29 C5R 191E.1E<E O .2.i/ 1. Mana e the handlin and disposal o" re ulated medi$al +astes enerated in isolation areas by usin the same methods used "or re ulated medi$al +astes "rom other patient,$are areas .2<=/. Cate ory ## C. 6se proper sharps disposal strate ies .2;//. Cate ory #C .@S&*3 29 C5R 191E.1E<E O d.=.iii.*/ 1. 6se a sharps $ontainer $apable o" maintainin its impermeability a"ter +aste treatment to a(oid subse0uent physi$al in:uries durin "inal disposal .2;//. Cate ory #C .@S&*3 29 C5R 191E.1E<E O d.=.iii.*/ 2. Pla$e disposable syrin es +ith needles, in$ludin sterile sharps that are bein dis$arded, s$alpel blades, and other sharp items into pun$ture,resistant $ontainers lo$ated as $lose as pra$ti$al to the point o" use .2;//. Cate ory #C .@S&*3 29 C5R 191E.1E<E O d.=.iii.*/ <. Do not bend, re$ap, or brea2 used syrin e needles be"ore dis$ardin them into a $ontainer ./:!2;/!0=7/. Cate ory #C .@S&*3 29 C5R 191E.1E<E O d.2.(ii and O d.2.(ii.*/

D. Store re ulated medi$al +astes a+aitin treatment in a properly (entilated area ina$$essible to (ertebrate pests' use +aste $ontainers that pre(ent de(elopment o" no7ious odors. Cate ory #C .States/ 4. #" treatment options are not a(ailable at the site +here the medi$al +aste is enerated, transport re ulated medi$al +astes in $losed, imper(ious $ontainers to the on,site treatment lo$ation or to another "a$ility "or treatment as appropriate. Cate ory #C .States/ I+' $reatment and Dis osal of Re&ulated !edical /astes *. Treat re ulated medi$al +astes by usin a method .e. ., steam sterili?ation, in$ineration, interment, or an alternati(e treatment te$hnolo y/ appro(ed by the appropriate authority ha(in :urisdi$tion .*&%/ .e. ., state, #ndian &ealth Ser(i$e, or 8eterans *dministration/ be"ore disposal in a sanitary land"ill. Cate ory #C .States, *&%/ 1. 5ollo+ pre$autions "or treatin mi$robiolo i$ +astes .e. ., ampli"ied $ultures and sto$2s o" mi$roor anisms/ .0==/. Cate ory #C .D&&S3 1M1L/ 1. 1iosa"ety le(el = laboratories must ina$ti(ate mi$robiolo i$ +astes in the laboratory by usin an appro(ed ina$ti(ation method .e. ., auto$la(in / be"ore transport to and disposal in a sanitary land"ill .0==/. Cate ory #C .D&&S3 1M1L/ 2. 1iosa"ety le(el < laboratories must ina$ti(ate mi$robiolo i$ +astes in the laboratory by usin an appro(ed ina$ti(ation method .e. ., auto$la(in / or in$inerate them at the "a$ility be"ore transport to and disposal in a sanitary land"ill .0==/. Cate ory #C .D&&S3 1M1L/ C. 1iosa"ety le(els 1 and 2 laboratories should de(elop strate ies to ina$ti(ate ampli"ied mi$robial $ultures and sto$2s onsite by usin an appro(ed ina$ti(ation method .e. ., auto$la(in / instead o" pa$2a in and shippin untreated +astes to an o""site "a$ility "or treatment and disposal .0==!0=:## 0=9/. Cate ory ## D. Laboratories that isolate sele$t a ents "rom $lini$al spe$imens must $omply +ith "ederal re ulations "or re$eipt, trans"er, mana ement, and appropriate disposal o" these a ents .0=;/. Cate ory #C .D&&S3 =2 C5R A2 O A2.D.i.1.iii/ 4. Sanitary se+ers may be used "or sa"e disposal o" blood, su$tioned "luids, round tissues, e7$retions, and se$retions, pro(ided that lo$al se+a e dis$har e re0uirements are met and that the state has de$lared this to be an a$$eptable method o" disposal .01=/. Cate ory ## +' ) ecial Precautions for /astes Generated Durin& Care of Patients 1ith Rare Diseases

*. When dis$ardin items $ontaminated +ith blood and body "luids "rom 8&5





patients, $ontain these re ulated medi$al +astes +ith minimal a itation durin handlin ./:!1=;/. Cate ory ## Mana e properly $ontained +astes "rom areas pro(idin $are to 8&5 patients in a$$ordan$e +ith re$ommendations "or other isolation areas .Re ulated Medi$al Waste3 ### 1/ ./:!1=;!2<=/. Cate ory ## De$ontaminate bul2 blood and body "luids "rom 8&5 patients by usin appro(ed ina$ti(ation methods .e. ., auto$la(in or $hemi$al treatment/ be"ore disposal ./:!1=;/. Cate ory #C, ## .States/ When dis$ardin re ulated medi$al +aste enerated durin the routine .i.e., nonsur i$al/ $are o" C%D patients, $ontain these +astes and de$ontaminate them by usin appro(ed ina$ti(ation methods .e. ., auto$la(in or in$ineration/ appropriate "or the medi$al +aste $ate ory .e. ., blood, sharps, or patholo i$al +aste/ ./:!2<=!2</!//:/. Cate ory #C, ## .States/ #n$inerate medi$al +astes .e. ., $entral ner(ous system tissues or $ontaminated disposable materials/ "rom brain autopsy or biopsy pro$edures o" dia nosed or suspe$ted C%D patients ./0=!/02/. Cate ory #1