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Infection Control in the Correctional Setting

August 2005

The crowded conditions that exist in most jails and prisons create an ideal environment for the transmission of contagious diseases. Limited availability of clean laundry, soap and water increase the probability that infectious diseases will be transmitted from one person to another. Furthermore, the transient status of inmates who are frequently moved from one location to another can complicate the diagnosis of infection, recognition of an outbreak, interruption of transmission, performance of a contact investigation and eradication of disease.

Many correctional facilities have inadequate information technology, and the linkages between different jurisdictions and agencies responsible for the care of inmates are often poor. Published guidelines for prevention, diagnosis and treatment of communicable diseases are not always readily applicable to the correctional setting.

This article is the second in a two-part series, the first of which appeared in the IDCR July/August 2004 issue.1 This article will address the following correctional infection control topics: gloves and hand washing, food handling hygiene, keeping food safe during an emergency, ice machines, vending machines, housekeeping and infectious waste. The July/August 2004 issue reviewed the infection control committee, personal protective equipment, blood borne pathogen exposures, post-exposure prophylaxis (PEP), standard precautions and isolation concepts, culinary services, food handlers, laundry and barbering.1

Careful attention to the infection control measures discussed in this article will benefit the health of inmates, those who interact with them during their incarceration and the public health at large.

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Gloves and Hand Washing

Gloves should be worn when one is likely to have contact with blood, other potentially infectious materials, mucous membranes, non-intact skin, or when touching contaminated surfaces.2 The appropriate use of gloves and handwashing can reduce the risk of acquiring infections from patients and decrease the transmission of organisms from employees to patients.3 Inmates should also be educated about the health benefits of frequent hand washing. Staff should be educated that gloves do not provide complete protection, due to defects in gloves and contamination during glove removal.4-6

The proper selection of glove depends upon the job being performed. Types of gloves include:

Utility gloves: These thick gloves are used while handling and cleaning potentially infectious wastes and can be decontaminated for re-use if still intact. Utility gloves may provide an extra measure of protection from sharps injury during cell searches.

Examination gloves: These gloves are used during procedures such as bathing patients, handling contaminated linen and other procedures during which contact with body fluids is likely. These gloves are to be disposed of after single use.

Sterile or surgical gloves: These gloves are used for procedures that involve contact with a patient's organs or open tissues and should be disposed of after single use.

Hands should be washed or decontaminated after gloves are removed.7 Health care staff should be reminded that failure to remove gloves between patients might lead to transmission of organisms.8 Wearing rings and artificial nails leads to an increase in bacterial colonization of the hands, although it is not clear whether this leads to an increased rate of transmission of organisms.9,10 Even after careful hand washing, a significant number of pathogenic bacteria can be found under fingernails.11

Many jails and prisons lack adequate facilities for hand washing with soap and water. Studies have demonstrated that alcohol based hand cleansers can be more effective than soap and water in reducing bacterial counts on hands. These cleansers are available as foams, gels, and liquids. Although these products are flammable, they have been approved for use in hospital settings. If used in a correctional setting,7 policies should be in place to minimize the potential for misuse of these products by inmates.

As the use of gloves by health care staff has increased, an increasing prevalence of latex sensitivity has been documented. Many officers in the correctional setting wear gloves throughout much of their assigned shift. As a result, the frequency of latex sensitivity among custody staff is likely to increase. Latex gloves with reduced protein contents and non-latex gloves are now available for use by latex-sensitive employees. Additionally, the use of non-latex gloves may help prevent latex-sensitivity from developing. Hence, the use of latex gloves should be minimized to only those applications where they are essential. Gloves should be readily available and staff should be encouraged to carry gloves with them at all times.1


Culinary Services and Food Handlers

Persons involved in the preparation and serving of food have commonly been implicated in food borne outbreaks.12,13 To minimize this risk, each correctional facility should have policies and procedures in place that encompass the basic infection control aspects of culinary services. Facilities should also have procedures for medical clearance of food handlers.


Keeping Food Safe During an Emergency

Power outages and floods can compromise the quality and safety of stored foods. It is important to have policies in place that provide guidance for what to do in emergency situations.14 In the event of a power outage, the refrigerator and freezer doors should be kept closed as much as possible to maintain the cold temperature. Unopened, a refrigerator can keep food safely cold for up to four hours. If the freezer doors are left closed, a full freezer can hold the temperature for approximately 48 hours. Foodstuffs that do not require refrigeration or cooking should be kept available for emergencies.

To avoid contamination by floodwaters and sewer back-ups, all food should be stored on shelves that are safely above floor level. In the event of a flood, all foods that came into contact with water should be discarded, including canned goods, because surfaces have been contaminated by floodwaters.

A thermometer should be kept in all refrigerators and freezers at all times. If refrigerated food rises to a temperature greater than 40°F, it should be discarded. Exceptions include butter, margarine, fresh fruits, raw vegetables, bread, cookies, pasta, peanut butter, jelly, relish, hot sauce, barbecue sauce, soy sauce, mustard, catsup and oil and vinegar salad dressings. If frozen food fully thaws, it should be immediately cooked or discarded rather than refrozen. If frozen meats, cheeses, fruits, vegetables or bread products still contain ice crystals and feel as cold as if refrigerated, they can be safely refrozen.


Ice and Vending Machines

Outbreaks of illness and colonization have been linked to ice machines.15,16 To decrease the chance of contamination, the outside of ice machines should be cleaned and sanitized daily, and the inside cleaned and sanitized at least monthly. On a quarterly basis, the inside of machines should be cultured for bacteria. Nothing should be stored in the ice; scoops should be stored on a clean dry surface and regularly cleaned and disinfected. Vending machines should be maintained by according to the manufacturers specifications for hygiene and temperature. See this month's ID 101 for more information on cleaning ice and vending machines.


Housekeeping and Infectious Waste

Each facility should have clearly defined policies and procedures for the performance of housekeeping duties.14 Surfaces such as examination tables, bed frames, counters, floors, walls, sinks and wastebaskets that may be contaminated with blood or other body fluids should be cleaned on a regular basis. Persons involved in cleaning should wear sturdy gloves to protect themselves from potential exposures. Procedures should describe which cleaning agent and technique should be used. There have been no reports of waste from correctional facilities causing disease in the surrounding community. There are no data to suggest that waste from jails or prisons is more hazardous than that produced in the community, or requires any special handling.14

Regulated waste refers to materials such as blood, any visibly bloody fluid, or other potentially infectious materials (OPIM) such as pleural fluid, peritoneal fluid, cerebrospinal fluid, semen and vaginal secretions. Regulated waste also includes contaminated sharps, surgical waste such as body tissues, materials that are saturated with dried blood or OPIMs, and dressings, towels or bandages from which blood or OPIMs can be expressed by squeezing. Regulated waste must be disposed of by being placed in containers that can be closed, are leak proof and puncture proof, are designed for safe transportation and are labeled or color coded (i.e., red bags).14

Spills of blood or other potentially infectious materials should be cleaned by trained staff, utilizing an approved sanitizing agent such as a solution of one part bleach to 10 parts water. During the cleaning of contaminated spills, appropriate personal protective equipment (PPE) should be worn.14

Correctional health care professionals can play an important role in the prevention, diagnosis and treatment of infectious diseases among prisoners and correctional employees. A well-planned infection control program will benefit the health of inmates, those who interact with them during their incarcerations and the public health at large.

Table 1 outlines some of the most important concepts of food handling hygiene. Adherence to these guidelines will decrease the likelihood of food borne outbreaks in institutional congregate living environments.


Table 1: Important Concepts of Food Handling Hygiene
Food Initial InspectionUpon receipt, all food should be inspected for spoilage and rodent or insect infestation. Observe for broken packages or swollen cans.
Food StorageFood should be stored in a manner that will decrease the likelihood of contamination and infestation.
LocationFood should be stored above the level of the floor and away from walls.
TemperatureBacteria multiply rapidly at temperatures above 40°F. Always keep meat, poultry, fish, dairy products and eggs refrigerated at or below 40°F and frozen food at or below 0°F. A record should be maintained of all refrigerator and freezer temperatures.
Food PreparationAt time of preparation, re-inspect food as above during initial inspection.
WashingRaw unprocessed fruits and vegetables should be thoroughly washed under clean running water.
Handling and ProcessingAll workers should wear gloves when handling food. Use different sinks, counters, knives, utensils and cutting boards for raw/uncooked meats and for fruits/vegetables. Food handlers should remove gloves, thoroughly wash hands with hot soapy water and put on a clean pair of gloves when moving from uncooked meats to fruits and vegetables and also when moving from uncooked meats to cooked meats.
CookingUse a food thermometer to check the internal temperature of meat, poultry and other food. Check temperature in several places to be sure the food is evenly heated. Fresh poultry (chicken, turkey) is to be cooked until it reaches an internal temperature of at least 180°F. Ground chicken and turkey are to be cooked until they reach an internal temperature of at least 165°F. Fresh or ground beef, fresh or ground pork, eggs and egg dishes are to be cooked until they reach an internal temperature of at least 160°F.
Food Service

  • Food should be served with clean serving instruments

  • Servers should wear clean gloves while serving food and should avoid direct skin contact with food

  • Steam tables should maintain hot food at a temperature of at least 140°F

  • Cold food should be maintained at a temperature of 45°F or lower
Dishwashing

  • Loading dirty dishes and emptying clean ones from the dishwasher should either be done by different staff, or employees should wash hands and put on a clean apron when moving from one job to the other

  • Food grinders, choppers and mixers should be cleaned, sanitized and dried between uses

  • The dishwasher should be drained and flushed after each use

  • Water in the dishwasher should be at least 150°F; the final rinse should reach 180°F
Kitchen and Dining Hall CleaningAll surfaces should be cleaned and sanitized at least daily.
Outbreak InvestigationTo facilitate the investigation of an outbreak of food borne illness, a portion of each meal should be refrigerated and saved for 48-72 hours.


Recommended Resources and Readings

The American Medical Association

Centers for Disease Control and Prevention

Center for Food Safety and Applied Nutrition, Food and Drug Administration

Food Safety and Inspection Service, US Department of Agriculture


Footnotes

  1. Bick J. Infection control in the correctional setting. IDCR. 2004; 7(7):1-3.

  2. Department of Labor, Occupational Safety and Health Administration. 29 CFR Part 1910.1030. Occupational exposure to blood borne pathogens; final rule. Federal Register 1991; 56:64004-182.

  3. Olsen RJ, Lynch P, Coyle MB, Cummings J, Bokete T, Stamm WE. Examination gloves as barriers to hand contamination in clinical practice. JAMA. 1993; 270:350-3.

  4. Reingold AL, Kane MA, Hightower AW. Failure of gloves and other protective devices to prevent transmission of hepatitis B virus to oral surgeons. JAMA. 1988; 259:2558-60.

  5. DeGroot-Kosolcharoen J, Jones JM. Permeability of latex and vinyl gloves to water and blood. Am J Infect Control. 1989; 17:196-201.

  6. Korniewicz DM, Laughon BE, Cyr WH, Lytle CD, Larson E. Leakage of virus through used vinyl and latex examination gloves. J Clin Microbiol. 1990; 28:787-8.

  7. CDC. Guideline for hand hygiene in health-care settings. MMWR. 2002; 51(RR16):1-44.

  8. Larson EL, APIC Guidelines Committee. APIC guideline for hand washing and hand antisepsis in health care settings. Am J Infect Control. 1995; 23:251-69.

  9. Hedderwick SA, McNeil SA, Lyons MJ, Kauffman CA. Pathogenic organisms associated with artificial fingernails worn by healthcare workers. Infect Control Hosp Epidemiol. 2000; 21:505-9.

  10. Pottinger J, Burns S, Manske C. Bacterial carriage by artificial versus natural nails. Am J Infect Control. 1989; 17:340-4.

  11. McNeil SA, Foster CL, Hedderwick SA, Kauffman CA. Effect of hand cleansing with antimicrobial soap or alcohol-based gel on microbial colonization of artificial fingernails worn by health care workers. Clin Infect Dis. 2001; 32:367-72.

  12. Food borne hepatitis A- Missouri, Wisconsin, and Alaska, 1990-1992. MMWR. 1993; 42:526-34.

  13. Diagnosis and Management of Foodborne Illnesses. MMWR. 2001; 50(RR-2):1-69.

  14. USDA Fact Sheet. (n.d.). Retrieved July 8 2005.

  15. Ravn P, Lundgren JD, Kjaeldgaard P, et al. Nosocomial Outbreak of Cryptosporidiosis in AIDS Patients. Br Med J. 1991; 302: 277-80.

  16. Gebo KA, Srinivasan A, Perl TM, Ross T, Groth A, Merz WG. Pseudo-outbreak of Mycobacterium fortuitum on a Human Immunodeficiency Virus Ward: transient respiratory tract colonization from a contaminated ice machine. Clin Infect Dis. 2002; 35(1):32-8.

Joseph Bick, M.D., C.C.H.P., has nothing to disclose.



  
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This article was provided by Brown Medical School. It is a part of the publication Infectious Diseases in Corrections Report.
 

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