R4.1.1 Dispensing opticians are reminded that they have a responsibility to apply the infection control procedures outlined in this guidance and to dispose of waste safely.
4.2.1 The dispensing optician should practise appropriate infection control procedures, for the protection of both the dispensing optician and their patients
4.2.2 It is in the patient’s and the practitioner’s best interests to avoid the transmission of any infection between patient and practitioner or between patients.
4.2.3 Practitioners should maintain high levels of hygiene.
4.3.1 Infection is recognised as a common, but largely avoidable, complication in healthcare provision. Patients may present to the dispensing optician in practice with an infectious illness, either knowingly or unknowingly, and pose a risk of cross infecting the dispensing optician or passing on the infection to other patients through use of medical devices. Dispensing Opticians themselves may also be harbouring infectious disease, which they may be at risk of passing on to their patients. In addition, the practice environment may pose a microbiological hazard and provide an infection risk to both staff and patients.
4.3.2 The main routes through which infections may be transmitted are: through physical contact, contact with body fluids and via airborne particles. The risk of the accidental transmission of infection in optical practice is low compared with that encountered in some other healthcare disciplines. Nevertheless, the direct transmission of skin infections, respiratory infections and enteric infections does occur, and ophthalmic infections such as bacterial and viral conjunctivitis may also be transmitted if inadequate infection control measures are in place. The close proximity (< 1m) between staff and patients in optical practice poses special risks which must always be borne in mind.
4.3.3 In recent years, attention has been drawn to the risk of transmission of blood borne viruses such as human immunodeficiency virus (HIV) and hepatitis B and C. The main risk of transmission is associated with invasive procedures in which injury e.g. needlestick, could result in blood from the infected individual entering open tissues of another person. The risk of transmission of blood borne viruses in practice is extremely low but transmission of skin infections e.g. staphylococcus, herpes simplex, fungi, respiratory infections (e.g. tuberculosis) and enteric infections (e.g. viral gastroenteritis) are more likely. Ophthalmic infections e.g. bacterial and adenoviral conjunctivitis may also be transmitted within the practice if inadequate infection control measures are in place.
4.3.4 Concern has also been raised about how to treat patients infected or colonised with Meticillin (formerly Methicillin)-Resistant Staphylococcus aureus (MRSA) or Clostridium difficile (C. diff) to avoid contracting or transmitting the infection. Defence against these infections in common with most others, is largely down to fastidious hand hygiene.
4.3.5 The theoretical transmission of prion proteins, implicated in Creutzfeldt Jakob Disease (CJD) and variant CJD (vCJD), through re-useable ophthalmic devices and trial contact lenses has been identified as a risk by the Department of Health (DH). Currently, there is no evidence that such transmission has occurred.
4.3.6 The Health and Safety at Work Act (1974) places a general duty on the employer to provide a working environment that is safe and without risks to health. Thus, infection control procedures in the practice are essential to protect anyone working in or visiting the practice and to ensure that the legal obligations of the employer are met.
4.3.7 This advice is aimed at dispensing opticians in general practice. Hospital opticians and optometrists should abide by the infection control procedures of their Trust.
4.4.1 There are numerous pieces of equipment that regularly come into contact with patients e.g. trial frames, chin rests, refractor heads, hand held occluders and rulers, as well as ophthalmic devices which come into direct contact with ocular tissues e.g. tonometer heads, gonioscope and other contact lenses. It is essential that they are all appropriately decontaminated, for example by wiping headrests and/or chin rests with a disinfectant wipe, to reduce the risk of transmission of infection.
There are three levels of decontamination:
4.4.2 To be effective all items must be physically clean before being exposed to any sterilisation or disinfection process.
4.4.3 Not all equipment, however, needs to be sterile before use and the following is a general guideline:
4.4.4 Surfaces in the consulting room should be cleaned periodically with detergent and water unless contaminated with body fluids. If contaminated with body fluids a chlorine based disinfectant should be used. All consulting rooms should have access to a wash hand basin and it is good practice for this to be within the consulting room.
4.5.1 Handwashing is perhaps the single most important means of preventing the spread of infection. There are a number of organisms present in healthy skin, some are resident organisms (also called skin commensals) and are mostly harmless, although some are known to cause mild eye infections.
4.5.2 There are other transient organisms that can be deposited on the skin, including certain gram-negative bacteria which could lead to more serious corneal infections. Most of these transient organisms can be removed with a thorough wash with liquid soap and water. The skin commensals, however, are mostly left on the skin after washing with soap and water but can be greatly reduced in number by washing with an antiseptic detergent preparation
4.5.3 The National Institute for Health and Clinical Excellence (NICE 2003) recommends that hands must be decontaminated immediately before each and every episode of direct patient contact or care and after any activity or contact that could potentially result in hands becoming contaminated.
4.5.4 There is no set frequency for washing your hands, this is determined by actions that are completed and those that are about to be performed – The following list gives some examples of when hand hygiene may be appropriate:
4.5.5 This technique is usually all that is required for most procedures performed in the clinical setting:
4.6.1. Soap – Hand washing with soap and water is effective in removing most transient micro- organisms and is usually all that is necessary to prevent cross infection. In clinical areas, soap should be supplied as liquid soap in disposable containers or containers that are washed and dried before refilling. The containers should never be “topped up”.
4.6.2 Antiseptic – Antiseptic agents are more effective in reducing both transient and resident micro- organisms (e.g. chlorhexidine, povidine – iodine). Chlorhexidine (4%) preparations have shown to be more effective as they have a residual effect against transient organisms influencing the survival time on hand surfaces. The use of an antiseptic agent is recommended:
4.6.3 Antibacterial (alcohol-based) handrub: Antibacterial handrubs (generally but not exclusively alcohol based) are effective antiseptic agents which rapidly destroy micro-organisms on the skin surface. It is indicated that, when used correctly, alcohol hand rubs reduce microbial load and increase compliance with hand hygiene. However they are not a cleaning agent and should not be used if hands are visibly dirty or contaminated with blood, bodily fluids or other potentially infectious agents. To be effective against staphylococci, including MRSA, hand rubs must contain 70% of either ethyl or isopropyl alcohol. They are especially useful in situations where handwashing and drying facilities are inadequate e.g. domiciliary visits, or between patient contacts. Using an unperfumed alcohol-based hand rub prior to contact lens insertion has been shown to have a negligible effect on ocular comfort, redness and lens wettability providing that the hand-rub has been allowed to dry on the hands as per the manufacturer’s instructions (often 15 seconds). Whilst the efficacy of alcohol hand rubs has been proven, they are not to be used as a substitute for good handwashing technique using soap and water when available. Good hand-washing is strongly advised at the start and finish of a session. Alcoholic hand-rubs are not effective against Clostridium difficile spores or norovirus (a cause of viral gastro- enteritis).
4.7.1 Frequent hand washing and the use of alcohol preparations can cause damage to the skin. Cracked skin may harbour more bacteria and increase the risk of the transmission of infection. Soap should always be applied to wet hands to minimise irritation to the skin. Thorough drying and the regular use of hand creams may help to prevent skin damage. Jars of hand cream should not be shared with others.
4.7.2 The World Health Organisation has produced guidance on handwashing and handrubbing technique. https://www.who.int/gpsc/clean_hands_protection/en/
4.8.1 Potentially infectious respiratory aerosols are generated when an individual sneezes, coughs or talks. A single cough can transmit up to 100 000 particles and a sneeze 20 times this number. Particles over 5 microns in diameter do not normally travel more than 1m but smaller particles can travel longer distances and remain airborne for longer. Large particles are deposited in the vulnerable mucous membranes (nose, eyes, mouth). Small particles can reach the respiratory tract including its lower parts. Environmental conditions, including temperature, humidity and airflow, influence the transmission of disease by droplet infection. Infections that can be transmitted in this way include a number of respiratory diseases such as the common cold and influenza.
4.8.2 Because of their professionally-necessary proximity to the patient’s nose and mouth, practitioners are at a special risk of airborne infection and of infecting their patients in the same way.
4.8.3 The risk of airborne infection can be minimised in a number of ways:
4.8.4 Masks: Research into whether the use of masks can help prevent infection is inconclusive. According to the Epic2 Guidelines research has not proved that facemasks prevent the transmission of hospital CA infections in routine procedures so the routine use of masks is not recommended or needed unless there is a serious respiratory risk involved (e.g. tuberculosis within the first two weeks of treatment or epidemic or pandemic flu (where there is no vaccination available)). NICE (2003) has concluded that surgical masks are not effective protection and specialised respiratory protective protection should be worn (e.g. particular filter mask).
4.8.5 The Royal College of Ophthalmologists does not issue advice to wear masks for normal ophthalmic examinations and minor procedures where there is no likelihood of cross-inoculation with bodily fluids.
4.9.1 Whilst all infections should be avoided wherever possible, infections such as MRSA and C. diff have caused particular concern in recent times.
4.9.2 MRSA: Staphylococcus aureus is a bacterium that can reside on the skin, or can be found in the nose. About one third of healthy individuals carry S. aureus . It is generally non- pathogenic except where it gains access to deep tissues, such as; broken skin, resulting in wound infection; the bloodstream, leading to bloodstream infection (bacteraemia), and to the lungs causing for example ventilator-associated pneumonia. MRSA is a less common variant of S. aureus which may be resistant to many antibiotics making it more difficult to treat than normal strains of the bacterium. MRSA may be a problem in many hospitals and, although the risk of serious infection with MRSA is lower in the community, it still exists and this organism is increasingly seen in community health care units such as nursing homes.
4.9.3 The impact of MRSA is considerable; patients with a MRSA bloodstream infection are twice as likely to die from their infection as patients with bloodstream infection caused by meticillin-sensitive S. aureus. Measures to control the emergence and spread of MRSA are justified therefore because the options available for the treatment of these infections are reduced and because they may spread amongst vulnerable, at risk, patients.
4.8.4 It is important to note, however, that MRSA infection does not cross intact skin and that there is very little risk of infection for normal, healthy clinical staff.
4.9.5 MRSA in the community: MRSA detected in the community may be the result of:
4.9.6 It has been shown that 12% of MRSA cases are community-associated , and skin and soft tissue infections are more common among community-associated cases compared with those acquired in hospital.
4.9.7 A patient/resident from whom MRSA is isolated, but who is not suffering from an obvious infection is said to be colonised with MRSA. People may be unknowingly colonised with MRSA for many years, and therefore anybody from whom MRSA has been isolated at any time in the past may still be carrying the organism. Unlike those who are infected with MRSA, those who are colonised are not treated with antibiotics but should exercise good personal hygiene control.
4.10.1 Staphylococci are common in skin folds and contaminated skin scales may contaminate flat surfaces if they become airborne, for example during activities such as bed making, or if the affected person has a condition such as eczema. Staphylococci that are shed into the environment may survive for long periods in dust. Flat surfaces act as reservoirs for S. aureus, including MRSA, and contamination will transfer easily to hands when such surfaces are touched. Contamination on hands and/or gloves may be similarly transferred by contact with curtains, equipment, switches, phones, computer keyboards, door handles, light switches etc.
4.10.2 When examining a patient/resident with a MRSA infection, or who is known to be colonised with MRSA, the following precautions are advised.
4.10.3 Personal: Hand hygiene is the single most important intervention to prevent transmission of infection. Hand hygiene must be carried out before and after each patient contact and before and after leaving the patient’s home or care facility. Hands should either be washed using an effective technique (see above) using liquid soap and water or a 70% alcohol hand rub should be used:
Suitable preparation increases the effectiveness of hand washing. You should therefore:
4.10.4 Gloves: NICE (2003) recommend that gloves are worn for invasive procedures, contact with sterile sites and non-intact skin or mucous membranes, and for all activities that have been assessed as carrying a risk of exposure to blood, body fluids, secretions or excretions, or sharp or contaminated instruments.
4.10.5 Gloves may be required (to protect the dispensing optician from the patient, and subsequent patients from cross infection), but only if contact with body fluids (e.g. tears) or other contaminated material (e.g. dressings) is likely. Gloves do not provide complete protection, so hand hygiene measures are necessary before wearing, and after the removal of gloves. If you believe that the gloves are contaminated, they should be considered as likely to cause an infection and disposed of appropriately. Many care homes will have dedicated disposal facilities.
4.10.6 There are two types of disposable gloves available – disposable examination gloves, and close fitting sterile surgical gloves, which are individually packaged for surgical procedures. The disposable gloves (which are not individually packaged) are not sterile.
4.10.7 When deciding whether or not to use gloves practitioners should consider the risk of infection. Factors to consider include:
4.10.8 The Royal College of Ophthalmologists does not issue advice to wear gloves for normal ophthalmic examinations and minor procedures where there is no likelihood of cross-inoculation with bodily fluids. They suggest that hand hygiene is sufficient for contact lens fitting.
4.10.10 The following precautions are advised in the case of any equipment or instruments that come into contact with a patient known to be infected with MRSA, who is known to be colonised with MRSA, or where the environment is contaminated or suspected of being contaminated:
4.10.11 The principles described above apply to all situations where patients or the dispensing optician are at risk of any known transmissible infection. This could include situations where patients spend time in close proximity to each other. Examples include residential or nursing homes, schools and workplaces.
4.10.12 Dispensing Opticians are also advised to take appropriate hygiene measures when leaving a patient’s house or care home. Environments such as care homes and hospitals frequently provide hand gels for visitors to use. Dispensing Opticians should use these according to the instructions given by the care home or hospital.
4.11. Dispensing Opticians must ensure that all contact lens care products and medicines used during the examination are carefully maintained and discarded prior to their expiry date. Any multidose container can be a source of cross infection and varying levels of contamination exist in the plastic bottles containing contact lens solutions. Clinicians should note when these bottles are opened and discard them in accordance with manufacturer’s guidelines, which vary depending on the product and its use. Care must be taken not to contaminate the dropper tip and the lid must be replaced on the container after use as all solutions are susceptible to contamination during the time that caps are removed. If suspected of contamination, solutions should be disposed of immediately. Single use drug delivery systems are recommended where possible
4.12.1 There are no known cases of transmission of variant Creutzfeldt-Jakob Disease (vCJD) by contact lenses or ophthalmic devices. However, the Spongiform Encephalopathy Advisory Committee (SEAC) in 1999 advised the Department of Health (DH) of a remote theoretical risk of transmitting prions from one patient to another by the re-use of contact lenses or ophthalmic devices that come into contact with the eye. Whether such a risk could exist has been called into question by a study1 which found abnormal prion protein in the retina and optic nerve of a vCJD victim, but not in any of the anterior segment structures that were examined. The Ophthalmology Sub-Group of the Government’s Advisory Committee on Dangerous Pathogens (ACDP) Transmissible Spongiform Encephalopathy (TSE) working group re-visited the topic in 2009, following the redesignation of the anterior eye as low risk. Where single patient use of lenses and devices contacting the surface of the eye is impracticable, best decontamination procedures should be applied. These procedures include the use of a solution of sodium hypochlorite (see later).
4.12.2 Clearly the risk of transmission of disease has to be balanced against the benefits that patients receive from contact lenses and ophthalmic devices, both directly and indirectly, so that other clinical outcomes are not compromised. Decontamination procedures include the removal of cellular and proteinaceous deposits from surfaces followed by the use of a disinfection agent to eliminate microorganisms. Future advice may vary with the advent of new lenses, materials and decontamination procedures, and increasing knowledge of prion disease.
These guidelines are intended to assist a clinician to render whatever services are clinically and professionally necessary to serve the best interests of the patient.
4.12.3 General principle: Wherever practicable, a contact lens or ophthalmic device that comes into contact with the ocular surface should not be used on more than one patient, as to do so may expose patients to unnecessary risk through the transmission of disease. Where this is impracticable suitable items should be decontaminated using a recognised method2.
4.12.4 Contact lenses: The definitions below apply to the following categories of lenses:
4.12.5 Contact Lenses: Special complex diagnostic lenses may be of any type. When using such lenses, the following conditions shall be observed:
4.12.6 Ophthalmic devices: An ophthalmic device is any instrument that comes into contact with the ocular surface. There are many examples, but commonly used devices are tonometers, contact pachymeters, gonioscopes and other lenses to aid diagnoses of disease.
4.12.7 The single use of these devices may be practicable in some cases, for example disposable tonometer heads. Alternatively some devices can be decontaminated using a recognised method (see below). Where a disposable form of the device is not available and the device is not able to withstand decontamination the optometrist must exercise professional judgement as to the risks and benefits of re-using the device, bearing in mind that undetected disease may have sight- or life-threatening consequences.
4.12.8 Information for the patient: When a device that cannot withstand decontamination is to be re-used in the management of a patient, the risks and benefits of using the device must be explained to that patient.
4.13.1 The DH has issued the following advice on the proper decontamination of surgical instruments before re-use, which also has relevance for the re-use of contact lenses and ophthalmic devices that come into contact with the ocular surface:
‘The abnormal protein associated with Transmissible Spongiform Encephalopathies (TSEs), including vCJD, is very resistant to all common methods of inactivation. Expert advice is that effective cleaning of surgical instruments prior to sterilisation is of the utmost importance in reducing the risk of transmission of vCJD via surgical procedures. It is therefore essential that all existing cleaning and sterilisation procedures operate to the highest standards.’3
4.13.2 Alcohol wipes: The practice of decontaminating contact devices with alcohol wipes alone is not sufficient to remove prion material, and may in fact fix the prion protein to the surface of the instrument.
4.13.3 How to Decontaminate: It is now agreed that there is a low potential for prion infectivity via the anterior eye and corneal and conjunctival surfaces. The guidelines on decontamination of contact lenses and ophthalmic devices that come into contact with the patient’s eye have therefore been revised. Prion proteins adhere strongly to materials including smooth surfaces. A key stage in the decontamination of the device is therefore to ensure that it is thoroughly cleaned to remove adhered debris as the potential for the transmission of cellular and proteinacious debris via tonometer prisms has been demonstrated 5,6. The concentration of the sodium hypochlorite advised has been reduced to a level that is appropriate for inactivating infectious agents such as bacteria and viruses, and is probably less harmful to the eye if it accidentally comes into contact with it7. It has been reported that all viruses tested in saline (>99.9%) were inactivated within 10 min by 0.1-0.5 ppm chlorine and that protozoan cysts (Giardia, Acanthamoeba and Naegleria spp) were significantly reduced (>90%) by 1-4 ppm chlorine8. The 1% solution that is recommended by the ACDP working group should therefore eradicate conventional microorganisms, including protozoal cysts.
4.13.4 Equipment needed for decontamination of contact lenses or other ophthalmic devices:
4.13.5 If a contact lens or ophthalmic device is to be reused it needs to be decontaminated and made ready for its next use. The essential steps are:
LINK TO TABLE
4.13.6 Agents or procedures capable of binding proteins to surfaces (e.g. isopropyl alcohol, glutaraldehyde, autoclaving) should never be used unless devices are first decontaminated using the protocol above10. See para 4.12.1.
4.13.7 A lens or device intended by the manufacturer for single use should not be re-used.
3 HSC 1999/178 Variant Creutzfeldt-Jakob disease (vCJD): Minimising the risk of transmission. August 1999. NHS Executive
4 Department of Health (2009). Managing CJD/vCJD risk in ophthalmology (para L32). Guidance from the TSE Working Group (http://www.dh.gov.uk/ab/ACDP/TSEguidance/index.htm)
5 For cellular debris: Lim R, Dhillon B, Kurian KM et al Retention of corneal epithelial cells following Goldmann tonometry: implications for CJD risk Br J Ophthalmol 87(5) 583-586 2003
6 For proteinaceous debris: Amin SZ, Smith L, Luthert PJ et al Minimising the risk of prion transmission by contact tonometry Br J Ophthalmol 87(11) 1360-1362 2003
7 Buckley R Decontamination Optometry in Practice 11(1) 25-29 2010
8 Sobsey MD Inactivation of health-related micro-organisms in water by disinfection processes Water Sci Technol 21 179-195 1989 cited in Rutala WA and Weber DJ Uses of inorganic hypochlorite (bleach) in health-care facilities Clinical Microbiology Reviews 1997 p.602
4.14.1 Although the risk of transmission of prion disease via contact lenses and ophthalmic devices is no more than theoretical in people with no predisposition to developing Transmissible Spongiform Encephalopathies (TSEs), there exist certain patient groups which have been identified as being at greater than normal risk of developing classical CJD:
4.14.2 Before carrying out any procedure that might involve re-use of a contact lens or ophthalmic device the practitioner should as far as possible question the patient to establish whether he or she falls into any of these categories. In such a situation, only single patient use items should be used. If this is not possible the clinician should consider referring the patient to the Hospital Eye Service.
4.14.3 If emergency management of a patient who falls into one of the above groups necessitates the use of a re-usable item, it should be discarded immediately after use.
4.14.4 Contamination via contact lens solutions and medicine bottles: Dispensing opticians must ensure that all contact lens care products and medicines used during the examination are carefully maintained and discarded prior to their expiry date. Any multidose container can be a source of cross infection and varying levels of contamination exist in the plastic bottles containing contact lens solutions. Clinicians should note when these bottles are opened and discard them in accordance with manufacturer’s guidelines, which vary depending on the product and its use. Care must be taken not to contaminate the dropper tip and the lid must be replaced on the container after use as all solutions are susceptible to contamination during the time that caps are removed. If suspected of contamination, solutions should be disposed of immediately. Single use drug delivery systems are recommended where possible.
4.15.1 Under section 34 of the Environmental Protection Act 1990 any person who ‘…imports, produces, carries, keeps, treats or disposes of…’ controlled waste has a duty of care to take all reasonable steps to deal with it appropriately. Controlled waste is defined as being waste from households, commerce or industry. Dispensing Opticians therefore have a responsibility to dispose of the waste that they produce responsibly. This applies to producers of both non-hazardous and hazardous waste.
4.15.2 Clinical waste is defined in the Controlled Waste Regulations 1992 10. It means any waste which consists wholly or partly of:
4.15.3 The disposal of waste must be safe, environmentally sound and legal.
4.15.4. For information, common optical/ophthalmic waste should be categorized and disposed of as follows: