![](media/image1.png){width="5.96875in" height="0.41944444444444445in"}

Top of Form

## Complete Summary

#### GUIDELINE TITLE

Guidelines for environmental infection control in health-care
facilities. Recommendations of CDC and the Healthcare Infection Control
Practices Advisory Committee.

#### BIBLIOGRAPHIC SOURCE(S)

Sehulster L, Chinn RY. Guidelines for environmental infection control in
health-care facilities. Recommendations of CDC and the Healthcare
Infection Control Practices Advisory Committee (HICPAC) \[Published
errata appear in MMWR Recomm Rep 2003 Oct 24;52(42):1025-6\]. MMWR
Recomm Rep 2003 Jun 6;52(RR-10):1-42. \[419 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12836624)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Infections associated with exposure to environmental pathogens (e.g.
*Aspergillus* spp. and *Legionella* spp.) or airborne pathogens (e.g.,
*Mycobacterium tuberculosis* and varicella zoster virus) in health-care
facilities

Recommendations are *[not]{.underline}* associated with infections
related to noninfectious adverse events (e.g., sick building syndrome),
environmental concerns in the home, infection that results from
terrorism, or health-care\--associated foodborne illness.

#### GUIDELINE CATEGORY

Evaluation\
Management\
Prevention\
Risk Assessment

#### CLINICAL SPECIALTY

Infectious Diseases\
Preventive Medicine

#### INTENDED USERS

Allied Health Personnel\
Health Care Providers\
Hospitals\
Public Health Departments

#### GUIDELINE OBJECTIVE(S)

-   To present evidence-based recommendations for environmental
    infection control in health-care facilities, describing control
    measures for preventing infections associated with air, water, or
    other elements of the environment

-   To update the following published guidelines and recommendations:

    -   Garner JS, Favero, MS. CDC guideline for handwashing and
        hospital environmental control (Infect Control 1986; 7:231-43).
        Replaces sections on microbiologic sampling, laundry, infective
        waste, and housekeeping.

    -   Tablan OC, Anderson LJ, Arden NH, et al., Hospital Infection
        Control Practices Advisory Committee. Guideline for prevention
        of nosocomial pneumonia. Infect Control Hosp Epidemiol
        1994;15:587\--627. Updates and expands environmental
        infection-control information for aspergillosis and Legionnaires
        disease; online version incorporates Appendices B, C, and D
        addressing environmental control and detection of Legionella
        spp.

    -   CDC. Guidelines for preventing the transmission of
        *mycobacterium tuberculosis* in health-care facilities. MMWR
        1994;43(No. RR13). Provides supplemental information on
        engineering controls.

    -   CDC. Recommendations for preventing the spread of vancomycin
        resistance: recommendations of the Hospital Infection Control
        Practices Advisory Committee (HICPAC). MMWR 1995;44(No. RR12).
        Supplements environmental infection-control information from the
        section, Hospitals with Endemic VRE or Continued VRE
        Transmission.

    -   Garner JS, Hospital Infection Control Practices Advisory
        Committee. Guideline for isolation precautions in hospitals.
        Infect Control Hosp Epidemiol 1996;17:53\--80. Supplements and
        updates topics in Part II \-\-- Recommendations for Isolation
        Precautions in Hospitals (linen and laundry, routine and
        terminal cleaning, airborne precautions).

    -   Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR, Hospital
        Infection Control Practices Advisory Committee. Guideline for
        prevention of surgical site infection. Infect Control Hosp
        Epidemiol 1999;4:250\--78. Updates operating room ventilation
        and surface cleaning/disinfection recommendations from the
        section, Intraoperative Issues: Operating Room Environment.

    -   U.S. Public Health Service, Infectious Diseases Society of
        America, Prevention of Opportunistic Infections Working Group.
        USPHS/IDSA guidelines for the prevention of opportunistic
        infections in persons infected with human immunodeficiency
        virus. Infect Dis Obstet Gynecol 2002; 10:3\--64. Supplements
        information regarding patient interaction with pets and animals
        in the home.

    -   CDC, Infectious Diseases Society of America, American Society of
        Blood and Marrow Transplantation. Guidelines for preventing
        opportunistic infections among hematopoietic stem cell
        transplant recipients. Cytotherapy 2001;3:41\--54. Supplements
        and updates the section, Hospital Infection Control.

#### TARGET POPULATION

Populations working or residing in health-care facilities in the United
States, including acute-care hospitals, outpatient surgical centers,
urgent care centers, clinics, outpatient dialysis centers, physicians´
offices, and skilled nursing facilities.

This guideline is *not* intended for home health care environments.

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Prevention of airborne infections**

1.  Construction, monitoring, and use of air-handling systems in
    health-care facilities (e.g., heating, cooling, and ventilation
    systems and humidity controls) aimed at reducing microbial
    contamination and spread

2.  Measures for infection control during construction, renovation,
    remediation, repair, and demolition of health-care facilities

3.  Infection control and ventilation requirements for protective
    environment (PE) rooms

4.  Infection control and ventilation requirements for airborne
    infection isolation (AII) rooms

5.  Infection control and ventilation requirements for operating rooms

6.  Measures to control other potential infectious aerosol hazards in
    health-care facilities

**Prevention of waterborne infections**

1.  Controlling the spread of waterborne microorganisms

2.  Routine prevention of waterborne microbial contamination within the
    distribution system

3.  Remediation strategies for distribution system repair or emergencies

4.  Additional engineering measures as indicated by epidemiologic
    investigation for controlling waterborne, health-care\--associated
    Legionnaires disease

5.  General infection-control strategies for preventing Legionnaires
    disease

6.  Preventing Legionnaires disease in protective environments and
    transplant units

7.  Measures for infection control during construction and operation of
    cooling towers and evaporative condensers

8.  Adherence to standards for preparing and processing dialysis water
    and dialysate

9.  Use and maintenance of ice machines and ice to prevent or reduce
    microbial contamination

10. Use and maintenance of hydrotherapy tanks and pools to prevent or
    reduce microbial contamination and spread of infection

11. Cleaning, disinfection, maintenance, and use of miscellaneous
    medical equipment (e.g., endoscopes, bronchoscopes, dental
    waterlines and equipment) connected to water systems to prevent
    microbial contamination

**Prevention of infection from environmental surfaces**

1.  Cleaning and disinfecting strategies for environmental surfaces in
    patient-care areas

2.  Cleaning spills of blood and body substances

3.  Vacuuming, cleaning, and maintenance of carpeting and cloth
    furnishings

4.  Care and maintenance of flowers and plants in patient-care areas

5.  Pest control

6.  Cleaning, disinfecting, and other measures to control special
    pathogens

**Environmental sampling**

1.  General measures for conducting microbiologic sampling

2.  Air, water, and environmental surface sampling

**Laundry and bedding**

1.  Employer responsibilities for laundering contaminated garments

2.  Maintenance and use of laundry facilities and equipment for
    contaminated textiles

3.  Routine handling of contaminated laundry

4.  Laundry process for contaminated textiles and fabrics

5.  Microbiologic sampling of textiles

6.  Measures to prevent infection in special laundry situations

7.  Cleaning, disinfection, and maintenance of mattresses and pillows

8.  Cleaning, disinfection, and maintenance of air-fluidized beds

**Preventing infection from animals in health-care facilities**

1.  General infection-control measures for animal encounters

2.  Measures to prevent microbial contamination and infection spread
    from animal-assisted activities and resident animal programs

3.  Protective measures for immunocompromised patients

4.  Use of service animals in health-care facilities

5.  Measures to avoid contamination and infection when animals are
    treated in human health-care facilities

6.  Measures to avoid contamination and infection from research animals
    in health-care facilities

**Regulated Medical Wastes**

1.  Designation of categories of regulated medical waste

2.  Disposal plan for regulated medical wastes

3.  Handling, transporting, and storing regulated medical wastes

4.  Treatment and disposal of regulated medical wastes

5.  Special precautions for wastes generated during care of patients
    with rare diseases

#### MAJOR OUTCOMES CONSIDERED

Not stated

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Contributors to this report reviewed primarily English-language
manuscripts identified from reference searches using the National
Library of Medicine\'s MEDLINE, bibliographies of published articles,
and infection-control textbooks.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

These recommendations represent the views of different divisions within
Center for Disease Control and Prevention\'s (CDC\'s) National Center
for Infectious Diseases and the Healthcare Infection Control Practices
Advisory Committee (HICPAC), a 12-member group that advises CDC on
concerns related to the surveillance, prevention, and control of
health-care--associated infections, primarily in U.S. health-care
facilities.

Wherever possible, the recommendations in this report are based on data
from well-designed scientific studies. However, certain of these studies
were conducted by using narrowly defined patient populations or specific
health-care settings (e.g., hospitals versus long-term care facilities),
making generalization of findings potentially problematic. Construction
standards for hospitals or other health-care facilities may not apply to
residential home-care units. Similarly, infection-control measures
indicated for immunosuppressed patient care are usually not necessary in
those facilities where such patients are not present.

Other recommendations were derived from knowledge gained during
infectious disease investigations in health-care facilities, where
successful termination of the outbreak was often the result of multiple
interventions, the majority of which cannot be independently and
rigorously evaluated. This is especially true for construction
situations involving air or water.

Other recommendations were derived from empiric engineering concepts and
may reflect industry standards rather than evidence-based conclusions.
Where recommendations refer to guidance from the American Institute of
Architects (AIA), the statements reflect standards intended for new
construction or renovation. Existing structures and engineered systems
are expected to be in continued compliance with those standards in
effect at the time of construction or renovation.

Also, in the absence of scientific confirmation, certain
infection-control recommendations that cannot be rigorously evaluated
are based on strong theoretic rationale and suggestive evidence.
Finally, certain recommendations are derived from existing federal
regulations.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

The Healthcare Infection Control Practices Advisory Committee (HICPAC)
system for categorizing recommendations has been modified to include a
category for engineering standards and actions required by state or
federal regulations. Guidelines and standards published by the American
Institute of Architects (AIA), American Society of Heating,
Refrigeration, and Air-Conditioning Engineers (ASHRAE), and the
Association for the Advancement of Medical Instrumentation (AAMI) form
the basis of certain recommendations. These standards reflect a
consensus of expert opinions and extensive consultation with agencies of
the U.S. Department of Health and Human Services. Compliance with these
standards is usually voluntary. However, state and federal governments
often adopt these standards as regulations. For example, the standards
from AIA regarding construction and design of new or renovated
health-care facilities, have been adopted by reference by \>40 states.
Certain recommendations have two category ratings (e.g., Categories IA
and IC or Categories IB and IC), indicating the recommendation is
evidence-based as well as a standard or regulation.

**Rating Categories**

Recommendations are rated according to the following categories:

**Category IA**. Strongly recommended for implementation and strongly
supported by well-designed experimental, clinical, or epidemiologic
studies.

**Category IB**. Strongly recommended for implementation and supported
by certain experimental, clinical, or epidemiologic studies and a strong
theoretic rationale.

**Category IC**. Required by state or federal regulation, or
representing an established association standard. (Note: Abbreviations
for governing agencies and regulatory citations are listed where
appropriate. Recommendations from regulations adopted at state levels
are also noted. Recommendations from AIA guidelines cite the appropriate
sections of the standards.)

**Category II**. Suggested for implementation and supported by
suggestive clinical or epidemiologic studies, or a theoretic rationale.

**Unresolved issue**. No recommendation is offered. No consensus or
insufficient evidence exists regarding efficacy.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Definitions for the strength of recommendation grading (IA-IC, II, and
Unresolved issue) are provided at the end of the \"Major
Recommendations\" field.

**[Recommendations - Air]{.underline}**

I.  **Air-Handling Systems in Health-Care Facilities**

    A.  Use American Institute of Architects (AIA) guidelines as minimum
        standards where state or local regulations are not in place for
        design and construction of ventilation systems in new or
        renovated health-care facilities. Ensure that existing
        structures continue to meet the specifications in effect at the
        time of construction (The American Institute of Architects and
        The Facilities Guidelines Institute, 2001). **Category IC**
        (AIA: 1.1.A, 5.4)

    B.  Monitor ventilation systems in accordance with engineers\' and
        manufacturers\' recommendations to ensure preventive
        engineering, optimal performance for removal of particulates,
        and elimination of excess moisture (The American Institute of
        Architects and The Facilities Guidelines Institute, 2001; Arnow
        et al., 1991; Streifel, 1999; Pittet et al., 1996; US
        Environmental Protection Agency, Office of Air and Radiation,
        and US Department of Health and Human Services, National
        Institute of Occupational Safety and Health, 1991; Rao, Burge, &
        Chang, 1996; Beck-Sague et al., 1992; Dooley et al., 1992).
        **Category IB, IC** (AIA: 7.2, 7.31.D, 8.31.D, 9.31.D, 10.31.D,
        11.31.D, Environmental Protection Agency \[EPA\] guidance)

        1.  Ensure that heating, ventilation, air conditioning (HVAC)
            filters are properly installed and maintained to prevent air
            leakages and dust overloads (Arnow et al., 1991; Pittet et
            al., 1996; Rao, Burge, & Chang, 1996; Sarubbi et al., 1982).
            **Category IB**

        2.  Monitor areas with special ventilation requirements (e.g.,
            airborne infection isolation \[AII\] or protective
            environment \[PE\]) for air changes per hour (ACH),
            filtration, and pressure differentials (The American
            Institute of Architects and The Facilities Guidelines
            Institute, 2001; Beck-Sague et al., 1992; Dooley et al.,
            1992; Streifel, Stevens, & Rhame, 1987; Hansen, 1997;
            Bartley, \"Ventilation,\" 2000; Bartley, \"Construction and
            renovation,\" 2000; Harvey, 1998; Infection Control Focus
            Group, 1998; Carter & Barr, 1997; Coronado et al.,
            \"Transmission,\" 1993; Coronado et al., \"Nosocomial
            transmission,\" 1993; Edlin et al., 1992; Fischl et al.,
            1992; Ikeda et al., 1995; Jarvis, 1993; Jarvis, 1995; Jereb
            et al., 1995; Moran et al., 1995; Pearson et al., 1992).
            **Category IB, IC** (AIA: 7.2.C7, 7.2.D6)

            a.  Develop and implement a maintenance schedule for ACH,
                pressure differentials, and filtration efficiencies by
                using facility-specific data as part of the
                multidisciplinary risk assessment. Take into account the
                age and reliability of the system.

            b.  Document these parameters, especially the pressure
                differentials.

        3.  Engineer humidity controls into the HVAC system and monitor
            the controls to ensure adequate moisture removal (The
            American Institute of Architects and The Facilities
            Guidelines Institute, 2001). **Category IC** (AIA: 7.31.D9)

            a.  Locate duct humidifiers upstream from the final filters.

            b.  Incorporate a water-removal mechanism into the system.

            c.  Locate all duct takeoffs sufficiently downstream from
                the humidifier so that moisture is completely absorbed.

        4.  Incorporate steam humidifiers, if possible, to reduce
            potential for microbial proliferation within the system, and
            avoid use of cool-mist humidifiers. **Category II**

        5.  Ensure that air intakes and exhaust outlets are located
            properly in construction of new facilities and renovation of
            existing facilities (The American Institute of Architects
            and The Facilities Guidelines Institute, 2001; Centers for
            Disease Control and Prevention \[CDC\], 1997). **Category
            IC** (AIA: 7.31.D3, 8.31.D3, 9.31.D3, 10.31.D3, 11.31.D3)

            a.  Locate exhaust outlets \>25 ft from air-intake systems.

            b.  Locate outdoor air intakes [\>]{.underline}6 ft above
                ground or [\>]{.underline}3 ft above roof level.

            c.  Locate exhaust outlets from contaminated areas above
                roof level to minimize recirculation of exhausted air.

        6.  Maintain air intakes and inspect filters periodically to
            ensure proper operation (The American Institute of
            Architects and The Facilities Guidelines Institute, 2001;
            Hansen, 1997; Bartley, \"Ventilation,\" 2000; Bartley,
            \"Construction and renovation,\" 2000; Harvey, 1998;
            Infection Control Focus Group, 1998; Carter & Barr, 1997;
            CDC, 1997). **Category IC** (AIA: 7.31.D8)

        7.  Bag dust-filled filters immediately upon removal to prevent
            dispersion of dust and fungal spores during transport within
            the facility (Pittet et al., 1996; Ko et al., 1998).
            **Category IB**

            a.  Seal or close the bag containing the discarded filter.

            b.  Discard spent filters as regular solid waste, regardless
                of the area from which they were removed (Ko et al.,
                1998).

        8.  Remove bird roosts and nests near air intakes to prevent
            mites and fungal spores from entering the ventilation system
            (CDC, 1997; Gage et al., 1970; Vargo, Ginsberg, & Mizrahi,
            1983). **Category IB**

        9.  Prevent dust accumulation by cleaning air-duct grilles in
            accordance with facility-specific procedures and schedules
            and when rooms are not occupied by patients (The American
            Institute of Architects and The Facilities Guidelines
            Institute, 2001; Streifel, Stevens, & Rhame, 1987; Hansen,
            1997; Bartley, \"Ventilation,\" 2000; Bartley,
            \"Construction and renovation,\" 2000; Harvey, 1998;
            Infection Control Focus Group, 1998; Carter & Barr, 1997).
            **Category IC, II** (AIA: 7.31.D10)

        10. Periodically measure output to monitor system function;
            clean ventilation ducts as part of routine HVAC maintenance
            to ensure optimum performance (The American Institute of
            Architects and The Facilities Guidelines Institute, 2001;
            National Air Duct Cleaners Association \[NADCA\], 2002; US
            Environmental Protection Agency, Office of Pesticide
            Programs, 2002). **Category IC, II** (AIA: 7.31.D10)

    C.  Use portable, industrial-grade high efficiency particulate air
        (HEPA) filter units capable of filtration rates in the range of
        300 to 800 ft^3^/min to augment removal of respirable particles
        as needed (Rutala et al., 1995). **Category II**

        1.  Select portable HEPA filters that can recirculate all or
            nearly all of the room air and provide the equivalent of
            [\>]{.underline}12 ACH (\"Guidelines,\" 1994). **Category
            II**

        2.  Portable HEPA filter units placed in construction zones can
            be used later in patient-care areas, provided all internal
            and external surfaces are cleaned, and the filter replaced
            or its performance verified by appropriate particle testing.
            **Category II**

        3.  Situate portable HEPA units with the advice of facility
            engineers to ensure that all room air is filtered
            (\"Guidelines,\" 1994). **Category II**

        4.  Ensure that fresh-air requirements for the area are met
            (Rutala et al., 1995; American Society of Heating,
            Refrigerating, and Air-Conditioning Engineers, Inc.
            \[ASHRAE\], \"Ventilation,\" 1999). **Category II**

    D.  Follow appropriate procedures for use of areas with
        through-the-wall ventilation units (The American Institute of
        Architects and The Facilities Guidelines Institute, 2001).
        **Category IC** (AIA: 8.31.D1, 8.31.D8, 9.31.D23, 10.31.D18,
        11.31.D15)

        1.  Do not use such areas as PE rooms (The American Institute of
            Architects and The Facilities Guidelines Institute, 2001).
            **Category IC** (AIA: 7.2.D3)

        2.  Do not use a room with a through-the-wall ventilation unit
            as an AII room unless it can be demonstrated that all
            required AII engineering controls are met (The American
            Institute of Architects and The Facilities Guidelines
            Institute, 2001; \"Guidelines,\" 1994). **Category IC**
            (AIA: 7.2.C3)

    E.  Conduct an infection-control risk assessment (ICRA) and provide
        an adequate number of AII and PE rooms (if required) or other
        areas to meet the needs of the patient population (The American
        Institute of Architects and The Facilities Guidelines Institute,
        2001; Arnow et al., 1991; Beck-Sague et al., 1992; Dooley et
        al., 1992; Coronado et al., \"Transmission,\" 1993; Edlin et
        al., 1992; Fischl et al., 1992; \"Guidelines,\" 1994; Garner,
        1996; \"Guidelines,\" 2000; Flynn et al., 1993; Tabbara & Al
        Jabarti, 1998; Rhame et al., 1984; Wells, 1955; \"Nosocomial
        transmission,\" 1991; \"Outbreak,\" 1993). **Category IA, IC**
        (AIA: 7.2.C, 7.2.D)

    F.  When ultraviolet germicidal irradiation (UVGI) is used as a
        supplemental engineering control, install fixtures 1) on the
        wall near the ceiling or suspended from the ceiling as an upper
        air unit; 2) in the air-return duct of an AII area; or 3) in
        designated enclosed areas or booths for sputum induction
        (\"Guidelines,\" 1994). **Category II**

    G.  Seal windows in buildings with centralized HVAC systems,
        including PE areas (The American Institute of Architects and The
        Facilities Guidelines Institute, 2001; Streifel, 1999; Gerson et
        al., 1994). **Category IB, IC** (AIA: 7.2.D3)

    H.  Keep emergency doors and exits from PE rooms closed except
        during an emergency; equip emergency doors and exits with
        alarms. **Category II**

    I.  Develop a contingency plan for backup capacity in the event of a
        general power failure (Joint Commission on Accreditation of
        Healthcare Organizations \[JCAHO\], 2001). **Category IC**
        (JCAHO: Environment of Care \[EC\] 1.4)

        1.  Emphasize restoration of appropriate air quality and
            ventilation conditions in AII rooms, PE rooms, operating
            rooms, emergency departments, and intensive care units (The
            American Institute of Architects and The Facilities
            Guidelines Institute, 2001; JCAHO, 2001).**Category IC**
            (AIA: 1.5.A1; JCAHO: EC 1.4)

        2.  Deploy infection-control procedures to protect occupants
            until power and systems functions are restored (The American
            Institute of Architects and The Facilities Guidelines
            Institute, 2001; Garner, 1996; JCAHO, 2001). **Category IC**
            (AIA: 5.1, 5.2; JCAHO: EC 1.4)

    J.  Do not shut down HVAC systems in patient-care areas except for
        maintenance, repair, testing of emergency backup capacity, or
        new construction (The American Institute of Architects and The
        Facilities Guidelines Institute, 2001; Fridkin et al., 1996).
        **Category IB, IC** (AIA: 5.1, 5.2.B, C)

        1.  Coordinate HVAC system maintenance with infection-control
            staff and relocate immunocompromised patients if necessary
            (The American Institute of Architects and The Facilities
            Guidelines Institute, 2001). **Category IC** (AIA: 5.1, 5.2)

        2.  Provide backup emergency power and air-handling and
            pressurization systems to maintain filtration, constant ACH,
            and pressure differentials in PE rooms, AII rooms, operating
            rooms, and other critical-care areas (The American Institute
            of Architects and The Facilities Guidelines Institute, 2001;
            \"Guidelines,\" 2000; Streifel, 2000). **Category IC** (AIA:
            5.1, 5.2)

        3.  For areas not served by installed emergency ventilation and
            backup systems, use portable units and monitor ventilation
            parameters and patients in those areas (Rutala et al.,
            1995). **Category II**

        4.  Coordinate system startups with infection-control staff to
            protect patients in PE rooms from bursts of fungal spores
            (The American Institute of Architects and The Facilities
            Guidelines Institute, 2001; Streifel, 1999; \"Guidelines,\"
            2000; Streifel, 2000). **Category IC** (AIA: 5.1, 5.2)

        5.  Allow sufficient time for ACH to clean the air once the
            system is operational (refer to Table 1 titled \"Air
            changes/hour and time required for airborne contaminant
            removal efficiencies of 99% and 99.9%\" in the original
            guideline document) (The American Institute of Architects
            and The Facilities Guidelines Institute, 2001; Rutala et
            al., 1995). **Category IC** (AIA: 5.1, 5.2)

    K.  HVAC systems serving offices and administrative areas may be
        shut down for energy conservation purposes, but the shutdown
        must not alter or adversely affect pressure differentials
        maintained in laboratories or critical-care areas with specific
        ventilation requirements (i.e., PE rooms, AII rooms, operating
        rooms). **Category II**

    L.  Whenever possible, avoid inactivating or shutting down the
        entire HVAC system, especially in acute-care facilities.
        **Category II**

    M.  Whenever feasible, design and install fixed backup ventilation
        systems for new or renovated construction of PE rooms, AII
        rooms, operating rooms, and other critical-care areas identified
        by ICRA (The American Institute of Architects and The Facilities
        Guidelines Institute, 2001). **Category IC** (AIA: 1.5.A1)

II. **Construction, Renovation, Remediation, Repair, and Demolition**

    A.  Establish a multidisciplinary team that includes
        infection-control staff to coordinate demolition, construction,
        and renovation projects and consider proactive preventive
        measures at the inception; produce and maintain summary
        statements of the team\'s activities (The American Institute of
        Architects and The Facilities Guidelines Institute, 2001;
        Sarubbi et al., 1982; Hansen, 1997; Bartley, \"Ventilation,\"
        2000; Bartley, \"Construction and renovation,\" 2000; Harvey,
        1998; Infection Control Focus Group, 1998; Carter & Barr, 1997;
        Flynn et al., 1993; Weems et al., 1987; Krasinski et al., 1985;
        Bartley, \"APIC state-of-the-art report,\" 2000; Walsh & Dixon,
        1989). **Category IB, IC** (AIA: 5.1)

    B.  Educate both the construction team and health-care staff in
        immunocompromised patient-care areas regarding the airborne
        infection risks associated with construction projects, dispersal
        of fungal spores during such activities, and methods to control
        the dissemination of fungal spores (Hansen, 1997; Bartley,
        \"Ventilation,\" 2000; Bartley, \"Construction and renovation,\"
        2000; Harvey, 1998; Infection Control Focus Group, 1998; Carter
        & Barr, 1997; CDC, 1997; Bartley, \"APIC state-of-the-art
        report,\" 2000; Johnson et al., 1982; Soumerai et al., 1993;
        Eisenberg, 1977; Rello et al., 1990; McWhinney et al., 1993).
        **Category IB**

    C.  Incorporate mandatory adherence agreements for infection control
        into construction contracts, with penalties for noncompliance
        and mechanisms to ensure timely correction of problems (The
        American Institute of Architects and The Facilities Guidelines
        Institute, 2001; Hansen, 1997; Bartley, \"Construction and
        renovation,\" 2000; Harvey, 1998; Infection Control Focus Group,
        1998; Carter & Barr, 1997; CDC, 1997; Bartley, \"APIC
        state-of-the-art report,\" 2000). **Category IC** (AIA: 5.1)

    D.  Establish and maintain surveillance for airborne environmental
        disease (e.g., aspergillosis) as appropriate during
        construction, renovation, repair, and demolition activities to
        ensure the health and safety of immunocompromised patients (CDC,
        1997; Pannuti et al., 1991; Wingard et al., 1987; Gerson et al.,
        1984). **Category IB**

        1.  Using active surveillance, monitor for airborne infections
            in immunocompromised patients (CDC, 1997; \"Guidelines,\"
            2000; Pannuti et al., 1991; Wingard et al., 1987).
            **Category IB**

        2.  Periodically review the facility\'s microbiologic,
            histopathologic, and postmortem data to identify additional
            cases (CDC, 1997, \"Guidelines,\" 2000; Pannuti et al.,
            1991; Wingard et al., 1987). **Category IB**

        3.  If cases of aspergillosis or other health-care\--associated
            airborne fungal infections occur, aggressively pursue the
            diagnosis with tissue biopsies and cultures as feasible
            (Hansen, 1997; Bartley, \"Construction and renovation,\"
            2000; Harvey, 1998; Infection Control Focus Group, 1998;
            Carter & Barr, 1997; CDC, 1997; Bartley, \"APIC
            state-of-the-art report,\" 2000; Pannuti et al., 1991;
            Wingard et al., 1987; Gerson et al., 1984). **Category IB**

    E.  Implement infection-control measures relevant to construction,
        renovation, maintenance, demolition, and repair (The American
        Institute of Architects and The Facilities Guidelines Institute,
        2001; Carter & Barr, 1997; Krasinski et al., 1985; Bartley,
        \"APIC state-of-the-art report,\" 2000; Lentino et al., 1982).
        **Category IB, IC** (AIA: 5.1, 5.2)

        1.  Before the project gets under way, perform an ICRA to define
            the scope of the activity and the need for barrier measures
            (The American Institute of Architects and The Facilities
            Guidelines Institute, 2001; Hansen, 1997; Bartley,
            \"Construction and renovation,\" 2000; Harvey, 1998;
            Infection Control Focus Group, 1998; Carter & Barr, 1997;
            Weems et al., 1987; Krasinski et al., 1985; Bartley, \"APIC
            state-of-the-art report,\" 2000; Lentino et al., 1982).
            **Category IB, IC** (AIA: 5.1)

            a.  Determine if immunocompromised patients may be at risk
                for exposure to fungal spores from dust generated during
                the project (Bartley, \"Construction and renovation,\"
                2000; Harvey, 1998; Infection Control Focus Group, 1998;
                Carter & Barr, 1997; Weems et al., 1987; Walsh & Dixon,
                1989).

            b.  Develop a contingency plan to prevent such exposures
                (Bartley, \"Construction and renovation,\" 2000; Harvey,
                1998; Infection Control Focus Group, 1998; Carter &
                Barr, 1997; Weems et al., 1987; Walsh & Dixon, 1989).

        2.  Implement infection-control measures for external demolition
            and construction activities (Hansen, 1997; Bartley,
            \"Construction and renovation,\" 2000; Harvey, 1998;
            Infection Control Focus Group, 1998; Carter & Barr, 1997;
            Bartley, \"APIC state-of-the-art report,\" 2000; Streifel et
            al., 1983; Thio et al., 2000). **Category IB**

            a.  Determine if the facility can operate temporarily on
                recirculated air; if feasible, seal off adjacent air
                intakes.

            b.  If this is not possible or practical, check the
                low-efficiency (roughing) filter banks frequently and
                replace as needed to avoid buildup of particulates.

            c.  Seal windows and reduce wherever possible other sources
                of outside air intrusion (e.g., open doors in stairwells
                and corridors), especially in PE areas.

        3.  Avoid damaging the underground water system (i.e., buried
            pipes) to prevent soil and dust contamination of the water
            (The American Institute of Architects and The Facilities
            Guidelines Institute, 2001; Mermel et al., 1995). **Category
            IB, IC** (AIA: 5.1)

        4.  Implement infection-control measures for internal
            construction activities (The American Institute of
            Architects and The Facilities Guidelines Institute, 2001;
            Hansen, 1997; Bartley, \"Construction and renovation,\"
            2000; Harvey, 1998; Infection Control Focus Group, 1998;
            Carter & Barr, 1997; Weems et al., 1987; Krasinski et al.,
            1985; Bartley, \"APIC state-of-the-art report,\" 2000; Arnow
            et al., 1978). **Category IB, IC** (AIA: 5.1, 5.2)

            a.  Construct barriers to prevent dust from construction
                areas from entering patient-care areas; ensure that
                barriers are impermeable to fungal spores and in
                compliance with local fire codes (The American Institute
                of Architects and The Facilities Guidelines Institute,
                2001; JCAHO, 2001; Weems et al., 1987; Krasinski et al.,
                1985; Rello et al., 1990; Kuehn et al., 1995; Mermel et
                al., 1995; Opal et al., 1986).

            b.  Seal off and block return air vents if rigid barriers
                are used for containment (The American Institute of
                Architects and The Facilities Guidelines Institute,
                2001; Carter & Barr, 1997; Bartley, \"APIC
                state-of-the-art report,\" 2000).

            c.  Implement dust-control measures on surfaces and divert
                pedestrian traffic away from work zones (The American
                Institute of Architects and The Facilities Guidelines
                Institute, 2001; Weems et al., 1987; Krasinski et al.,
                1985; Arnow et al., 1978).

            d.  Relocate patients whose rooms are adjacent to work
                zones, depending on their immune status, the scope of
                the project, the potential for generation of dust or
                water aerosols, and the methods used to control these
                aerosols (The American Institute of Architects and The
                Facilities Guidelines Institute, 2001; Arnow et al.,
                1978; Kuehn et al., 1995).

        5.  Perform those engineering and work-site related
            infection-control measures as needed for internal
            construction, repairs, and renovations (The American
            Institute of Architects and The Facilities Guidelines
            Institute, 2001; Weems et al., 1987; Krasinski et al., 1985;
            Walsh & Dixon, 1989; Arnow et al., 1978; Opal et al., 1986).
            **Category IB, IC** (AIA: 5.1, 5.2)

            a.  Ensure proper operation of the air-handling system in
                the affected area after erection of barriers and before
                the room or area is set to negative pressure (Tabbara &
                Al Jabarti, 1998; Streifel, 2000; Bartley, \"APIC
                state-of-the-art report,\" 2000; Arnow et al., 1978).
                **Category IB**

            b.  Create and maintain negative air pressure in work zones
                adjacent to patient-care areas and ensure that required
                engineering controls are maintained (The American
                Institute of Architects and The Facilities Guidelines
                Institute, 2001; Weems et al., 1987; Krasinski et al.,
                1985; Walsh & Dixon, 1989; Arnow et al., 1978; Opal et
                al., 1986).

            c.  Monitor negative airflow inside rigid barriers (The
                American Institute of Architects and The Facilities
                Guidelines Institute, 2001; Association for
                Professionals in Infection Control and Epidemiology,
                1999).

            d.  Monitor barriers and ensure integrity of the
                construction barriers; repair gaps or breaks in barrier
                joints (The American Institute of Architects and The
                Facilities Guidelines Institute, 2001; Kuehn et al.,
                1995; Opal et al., 1986; Ottney, 1993).

            e.  Seal windows in work zones if practical; use window
                chutes for disposal of large pieces of debris as needed,
                but ensure that the negative pressure differential for
                the area is maintained (The American Institute of
                Architects and The Facilities Guidelines Institute,
                2001; Bartley, \"Construction and renovation,\" 2000;
                Weems et al., 1987).

            f.  Direct pedestrian traffic from construction zones away
                from patient-care areas to minimize dispersion of dust
                (The American Institute of Architects and The Facilities
                Guidelines Institute, 2001; Bartley, \"Construction and
                renovation,\" 2000; Harvey, 1998; Infection Control
                Focus Group, 1998; Carter & Barr, 1997; Gerson et al.,
                1994; Weems et al., 1987; Krasinski et al., 1985;
                Bartley, \"APIC state-of-the-art report,\" 2000; Walsh &
                Dixon, 1989; Arnow et al., 1978).

            g.  Provide construction crews with 1) designated entrances,
                corridors, and elevators wherever practical; 2)
                essential services (e.g., toilet facilities) and
                convenience services (e.g., vending machines); 3)
                protective clothing (e.g., coveralls, footgear, and
                headgear) for travel to patient-care areas; and 4) a
                space or anteroom for changing clothing and storing
                equipment (The American Institute of Architects and The
                Facilities Guidelines Institute, 2001; Hansen, 1997;
                Bartley, \"Construction and renovation,\" 2000; Harvey,
                1998; Infection Control Focus Group, 1998; Carter &
                Barr, 1997; Bartley, \"APIC state-of-the-art report,\"
                2000).

            h.  Clean work zones and their entrances daily by 1)
                wet-wiping tools and tool carts before their removal
                from the work zone; 2) placing mats with tacky surfaces
                inside the entrance; and 3) covering debris and securing
                this covering before removing debris from the work zone
                (The American Institute of Architects and The Facilities
                Guidelines Institute, 2001; Hansen, 1997; Bartley,
                \"Construction and renovation,\" 2000; Harvey, 1998;
                Infection Control Focus Group, 1998; Carter & Barr,
                1997; Bartley, \"APIC state-of-the-art report,\" 2000).

            i.  In patient-care areas, for major repairs that include
                removal of ceiling tiles and disruption of the space
                above the false ceiling, use plastic sheets or
                prefabricated plastic units to contain dust; use a
                negative pressure system within this enclosure to remove
                dust; and either pass air through an industrial-grade,
                portable HEPA filter capable of filtration rates of 300
                to 800 ft^3^/min., or exhaust air directly to the
                outside (Carter & Barr, 1997; Bartley, \"APIC
                state-of-the-art report,\" 2000; Arnow et al., 1978;
                Association for Professionals in Infection Control and
                Epidemiology, 1999; Finkelstein & Mendelson, 1997).

            j.  Upon completion of the project, clean the work zone
                according to facility procedures, and install barrier
                curtains to contain dust and debris before removing
                rigid barriers (The American Institute of Architects and
                The Facilities Guidelines Institute, 2001; Hansen, 1997;
                Bartley, \"Construction and renovation,\" 2000; Harvey,
                1998; Infection Control Focus Group, 1998; Carter &
                Barr, 1997; Weems et al., 1987; Krasinski et al., 1985;
                Bartley, \"APIC state-of-the-art report,\" 2000).

            k.  Flush the water system to clear sediment from pipes to
                minimize waterborne microorganism proliferation (The
                American Institute of Architects and The Facilities
                Guidelines Institute, 2001; Mermel et al., 1995).

            l.  Restore appropriate ACH, humidity, and pressure
                differential; clean or replace air filters; dispose of
                spent filters (Streifel, 1999; Pittet et al., 1996; Ko
                et al., 1998; Streifel, 2000).

    F.  Use airborne-particle sampling as a tool to evaluate barrier
        integrity (Streifel, 1999; Overberger, Wadowsky, & Schaper,
        1995). **Category II**

    G.  Commission the HVAC system for newly constructed health-care
        facilities and renovated spaces before occupancy and use, with
        emphasis on ensuring proper ventilation for operating rooms, AII
        rooms, and PE areas (The American Institute of Architects and
        The Facilities Guidelines Institute, 2001; Overberger, Wadowsky,
        & Schaper, 1995; Streifel & Marshall, 1998; American Society of
        Heating, Refrigerating, and Air-Conditioning Engineers
        \[ASHRAE\], 1996). **Category IC** (AIA: 5.1; ASHRAE: 1-1996)

    H.  No recommendation is offered regarding routine microbiologic air
        sampling before, during, or after construction, or before or
        during occupancy of areas housing immunocompromised patients
        (Sarubbi et al., 1982; Weems et al., 1987; Krasinski et al.,
        1985; Walsh & Dixon, 1989; Arnow et al., 1978; Morey & Williams,
        1990; Aisner et al., 1979). **Unresolved issue**

    I.  If a case of health-care\--acquired aspergillosis or other
        opportunistic environmental airborne fungal disease occurs
        during or immediately after construction, implement appropriate
        follow-up measures (Rhame et al., 1984; Weems et al., 1987;
        McCarty et al., 1986; Klimowski, Rotstein, & Cummings, 1989;
        Pfundstein, 1997; Rhame et al., 1985). **Category IB**

        1.  Review pressure-differential monitoring documentation to
            verify that pressure differentials in the construction zone
            and in PE rooms are appropriate for their settings (The
            American Institute of Architects and The Facilities
            Guidelines Institute, 2001; Rhame et al., 1984; Rhame et
            al., 1985). **Category IB, IC** (AIA: 5.1)

        2.  Implement corrective engineering measures to restore proper
            pressure differentials as needed (The American Institute of
            Architects and The Facilities Guidelines Institute, 2001;
            Rhame et al., 1984; Rhame et al., 1985). **Category IB, IC**
            (AIA: 5.1)

        3.  Conduct a prospective search for additional cases and
            intensify retrospective epidemiologic review of the
            hospital\'s medical and laboratory records (CDC, 1997; Weems
            et al., 1987; Klimowski, Rotstein, & Cummings, 1989;
            Walmsley et al., 1993; Kyriakides et al., 1976). **Category
            IB**

        4.  If no epidemiologic evidence of ongoing transmission exists,
            continue routine maintenance in the area to prevent
            health-care--acquired fungal disease (CDC, 1997; McCarty et
            al., 1986). **Category IB**

    J.  If epidemiologic evidence exists of ongoing transmission of
        fungal disease, conduct an environmental assessment to find and
        eliminate the source (Hansen, 1997; Bartley, \"Construction and
        renovation,\" 2000; Harvey, 1998; Infection Control Focus Group,
        1998; Carter & Barr, 1997; CDC, 1997; Gerson et al., 1994;
        Krasinski et al., 1985; Bartley, \"APIC state-of-the-art
        report,\" 2000; Walsh & Dixon, 1989; Lentino et al., 1982; Abzug
        et al., 1992). **Category IB**

        1.  Collect environmental samples from potential sources of
            airborne fungal spores, preferably by using a high-volume
            air sampler rather than settle plates (Arnow et al., 1991;
            Pittet et al., 1996; Hansen, 1997; Bartley, \"Construction
            and renovation,\" 2000; Harvey, 1998; Infection Control
            Focus Group, 1998; Carter & Barr, 1997; CDC, 1997; Gerson et
            al., 1994; Krasinski et al., 1985; Bartley, \"APIC
            state-of-the-art report,\" 2000; Arnow et al., 1978; Kuehn
            et al., 1995; Abzug et al., 1992; Sherertz et al., 1987;
            Aisner et al., 1976; Fox et al., 1990; Barnes & Rogers,
            1989; Leenders et al., 1996). **Category IB**

        2.  If either an environmental source of airborne fungi or an
            engineering problem with filtration or pressure
            differentials is identified, promptly perform corrective
            measures to eliminate the source and route of entry
            (Krasinski et al., 1985; Lentino et al., 1982). **Category
            IB**

        3.  Use an Environmental Protection Agency (EPA)-registered
            antifungal biocide (e.g., copper-8-quinolinolate) for
            decontaminating structural materials (Carter & Barr, 1997;
            Streifel et al., 1983; Opal et al., 1986; Yeager, 1991).
            **Category IB**

        4.  If an environmental source of airborne fungi is not
            identified, review infection-control measures, including
            engineering controls, to identify potential areas for
            correction or improvement (Allo et al., 1987; Schleupner &
            Hamilton, 1980). **Category IB**

        5.  If possible, perform molecular subtyping of *Aspergillus*
            spp. isolated from patients and the environment to compare
            their strain identities (Denning et al., 1990; James et al.,
            2000; Skladny et al., 1999; Symoens et al., 2000;
            Diaz-Guerra et al., 2000). **Category II**

    K.  If air-supply systems to high-risk areas (e.g., PE rooms) are
        not optimal, use portable, industrial-grade HEPA filters on a
        temporary basis until rooms with optimal air-handling systems
        become available (The American Institute of Architects and The
        Facilities Guidelines Institute, 2001; Bartley, \"Construction
        and renovation,\" 2000; Harvey, 1998; Infection Control Focus
        Group, 1998; Carter & Barr, 1997; CDC, 1997; Bartley, \"APIC
        state-of-the-art report,\" 2000). **Category II**

III. **Infection Control and Ventilation Requirements for PE rooms**

     A.  Minimize exposures of severely immunocompromised patients
         (e.g., solid-organ transplant patients or allogeneic
         neutropenic patients) to activities that might cause
         aerosolization of fungal spores (e.g., vacuuming or disruption
         of ceiling tiles) (\"Guidelines,\" 2000; Weems et al., 1987;
         Walsh & Dixon, 1989; Morey & Williams, 1990). **Category IB**

     B.  Minimize the length of time that immunocompromised patients in
         PE are outside their rooms for diagnostic procedures and other
         activities (\"Guidelines,\" 2000; Thio et al., 2000).
         **Category IB**

     C.  Provide respiratory protection for severely immunocompromised
         patients when they must leave PE for diagnostic procedures and
         other activities; consult the most recent revision of the
         CDC\'s *Guideline for Prevention of Health-Care\--Associated
         Pneumonia* for information regarding the appropriate type of
         respiratory protection. (CDC, 1997; \"Guidelines,\" 2000).
         **Category II**

     D.  Incorporate ventilation engineering specifications and
         dust-controlling processes into the planning and construction
         of new PE units (refer to Figure 1 titled \"Example of
         positive-pressure room control for protection from airborne
         environmental microbes\" in the original guideline document).
         **Category IB, IC**

         1.  Install central or point-of-use HEPA filters for supply
             (incoming) air (The American Institute of Architects and
             The Facilities Guidelines Institute, 2001; Arnow et al.,
             1991; CDC, 1997; Weems et al., 1987; McWhinney et al.,
             1993; Overberger, Wadowsky, & Schaper, 1995; Kyriakides et
             al., 1976; Sherertz et al., 1987; Barnes & Rogers, 1989;
             Siegler & Kennedy, 1999; Breton et al., 1998; Guarro et
             al., 2000; Burton et al., 1972; Buckner et al., 1978;
             Murray et al., 1988; \"Control of airborne fungal spores,\"
             1989; Rhame, 1986). **Category IB, IC** (AIA: 5.1, 5.2,
             7.2.D)

         2.  Ensure that rooms are well-sealed by 1) properly
             constructing windows, doors, and intake and exhaust
             ports; 2) maintaining ceilings that are smooth and free of
             fissures, open joints, and crevices; 3) sealing walls above
             and below the ceiling; and 4) monitoring for leakage and
             making any necessary repairs (The American Institute of
             Architects and The Facilities Guidelines Institute, 2001;
             CDC, 1997; Gerson et al., 1994; Murray et al., 1988;
             \"Control of airborne fungal spores,\" 1989). **Category
             IB, IC** (AIA: 7.2.D3)

         3.  Ventilate the room to maintain [\>]{.underline}12 ACH (The
             American Institute of Architects and The Facilities
             Guidelines Institute, 2001; CDC, 1997; \"Guidelines,\"
             2000; Murray et al., 1988; \"Control of airborne fungal
             spores,\" 1989; ASHRAE, \"1999 handbook,\" 1999).
             **Category IC** (AIA: 7.2.D)

         4.  Locate air supply and exhaust grilles so that clean,
             filtered air enters from one side of the room, flows across
             the patient\'s bed, and exits from the opposite side of the
             room (The American Institute of Architects and The
             Facilities Guidelines Institute, 2001; CDC, 1997; Murray et
             al., 1988; \"Control of airborne fungal spores,\" 1989).
             **Category IC** (AIA: 7.31.D1)

         5.  Maintain positive room air pressure ([\>]{.underline}2.5 Pa
             \[0.01-inch water gauge\]) in relation to the corridor (The
             American Institute of Architects and The Facilities
             Guidelines Institute, 2001; Streifel, 1999; CDC, 1997;
             Murray et al., 1988; \"Control of airborne fungal spores,\"
             1989). **Category IB, IC** (AIA: Table 7.2)

         6.  Maintain airflow patterns and monitor these on a daily
             basis by using permanently installed visual means of
             detecting airflow in new or renovated construction, or by
             using other visual methods (e.g., flutter strips or smoke
             tubes) in existing PE units. Document the monitoring
             results (The American Institute of Architects and The
             Facilities Guidelines Institute, 2001; Bartley,
             \"Construction and renovation,\" 2000). **Category IC**
             (AIA: 7.2.D6)

         7.  Install self-closing devices on all room exit doors in PE
             rooms (The American Institute of Architects and The
             Facilities Guidelines Institute, 2001). **Category IC**
             (AIA: 7.2.D4)

     E.  Do not use laminar air flow systems in newly constructed PE
         rooms (Buckner et al., 1978; \"Control of airborne fungal
         spores,\" 1989). **Category II**

     F.  Take measures to protect immunocompromised patients who would
         benefit from a PE room and who also have an airborne infectious
         disease (e.g., acute varicella zoster virus \[VZV\] infection
         or tuberculosis).

         1.  Ensure that the patient\'s room is designed to maintain
             positive pressure.

         2.  Use an anteroom to ensure appropriate air-balance
             relationships and provide independent exhaust of
             contaminated air to the outside, or place a HEPA filter in
             the exhaust duct if the return air must be recirculated
             (The American Institute of Architects and The Facilities
             Guidelines Institute, 2001; Murray et al., 1988) (refer to
             Figure 2 titled \"Example of airborne infection isolation
             \[AII\] room with anteroom and neutral anteroom\").
             **Category IC** (AIA: 7.2.D1, A7.2.D)

         3.  If an anteroom is not available, place the patient in AII
             and use portable, industrial-grade HEPA filters to enhance
             filtration of spores in the room (Rutala et al., 1995).
             **Category II**

     G.  Maintain backup ventilation equipment (e.g., portable units for
         fans or filters) for emergency provision of required
         ventilation for PE areas and take immediate steps to restore
         the fixed ventilation system (The American Institute of
         Architects and The Facilities Guidelines Institute, 2001;
         \"Guidelines,\" 2000; Streifel, 2000). **Category IC** (AIA:
         5.1)

IV. **Infection-Control and Ventilation Requirements for AII Rooms**

    A.  Incorporate certain specifications into the planning and
        construction or renovation of AII units (The American Institute
        of Architects and The Facilities Guidelines Institute, 2001;
        \"Guidelines,\" 1994; Murray et al., 1988; \"Control of airborne
        fungal spores,\" 1989; Mahoney et al., 1979) (refer to Figure 3
        \"Example of negative-pressure room control for airborne
        infection isolation\" in the original guideline document).
        **Category IB, IC**

        1.  Maintain continuous negative air pressure (2.5 Pa \[0.01
            inch water gauge\]) in relation to the air pressure in the
            corridor; monitor air pressure periodically, preferably
            daily, with audible manometers or smoke tubes at the door
            (for existing AII rooms), or with a permanently installed
            visual monitoring mechanism. Document the results of
            monitoring (The American Institute of Architects and The
            Facilities Guidelines Institute, 2001; Murray et al., 1988;
            \"Control of airborne fungal spores,\" 1989). **Category
            IC** (AIA: 7.2.C7, Table 7.2)

        2.  Ensure that rooms are well-sealed by properly constructing
            windows, doors, and air-intake and exhaust ports; when
            monitoring indicates air leakage, locate the leak and make
            necessary repairs (The American Institute of Architects and
            The Facilities Guidelines Institute, 2001; Buckner et al.,
            1978; Murray et al., 1988). **Category IB, IC** (AIA:
            7.2.C3)

        3.  Install self-closing devices on all AII room exit doors (The
            American Institute of Architects and The Facilities
            Guidelines Institute, 2001). **Category IC** (AIA: 7.2.C4)

        4.  Provide ventilation to ensure [\>]{.underline}12 ACH for
            renovated rooms and new rooms, and [\>]{.underline}6 ACH for
            existing AII rooms (The American Institute of Architects and
            The Facilities Guidelines Institute, 2001; \"Guidelines,\"
            1994; Mahoney et al., 1979). **Category IB, IC** (AIA: Table
            7.2)

        5.  Direct exhaust air to the outside, away from air-intake and
            populated areas. If this is not practical, air from the room
            can be recirculated after passing through a HEPA filter (The
            American Institute of Architects and The Facilities
            Guidelines Institute, 2001; \"Guidelines,\" 1994).
            **Category IC** (AIA: Table 7.2)

    B.  Where supplemental engineering controls for air cleaning are
        indicated from a risk assessment of the AII area, install UVGI
        units in the exhaust air ducts of the HVAC system to supplement
        HEPA filtration or install UVGI fixtures on or near the ceiling
        to irradiate upper room air (\"Guidelines,\" 1994). **Category
        II**

    C.  Implement environmental infection-control measures for persons
        with diagnosed or suspected airborne infectious diseases.

        1.  Use AII rooms for patients with or suspected of having an
            airborne infection who also require cough-inducing
            procedures, or use an enclosed booth that is engineered to
            provide 1) [\>]{.underline}12 ACH; 2) air supply and exhaust
            rate sufficient to maintain a 2.5 Pa (0.01-inch water gauge)
            negative pressure difference with respect to all surrounding
            spaces with an exhaust rate of [\>]{.underline}50 ft^3^/min;
            and 3) air exhausted directly outside away from air intakes
            and traffic or exhausted after HEPA filtration before
            recirculation (The American Institute of Architects and The
            Facilities Guidelines Institute, 2001; \"Guidelines,\" 1994;
            Ehrenkranz & Kicklighter, 1972; Calder et al., 1991; Jereb
            et al., 1993). **Category IB, IC** (AIA: 7.15.E, 7.31.D23,
            9.10, Table 7.2)

        2.  Although airborne spread of viral hemorrhagic fever (VHF)
            has not been documented in a health-care setting, prudence
            dictates placing a VHF patient in an AII room, preferably
            with an anteroom, to reduce the risk of occupational
            exposure to aerosolized infectious material in blood,
            vomitus, liquid stool, and respiratory secretions present in
            large amounts during the end stage of a patient\'s illness
            (Monath, 1991; \"Update,\" 1995; Weber & Rutala, 2001).
            **Category II**

            a.  If an anteroom is not available, use portable,
                industrial-grade HEPA filters in the patient\'s room to
                provide additional ACH equivalents for removing airborne
                particulates.

            b.  Ensure that health-care workers wear face shields or
                goggles with appropriate respirators when entering the
                rooms of VHF patients with prominent cough, vomiting,
                diarrhea, or hemorrhage (\"Update,\" 1995).

        3.  Place smallpox patients in negative pressure rooms at the
            onset of their illness, preferably using a room with an
            anteroom, if available (Garner, 1996). **Category II**

    D.  No recommendation is offered regarding negative pressure or
        isolation for patients with *Pneumocystis carinii* pneumonia
        (Gerberding, 1998; Vargas et al., 2000; Walzer, 2000).
        **Unresolved issue**.

    E.  Maintain backup ventilation equipment (e.g., portable units for
        fans or filters) for emergency provision of ventilation
        requirements for AII rooms, and take immediate steps to restore
        the fixed ventilation system (The American Institute of
        Architects and The Facilities Guidelines Institute, 2001;
        \"Guidelines,\" 1994; Streifel, 2000). **Category IC** (AIA:
        5.1)

V.  **Infection-Control and Ventilation Requirements for Operating
    Rooms**

    A.  Implement environmental infection-control and ventilation
        measures for operating rooms.

        1.  Maintain positive-pressure ventilation with respect to
            corridors and adjacent areas (The American Institute of
            Architects and The Facilities Guidelines Institute, 2001;
            CDC, \"Guideline,\" 1999; Lidwell, 1986). **Category IB,
            IC** (AIA: Table 7.2)

        2.  Maintain [\>]{.underline}15 ACH, of which [\>]{.underline}3
            ACH should be fresh air (The American Institute of
            Architects and The Facilities Guidelines Institute, 2001;
            Nichols, 1992; Clark et al., 1985). **Category IC** (AIA:
            Table 7.2)

        3.  Filter all recirculated and fresh air through the
            appropriate filters, providing 90% efficiency (dust-spot
            testing) at a minimum (The American Institute of Architects
            and The Facilities Guidelines Institute, 2001; Babb, Lynam,
            & Ayliffe, 1995). **Category IC** (AIA: Table 7.3)

        4.  In rooms not engineered for horizontal laminar airflow,
            introduce air at the ceiling and exhaust air near the floor
            (The American Institute of Architects and The Facilities
            Guidelines Institute, 2001; Lidwell, 1986; Laufman, 1986).
            **Category IC** (AIA: 7.31.D4)

        5.  Do not use ultraviolet (UV) lights to prevent surgical-site
            infections (Lidwell, 1986; B´erard & Gandon, 1964; Charnley,
            1964; Lidwell et al., 1982; Hill et al., 1981; Ha´eri &
            Wiley, 1980; Collis & Steinhaus, 1976; Taylor, Bannister, &
            Leeming, 1995). **Category IB**

        6.  Keep operating room doors closed except for the passage of
            equipment, personnel, and patients, and limit entry to
            essential personnel (Ayliffe, 1991; Choux et al., 1992).
            **Category IB**

    B.  Follow precautionary procedures for infectious tuberculosis (TB)
        patients who also require emergency surgery (\"Guidelines,\"
        1994; \"Respiratory protection,\" 1998; Langevin, Rand, &
        Layton, 1999). **Category IB, IC**

        1.  Use an N95 respirator approved by the National Institute for
            Occupational Safety and Health without exhalation valves in
            the operating room (\"Respiratory protection,\" 1998;
            \"Occupational exposure to tuberculosis,\" 1997). **Category
            IC** (Occupational Safety and Health Administration
            \[OSHA\]; 29 Code of Federal Regulations \[CFR\]
            1910.134,139)

        2.  Intubate the patient in either the AII room or the operating
            room; if intubating the patient in the operating room, do
            not allow the doors to open until 99% of the airborne
            contaminants are removed (refer to Table 1 titled \"Air
            changes/hour and time required for airborne-contaminant
            removal efficiencies of 99% and 99.9%\" in the original
            guideline document) (\"Guidelines,\" 1994; Clark et al.,
            1985). **Category IB**

        3.  When anesthetizing a patient with confirmed or suspected TB,
            place a bacterial filter between the anesthesia circuit and
            patient\'s airway to prevent contamination of anesthesia
            equipment or discharge of tubercle bacilli into the ambient
            air (Langevin, Rand, & Layton, 1999; Aranha-Creado et al.,
            1997). **Category IB**

        4.  Extubate and allow the patient to recover in an AII room
            (\"Guidelines,\" 1994; Clark et al., 1985). **Category IB**

        5.  If the patient has to be extubated in the operating room,
            allow adequate time for ACH to clean 99% of airborne
            particles from the air (refer to Table 1 titled \"Air
            changes/hour and time required for airborne-contaminant
            removal efficiencies of 99% and 99.9%\" in the original
            guideline document), because extubation is a cough-producing
            procedure (\"Guidelines,\" 1994; Clark et al., 1985).
            **Category IB**

    C.  Use portable, industrial-grade HEPA filters temporarily for
        supplemental air cleaning during intubation and extubation for
        TB patients who require surgery (Rutala et al., 1995;
        \"Guidelines,\" 1994; Clark et al., 1985). **Category II**

        1.  Position the units appropriately so that all room air passes
            through the filter; obtain engineering consultation to
            determine the appropriate placements (\"Guidelines,\" 1994).
            **Category II**

        2.  Switch the portable unit off during the surgical procedure.
            **Category II**

        3.  Provide fresh air as per ventilation standards for operating
            rooms; portable units do not meet the requirements for the
            number of fresh ACH (The American Institute of Architects
            and The Facilities Guidelines Institute, 2001; Rutala et
            al., 1995; Burroughs, 1997). **Category II**

    D.  If possible, schedule TB patients as the last surgical cases of
        the day to maximize the time available for removal of airborne
        contamination. **Category II**

    E.  No recommendation is offered for performing orthopedic implant
        operations in rooms supplied with laminar airflow (Babb, Lynam,
        & Ayliffe, 1995; B\'erard & Gandon, 1964). **Unresolved issue**

    F.  Maintain backup ventilation equipment (e.g., portable units for
        fans or filters) for emergency ventilation of operating rooms,
        and take immediate steps to restore the fixed ventilation system
        (The American Institute of Architects and The Facilities
        Guidelines Institute, 2001; Streifel, 2000; \"Occupational
        exposure to tuberculosis,\" 1997; Anderson et al., 1996).
        **Category IB, IC** (AIA: 5.1)

VI. **Other Potential Infectious Aerosol Hazards in Health-Care
    Facilities**

    A.  In settings where surgical lasers are used, wear appropriate
        personal protective equipment (PPE), including N95 or N100
        respirators, to minimize exposure to laser plumes (\"Respiratory
        protection,\" 1998; National Institute for Occupational Safety
        and Health, 1996; \"Recommended practices,\" 1998). **Category
        IC** (OSHA; 29 CFR 1910.134,139)

    B.  Use central wall suction units with in-line filters to evacuate
        minimal laser plumes (National Institute for Occupational Safety
        and Health, 1996; \"Recommended practices,\" 1998; Hughes &
        Hughes, 1998; Capizzi, Clay, & Battey, 1998). **Category II**

    C.  Use a mechanical smoke evacuation system with a high-efficiency
        filter to manage the generation of large amounts of laser plume,
        when ablating tissue infected with human papilloma virus (HPV)
        or performing procedures on a patient with extrapulmonary TB
        (\"Guidelines,\" 1994; \"Recommended practices,\" 1998; Hughes &
        Hughes, 1998; \"Surgical smoke,\" 1997; \"Surgical smoke,\"
        1999; \"Stationary surgical smoke,\" 2001). **Category II**

**[Recommendations -- Water]{.underline}**

I.  **Controlling the Spread of Waterborne Microorganisms**

    A.  Practice hand hygiene to prevent the hand transfer of waterborne
        pathogens, and use barrier precautions (e.g., gloves) as defined
        by other guidelines (Garner, 1996; Villarino et al., 1992;
        Seifert, Strate, & Pulverer, 1995; Yu, 1979; Go et al., 1994;
        Boyce & Pittet, 2002). **Category IA**

    B.  Eliminate contaminated water or fluid environmental reservoirs
        (e.g., in equipment or solutions) wherever possible (Villarino
        et al., 1992; Burdge, Nakielna, & Noble, 1993). **Category IB**

    C.  Clean and disinfect sinks and wash basins on a regular basis by
        using an EPA-registered product as set by facility policies.
        **Category II**

    D.  Evaluate for possible environmental sources (e.g., potable
        water) of specimen contamination when waterborne microorganisms
        (e.g., nontuberculous mycobacteria \[NTM\]) of unlikely clinical
        importance are isolated from clinical cultures (e.g., specimens
        collected aseptically from sterile sites or, if postprocedural,
        colonization after use of tap water in patient care) (Cox,
        deBorja, & Bach, 1997; Hoy, Rolston, & Hopfer, 1987; Stine et
        al., 1987; Bennett et al., 1994). **Category IB**

    E.  Avoid placing decorative fountains and fish tanks in
        patient-care areas; ensure disinfection and fountain maintenance
        if decorative fountains are used in public areas of the
        health-care facility (Hlady et al., 1993). **Category IB**

II. **Routine Prevention of Waterborne Microbial Contamination Within
    the Distribution System**

    A.  Maintain hot water temperature at the return at the highest
        temperature allowable by state regulations or codes, preferably
        [\>]{.underline}124 degrees F ([\>]{.underline}51 degrees C),
        and maintain cold water temperature at \<68 degrees F (\<20
        degrees C) (CDC, 1997; American Society of Heating,
        Refrigerating, and Air-Conditioning Engineers, Inc. \[ASHRAE\],
        2000). **Category IC** (States; ASHRAE: 12:2000)

    B.  If the hot water temperature can be maintained at
        [\>]{.underline}124 degrees F ([\>]{.underline}51 degrees C),
        explore engineering options (e.g., installing preset
        thermostatic valves in point-of-use fixtures) to help minimize
        the risk of scalding (American Society of Heating,
        Refrigerating, and Air-Conditioning Engineers, Inc. \[ASHRAE\],
        2000). **Category II**

    C.  When state regulations or codes do not allow hot water
        temperatures above the range of 105 to 120 degrees F (40.6 to 49
        degrees C) for hospitals or 95 to 110 degrees F (35 to 43.3
        degrees C) for nursing care facilities or when buildings cannot
        be retrofitted for thermostatic mixing valves, follow either of
        these alternative preventive measures to minimize the growth of
        *Legionella* spp. in water systems. **Category II**

        1.  Periodically increase the hot water temperature to
            [\>]{.underline}150 degree F ([\>]{.underline}66 degrees C)
            at the point of use (American Society of Heating,
            Refrigerating, and Air-Conditioning Engineers, Inc.
            \[ASHRAE\], 2000). **Category II**

        2.  Alternatively, chlorinate the water and then flush it
            through the system (American Society of Heating,
            Refrigerating, and Air-Conditioning Engineers, Inc.
            \[ASHRAE\], 2000; Snyder et al., 1990; Ezzeddine et al.,
            1989). **Category II**

    D.  Maintain constant recirculation in hot-water distribution
        systems serving patient-care areas (The American Institute of
        Architects and The Facilities Guidelines Institute, 2001).
        **Category IC** (AIA: 7.31.E.3)

III. **Remediation Strategies for Distribution System Repair or
     Emergencies**

     A.  Whenever possible, disconnect the ice machine before planned
         water disruptions. **Category II**

     B.  Prepare a contingency plan to estimate water demands for the
         entire facility in advance of significant water disruptions
         (i.e., those expected to result in extensive and heavy
         microbial or chemical contamination of the potable water),
         sewage intrusion, or flooding (Joint Commission on
         Accreditation of Healthcare Organizations \[JCAHO\], 2001;
         Joint Commission on Accreditation of Healthcare Organizations
         \[JCAHO\], 2000). **Category IC** (JCAHO: EC 1.4)

     C.  When a significant water disruption or an emergency occurs,
         adhere to any advisory to boil water issued by the municipal
         water utility (Juranek et al., 1995). **Category IB, IC**
         (Municipal order)

         1.  Alert patients, families, staff, and visitors not to
             consume water from drinking fountains, ice, or drinks made
             from municipal tap water, while the advisory is in effect,
             unless the water has been disinfected (e.g., by bringing to
             a rolling boil for [\>]{.underline}1 minute) (Juranek et
             al., 1995). **Category IB, IC** (Municipal order)

         2.  After the advisory is lifted, run faucets and drinking
             fountains at full flow for [\>]{.underline}5minutes, or use
             high-temperature water flushing or chlorination (American
             Society of Heating, Refrigerating, and Air-Conditioning
             Engineers, Inc. \[ASHRAE\], 2000; Juranek et al., 1995).
             **Category IC, II** (Municipal order; ASHRAE: 12:2000)

     D.  Maintain a high level of surveillance for waterborne disease
         among patients after a boil water advisory is lifted.
         **Category II**

     E.  Corrective decontamination of the hot water system might be
         necessary after a disruption in service or a cross-connection
         with sewer lines has occurred.

         1.  Decontaminate the system when the fewest occupants are
             present in the building (e.g., nights or weekends) (CDC,
             1997; American Society of Heating, Refrigerating, and
             Air-Conditioning Engineers, Inc. \[ASHRAE\], 2000).
             **Category IC** (ASHRAE: 12:2000)

         2.  If using high-temperature decontamination, raise the
             hot-water temperature to 160 to 170 degrees F (71 to 77
             degrees C) and maintain that level while progressively
             flushing each outlet around the system for
             [\>]{.underline}5 minutes (CDC, 1997; American Society of
             Heating, Refrigerating, and Air-Conditioning Engineers,
             Inc. \[ASHRAE\], 2000). **Category IC** (ASHRAE: 12:2000)

         3.  If using chlorination, add enough chlorine, preferably
             overnight, to achieve a free chlorine residual of
             [\>]{.underline}2 mg/L ([\>]{.underline}2 ppm) throughout
             the system (American Society of Heating, Refrigerating, and
             Air-Conditioning Engineers, Inc. \[ASHRAE\], 2000).
             **Category IC** (ASHRAE: 12:2000)

             a.  Flush each outlet until chlorine odor is detected.

             b.  Maintain the elevated chlorine concentration in the
                 system for [\>]{.underline}2 (but [\<]{.underline}24
                 hrs).

         4.  Use a thorough flushing of the water system instead of
             chlorination if a highly chlorine-resistant microorganism
             (e.g., *Cryptosporidium* spp.) is suspected as the water
             contaminant. **Category II**

     F.  Flush and restart equipment and fixtures according to
         manufacturer\'s instructions. **Category II**

     G.  Change the pretreatment filter and disinfect the dialysis water
         system with an EPA-registered product to prevent colonization
         of the reverse osmosis membrane and downstream microbial
         contamination (Tokars et al., 2000). **Category II**

     H.  Run water softeners through a regeneration cycle to restore
         their capacity and function. **Category II**

     I.  If the facility has a water-holding reservoir or water-storage
         tank, consult the facility engineer or local health department
         to determine whether this equipment needs to be drained,
         disinfected with an EPA-registered product, and refilled.
         **Category II**

     J.  Implement facility procedures to manage a sewage system failure
         or flooding (e.g., arranging with other health-care facilities
         for temporary transfer of patients or provision of services),
         and establish communications with the local municipal water
         utility and the local health department to ensure that
         advisories are received in a timely manner after release (Joint
         Commission on Accreditation of Healthcare Organizations
         \[JCAHO\], 2001; Joint Commission on Accreditation of
         Healthcare Organizations \[JCAHO\], 2000). **Category IC**
         (JCAHO: EC 1.4; Municipal order)

     K.  Implement infection-control measures during sewage intrusion,
         flooding, or other water-related emergencies.

         1.  Relocate patients and clean or sterilize supplies from
             affected areas. **Category II**

         2.  If hands are not visibly soiled or contaminated with
             proteinaceous material, include an alcohol-based hand rub
             in the hand hygiene process 1) before performing invasive
             procedures; 2) before and after each patient contact;
             and 3) whenever hand hygiene is indicated (Boyce & Pittet,
             2002). **Category II**

         3.  If hands are visibly soiled or contaminated with
             proteinaceous material, use soap and bottled water for
             handwashing (Boyce & Pittet, 2002). **Category II**

         4.  If the potable water system is not affected by flooding or
             sewage contamination, process surgical instruments for
             sterilization according to standard procedures. **Category
             II**

         5.  Contact the manufacturer of the automated endoscope
             reprocessor (AER) for specific instructions on the use of
             this equipment during a water advisory. **Category II**

     L.  Remediate the facility after sewage intrusion, flooding, or
         other water-related emergencies.

         1.  Close off affected areas during cleanup procedures.
             **Category II**

         2.  Ensure that the sewage system is fully functional before
             beginning remediation so contaminated solids and standing
             water can be removed. **Category II**

         3.  If hard-surfaced equipment, floors, and walls remain in
             good repair, ensure that these are dry within 72 hours;
             clean with detergent according to standard cleaning
             procedures. **Category II**

         4.  Clean wood furniture and materials (if still in good
             repair); allow them to dry thoroughly before restoring
             varnish or other surface coatings. **Category II**

         5.  Contain dust and debris during remediation and repair as
             outlined in air recommendations (Air: IIG 4, 5). **Category
             II**

     M.  Regardless of the original source of water damage (e.g.,
         flooding versus water leaks from point-of-use fixtures or
         roofs), remove wet, absorbent structural items (e.g.,
         carpeting, wallboard, and wallpaper) and cloth furnishings if
         they cannot be easily and thoroughly cleaned and dried within
         72 hours (e.g., moisture content [\<]{.underline}20% as
         determined by moisture meter readings); replace with new
         materials as soon as the underlying structure is declared by
         the facility engineer to be thoroughly dry (Arnow et al., 1991;
         Streifel, 2000; Vujanovic, Smoragiewicz, & Krzysztyniak, 2001;
         Vesper et al., 2000). **Category IB**

IV. **Additional Engineering Measures as Indicated by Epidemiologic
    Investigation for Controlling Waterborne, Health-Care\--Associated
    Legionnaires Disease**

    A.  When using a pulse or one-time decontamination method, superheat
        the water by flushing each outlet for [\>]{.underline}5 minutes
        with water at 160 to 170 degrees F (71 to 77 degrees C) or
        hyperchlorinate the system by flushing all outlets for
        [\>]{.underline}5 minutes with water containing
        [\>]{.underline}2 mg/L ([\>]{.underline}2 ppm) free residual
        chlorine using a chlorine-based product registered by the EPA
        for water treatment (e.g., sodium hypochlorite \[chlorine
        bleach\]) (American Society of Heating, Refrigerating, and
        Air-Conditioning Engineers, Inc. \[ASHRAE\], 2000; Ezzeddine et
        al., 1989; Best et al., 1983; Meenhorst et al., 1985; Johnston
        et al., 1987; Muraca, Yu, & Goetz, 1990). **Category IB**

    B.  After a pulse treatment, maintain both the heated water
        temperature at the return and the cold water temperature per the
        recommendation (Water: II A) wherever practical and permitted by
        state codes, or chlorinate heated water to achieve 1 to 2 mg/L
        (1\--2 ppm) free residual chlorine at the tap by using a
        chlorine-based product registered by the EPA for water treatment
        (e.g., sodium hypochlorite \[bleach\]) (American Society of
        Heating, Refrigerating, and Air-Conditioning Engineers, Inc.
        \[ASHRAE\], 2000; Johnson et al., 1985; Marrie et al.,
        \"Nosocomial legionnaires\' disease,\" 1991; Marrie et al.,
        1992; Department of Health and Social Security and the Welsh
        Office, 1991; Helms et al., 1988). **Category IC** (States;
        ASHRAE: 12:2000)

    C.  Explore engineering or educational options (e.g., install preset
        thermostatic mixing valves in point-of-use fixtures or post
        warning signs at each outlet) to minimize the risk of scalding
        for patients, visitors, and staff. **Category II**

    D.  No recommendation is offered for treating water in the
        facility\'s distribution system with chlorine dioxide,
        heavy-metal ions (e.g., copper or silver), monochloramines,
        ozone, or ultraviolet (UV) light (Edelstein et al., 1982;
        Muraca, Stout, & Yu, 1987; Domingue et al., 1988; Landeen,
        Yahya, & Gerba, 1989; Matulonis, Rosenfeld, & Shadduck, 1993;
        Liu et al., 1994; Margolin, 1997; Freije, 1996; Lin et al.,
        1998; Biurrun et al., 1999; Goetz & Yu, 1997; Stout et al.,
        1998; Walker et al., 1995; Hambidge, 2001; Rohr et al., 1999;
        Cunliffe, 1990; Kirmeyer et al., 1993; Kool, Carpenter, &
        Fields, 1999; Kool et al., 1999). **Unresolved issue**

V.  **General Infection-Control Strategies for Preventing Legionnaires
    Disease**

    A.  Conduct an infection-control risk assessment of the facility to
        determine if patients at risk or severely immunocompromised
        patients are present (CDC, 1997; Kool et al., 1998; Le Saux et
        al., 1989). **Category IB**

    B.  Implement general strategies for detecting and preventing
        Legionnaires disease in facilities that do not provide care for
        severely immunocompromised patients (i.e., facilities that do
        not have hematopoietic stem cell transplant \[HSCT\] or
        solid-organ transplant programs) (see Appendix in the original
        guideline document) (CDC, 1997; Kool et al., 1998; Le Saux et
        al., 1989). **Category IB**

        1.  Establish a surveillance process to detect
            health-care\--associated Legionnaires disease (CDC, 1997;
            Kool et al., 1998; Le Saux et al., 1989). **Category IB**

        2.  Inform health-care personnel (e.g., infection control,
            physicians, patient-care staff, engineering) regarding the
            potential for Legionnaires disease to occur and measures to
            prevent and control health-care\--associated legionellosis
            (Marrie et al., \"Nosocomial legionnaires\' disease,\" 1991;
            Kugler et al., 1983). **Category IB**

        3.  Establish mechanisms to provide clinicians with laboratory
            tests (e.g., culture, urine antigen, direct fluorescence
            assay \[DFA\], and serology) for the diagnosis of
            Legionnaires disease (CDC, 1997; Kool et al., 1998).
            **Category IB**

    C.  Maintain a high index of suspicion for health-care\--associated
        Legionnaires disease, and perform laboratory diagnostic tests
        for legionellosis on suspected cases, especially in patients at
        risk who do not require a PE for care (e.g., patients receiving
        systemic steroids; patients aged [\>]{.underline}65 years; or
        patients with chronic underlying disease \[e.g., diabetes
        mellitus, congestive heart failure, or chronic obstructive lung
        disease\]) (CDC, 1997; Marrie et al., \"Nosocomial
        legionnaires\' disease,\" 1991; Le Saux et al., 1989; Marston,
        Lipman, & Breiman, 1994; Haley et al., 1979; Jimenez et al.,
        1991; Bock et al., 1978; Kirby et al., 1980; Brady, 1989; Muder
        et al., 1983). **Category IA**

    D.  Periodically review the availability and clinicians\' use of
        laboratory diagnostic tests for Legionnaires disease in the
        facility; if clinicians\' use of the tests on patients with
        diagnosed or suspected pneumonia is limited, implement measures
        (e.g., an educational campaign) to enhance clinicians\' use of
        the test(s) (Haley et al., 1979). **Category IB**

    E.  If one case of laboratory-confirmed, health-care\--associated
        Legionnaires disease is identified, or if two or more cases of
        laboratory-suspected, health-care-associated Legionnaires
        disease occur during a 6-month period, certain activities should
        be initiated (Stout et al., 1998; Kool et al., 1998; Kugler et
        al., 1983; Haley et al., 1979; Garbe et al., 1985; Hanrahan et
        al., 1987). **Category IB**

        1.  Report the cases to state and local health departments where
            required. **Category IC** (States)

        2.  If the facility does not treat severely immunocompromised
            patients, conduct an epidemiologic investigation, including
            retrospective review of microbiologic, serologic, and
            postmortem data to look for previously unidentified cases of
            health-care\--associated Legionnaires disease, and begin
            intensive prospective surveillance for additional cases
            (CDC, 1997; Stout et al., 1998; Kool et al., 1998; Kugler et
            al., 1983; Haley et al., 1979; Garbe et al., 1985; Hanrahan
            et al., 1987). **Category IB**

        3.  If no evidence of continued health-care\--associated
            transmission exists, continue intensive prospective
            surveillance for [\>]{.underline}2 months after the
            initiation of surveillance (CDC, 1997; Stout et al., 1998;
            Kool et al., 1998; Kugler et al., 1983; Haley et al., 1979;
            Garbe et al., 1985; Hanrahan et al., 1987). **Category IB**

    F.  If there is evidence of continued health-care\--associated
        transmission (i.e., an outbreak), conduct an environmental
        assessment to determine the source of *Legionella* spp. (Garbe
        et al., 1985; Hanrahan et al., 1987; Arnow et al., 1982; Mastro
        et al., 1991; Dondero et al., 1980; O\'Mahony et al., 1990;
        Breiman et al., 1990; Breiman et al., 1991; Struelens et al.,
        1992). **Category IB**

        1.  Collect water samples from potential aerosolized water
            sources (refer to Box 1 titled \"Potential sampling sites
            for *Legionella* spp. in health-care facilities\" and Box 2
            titled \"Procedures for collecting and processing
            environmental specimens for *Legionella* spp\" in the
            original guideline document) (Barbaree et al., 1987).
            **Category IB**

        2.  Save and subtype isolates of *Legionella* spp. obtained from
            patients and the environment (Johnston et al., 1987; Garbe
            et al., 1985; Hanrahan et al., 1987; Arnow et al., 1982;
            Mastro et al., 1991; Dondero et al., 1980; O\'Mahony et al.,
            1990; Breiman et al., 1990; Breiman et al., 1991; Struelens
            et al., 1992; Schoonmaker, Heimberger, & Birkhead, 1992).
            **Category IB**

        3.  If a source is identified, promptly institute water system
            decontamination measures per recommendations (see Water IV)
            (Muraca, Yu, & Goetz, 1990; Knirsch et al., 2000).
            **Category IB**

        4.  If *Legionella* spp. are detected in [\>]{.underline}1
            culture (e.g., conducted at 2-week intervals during 3
            months), reassess the control measures, modify them
            accordingly, and repeat the decontamination procedures;
            consider intensive use of techniques used in the initial
            decontamination, or a combination of superheating and
            hyperchlorination (CDC, 1997; Knirsch et al., 2000;
            \"Sustained transmission of nosocomial Legionnaires
            Disease,\" 1997). **Category IB**

    G.  If an environmental source is not identified during a
        Legionnaires disease outbreak, continue surveillance for new
        cases for [\>]{.underline}2 months. Either defer decontamination
        pending identification of the source of *Legionella* spp. or
        proceed with decontamination of the hospital\'s water
        distribution system, with special attention to areas involved in
        the outbreak. **Category II**

    H.  No recommendation is offered regarding routine culturing of
        water systems in health-care facilities that do not have
        patient-care areas (i.e., PE or transplant units) for persons at
        high risk for *Legionella* spp. infection (see Appendix of the
        original guideline) (Best et al., 1983; Johnson et al., 1985;
        Marrie et al., 1992; Muder et al., 1983; Alary & Joly, 1992; Yu
        et al., 1987; Tobin, Swann, & Bartlett, 1981). **Unresolved
        issue**

    I.  No recommendation is offered regarding the removal of faucet
        aerators in areas for immunocompetent patients. **Unresolved
        issue**

    J.  Keep adequate records of all infection-control measures and
        environmental test results for potable water systems. **Category
        II**

VI. **Preventing Legionnaires Disease in Protective Environments and
    Transplant Units**

    A.  When implementing strategies for preventing Legionnaires disease
        among severely immunocompromised patients housed in facilities
        with HSCT or solid-organ transplant programs, incorporate these
        specific surveillance and epidemiologic measures in addition to
        the steps outlined previously (see Appendix in the original
        guideline document).

        1.  Maintain a high index of suspicion for legionellosis in
            transplant patients even when environmental surveillance
            cultures do not yield legionellae (Kool et al., 1998; Chow &
            Yu, 1998). **Category IB**

        2.  If a case occurs in a severely immunocompromised patient, or
            if severely immunocompromised patients are present in
            high-risk areas of the hospital (e.g., PE or transplant
            units) and cases are identified elsewhere in the facility,
            conduct a combined epidemiologic and environmental
            investigation to determine the source of *Legionella* spp.
            (Kool et al., 1998; Knirsch et al., 2000). **Category IB**

    B.  Implement culture strategies and potable water and fixture
        treatment measures in addition to those previous outlined
        (Water: V). **Category II**

        1.  Depending on state regulations on potable water temperature
            in public buildings (Mandel et al., 1993), hospitals housing
            patients at high risk for health-care\--associated
            legionellosis should either maintain heated water with a
            minimum return temperature of [\>]{.underline}124 degrees F
            ([\>]{.underline}51 degrees C) and cold water at \<68
            degrees F (\<20 degrees C), or chlorinate heated water to
            achieve 1 to 2 mg/L (1\--2 ppm) of free residual chlorine at
            the tap (American Society of Heating, Refrigerating, and
            Air-Conditioning Engineers, Inc. \[ASHRAE\], 2000; Snyder et
            al., 1990; Ezzeddine et al., 1989; Johnson et al., 1985;
            Marrie et al., 1992; Department of Health and Social
            Security and the Welsh Office, 1991; Helms et al., 1988;
            Hirani & Macfarlane, 1997). **Category II**

        2.  Periodic culturing for legionellae in potable water samples
            from HSCT or solid-organ transplant units can be performed
            as part of a comprehensive strategy to prevent Legionnaires
            disease in these units (\"Guidelines,\" 2000; Snyder et al.,
            1990; Kool et al., 1998; Patterson et al., 1997). **Category
            II**

        3.  No recommendation is offered regarding the optimal
            methodology (i.e., frequency or number of sites) for
            environmental surveillance cultures in HSCT or solid-organ
            transplant units. **Unresolved issue**

        4.  In areas with patients at risk, when *Legionella* spp. are
            not detectable in unit water, remove, clean, and disinfect
            shower heads and tap aerators monthly by using a
            chlorine-based, EPA-registered product. If an EPA-registered
            chlorine disinfectant is not available, use a chlorine
            bleach solution (500\--615 ppm \[1:100 v/v dilution\])
            (American Society of Heating, Refrigerating, and
            Air-Conditioning Engineers, Inc. \[ASHRAE\], 2000; Kool,
            Carpenter, & Fields, 1999). **Category II**

    C.  If *Legionella* spp. are determined to be present in the water
        of a transplant unit, implement certain measures until
        *Legionella* spp. are no longer detected by culture.

        1.  Decontaminate the water supply as outlined previously
            (Water: IV) (CDC, 1997; \"Guidelines,\" 2000; American
            Society of Heating, Refrigerating, and Air-Conditioning
            Engineers, Inc. \[ASHRAE\], 2000; Muraca, Yu, & Goetz, 1990;
            Knirsch et al., 2000). **Category IB**

        2.  Do not use water from the faucets in patient-care rooms to
            avoid creating infectious aerosols (\"Guidelines,\" 2000;
            Marrie et al., \"Control of endemic nosocomial
            Legionnaires\' disease,\" 1991). **Category IB**

        3.  Restrict severely immunocompromised patients from taking
            showers (\"Guidelines,\" 2000; Marrie et al., \"Control of
            endemic nosocomial Legionnaires\' disease,\" 1991).
            **Category IB**

        4.  Use water that is not contaminated with *Legionella* spp.
            for HSCT patients\' sponge baths (\"Guidelines,\" 2000;
            Marrie et al., \"Control of endemic nosocomial
            Legionnaires\' disease,\" 1991). **Category IB**

        5.  Provide patients with sterile water for tooth brushing, for
            drinking, and for flushing nasogastric tubing during
            legionellosis outbreaks (\"Guidelines,\" 2000; Marrie et
            al., \"Control of endemic nosocomial Legionnaires\'
            disease,\" 1991). **Category IB**

    D.  Do not use large-volume room air humidifiers that create
        aerosols (e.g., by Venturi principle, ultrasound, or spinning
        disk) unless they are subjected to high-level disinfection and
        filled only with sterile water (CDC, 1997; \"Guidelines,\" 2000;
        Arnow et al., 1982; Zuravleff et al., 1983). **Category IB**

VII. **Cooling Towers and Evaporative Condensers**

     A.  When planning construction of new health-care facilities,
         locate cooling towers so that the drift is directed away from
         the air-intake system, and design the towers to minimize the
         volume of aerosol drift (American Society of Heating,
         Refrigerating, and Air-Conditioning Engineers, Inc. \[ASHRAE\],
         2000; Dondero et al., 1980; \"Environmental health aspects,\"
         1993). **Category IC** (ASHRAE 12-2000)

     B.  Implement infection-control procedures for operational cooling
         towers (American Society of Heating, Refrigerating, and
         Air-Conditioning Engineers, Inc. \[ASHRAE\], 2000; Dondero et
         al., 1980; Bhopal & Barr, 1990). **Category IC** (ASHRAE
         12-2000)

         1.  Install drift eliminators (American Society of Heating,
             Refrigerating, and Air-Conditioning Engineers, Inc.
             \[ASHRAE\], 2000; Dondero et al., 1980; Bhopal & Barr,
             1990). **Category IC** (ASHRAE 12-2000)

         2.  Use an effective EPA-registered biocide on a regular basis
             (American Society of Heating, Refrigerating, and
             Air-Conditioning Engineers, Inc. \[ASHRAE\], 2000).
             **Category IC** (ASHRAE 12-2000)

         3.  Maintain towers according to manufacturers\'
             recommendations, and keep detailed maintenance and
             infection-control records, including environmental test
             results from legionellosis outbreak investigations
             (American Society of Heating, Refrigerating, and
             Air-Conditioning Engineers, Inc. \[ASHRAE\], 2000).
             **Category IC** (ASHRAE 12-2000)

     C.  If cooling towers or evaporative condensers are implicated in
         health-care\--associated legionellosis, decontaminate the
         cooling-tower system (Garbe et al., 1985; Dondero et al., 1980;
         \"Environmental health aspects,\" 1993; \"Epidemiology,
         prevention and control,\" 1990). **Category IB**

VIII. **Dialysis Water Quality and Dialysate**

      A.  Adhere to current Association for the Advancement of Medical
          Instrumentation (AAMI) standards for quality-assurance
          performance of devices and equipment used to treat, store, and
          distribute water in hemodialysis centers (both acute and
          maintenance \[chronic\] settings) and for the preparation of
          concentrates and dialysate (Bolan et al., 1985; Lowry et al.,
          1990; Favero et al., 1974; Favero et al., 1975; Favero &
          Peterson, 1997; Association for the Advancement of Medical
          Instrumentation and American National Standards Institute,
          *Hemodialysis systems*, 1993; Association for the Advancement
          of Medical Instrumentation, American National Standards
          Institute, *Reuse of hemodialyzers*, 1993; Petersen et al.,
          1978; Dawids & Vejlsgaard, 1976; Kidd, 1964; Klein et al.,
          1990; Man et al., 1998). **Category IA, IC** (AAMI: American
          National Standards Institute \[ANSI\]/AAMI RD5:1992, ANSI/AAMI
          RD47:1993)

      B.  No recommendation is offered regarding whether more stringent
          requirements for water quality should be imposed in
          hemofiltration and hemodiafiltration. **Unresolved issue**

      C.  Conduct microbiologic testing specific to water in dialysis
          settings (Association for the Advancement of Medical
          Instrumentation and American National Standards Institute,
          *Hemodialysis systems*, 1993; Association for the Advancement
          of Medical Instrumentation, American National Standards
          Institute, *Reuse of hemodialyzers*, 1993; Association for the
          Advancement of Medical Instrumentation, 2001; Bland, 1995;
          Arduino et al., 1991). **Category IA, IC** (AAMI: ANSI/AAMI
          RD5:1992, ANSI/AAMI RD47:1993, RD62:2001)

          1.  Perform bacteriologic assays of water and dialysis fluids
              at least once a month and during outbreaks by using
              standard quantitative methods (Association for the
              Advancement of Medical Instrumentation, 2001; Bland, 1995;
              Arduino et al., 1991). **Category IA, IC** (AAMI:
              ANSI/AAMI RD62:2001)

              a.  Assay for heterotrophic, mesophilic bacteria (e.g.,
                  *Pseudomonas* spp).

              b.  Do not use nutrient-rich media (e.g., blood agar or
                  chocolate agar).

          2.  In conjunction with microbiologic testing, perform
              endotoxin testing on product water used to reprocess
              dialyzers for multiple use (Association for the
              Advancement of Medical Instrumentation and American
              National Standards Institute, *Hemodialysis systems*,
              1993; Association for the Advancement of Medical
              Instrumentation, American National Standards Institute,
              *Reuse of hemodialyzers*, 1993; Bland et al., 1987; Raij,
              Shapiro, & Michael, 1973; Bommer, Becker, & Urbaschek,
              1996; Arduino & Favero, 1998). **Category IA, IC** (AAMI:
              ANSI/AAMI RD5:1992, ANSI/AAMI RD47:1993)

          3.  Ensure that water does not exceed the limits for microbial
              counts and endotoxin concentrations (refer to Table 2
              titled \"Microbiologic limits for hemodialysis fluids\" in
              the original guideline document) (Association for the
              Advancement of Medical Instrumentation and American
              National Standards Institute, *Hemodialysis systems*,
              1993; Association for the Advancement of Medical
              Instrumentation, American National Standards Institute,
              *Reuse of hemodialyzers*, 1993; Petersen et al., 1978).
              **Category IA, IC** (AAMI: ANSI/AAMI RD5:1992, ANSI/AAMI
              RD47:1993)

      D.  Disinfect water distribution systems in dialysis settings at
          least weekly (Favero et al., 1974; Favero et al., 1975; Favero
          & Petersen, 1997; Petersen et al., 1978; Association for the
          Advancement of Medical Instrumentation, 2001). **Category IA,
          IC** (AAMI: ANSI/AAMI RD62:2001)

      E.  Wherever practical, design and engineer water systems in
          dialysis settings to avoid incorporating joints, dead-end
          pipes, and unused branches and taps that can harbor bacteria
          (Favero et al., 1974; Favero et al., 1975; Favero & Petersen,
          1997; Petersen et al., 1978; Association for the Advancement
          of Medical Instrumentation, 2001). **Category IA, IC** (AAMI:
          ANSI/AAMI RD62:2001)

      F.  When storage tanks are used in dialysis systems, they should
          be routinely drained, disinfected with an EPA-registered
          product, and fitted with an ultrafilter or pyrogenic filter
          (membrane filter with a pore size sufficient to remove
          particles and molecules [\>]{.underline}1 kilodalton)
          installed in the water line distal to the storage tank
          (Association for the Advancement of Medical Instrumentation,
          2001). **Category IC** (AAMI: ANSI/AAMI RD62:2001)

IX. **Ice Machines and Ice**

    A.  Do not handle ice directly by hand, and wash hands before
        obtaining ice. **Category II**

    B.  Use a smooth-surface ice scoop to dispense ice (Koepke &
        Christopher, 1965; \"Outbreak,\" 1987). **Category II**

        1.  Keep the ice scoop on a chain short enough that the scoop
            cannot touch the floor or keep the scoop on a clean, hard
            surface when not in use (Koepke & Christopher, 1965;
            \"Outbreak,\" 1987). **Category II**

        2.  Do not store the ice scoop in the ice bin. **Category II**

    C.  Do not store pharmaceuticals or medical solutions on ice
        intended for consumption; use sterile ice to keep medical
        solutions cold, or use equipment specifically manufactured for
        this purpose (\"Outbreak,\" 1987; Crow, Corpe, & Smith, 1961).
        **Category IB**

    D.  Machines that dispense ice are preferred to those that require
        ice to be removed from bins or chests with a scoop (Stout, Yu, &
        Muraca, 1985; Manangan et al., 1998). **Category II**

    E.  Limit access to ice-storage chests, and keep container doors
        closed except when removing ice (\"Outbreak,\" 1987). **Category
        II**

    F.  Clean, disinfect, and maintain ice-storage chests on a regular
        basis. **Category II**

        1.  Follow the manufacturer\'s instructions for cleaning.
            **Category II**

        2.  Use an EPA-registered disinfectant suitable for use on ice
            machines, dispensers, or storage chests in accordance with
            label instructions. **Category II**

        3.  If instructions and EPA-registered disinfectants suitable
            for use on ice machines are not available, use a general
            cleaning/disinfecting regimen (Refer to Box 3 titled
            \"General steps for cleaning and maintaining ice machines,
            dispensers, and storage chests\" in the original guideline
            document) (\"Outbreak,\" 1987). **Category II**

        4.  Flush and clean ice machines and dispensers if they have not
            been disconnected before anticipated lengthy water
            disruptions. **Category II**

    G.  Install proper air gaps where the condensate lines meet the
        waste lines. **Category II**

    H.  Conduct microbiologic sampling of ice, ice chests, and
        ice-making machines and dispensers where indicated during an
        epidemiologic investigation (\"Outbreak,\" 1987; Cannon et al.,
        1991; Khan et al., 1994). **Category IB**

X.  **Hydrotherapy Tanks and Pools**

    A.  Drain and clean hydrotherapy equipment (e.g., Hubbard tanks,
        tubs, whirlpools, whirlpool spas, or birthing tanks) after each
        patient\'s use, and disinfect equipment surfaces and components
        by using an EPA-registered product in accordance with the
        manufacturer\'s instructions. **Category II**

    B.  In the absence of an EPA-registered product for water treatment,
        add sodium hypochlorite to the water:

        1.  Maintain a 15-ppm chlorine residual in the water of small
            hydrotherapy tanks, Hubbard tanks, and tubs (Schmidt,
            Cooney, & Foy, 1975). **Category II**

        2.  Maintain a 2- to 5-ppm chlorine residual in the water of
            whirlpools and whirlpool spas (McCandlish & Renfrew, 1993).
            **Category II**

        3.  If the pH of the municipal water is in the basic range
            (e.g., when chloramine is used as the primary drinking water
            disinfectant in the community), consult the facility
            engineer regarding the possible need to adjust the pH of the
            water to a more acidic level before disinfection, to enhance
            the biocidal activity of the chlorine (White, 1992).
            **Category II**

    C.  Clean and disinfect hydrotherapy equipment after using tub
        liners. **Category II**

    D.  Clean and disinfect inflatable tubs unless they are single-use
        equipment. **Category II**

    E.  No recommendation is offered regarding the use of antiseptic
        chemicals (e.g., chloramine-T) in the water during hydrotherapy
        sessions. **Unresolved issue**

    F.  Conduct a risk assessment of patients before their use of large
        hydrotherapy pools, deferring patients with draining wounds or
        fecal incontinence from pool use until their condition resolves.
        **Category II**

    G.  For large hydrotherapy pools, use pH and chlorine residual
        levels appropriate for an indoor pool as provided by local and
        state health agencies. **Category IC** (States)

    H.  No recommendation is offered regarding the use in health-care
        settings of whirlpool or spa equipment manufactured for home or
        recreational use. **Unresolved issue**

XI. **Miscellaneous Medical Equipment Connected to Water Systems**

    A.  Clean, disinfect, and maintain AER equipment according to the
        manufacturer\'s instructions and relevant scientific literature
        to prevent inadvertent contamination of endoscopes and
        bronchoscopes with waterborne microorganisms (Muscarella,
        \"Automatic flexible,\" 2000; Muscarella, 1998; Muscarella,
        \"Déjà vu,\" 2000; Gubler, Salfinger, & von Graevenitz, 1992;
        Fraser et al., 1992). **Category IB**

        1.  To rinse disinfected endoscopes and bronchoscopes, use water
            of the highest quality practical for the system\'s
            engineering and design (e.g., sterile water or
            bacteriologically filtered water \[water filtered through
            0.1 to 0.2-micrometer filters\]) (Muscarella, 1998; Gubler,
            Salfinger, & von Graevenitz, 1992; Fraser et al., 1992;
            Muscarella, 2002). **Category IB**

        2.  Dry the internal channels of the reprocessed endoscope or
            bronchoscope by using a proven method (e.g., 70% alcohol
            followed by forced-air treatment) to lessen the potential
            for proliferation of waterborne microorganisms and to help
            prevent biofilm formation (Cooke et al., 1998; Allen JI et
            al., 1987; Michele et al., 1997; US Food and Drug
            Administration, CDC, 1999; Alvarado & Reichelderfer, 2000).
            **Category IB**

    B.  Use water that meets nationally recognized standards set by the
        EPA for drinking water (\<500 CFU/mL for heterotrophic plate
        count) for routine dental treatment output water (CDC,
        *Statement from CDC regarding biofilm*, 1999; \"Recommended
        infection control,\" 1993; Office of Safety and Asepsis
        Procedures Research Foundation, 2000; US Environmental
        Protection Agency, 1999). **Category IC** (EPA: 40 CFR 1 Part
        141, Subpart G)

    C.  Take precautions to prevent waterborne contamination of dental
        unit water lines and instruments.

        1.  After each patient, discharge water and air for a minimum of
            20 to 30 seconds from any dental device connected to the
            dental water system that enters a patient\'s mouth (e.g.,
            handpieces, ultrasonic scalers, or air/water syringes)
            (\"Recommended infection control,\" 1993; Bagga et al.,
            1984). **Category II**

        2.  Consult with dental water-line manufacturers to 1) determine
            suitable methods and equipment to obtain the recommended
            water quality; and 2) determine appropriate methods for
            monitoring the water to ensure quality is maintained
            (\"Recommended infection control,\" 1993; Shearer, 1996).
            **Category II**

        3.  Consult with the dental unit manufacturer regarding the need
            for periodic maintenance of antiretraction mechanisms (Bagga
            et al., 1984; Shearer, 1996). **Category IB**

**[Recommendations -- Environmental Services]{.underline}**

I.  **Cleaning and Disinfecting Strategies for Environmental Surfaces in
    Patient-Care Areas**

    A.  Select EPA-registered disinfectants, if available, and use them
        in accordance with the manufacturer\'s instructions (Garner &
        Favero, 1986; US Environmental Protection Agency, 1972;
        Mallison, 1984). **Category IC** (EPA: 7 United States Code
        \[USC\] section 136 et seq.)

    B.  Do not use high-level disinfectants/liquid chemical sterilants
        for disinfection of either noncritical instruments and devices
        or any environmental surfaces; such use is counter to label
        instructions for these toxic chemicals (Favero & Bond, 2001;
        Association for Professionals in Infection Control and
        Epidemiology, 1996; Stingeni, Lapomarda, & Lisi, 1995; Ashdown
        et al., 1998; Busch & Werner, 1974; US Food and Drug
        Administration). **Category IC** (Food and Drug Administration
        \[FDA\]: 21 CFR 801.5, 807.87.e)

    C.  Follow manufacturers\' instructions for cleaning and maintaining
        noncritical medical equipment. **Category II**

    D.  In the absence of a manufacturer\'s cleaning instructions,
        follow certain procedures.

        1.  Clean noncritical medical equipment surfaces with a
            detergent/disinfectant. This may be followed by an
            application of an EPA-registered hospital disinfectant with
            or without a tuberculocidal claim (depending on the nature
            of the surface and the degree of contamination), in
            accordance with germicide label instructions (Association
            for Professionals in Infection Control and Epidemiology,
            1996). **Category II**

        2.  Do not use alcohol to disinfect large environmental surfaces
            (Favero & Bond, 2001). **Category II**

        3.  Use barrier protective coverings as appropriate for
            noncritical surfaces that are 1) touched frequently with
            gloved hands during the delivery of patient care; 2) likely
            to become contaminated with blood or body substances; or 3)
            difficult to clean (e.g., computer keyboards) (\"Recommended
            infection control,\" 1993). **Category II**

    E.  Keep housekeeping surfaces (e.g., floors, walls, tabletops)
        visibly clean on a regular basis and clean up spills promptly
        (Favero & Bond, 1991). **Category II**

        1.  Use a one-step process and an EPA-registered hospital
            detergent/disinfectant designed for general housekeeping
            purposes in patient-care areas where 1) uncertainty exists
            as to the nature of the soil on the surfaces (e.g., blood or
            body fluid contamination versus routine dust or dirt); or 2)
            uncertainty exists regarding the presence of multidrug
            resistant organisms on such surfaces (Mallison, 1984;
            Association for Professionals in Infection Control and
            Epidemiology, 1996; Chou, 2000; Rutala & Weber, 2000).
            **Category II**

        2.  Detergent and water are adequate for cleaning surfaces in
            nonpatient-care areas (e.g., administrative offices).
            **Category II**

        3.  Clean and disinfect high-touch surfaces (e.g., doorknobs,
            bed rails, light switches, and surfaces in and around
            toilets in patients\' rooms) on a more frequent schedule
            than minimal-touch housekeeping surfaces. **Category II**

        4.  Clean walls, blinds, and window curtains in patient-care
            areas when they are visibly dusty or soiled (Garner &
            Favero, 1986; Ayliffe et al., 1967; Dancer, 1999; Schmidt,
            Coleman, & Mallison, 1984). **Category II**

    F.  Do not perform disinfectant fogging in patient-care areas
        (Garner & Favero, 1986; Mallison, 1980). **Category IB**

    G.  Avoid large-surface cleaning methods that produce mists or
        aerosols or disperse dust in patient-care areas (\"Guidelines,\"
        2000; Weems et al., 1987; Walsh & Dixon, 1989; Morey & Williams,
        1990). **Category IB**

    H.  Follow proper procedures for effective uses of mops, cloths, and
        solutions. **Category II**

        1.  Prepare cleaning solutions daily or as needed, and replace
            with fresh solution frequently according to facility
            policies and procedures (Chou, 2000; Rutala & Weber, 2000).
            **Category II**

        2.  Change the mop head at the beginning of each day and also as
            required by facility policy, or after cleaning up large
            spills of blood or other body substances. **Category II**

        3.  Clean mops and cloths after use and allow to dry before
            reuse; or use single-use, disposable mop heads and cloths
            (Ayliffe et al., 1967; Walter & Kundsin, 1960; Scott &
            Bloomfield, \"The survival and transfer,\" 1990; Scott &
            Bloomfield, \"Investigations of the effectiveness,\" 1990).
            **Category II**

    I.  After the last surgical procedure of the day or night, wet
        vacuum or mop operating room floors with a single-use mop and an
        EPA-registered hospital disinfectant (CDC, \"Guideline,\" 1999).
        **Category IB**

    J.  Do not use mats with tacky surfaces at the entrances to
        operating rooms or infection-control suites (CDC, \"Guideline,\"
        1999). **Category IB**

    K.  Use appropriate dusting methods for patient-care areas
        designated for immunocompromised patients (e.g., HSCT patients)
        (\"Guidelines,\" 2000; Rhame et al., 1984; Chou, 2000).
        **Category IB**

        1.  Wet-dust horizontal surfaces daily by moistening a cloth
            with a small amount of an EPA-registered hospital
            detergent/disinfectant (\"Guidelines,\" 2000; Rhame et al.,
            1984; Chou, 2000). **Category IB**

        2.  Avoid dusting methods that disperse dust (e.g.,
            feather-dusting) (Rhame et al., 1984). **Category IB**

    L.  Keep vacuums in good repair and equip vacuums with HEPA filters
        for in use areas with patients at risk (\"Guidelines,\" 2000;
        Rhame et al., 1984; Chou, 2000; Brown, Schatzle, & Gable 1980).
        **Category IB**

    M.  Close the doors of immunocompromised patients\' rooms when
        vacuuming, waxing, or buffing corridor floors to minimize
        exposure to airborne dust (\"Guidelines,\" 2000; Rhame et al.,
        1984; Brown, Schatzle, & Gable 1980). **Category IB**

    N.  When performing low- or intermediate-level disinfection of
        environmental surfaces in nurseries and neonatal units, avoid
        unnecessary exposure of neonates to disinfectant residues on
        these surfaces by using EPA-registered germicides in accordance
        with manufacturers\' instructions and safety advisories (US
        Environmental Protection Agency, 1972; Wysowski et al., 1978;
        Doan, Keith, & Shennan, 1979; American Academy of Pediatrics
        \[AAP\] & American College of Obstetricians and Gynecologists
        \[ACOG\], 1997). **Category IB, IC** (EPA: 7 USC section 136 et
        seq.)

        1.  Do not use phenolics or any other chemical germicide to
            disinfect bassinets or incubators during an infant\'s stay
            (US Environmental Protection Agency, 1972; Wysowski et al.,
            1978; Doan, Keith, & Shennan, 1979; American Academy of
            Pediatrics \[AAP\] & American College of Obstetricians and
            Gynecologists \[ACOG\], 1997). **Category IB**

        2.  Rinse disinfectant-treated surfaces, especially those
            treated with phenolics, with water (Wysowski et al., 1978;
            Doan, Keith, & Shennan, 1979; American Academy of Pediatrics
            \[AAP\] & American College of Obstetricians and
            Gynecologists \[ACOG\], 1997). **Category IB**

    O.  When using phenolic disinfectants in neonatal units, prepare
        solutions to correct concentrations in accordance with
        manufacturers\' instructions, or use premixed formulations (US
        Environmental Protection Agency, 1972; Wysowski et al., 1978;
        Doan, Keith, & Shennan, 1979; American Academy of Pediatrics
        \[AAP\] & American College of Obstetricians and Gynecologists
        \[ACOG\], 1997). **Category IB, IC** (EPA: 7 USC section 136 et
        seq.)

II. **Cleaning Spills of Blood and Body Substances**

    A.  Promptly clean and decontaminate spills of blood or other
        potentially infectious materials (\"Occupational exposure to
        bloodborne pathogens,\" 1991; Spire et al., 1984; Martin,
        McDougal, & Loskoski, 1985; Hanson et al., 1989; Bloomfield,
        Smith-Burchnell, & Dalgleish, 1990; Druce et al., 1995; Van
        Bueren et al., 1995; Prince et al., 1993). **Category IB, IC**
        (OSHA: 29 CFR 1910.1030 section d.4.ii.A)

    B.  Follow proper procedures for site decontamination of spills of
        blood or blood-containing body fluids (\"Occupational exposure
        to bloodborne pathogens,\" 1991; Spire et al., 1984; Martin,
        McDougal, & Loskoski, 1985; Hanson et al., 1989; Bloomfield,
        Smith-Burchnell, & Dalgleish, 1990; Druce et al., 1995; Van
        Bueren et al., 1995; Prince et al., 1993). **Category IC**
        (OSHA: 29 CFR 1910.1030 section d.4.ii.A)

        1.  Use protective gloves and other PPE appropriate for this
            task (\"Occupational exposure to bloodborne pathogens,\"
            1991). **Category IC** (OSHA: 29 CFR 1910.1030 section
            d.3.i, ii)

        2.  If the spill contains large amounts of blood or body fluids,
            clean the visible matter with disposable absorbent material,
            and discard the used cleaning materials in appropriate,
            labeled containers (\"Occupational exposure to bloodborne
            pathogens,\" 1991; Druce et al., 1995; Van Bueren et al.,
            1995; \"Recommendations for prevention,\" 1987; Sattar &
            Springthorpe, 1991). **Category IC** (OSHA: 29 CFR 1910.1030
            section d.4.iii.B)

        3.  Swab the area with a cloth or paper towels moderately wetted
            with disinfectant, and allow the surface to dry
            (\"Occupational exposure to bloodborne pathogens,\" 1991;
            \"Recommendations for prevention,\" 1987). **Category IC**
            (OSHA: 29 CFR 1910.1030 section d.4.ii.A)

    C.  Use germicides registered by the EPA for use as hospital
        disinfectants and labeled tuberculocidal or registered
        germicides on the EPA Lists D and E (i.e., products with
        specific label claims for HIV or hepatitis B virus \[HBV\]) in
        accordance with label instructions to decontaminate spills of
        blood and other body fluids (\"Occupational exposure to
        bloodborne pathogens,\" 1991; \"Recommendations for
        prevention,\" 1987; US Department of Labor, Occupational Safety
        and Health Administration, 1997). **Category IC** (OSHA 29 CFR
        1910.1030 section d.4.ii. A memorandum 2/28/97; compliance
        document \[CPL\] 2-2.44D \[11/99\])

    D.  An EPA-registered sodium hypochlorite product is preferred, but
        if such products are not available, generic sodium hypochlorite
        solutions (e.g., household chlorine bleach) may be used.

        1.  Use a 1:100 dilution (500\--615 ppm available chlorine) to
            decontaminate nonporous surfaces after cleaning a spill of
            either blood or body fluids in patient-care settings
            \"Recommendations for prevention,\" 1987; Weber et al.,
            1999). **Category IB**

        2.  If a spill involves large amounts of blood or body fluids,
            or if a blood or culture spill occurs in the laboratory, use
            a 1:10 dilution (5,000\--6,150 ppm available chlorine) for
            the first application of germicide before cleaning (Favero &
            Bond, 1991; \"Recommendations for prevention,\" 1987).
            **Category IB**

III. **Carpeting and Cloth Furnishings**

     A.  Vacuum carpeting in public areas of health-care facilities and
         in general patient-care areas regularly with well-maintained
         equipment designed to minimize dust dispersion (Chou, 2000).
         **Category II**

     B.  Periodically perform a thorough, deep cleaning of carpeting as
         determined by facility policy by using a method that minimizes
         the production of aerosols and leaves little or no residue
         (Gerson et al., 1994). **Category II**

     C.  Avoid use of carpeting in high-traffic zones in patient-care
         areas or where spills are likely (e.g., burn therapy units,
         operating rooms, laboratories, or intensive care units) (Gerson
         et al., 1994; Suzuki et al., 1984; Richet et al., 1989).
         **Category IB**

     D.  Follow appropriate procedures for managing spills on carpeting.

         1.  Spot-clean blood or body substance spills promptly
             (\"Occupational exposure to bloodborne pathogens,\" 1991;
             \"Recommendations for prevention,\" 1987; Weber et al.,
             1999; US Department of Labor, Occupational Safety and
             Health Administration, 1994). **Category IC** (OSHA: 29 CFR
             1910.1030 section d.4.ii.A, interpretation)

         2.  If a spill occurs on carpet tiles, replace any tiles
             contaminated by blood and body fluids or body substances
             (US Department of Labor, Occupational Safety and Health
             Administration, 1994). **Category IC** (OSHA 29 CFR
             1910.1030 section d.4.ii interpretation)

     E.  Thoroughly dry wet carpeting to prevent the growth of fungi;
         replace carpeting that remains wet after 72 hours
         (\"Guidelines,\" 2000; Vesper et al., 2000). **Category IB**

     F.  No recommendation is offered regarding the routine use of
         fungicidal or bactericidal treatments for carpeting in public
         areas of a health-care facility or in general patient-care
         areas. **Unresolved issue**

     G.  Do not use carpeting in hallways and patient rooms in areas
         housing immunosuppressed patients (e.g., PE areas)
         (\"Guidelines,\" 2000; Gerson et al., 1994). **Category IB**

     H.  Avoid using upholstered furniture and furnishings in high-risk
         patient-care areas and in areas with increased potential for
         body substance contamination (e.g., pediatrics units)
         (\"Guidelines,\" 2000). **Category II**

     I.  No recommendation is offered regarding whether upholstered
         furniture and furnishings should be avoided in general
         patient-care areas. **Unresolved issue**

         1.  Maintain upholstered furniture in good repair. **Category
             II**

         2.  Maintain the surface integrity of the upholstery by
             repairing tears and holes. **Category II**

         3.  If upholstered furniture in a patient\'s room requires
             cleaning to remove visible soil or body substance
             contamination, move that item to a maintenance area where
             it can be adequately cleaned with a process appropriate for
             the type of upholstery and nature of the soil. **Category
             II**

IV. **Flowers and Plants in Patient-Care Areas**

    A.  Flowers and potted plants need not be restricted from areas for
        immunocompetent patients (Taplin & Mertz, 1973; Kates et al.,
        1991; Bartzokas, Holley, & Sharp, 1975; Siegman-Igra et al.,
        1986). **Category II**

    B.  Designate care and maintenance of flowers and potted plants to
        staff not directly involved with patient care (Kates et al.,
        1991). **Category II**

    C.  If plant or flower care by patient-care staff is unavoidable,
        instruct the staff to wear gloves when handling plants and
        flowers and perform hand hygiene after glove removal (Kates et
        al., 1991). **Category II**

    D.  Do not allow fresh or dried flowers, or potted plants, in
        patient-care areas for immunosuppressed patients
        (\"Guidelines,\" 2000; Walsh & Dixon, 1989; Taplin & Mertz,
        1973; Lass-Florl et al., 2000). **Category II**

V.  **Pest Control**

    A.  Develop pest-control strategies, with emphasis on kitchens,
        cafeterias, laundries, central sterile supply areas, operating
        rooms, loading docks, construction activities, and other areas
        prone to infestations (Burgess, 1984; Lukin, 1989; Bruesch,
        1994). **Category II**

    B.  Install screens on all windows that open to the outside; keep
        screens in good repair (Lukin, 1989). **Category IB**

    C.  Contract for routine pest control service by a credentialed
        pest-control specialist who will tailor the application to the
        needs of a health-care facility (Bruesch, 1994). **Category II**

    D.  Place laboratory specimens (e.g., fixed sputum smears) in
        covered containers for overnight storage (Allen BW, 1987;
        Laszlo, 2000). **Category II**

VI. **Special Pathogens**

    A.  Use appropriate hand hygiene, personal protective equipment
        (PPE) (e.g., gloves), and isolation precautions during cleaning
        and disinfecting procedures (Boyce & Pittet, 2002; Association
        for Professionals in Infection Control and Epidemiology, 1996;
        \"Recommendations for preventing,\" 1995; Gerding et al., 1995).
        **Category IB**

    B.  Use standard cleaning and disinfection protocols to control
        environmental contamination with antibiotic-resistant,
        gram-positive cocci (e.g., methicillin-resistant *Staphylococcus
        aureus*, vancomycin-intermediate *Staphylococcus aureus*, or
        vancomycin-resistant *Enterococcus* \[VRE\]) (\"Recommendations
        for preventing,\" 1995; Weber & Rutala, 1997; Lai et al., 1998;
        Byers et al., 1998). **Category IB**

        1.  Pay close attention to cleaning and disinfection of
            high-touch surfaces in patient-care areas (e.g., bed rails,
            carts, charts, bedside commodes, bed rails, doorknobs, or
            faucet handles) (\"Recommendations for preventing,\" 1995;
            Weber & Rutala, 1997; Lai et al., 1998; Byers et al., 1998).
            **Category IB**

        2.  Ensure compliance by housekeeping staff with cleaning and
            disinfection procedures (\"Recommendations for preventing,\"
            1995; Weber & Rutala, 1997; Lai et al., 1998; Byers et al.,
            1998). **Category IB**

        3.  Use EPA-registered chemical germicides appropriate for the
            surface to be disinfected (e.g., either low- or
            intermediate-level disinfection) as specified by the
            manufacturer\'s instructions (US Environmental Protection
            Agency, 1972; Byers et al., 1998; Bradley & Fraise, 1996;
            Anderson et al., 1997; Saurina, Landman, & Quale, 1997;
            Rutala et al., 1997; Sehulster & Anderson, 1998). **Category
            IB, IC** (EPA: 7 USC section 136 et seq.)

        4.  When contact precautions are indicated for patient care, use
            disposable patient-care items (e.g., blood pressure cuffs)
            wherever possible to minimize cross-contamination with
            multiple-resistant microorganisms (Layton et al., 1993).
            **Category IB**

        5.  Follow these same surface-cleaning and disinfecting measures
            for managing the environment of vancomycin-resistant
            *Staphylococcus aureus* (VRSA) patients (Weber & Rutala,
            1997; Lai et al., 1998; Byers et al., 1998; Sehulster &
            Anderson, 1998). **Category II**

    C.  Environmental-surface culturing can be used to verify the
        efficacy of hospital policies and procedures before and after
        cleaning and disinfecting rooms that house patients with
        vancomycin-resistant *Enteroccus* (VRE) (\"Recommendations for
        preventing,\" 1995; Karanfil et al., 1992; Boyce et al., 1994;
        Rhinehart et al., 1990; Livornese et al., 1992; Zervos et al.,
        1987). **Category II**

        1.  Obtain prior approval from infection-control staff and the
            clinical laboratory before performing environmental-surface
            culturing. **Category II**

        2.  Infection-control staff, with clinical laboratory staff
            consultation, must supervise all environmental culturing.
            **Category II**

    D.  Thoroughly clean and disinfect environmental and medical
        equipment surfaces on a regular basis by using EPA-registered
        disinfectants in accordance with manufacturers\' instructions
        (US Environmental Protection Agency, 1972; Association for
        Professionals in Infection Control and Epidemiology, 1996;
        Gerding et al., 1995; Worsley, 1998). **Category IB, IC** (EPA:
        7 USC section 136 et seq.)

    E.  Advise families, visitors, and patients regarding the importance
        of hand hygiene to minimize the spread of body substance
        contamination (e.g., respiratory secretions or fecal matter) to
        surfaces (Association for Professionals in Infection Control and
        Epidemiology, 1996). **Category II**

    F.  Do not use high-level disinfectants (i.e., liquid chemical
        sterilants) on environmental surfaces; such use is inconsistent
        with label instructions because of the toxicity of the chemicals
        (Garner & Favero, 1986; Favero & Bond, 2001; Association for
        Professionals in Infection Control and Epidemiology, 1996; US
        Food and Drug Administration). **Category IC** (FDA: 21 CFR
        801.5, 807.87.e)

    G.  Because no EPA-registered products are specific for inactivating
        *Clostridium difficile* spores, use hypochlorite-based products
        for disinfection of environmental surfaces in accordance with
        guidance from the scientific literature in those patient-care
        areas where surveillance and epidemiology indicate ongoing
        transmission of *C. difficile* (Association for Professionals in
        Infection Control and Epidemiology, 1996; Gerding et al., 1995;
        Worsley, 1998). **Category II**

    H.  No recommendation is offered regarding the use of specific
        EPA-registered hospital disinfectants with respect to
        environmental control of *C. difficile*. **Unresolved issue**

    I.  Apply standard cleaning and disinfection procedures to control
        environmental contamination with respiratory and enteric viruses
        in pediatric-care units and care areas for immunocompromised
        patients (Chou, 2000; Lloyd-Evans, Springthorpe, & Sattar,
        1986). **Category IC** (EPA: 7 USC section 136 et seq.)

    J.  Clean surfaces that have been contaminated with body substances;
        perform low- to intermediate-level disinfection on cleaned
        surfaces with an EPA-registered disinfectant in accordance with
        the manufacturer\'s instructions (US Environmental Protection
        Agency, 1972; \"Occupational exposure to bloodborne pathogens,\"
        1991; Lloyd-Evans, Springthorpe, & Sattar, 1986). **Category
        IC** (OSHA: 29 CFR 1910.1030 section d.4.ii.A; EPA: 7 USC
        section 136 et seq.)

    K.  Use disposable barrier coverings as appropriate to minimize
        surface contamination. **Category II**

    L.  Develop and maintain cleaning and disinfection procedures in
        patient-care areas to control environmental contamination with
        agents of Creutzfeldt-Jakob disease (CJD), for which no
        EPA-registered product exists. **Category II**

        1.  In the absence of contamination with central nervous system
            tissue, extraordinary measures (e.g., use of 2N sodium
            hydroxide \[NaOH\] or applying full-strength sodium
            hypochlorite) are not needed for routine cleaning or
            terminal disinfection of a room housing a confirmed or
            suspected CJD patient (Favero & Bond, 2001; Rutala & Weber,
            2001). **Category II**

        2.  After removing gross tissue from the surface, use either 1N
            NaOH or a sodium hypochlorite solution containing
            approximately 10,000- to 20,000 ppm available chlorine
            (dilutions of 1:5 to 1:3 v/v, respectively, of U.S.
            household chlorine bleach; contact the manufacturers of
            commercially available sodium hypochlorite products for
            advice) to decontaminate operating room or autopsy surfaces
            with central nervous system or cerebral spinal fluid
            contamination from a diagnosed or suspected CJD patient
            (Favero & Bond, 2001; Kimberlin et al., 1983;
            \"Precautions,\" 1986; Taylor, 1991; Budka et al., 1995;
            Ironside & Bell, 1996; World Health Organization \[WHO\],
            1999). **Category II**

            a.  The contact time for the chemical used during this
                process should be 30 min to 1 hour (Taylor, 1991; Budka
                et al., 1995; World Health Organization \[WHO\], 1999).

            b.  Blot up the chemical with absorbent material and rinse
                the treated surface thoroughly with water.

            c.  Discard the used, absorbent material into appropriate
                waste containers.

        3.  Use disposable, impervious covers to minimize body substance
            contamination to autopsy tables and surfaces (Budka et al.,
            1995; World Health Organization \[WHO\], 1999). **Category
            II**

    M.  Use standard procedures for containment, cleaning, and
        decontamination of blood spills on surfaces as previously
        described (Environmental Services: II) (\"Occupational exposure
        to bloodborne pathogens,\" 1991). **Category IC** (OSHA: 29 CFR
        1910.1030 section d.4.ii.A)

        1.  Wear PPE appropriate for a surface decontamination and
            cleaning task (\"Occupational exposure to bloodborne
            pathogens,\" 1991; Rutala & Weber, 2001). **Category IC**
            (OSHA 29 CFR 1910.1030 Â§ d.3.i, ii)

        2.  Discard used PPE by using routine disposal procedures or
            decontaminate reusable PPE as appropriate (\"Occupational
            exposure to bloodborne pathogens,\" 1991; Rutala & Weber,
            2001). **Category IC** (OSHA 29 CFR 1910.1030 Â§ d.3.viii)

**[Recommendations -- Environmental Sampling]{.underline}**

I.  **General Information**

    A.  Do not conduct random, undirected, microbiologic sampling of
        air, water, and environmental surfaces in health-care facilities
        (Garner & Favero, 1986; Bond & Sehulster, 2003). **Category IB**

    B.  When indicated, conduct microbiologic sampling as part of an
        epidemiologic investigation or during assessment of hazardous
        environmental conditions to detect contamination or verify
        abatement of a hazard (Garner & Favero, 1986; Bond & Sehulster,
        2003). **Category IB**

    C.  Limit microbiologic sampling for quality assurance purposes
        to 1) biologic monitoring of sterilization processes; 2) monthly
        cultures of water and dialysate in hemodialysis units; and 3)
        short-term evaluation of the impact of infection-control
        measures or changes in infection-control protocols (Garner &
        Favero, 1986; Bond & Sehulster, 2003). **Category IB**

II. **Air, Water, and Environmental Surface Sampling**

    A.  When conducting any form of environmental sampling, identify
        existing comparative standards and fully document departures
        from standard methods (Bond & Sehulster, 2003; Clesceri,
        Greenberg, & Eaton, 1998; Buttner, Willeke, & Grinshpun, 1997;
        Jensen, 1998; International Organization for Standardization,
        1995). **Category II**

    B.  Select a high-volume air sampling device if anticipated levels
        of microbial airborne contamination are expected to be low
        (Buttner, Willeke, & Grinshpun, 1997; Jensen, 1998; Streifel,
        1992; Wolf et al., 1964). **Category II**

    C.  Do not use settle plates to quantify the concentration of
        airborne fungal spores (Streifel, 1992). **Category II**

    D.  When sampling water, choose growth media and incubation
        conditions that will facilitate recovery of waterborne organisms
        (Clesceri, Greenberg, & Eaton, 1998). **Category II**

    E.  When using a sample/rinse method for sampling an environmental
        surface, develop and document a procedure for manipulating the
        swab, gauze, or sponge in a reproducible manner so that results
        are comparable (International Organization for Standardization,
        1995). **Category II**

    F.  When environmental samples and patient specimens are available
        for comparison, perform the laboratory analysis on the recovered
        microorganisms down to the species level at a minimum, and
        beyond the species level if possible (Bond & Sehulster, 2003).
        **Category II**

**[Recommendations -- Laundry and Bedding]{.underline}**

I.  **Employer Responsibilities**

    A.  Employers must launder workers\' personal protective garments or
        uniforms that are contaminated with blood or other potentially
        infectious materials (\"Occupational exposure to bloodborne
        pathogens,\" 1991). **Category IC** (OSHA: 29 CFR 1910.1030
        section d.3.iv)

II. **Laundry Facilities and Equipment**

    A.  Maintain the receiving area for contaminated textiles at
        negative pressure compared with the clean areas of the laundry
        in accordance with AIA construction standards in effect during
        the time of facility construction (The American Institute of
        Architects and The Facilities Guidelines Institute, 2001;
        Wagner, 1966; Hambraeus & Malmborg, 1982; McDonald & Pugliese,
        1999). **Category IC** (AIA: 7.23.B1, B2)

    B.  Ensure that laundry areas have handwashing facilities and
        products and appropriate PPE available for workers (The American
        Institute of Architects and The Facilities Guidelines Institute,
        2001; \"Occupational exposure to bloodborne pathogens,\" 1991).
        **Category IC** (AIA: 7.23.D4; OSHA: 29 CFR 1910.1030 section
        d.2.iii)

    C.  Use and maintain laundry equipment according to manufacturers\'
        instructions (Barrie et al., 1994; Legnani & Leoni, 1997).
        **Category II**

    D.  Do not leave damp textiles or fabrics in machines overnight
        (Barrie et al., 1994). **Category II**

    E.  Disinfection of washing and drying machines in residential care
        is not needed as long as gross soil is removed from items before
        washing and proper washing and drying procedures are used.
        **Category II**

III. **Routine Handling of Contaminated Laundry**

     A.  Handle contaminated textiles and fabrics with minimum agitation
         to avoid contamination of air, surfaces, and persons (Garner,
         1996; \"Occupational exposure to bloodborne pathogens,\" 1991;
         Joint Committee on Healthcare Laundry Guidelines, 1999; Greene,
         1970). **Category IC** (OSHA: 29 CFR 1910.1030 section d.4.iv)

     B.  Bag or otherwise contain contaminated textiles and fabrics at
         the point of use (\"Occupational exposure to bloodborne
         pathogens,\" 1991). **Category IC** (OSHA: 29 CFR 1910.1030
         section d.4.iv)

         1.  Do not sort or prerinse contaminated textiles or fabrics in
             patient-care areas (\"Occupational exposure to bloodborne
             pathogens,\" 1991). **Category IC** (OSHA: 29 CFR 1910.1030
             section d.4.iv)

         2.  Use leak-resistant containment for textiles and fabrics
             contaminated with blood or body substances (\"Occupational
             exposure to bloodborne pathogens,\" 1991; Joint Committee
             on Healthcare Laundry Guidelines, 1999). **Category IC**
             (OSHA: 29 CFR 1910.1030 section d.4.iv)

         3.  Identify bags or containers for contaminated textiles with
             labels, color coding, or other alternative means of
             communication as appropriate (\"Occupational exposure to
             bloodborne pathogens,\" 1991). **Category IC** (OSHA: 29
             CFR 1910.1030 section d.4.iv)

     C.  Covers are not needed on contaminated textile hampers in
         patient-care areas. **Category II**

     D.  If laundry chutes are used, ensure that they are properly
         designed, maintained, and used in a manner to minimize
         dispersion of aerosols from contaminated laundry (Association
         for the Advancement of Medical Instrumentation, 2000; Hughes,
         1964; Michaelsen, 1965; Hoeh, 1982; Whyte, Baird, & Annand,
         1969). **Category IC** (AAMI: ANSI/AAMI ST65:2000)

         1.  Ensure that laundry bags are closed before tossing the
             filled bag into the chute. **Category II**

         2.  Do not place loose items in the laundry chute. **Category
             II**

     E.  Establish a facility policy to determine when textiles or
         fabrics should be sorted in the laundry facility (i.e., before
         or after washing) (Taylor, 1988; Walter & Schillinger, 1975).
         **Category II**

IV. **Laundry Process**

    A.  If hot-water laundry cycles are used, wash with detergent in
        water [\>]{.underline}160 degrees F ([\>]{.underline}71
        degrees C) for [\>]{.underline}25 minutes (The American
        Institute of Architects and The Facilities Guidelines Institute,
        2001; Garner & Favero, 1986). **Category IC** (AIA: 7.31.E3)

    B.  No recommendation is offered regarding a hot-water temperature
        setting and cycle duration for items laundered in
        residence-style health-care facilities. **Unresolved issue**

    C.  Follow fabric-care instructions and special laundering
        requirements for items used in the facility (Belkin, 1998).
        **Category II**

    D.  Choose chemicals suitable for low-temperature washing at proper
        use concentration if low-temperature (\<160 degrees F \[\<70
        degrees C\]) laundry cycles are used (Blaser et al., 1984; Jaska
        & Fredell, 1980; Battles & Vesley, 1981; Christian, Manchester,
        & Mellor, 1983; Smith et al., 1987; Tompkins, Johnson, &
        Fittall, 1988). **Category II**

    E.  Package, transport, and store clean textiles and fabrics by
        methods that will ensure their cleanliness and protect them from
        dust and soil during interfacility loading, transport, and
        unloading (Garner & Favero, 1986). **Category II**

V.  **Microbiologic Sampling of Textiles**

    A.  Do not conduct routine microbiologic sampling of clean textiles
        (Garner & Favero, 1986; Ayliffe, Collins, & Taylor, 1982).
        **Category IB**

    B.  Use microbiologic sampling during outbreak investigations if
        epidemiologic evidence indicates a role for health-care textiles
        and clothing in disease transmission (Ayliffe, Collins, &
        Taylor, 1982). **Category IB**

VI. **Special Laundry Situations**

    A.  Use sterilized textiles, surgical drapes, and gowns for
        situations requiring sterility in patient care (CDC,
        \"Guideline,\" 1999). **Category IB**

    B.  Use hygienically clean textiles (i.e., laundered, but not
        sterilized) in neonatal intensive care units (American Academy
        of Pediatrics \[AAP\] & American College of Obstetricians and
        Gynecologists \[ACOG\], 1997; Meyer et al., 1981). **Category
        IB**

    C.  Follow manufacturers\' recommendations for cleaning fabric
        products, including those with coated or laminated surfaces.
        **Category II**

    D.  Do not use dry cleaning for routine laundering in health-care
        facilities (Wagg, 1965; Bates et al., 1993; Oehnel, 1971).
        **Category II**

    E.  Use caution when considering use of antimicrobial mattresses,
        textiles, and clothing as replacements for standard bedding and
        other fabric items; EPA has not approved public health claims
        asserting protection against human pathogens for such treated
        items (US Environmental Protection Agency, 2003). **Category
        II**

    F.  No recommendation is offered regarding using disposable fabrics
        and textiles versus durable goods. **Unresolved issue**

VII. **Mattresses and Pillows**

     A.  Keep mattresses dry; discard them if they remain wet or
         stained, particularly in burn units (Fujita et al., 1981; Grubb
         & Watson, 1982; Sherertz & Sullivan, 1985; Ndawula & Brown,
         1991; O\'Donoghue & Allen, 1992; Weernink et al., 1995).
         **Category IB**

     B.  Clean and disinfect mattress covers by using EPA-registered
         disinfectants that are compatible with the materials to prevent
         the development of tears, cracks, or holes in the covers
         (Fujita et al., 1981; Grubb & Watson, 1982; Sherertz &
         Sullivan, 1985; Ndawula & Brown, 1991; O\'Donoghue & Allen,
         1992; Weernink et al., 1995). **Category IB**

     C.  Maintain the integrity of mattress and pillow covers.
         **Category II**

         1.  Replace mattress and pillow covers if they become torn or
             otherwise in need of repair. **Category II**

         2.  Do not stick needles into a mattress through the cover.
             **Category II**

     D.  Clean and disinfect moisture-resistant mattress covers between
         patient use by using an EPA-registered product (Fujita et al.,
         1981; Grubb & Watson, 1982; Sherertz & Sullivan, 1985; Ndawula
         & Brown, 1991; O\'Donoghue & Allen, 1992; Weernink et al.,
         1995). **Category IB**

     E.  If using a mattress cover completely made of fabric, change
         these covers and launder between patient use (Fujita et al.,
         1981; Grubb & Watson, 1982; Sherertz & Sullivan, 1985; Ndawula
         & Brown, 1991; O\'Donoghue & Allen, 1992; Weernink et al.,
         1995). **Category IB**

     F.  Launder pillow covers and washable pillows in the hot-water
         cycle between patients or when they become contaminated with
         body substances (Weernink et al., 1995). **Category IB**

VIII. **Air-Fluidized Beds**

      A.  Follow manufacturers\' instructions for air-fluidized bed
          maintenance and decontamination. **Category II**

      B.  Change the polyester filter sheet at least weekly or as
          indicated by the manufacturer (Scheidt & Drusin, 1983; Freeman
          et al., 1994; Clancy, 1993; Clancy, 1994). **Category II**

      C.  Clean and disinfect the polyester filter sheet thoroughly,
          especially between patients, using an EPA-registered product
          (Scheidt & Drusin, 1983; Freeman et al., 1994; Clancy, 1993;
          Clancy, 1994). **Category IB**

      D.  Consult the facility engineer to determine the proper
          placement of air-fluidized beds in negative-pressure rooms
          (Jacobsen, Gurevich, & Cunha, 1993). **Category II**

**[Recommendations -- Animals in Health-Care Facilities]{.underline}**

I.  **General Infection-Control Measures for Animal Encounters**

    A.  Minimize contact with animal saliva, dander, urine, and feces
        (Tips to remember, 2003; Duncan, 2000; Murray, Ferguson, &
        Morrison, 1983). **Category II**

    B.  Practice hand hygiene after any animal contact (Boyce & Pittet,
        2002; Garner & Favero, 1986). **Category II**

        1.  Wash hands with soap and water, especially if hands are
            visibly soiled or contaminated with proteinaceous material
            (Boyce & Pittet, 2002). **Category II**

        2.  Use either soap and water or alcohol-based hand rubs when
            hands are not visibly soiled or contaminated (Boyce &
            Pittet, 2002). **Category II**

II. **Animal-Assisted Activities and Resident Animal Programs**

    A.  Avoid selection of nonhuman primates and reptiles in
        animal-assisted activities, animal-assisted therapy, or resident
        animal programs (Delta Society, 1996; Fox, 1975; Ostrowski et
        al., 1998). **Category IB**

    B.  Enroll animals that are fully vaccinated for zoonotic diseases
        and that are healthy, clean, well-groomed, and negative for
        enteric parasites or otherwise have completed recent
        anthelmintic treatment under the regular care of a veterinarian
        (Delta Society, 1996; Saylor, 1998). **Category II**

    C.  Enroll animals that are trained with the assistance or under the
        direction of persons who are experienced in this field (Delta
        Society, 1996). **Category II**

    D.  Ensure that animals are controlled by persons trained in
        providing activities or therapies safely, and who know the
        animal\'s health status and behavior traits (Delta Society,
        1996; Saylor, 1998). **Category II**

    E.  Take prompt action when an incident of biting or scratching by
        an animal occurs during an animal-assisted activity or therapy.

        1.  Remove the animal permanently from these programs (Delta
            Society, 1996). **Category II**

        2.  Report the incident promptly to appropriate authorities
            (e.g., infection-control staff, animal program coordinator,
            or local animal control personnel) (Delta Society, 1996).
            **Category II**

        3.  Promptly clean and treat scratches, bites, or other breaks
            in the skin. **Category II**

    F.  Perform an ICRA and work actively with the animal handler before
        conducting an animal-assisted activity or therapy to determine
        whether the session should be held in a public area of the
        facility or in individual patient rooms (Delta Society, 1996;
        Saylor, 1998). **Category II**

    G.  Take precautions to mitigate allergic responses to animals.
        **Category II**

        1.  Minimize shedding of animal dander by bathing animals \<24
            hours before a visit (Delta Society, 1996). **Category II**

        2.  Groom animals to remove loose hair before a visit, or use a
            therapy animal cape (Draper, Gerber, & Layng, 1990).
            **Category II**

    H.  Use routine cleaning protocols for housekeeping surfaces after
        therapy sessions. **Category II**

    I.  Restrict resident animals, including fish in tanks, from access
        to patient-care areas, food-preparation areas, dining areas,
        laundry, central sterile supply areas, sterile and clean supply
        storage areas, medication preparation areas, operating rooms,
        isolation areas, and PE areas. **Category II**

    J.  Establish a facility policy for regular cleaning of fish tanks,
        rodent cages, bird cages, and any other animal dwellings and
        assign this cleaning task to a nonpatient-care staff member;
        avoid splashing tank water or contaminating environmental
        surfaces with animal bedding. **Category II**

III. **Protective Measures for Immunocompromised Patients**

     A.  Advise patients to avoid contact with animal feces, saliva,
         urine, or solid litter box material (\"1999 USPHS/IDSA
         guidelines,\" 1999). **Category II**

     B.  Promptly clean and treat scratches, bites, or other wounds that
         break the skin (\"1999 USPHS/IDSA guidelines,\" 1999).
         **Category II**

     C.  Advise patients to avoid direct or indirect contact with
         reptiles (\"Reptile-associated salmonellosis,\" 1999).
         **Category IB**

     D.  Conduct a case-by-case assessment to determine if
         animal-assisted activities or animal-assisted therapy programs
         are appropriate for immunocompromised patients (Saylor, 1998).
         **Category II**

     E.  No recommendation is offered regarding permitting pet visits to
         terminally ill immunocompromised patients outside their PE
         units. **Unresolved issue**

IV. **Service Animals**

    A.  Avoid providing facility access to nonhuman primates and
        reptiles as service animals (Ostrowski et al., 1998;
        \"Reptile-associated salmonellosis,\" 1999). **Category IB**

    B.  Allow service animals access to the facility in accordance with
        the Americans with Disabilities Act of 1990, unless the presence
        of the animal creates a direct threat to other persons or a
        fundamental alteration in the nature of services (Duncan, 2000;
        US Department of Justice, 1990). **Category IC** (U.S.
        Department of Justice: 28 CFR section 36.302)

    C.  When a decision must be made regarding a service animal\'s
        access to any particular area of the health-care facility,
        evaluate the service animal, patient, and health-care situation
        on a case-by-case basis to determine whether significant risk of
        harm exists and whether reasonable modifications in policies and
        procedures will mitigate this risk (US Department of Justice,
        1990). **Category IC** (U.S. Department of Justice: 28 CFR
        section 36.208)

    D.  If a patient must be separated from his or her service animal
        while in the health-care facility 1) ascertain from the person
        what arrangements have been made for supervision or care of the
        animal during this period of separation; and 2) make appropriate
        arrangements to address the patient\'s needs in the absence of
        the service animal. **Category II**

V.  **Animals as Patients in Human Health-Care Facilities**

    A.  Develop health-care facility policies to address the treatment
        of animals in human health-care facilities.

        1.  Use the multidisciplinary team approach to policy
            development, including public media relations efforts to
            disclose and discuss these activities. **Category II**

        2.  Exhaust all veterinary facility, equipment, and instrument
            options before undertaking the procedure. **Category II**

        3.  Ensure that the care of the animal is supervised by a
            licensed veterinarian. **Category II**

    B.  When animals are treated in human health-care facilities, avoid
        treating animals in operating rooms or other patient-care areas
        where invasive procedures are performed (e.g., cardiac
        catheterization laboratories or invasive nuclear medicine
        areas). **Category II**

    C.  Schedule the animal procedure for the last procedure of the day
        in the area, at a time when human patients are not scheduled to
        be in the vicinity. **Category II**

    D.  Adhere strictly to standard precautions. **Category II**

    E.  Clean and disinfect environmental surfaces thoroughly by using
        an EPA-registered product in the room after the animal has been
        removed. **Category II**

    F.  Allow sufficient ACH to clean the air and help remove airborne
        dander, microorganisms, and allergens (refer to Table 1 titled
        \"Air changes/hour and time required for airborne-contaminant
        removal efficiencies of 99% and 99.9%\" in the original
        guideline document). **Category II**

    G.  Clean and disinfect using EPA-registered products or sterilize
        equipment that has been in contact with the animal; or use
        disposable equipment. **Category II**

    H.  If reusable medical or surgical instruments are used in an
        animal procedure, restrict future use of these instruments to
        animals only. **Category II**

VI. **Research Animals in Health-Care Facilities**

    A.  Use animals obtained from quality stock, or quarantine incoming
        animals to detect zoonotic diseases. **Category II**

    B.  Treat sick animals or remove them from the facility. **Category
        II**

    C.  Provide prophylactic vaccinations, as available, to animal
        handlers and contacts at high risk. **Category II**

    D.  Ensure proper ventilation through appropriate facility design
        and location (US Department of Agriculture). **Category IC**
        (U.S. Department of Agriculture \[USDA\]: 7 USC 2131)

        1.  Keep animal rooms at negative pressure relative to corridors
            (US Department of Agriculture). **Category IC** (USDA: 7 USC
            2131)

        2.  Prevent air in animal rooms from recirculating elsewhere in
            the health-care facility (US Department of Agriculture).
            **Category IC** (USDA: 7 USC 2131)

    E.  Keep doors to animal research rooms closed. **Category II**

    F.  Restrict access to animal facilities to essential personnel.
        **Category II**

    G.  Establish employee occupational health programs specific to the
        animal research facility, and coordinate management of
        postexposure procedures specific to zoonoses with occupational
        health clinics in the health-care facility (CDC & National
        Institutes of Health, 1993; US Department of Labor, Occupational
        Safety and Health Administration). **Category IC** (U.S.
        Department of Health and Human Services \[DHHS\]: Biosafety in
        Microbiological and Biomedical Laboratories \[BMBL\]; OSHA: 29
        CFR 1910.1030.132-139)

    H.  Document standard operating procedures for the unit (CDC &
        National Institutes of Health, 1993). **Category IC** (DHHS:
        BMBL)

    I.  Conduct routine employee training on worker safety concerns
        relevant to the animal research facility (e.g., working safely
        with animals, animal handling) (CDC & National Institutes of
        Health, 1993; US Department of Labor, Occupational Safety and
        Health Administration). **Category IC** (DHHS: BMBL; OSHA: 29
        CFR 1910.1030.132\--139)

    J.  Use precautions to prevent development of animal-induced asthma
        in animal workers (CDC & National Institutes of Health).
        **Category IC** (DHHS: BMBL)

**[Recommendations -- Regulated Medical Wastes]{.underline}**

I.  **Categories of Regulated Medical Waste**

    A.  Designate the following as major categories of medical waste
        that require special handling and disposal precautions: 1)
        microbiology laboratory wastes \[e.g., cultures and stocks of
        microorganisms\]; 2) bulk blood, blood products, blood, and
        bloody body fluid specimens; 3) pathology and anatomy waste;
        and 4) sharps \[e.g., needles and scalpels\] (Garner & Favero,
        1986). **Category II**

    B.  Consult federal, state, and local regulations to determine if
        other waste items are considered regulated medical wastes
        (\"Occupational exposure,\" 1991; US Department of
        Transportation, 1998; US Postal Service, 2003). **Category IC**
        (States; OSHA: 29 CFR 1910.1030 section g.2.1; Department of
        Transportation \[DOT\]: 49 CFR 171-180; US Postal Service:
        CO23.8)

II. **Disposal Plan for Regulated Medical Wastes**

    A.  Develop a plan for the collection, handling, predisposal
        treatment, and terminal disposal of regulated medical wastes
        (\"Occupational exposure to bloodborne pathogens,\" 1991;
        Greene, Miele, & Slavik, 1994). **Category IC** (States; OSHA:
        29 CFR 1910.1030 section g.2.i)

    B.  Designate a person or persons as responsible for establishing,
        monitoring, reviewing, and administering the plan. **Category
        II**

III. **Handling, Transporting, and Storing Regulated Medical Wastes**

     A.  Inform personnel involved in handling and disposal of
         potentially infective waste of possible health and safety
         hazards; ensure that they are trained in appropriate handling
         and disposal methods (\"Occupational exposure to bloodborne
         pathogens,\" 1991). **Category IC** (OSHA: 29 CFR 1910.1030
         section g.2.i)

     B.  Manage the handling and disposal of regulated medical wastes
         generated in isolation areas by using the same methods used for
         regulated medical wastes from other patient-care areas (Garner
         & Favero, 1986). **Category II**

     C.  Use proper sharps disposal strategies (\"Occupational exposure
         to bloodborne pathogens\" 1991). **Category IC** (OSHA: 29 CFR
         1910.1030 section d.4.iii.A)

         1.  Use a sharps container capable of maintaining its
             impermeability after waste treatment to avoid subsequent
             physical injuries during final disposal (\"Occupational
             exposure to bloodborne pathogens,\" 1991). **Category IC**
             (OSHA: 29 CFR 1910.1030 section d.4.iii.A)

         2.  Place disposable syringes with needles, including sterile
             sharps that are being discarded, scalpel blades, and other
             sharp items into puncture-resistant containers located as
             close as practical to the point of use (\"Occupational
             exposure to bloodborne pathogens,\" 1991). **Category IC**
             (OSHA: 29 CFR 1910.1030 section d.4.iii.A)

         3.  Do not bend, recap, or break used syringe needles before
             discarding them into a container (Garner, 1996;
             \"Occupational exposure to bloodborne pathogens,\" 1991;
             National Institute for Occupational Safety and Health,
             1999). **Category IC** (OSHA: 29 CFR 1910.1030 section
             d.2.vii and section d.2.vii.A)

     D.  Store regulated medical wastes awaiting treatment in a properly
         ventilated area inaccessible to vertebrate pests; use waste
         containers that prevent development of noxious odors.
         **Category IC** (States)

     E.  If treatment options are not available at the site where the
         medical waste is generated, transport regulated medical wastes
         in closed, impervious containers to the on-site treatment
         location or to another facility for treatment as appropriate.
         **Category IC** (States)

IV. **Treatment and Disposal of Regulated Medical Wastes**

    A.  Treat regulated medical wastes by using a method (e.g., steam
        sterilization, incineration, interment, or an alternative
        treatment technology) approved by the appropriate authority
        having jurisdiction (AHJ) (e.g., state, Indian Health Service,
        or Veterans Administration) before disposal in a sanitary
        landfill. **Category IC** (States, AHJ)

    B.  Follow precautions for treating microbiologic wastes (e.g.,
        amplified cultures and stocks of microorganisms) (CDC & National
        Institutes of Health). **Category IC** (DHHS: BMBL)

        1.  Biosafety level 4 laboratories must inactivate microbiologic
            wastes in the laboratory by using an approved inactivation
            method (e.g., autoclaving) before transport to and disposal
            in a sanitary landfill (CDC & National Institutes of
            Health). **Category IC** (DHHS: BMBL)

        2.  Biosafety level 3 laboratories must inactivate microbiologic
            wastes in the laboratory by using an approved inactivation
            method (e.g., autoclaving) or incinerate them at the
            facility before transport to and disposal in a sanitary
            landfill (CDC & National Institutes of Health, 1993).
            **Category IC** (DHHS: BMBL)

    C.  Biosafety levels 1 and 2 laboratories should develop strategies
        to inactivate amplified microbial cultures and stocks onsite by
        using an approved inactivation method (e.g., autoclaving)
        instead of packaging and shipping untreated wastes to an offsite
        facility for treatment and disposal (CDC & National Institutes
        of Health, 1993; Weber, Boudreau, & Mortimer, 1998; Johnson et
        al., 2000; Emery et al., 1992). **Category II**

    D.  Laboratories that isolate select agents from clinical specimens
        must comply with federal regulations for receipt, transfer,
        management, and appropriate disposal of these agents (US
        Department of Health and Human Services & CDC, 1996). **Category
        IC** (DHHS: 42 CFR 72 section 72.6.i.1.iii)

    E.  Sanitary sewers may be used for safe disposal of blood,
        suctioned fluids, ground tissues, excretions, and secretions,
        provided that local sewage discharge requirements are met and
        that the state has declared this to be an acceptable method of
        disposal (CDC, 1988). **Category II**

V.  **Special Precautions for Wastes Generated During Care of Patients
    with Rare Diseases**

    A.  When discarding items contaminated with blood and body fluids
        from VHF patients, contain these regulated medical wastes with
        minimal agitation during handling (Garner, 1996; \"Update,\"
        1995). **Category II**

    B.  Manage properly contained wastes from areas providing care to
        VHF patients in accordance with recommendations for other
        isolation areas (Regulated Medical Waste: III B) (Garner, 1996;
        \"Update,\" 1995; Garner & Favero, 1986). **Category II**

    C.  Decontaminate bulk blood and body fluids from VHF patients by
        using approved inactivation methods (e.g., autoclaving or
        chemical treatment) before disposal (Garner, 1996; \"Update,\"
        1995). **Category IC, II** (States)

    D.  When discarding regulated medical waste generated during the
        routine (i.e., nonsurgical) care of Creutzfeldt-Jakob disease
        (CJD) patients, contain these wastes and decontaminate them by
        using approved inactivation methods (e.g., autoclaving or
        incineration) appropriate for the medical waste category (e.g.,
        blood, sharps, or pathological waste) (Garner, 1996; Garner &
        Favero, 1986; Favero & Bond, 2001; Rutala & Weber, 2001).
        **Category IC, II** (States)

    E.  Incinerate medical wastes (e.g., central nervous system tissues
        or contaminated disposable materials) from brain autopsy or
        biopsy procedures of diagnosed or suspected CJD patients (Budka
        et al., 1995; World Health Organization \[WHO\], 1999).
        **Category IB**

**[Definitions]{.underline}**:

The HICPAC system for categorizing recommendations has been modified to
include a category for engineering standards and actions required by
state or federal regulations. Guidelines and standards published by the
American Institute of Architects (AIA), American Society of Heating,
Refrigeration, and Air-Conditioning Engineers (ASHRAE), and the
Association for the Advancement of Medical Instrumentation (AAMI) form
the basis of certain recommendations. These standards reflect a
consensus of expert opinions and extensive consultation with agencies of
the U.S. Department of Health and Human Services. Compliance with these
standards is usually voluntary. However, state and federal governments
often adopt these standards as regulations. For example, the standards
from AIA regarding construction and design of new or renovated
health-care facilities, have been adopted by reference by \>40 states.
Certain recommendations have two category ratings (e.g., Categories IA
and IC or Categories IB and IC), indicating the recommendation is
evidence-based as well as a standard or regulation.

**Rating Categories**

Recommendations are rated according to the following categories:

**Category IA**. Strongly recommended for implementation and strongly
supported by well-designed experimental, clinical, or epidemiologic
studies.

**Category IB**. Strongly recommended for implementation and supported
by certain experimental, clinical, or epidemiologic studies and a strong
theoretic rationale.

**Category IC**. Required by state or federal regulation, or
representing an established association standard. (Note: Abbreviations
for governing agencies and regulatory citations are listed where
appropriate. Recommendations from regulations adopted at state levels
are also noted. Recommendations from AIA guidelines cite the appropriate
sections of the standards.)

**Category II**. Suggested for implementation and supported by
suggestive clinical or epidemiologic studies, or a theoretic rationale.

**Unresolved issue**. No recommendation is offered. No consensus or
insufficient evidence exists regarding efficacy.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=3843)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations are evidence-based wherever possible. However,
certain recommendations are derived from empiric infection-control or
engineering principles, theoretic rationale, or experience gained from
events that cannot be readily studied (e.g., floods).

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Environmental infection-control strategies and engineering controls
    can effectively prevent infections from environmental pathogens or
    airborne pathogens.

-   The incidence of health-care\--associated infections and
    pseudo-outbreaks can be minimized.

#### POTENTIAL HARMS

None stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   All the recommendations may not reflect the opinions of all
    reviewers.

-   Wherever possible, the recommendations in this report are based on
    data from well-designed scientific studies. However, certain of
    these studies were conducted by using narrowly defined patient
    populations or specific health-care settings (e.g., hospitals versus
    long-term care facilities), making generalization of findings
    potentially problematic. Construction standards for hospitals or
    other health-care facilities may not apply to residential home-care
    units. Similarly, infection-control measures indicated for
    immunosupressed patient care are usually not necessary in those
    facilities where such patients are not present.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

**Performance Measurements**

Infections caused by the microorganisms described in this guideline are
rare events, and the effect of these recommendations on infection rates
in a facility may not be readily measurable. Therefore, the following
steps to measure performance are suggested to evaluate these
recommendations:

1.  Document whether infection-control personnel are actively involved
    in all phases of a health-care facility\'s demolition, construction,
    and renovation. Activities should include performing a risk
    assessment of the necessary types of construction barriers, and
    daily monitoring and documenting of the presence of negative airflow
    within the construction zone or renovation area.

2.  Monitor and document daily the negative airflow in airborne
    infection isolation (AII) rooms and positive airflow in protective
    environment (PE) rooms, especially when patients are in these rooms.

3.  Perform assays at least once a month by using standard quantitative
    methods for endotoxin in water used to reprocess hemodialyzers, and
    for heterotrophic and mesophilic bacteria in water used to prepare
    dialysate and for hemodialyzer reprocessing.

4.  Evaluate possible environmental sources (e.g., water, laboratory
    solutions, or reagents) of specimen contamination when
    nontuberculous mycobacteria (NTM) of unlikely clinical importance
    are isolated from clinical cultures. If environmental contamination
    is found, eliminate the probable mechanisms.

5.  Document policies to identify and respond to water damage. Such
    policies should result in either repair and drying of wet structural
    or porous materials within 72 hours, or removal of the wet material
    if drying is unlikely within 72 hours.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Effectiveness\
Safety

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Sehulster L, Chinn RY. Guidelines for environmental infection control in
health-care facilities. Recommendations of CDC and the Healthcare
Infection Control Practices Advisory Committee (HICPAC) \[Published
errata appear in MMWR Recomm Rep 2003 Oct 24;52(42):1025-6\]. MMWR
Recomm Rep 2003 Jun 6;52(RR-10):1-42. \[419 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12836624)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 Jun 6

#### GUIDELINE DEVELOPER(S)

Centers for Disease Control and Prevention - Federal Government Agency
\[U.S.\]

#### SOURCE(S) OF FUNDING

United States Government

#### GUIDELINE COMMITTEE

Healthcare Infection Control Practices Advisory Committee (HICPAC)

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Healthcare Infection Control Practices advisory Committee*: Robert A.
Weinstein, MD, Cook County Hospital, Chicago, Illinois (Chair); Jane D.
Siegel, MD, University of Texas Southwestern Medical Center, Dallas,
Texas (Co-chair); Michele L. Pearson, MD, CDC, Atlanta, Georgia
(Executive Secretary); Raymond Y. W. Chinn, MD, Sharp Memorial Hospital,
San Diego, California; Alfred DeMaria, Jr., MD, Massachusetts Department
of Public Health, Jamaica Plain, Massachusetts; Elaine L. Larson, PhD,
Columbia University School of Nursing, New York, New York; James T. Lee,
MD, PhD, University of Minnesota VA Medical Center, St. Paul, Minnesota;
Ramon E. Moncada, MD, Coronado Physician\'s Medical Center, Coronado,
California; William A. Rutala, PhD, University of North Carolina School
of Medicine, Chapel Hill, North Carolina; William E. Scheckler, MD,
University of Wisconsin Medical School, Madison, Wisconsin; Beth H.
Stover, Kosair Children\'s Hospital, Louisville, Kentucky; Marjorie A.
Underwood, Mt. Diablo Medical Center, Concord, California

*Liaison Members*: Loretta L. Fauerbach, MS, Association for
Professionals of Infection Control and Epidemiology, Inc. (APIC),
Washington, DC; Sandra L. Fitzler, American Health Care Association,
Washington, DC; Dorothy M. Fogg, MA, Association of Perioperative
Registered Nurses, Denver, Colorado; Chiquita Johnson-Bond, Council of
Nephrology Nurses and Technicians, Rex, Georgia; Stephen F. Jencks, MD,
Centers for Medicare and Medicaid Services, Baltimore, Maryland; Chiu S.
Lin, PhD, Food and Drug Administration, Rockville Maryland; Joseph G.
Ouslander, MD, Emory University, Atlanta, Georgia; James P. Steinberg,
MD, Society for Healthcare Epidemiology of America, Inc., Atlanta,
Georgia; Michael L. Tapper, MD, Advisory Committee for the Elimination
of Tuberculosis, New York, New York

*Centers for Disease Control and Prevention Consultants*: Matthew
Arduino, DrPH; Joe Carpenter; Rodney Donlan, PhD; Lynne Sehulster, PhD,
Division of Healthcare Quality Promotion, National Center for Infectious
Diseases (NCID); David Ashford, DVM, DSc; Richard Besser, MD; Barry
Fields, PhD; Michael M. McNeil, MBBS; Cynthia Whitney, MD; Stephanie
Wong, DVM, Division of Bacterial and Mycotic Diseases, NCID; Dennis
Juranek, DVM, Division of Parasitic Disease, NCID; Jennifer Cleveland,
DDS, Division of Oral Health, National Center for Chronic Disease
Prevention and Health Promotion

*External Consultants*: Trisha Barrett, MBA, Alta Bates Medical Center,
Berkeley, California; Judene Bartley, MS, MPH, Epidemiology Consulting
Services, Inc., Beverly Hills, Michigan; Michael Berry, University of
North Carolina, Chapel Hill, North Carolina; Nancy Bjerke, MA, MEd, MPH,
Infection Control Associates, San Antonio, Texas; Walter W. Bond, MS,
RCSA, Inc., Lawrenceville, Georgia; Cheryl Carter, University of Iowa
Health Center, Iowa City, Iowa; Douglas Erickson, American Society for
Healthcare Engineering (ASHE) Park Ridge, Illinois; Martin S. Favero,
PhD, Advanced Sterilization Products, Johnson and Johnson, Irvine,
California; Richard Miller, MD, University of Louisville School of
Medicine, Louisville, Kentucky; Shannon E. Mills, DDS, HQ USAF/Surgeon
General Detail, Bolin AFB, District of Columbia; Gina Pugliese, MS,
Premier Safety Institute, Oak Brook, Illinois; Craig E. Rubens, MD, PhD,
Children\'s Hospital & Medical Center, Seattle, Washington; James D.
Scott, Michigan Department of Consumer and Industry Services, Lansing,
Michigan; Andrew J. Streifel, MPH, University of Minnesota, Minneapolis,
Minnesota; Dale Woodin, ASHE, Chicago, Illinois

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Raymond Y.W. Chinn is a private-practice physician and salaried employee
of Sharp Memorial Hospital in San Diego, California. Dr. Chinn received
no research funds from commercial sources either directly, or indirectly
through awards made to the hospital, before or during the development of
this guideline.

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the Centers for Disease Control and
Prevention (CDC) Web site:

-   [HTML format](http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm)

-   [Portable Document Format
    (PDF)](http://www.cdc.gov/mmwr/PDF/rr/rr5210.pdf)

Print copies: Available from the Centers for Disease Control and
Prevention, MMWR, Atlanta, GA 30333. Additional copies can be purchased
from the Superintendent of Documents, U.S. Government Printing Office,
Washington, DC 20402-9325; (202) 783-3238.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on April 19, 2004.

#### COPYRIGHT STATEMENT

No copyright restrictions apply.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public or private organizations, other government
agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
clinical practice guidelines and related materials represented on this
site. Moreover, the views and opinions of developers or authors of
guidelines represented on this site do not necessarily state or reflect
those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or
hosting of guidelines in NGC may not be used for advertising or
commercial endorsement purposes.

Readers with questions regarding guideline content are directed to
contact the guideline developer.

Bottom of Form

© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008