Learning Objectives

Define infection.

Explain how harmful infections can be transmitted during a quinacrine sterilization.

List resources needed to prevent the transmission of infection during a QS.

List specific ways to prevent the transmission of infection during a QS.

Introduction

Each year millions of clients and health care workers are needlessly infected with diseases in clinics and hospitals. This happens because of the failure to follow adequate infection control procedures. Following adequate infection control procedures is difficult, but not impossible, even where there are problems of adequate instruments and supplies and no electricity or water. Understanding how microorganisms are transmitted and the steps that can be taken to prevent their transmission is basic to providing a safe environment for health care workers and clients. Taking steps to control infections at your clinic is all the more important because diseases like hepatitis and acquired immunodeficiency syndrome (AIDS) can be unknowingly transmitted.

Infection

Infection occurs when the body or part of it is invaded by a microorganism which, under favorable conditions, multiplies and may cause harmful effects. Microorganisms are defined as organisms that cannot be seen by the naked eye and can be seen only through a microscope. While microorganisms are naturally present in the environment, some are harmful and some are not.
When microorganisms are harmful, they can cause infection and disease in the body. Often, sick people come to health clinics with diseases or infections caused by harmful microorganisms which can be passed to health clinic workers or other clients visiting the clinic.

How Infections Are Transmitted

Here is a story that could have happened in any health clinic:
A village woman had been feeling tired and run down for some time. She noticed that she was also having a vaginal discharge that was grey. She decided to go to her local health clinic for an examination . When she arrived at the clinic, she described her symptoms to the health worker. The health worker gave her a speculum examination and took a wet prep of vaginal secretions. When the sample was examined under a microscope, it was confirmed that the woman had a bacterial vaginosis infection. The health worker gave the woman a prescription for antibiotics.
On the same day, a woman from a nearby village went to the same health clinic to have a quinacrine sterilization. She had three children and did not want anymore. When she arrived at the clinic for her appointment, the procedure was explained to her. First she was given a bimanual pelvic examination and speculum examination using the same unsterilized speculum previously used to make sure there were no problems or contraindications. Then the quinacrine was inserted. The woman went back to her village. A few days later she developed a vaginal infection that was diagnosed as bacterial vaginosis.
It is very possible that the second village woman unnecessarily contracted bacterial vaginosis at the health clinic.

Common Vehicles of Infection Transmission

Harmful microorganisms can exit the body through blood, droplets in the air from coughs or sneezes, vaginal or wound secretions and discharges, urine and feces. In health clinics, these can end up on instruments such as needles and specula, on clothes and linens, and on the hands. Hands, gloves, instruments, linens and clothes are the most common vehicles to transmit infection in health clinics.

How to Prevent the Transmission of Infection

To prevent infection, a barrier is placed between the infected carrier and the vehicles which could transmit the infection. For example, in the above story the first client likely transmitted her infection to the second client. The probably vehicle of transmission was the speculum.
A barrier can be physical (like a pair of gloves), mechanical or chemical (like an antiseptic). The primary way to prevent infection is to destroy harmful microorganisms when they are on vehicles of transmission, such as instruments, linens, gloves, clothes or even hands.

Resources Necessary for Infection Control

Harmful microorganisms that end up on instruments, linens, and hands during a QS can be destroyed through a process called sterilization and decreased through disinfection. Sterilization requires extreme heat; high-level disinfection requires extreme heat or chemical disinfectants. To high-level disinfect instruments and supplies, health clinics need the following basic items:

1 nearby source of water
2 a heat source capable of boiling water
3 cleaning agents
4 containers of various sizes with lids

Their purpose, possible sources and examples are shown in the box that follows. None of the resources need to be elaborate or expensive. Health care workers can find all of these items in most villages. However, sterilization requires an oven or autoclave, resources which may be more difficult to find.

1. Water source
Purpose:	For hand washing
	For cleaning equipment
	For washing linen
	For boiling instruments
Possible sources:	tap in clinic	rain collection barrels
	nearby well	nearby river
2. Heat Source
Purpose:	To sterilize or high-level disinfect instruments and linens
Possible sources:	fire	oven or stove
	petrol gas burner	autoclave
3. Chemical agents: soaps, disinfectants and antiseptics
Purpose:	For handwashing
	For cleaning equipment
	For cleaning linen
Examples:	Soap:	bar, liquid and detergent soaps
	Disinfectants:	chlorine (bleach), alcohol, betadine, glutaraldehyde, formaldehyde
	Antiseptics:	hexachlorophene, chlorhexidine gluconate, hibitane, savlon
4. Containers of various sizes with lids
Purpose:	For storing equipment
	For boiling water
Examples:	iron or aluminum pots	plastic containers
	basins	metal containers
	glass jars

Steps to Prevent Infection Transmission during a QS

PRE-PROCEDURE

1. Wash hands thoroughly with soap and water before and after the procedure.

2. When possible, have the client wash her genital area before doing the screening pelvic exam.

3. Use clean, high-level disinfected (or sterilized) instruments and gloves (both hands).

4. After inserting the clean speculum and while looking at the cervix, thoroughly apply antiseptic solution several times to the cervix and vagina before beginning the procedure.

5. Use a pre-loaded, sterile inserter or one that has been disinfected and dried.

6. Use a "no touch" insertion technique to reduce contamination of the uterine cavity (i.e., do not pass the uterine sound/cannula or loaded inserter through the cervical os more than once and do not touch the end of the sound/cannula which enters the uterus).

POST-PROCEDURE

1. Waste disposal and decontamination
After completing a quinacrine insertion, and while still wearing gloves, dispose of contaminated objects (sponge sticks, gauze and other waste items) in a properly marked leakproof container (with a tight fitting lid) or plastic bag.
Fully immerse all metal instruments in a plastic bucket containing 0.5% chlorine solution (bleach) for 10 minutes before allowing staff and cleaning personnel to handle or clean them.
All surfaces (such as the procedure table or instrument stand) that could have been contaminated by blood and mucus also should be decontaminated by wiping down with chlorine solution.
If single-use (disposable) gloves were used, carefully remove them by inverting, and place in the leakproof waste container. However, if the gloves are reusable, first briefly immerse both gloved hands in the bucket containing the chlorine solution and then carefully remove by inverting. Deposit the gloves in chlorine solution.

2. Cleaning and Rinsing
After decontamination, thoroughly clean instruments with water, detergent and soft brush, taking care to brush all teeth, joints and surfaces. Next, rinse well after cleaning to remove all detergent (some detergents can render chemical disinfectants inert.) Dry instruments before further processing.

3. High-level Disinfection (HLD) or Sterilization
High-level disinfection through boiling or the use of chemicals is the recommended practice. Surgical (metal) instruments and reusable gloves should be boiled for 20 minutes. Alternatively, instruments can be soaked for 20 minutes in a glutaraldehyde or 8% formaldehyde solution. After cooling (if boiled) or rinsing in boiled water (if chemical disinfectants used) and drying, instruments are ready to use. Use immediately or store for up to one week in a clean, dry, HLD container with a tight-fitting lid or cover.
Alternatively, instruments and reusable gloves used for the quinacrine insertion can be sterilized by autoclaving (121°C [250°F] and 106 kPa [15 lb/in²] for 20 minutes if unwrapped and 30 minutes if wrapped).

Note: Dry heat sterilization (170°C [340°F] for 60 minutes) can be used only for metal or glass instruments.

4. Storage
Unwrapped instruments must be used immediately or within one week if properly stored in a clean, dry HLD container with a lid. Wrapped instruments, gloves and drapes can be stored for up to one week if the package remains dry and intact, one month if sealed in a plastic bag.

Reusing the Cannula/Sound and/or the Inserter

Reuse of the cannula and inserter is not usually encouraged but has been widely done with good results. In these cases, special attention should be paid to cleaning and maintenance.

Cannula/Sound:
After using the cannula/sound, disinfect it for 10 minutes in a 0.5% chlorine solution (bleach). Then, wash it thoroughly with warm soapy water and rinse the cannula with sterile or boiled water. Use sterile technique during and after rinsing. Finally, apply alcohol and allow it to dry, then store it in a sterile environment.

Inserter:
After using the inserter, take it apart and disinfect the parts for 10 minutes in a 0.5% chlorine solution (bleach). Then, wash the parts thoroughly in soapy water and rinse with boiled water. Finally, rinse in alcohol and air dry. Then, using a sterile technique, reassemble and store in a sterile environment.

End of lesson. Proceed to the case study.

Case Study VI

After completing a QS, provider M removes his gloves and places the contaminated, disposable objects into a leakproof container. He then immerses all non-disposable, metal objects into a bucket containing 0.05% chlorine solution for 5 minutes. He then removes the instruments and rinses them in cold water and allows them to dry.

Has he performed the disinfection procedure incorrectly?

If not, list some of the mistakes he has made and rewrite the steps of post-procedure waste disposal and decontamination according to the correct technique.

Check your answers against those provided on page 50.Return to the chapter text for any information you did not understand.