Keep the flu away from you!

Dental nurses, are you involved in the fight against the further spread of the pandemic influenza H1N1 (swine flu)? Are you protecting yourselves, your families and those in your care?

Dental nurses should act ethically in this matter to prevent and to minimise the spread of influenza. They should take into account their professional duty to put their patients’ interests first, as well as considering their own health and safety and their commitments to the dental team.

The HSE has given an undertaking to prepare such guidance for dentists, but unfortunately, at the time of writing, they are still awaiting these guidelines. However, there are Standard Precautions that should be applied by all healthcare workers during contact/care of all patients, regardless of their diagnosis or presumed infection status.

H1N1: pandemic influenza
Pandemic flu differs from seasonal flu because it occurs when a new flu virus emerges into the human population to which most people will be susceptible and which can be spread easily from person to person worldwide. Flu is generally transmitted from person to person through close contact and over short distances – in the region of 1m –  and is spread by respiratory droplets from coughs and sneezes, by direct contact with an infected person, or indirectly from objects or surfaces that have become covered with virus-infected secretions.

Dental nurses should be aware of the signs and symptoms of pandemic flu, which is similar to seasonal flu, but they may be more severe and cause more serious complications. The most significant symptoms are the sudden onset of:
• Fever
• Cough or shortness of breath
• Headache   
• Tiredness
• Chills   
• Aching muscles
• Sore throat   
• Runny nose
• Sneezing   
• Loss of appetite.

The incubation period of the virus ranges from one to four days. This is the time between contact with the virus and the onset of symptoms. The infectious period of the virus from onset of symptoms can be up to five to seven days.

Respiratory etiquette
There are many ways in which a dental nurse can work to prevent the spread of the infection and it is paramount that they stay informed and up to date of current developments (www.hse.ie).

It is important to educate visitors to your practice about the spread of influenza. This can be achieved by using information posters and leaflets in the waiting areas. These remind patients of the signs and symptoms of flu, the importance of self-isolation of individuals with symptoms, hand hygiene and, more importantly, on respiratory etiquette:
• Using disposable tissues
• Covering their mouth with a tissue when coughing, or both nose and mouth when sneezing
• Disposing of the tissue, after which they should wash their hands
• Individuals should not use cloth handkerchiefs or reuse tissues, as this practice carries a risk of contaminating pockets or handbags, which then contaminate hands every time they go into those pockets or handbags!

Dental nurses should always practise good personal hygiene measures themselves. Flu viruses are easily removed or destroyed by soap/detergent and water or hand rubs (microbicidal hand rubs, particularly alcohol-based).

Personal protective equipment
Personal protective equipment should be dealt with in the following order and items disposed of into clinical waste if contaminated with blood and/or body fluids:
1. Gloves
2. Apron/gown
3. Decontaminate hands
4. Eye wear/protective goggles
5. Mask (do not touch the front of the mask)
6. Decontaminate hands.

Where practicable, effective use of disposable barriers should be used to prevent direct contact with the virus on equipment/ surfaces, where it can survive for two to eight hours. Surfaces are one of the least resistant components of a dental practice to the micro-organisms and they should be cleaned frequently using disinfectants such as hypochlorite solution – 1000ppm (parts per million) – to inactivate the virus.

Hand hygiene
Hand hygiene is the responsibility of the dental nurse, is the single most important intervention to prevent transmission of infection and should be of a quality standard. Dental nurses should act as role models to promote hand hygiene and to ensure better compliance.

Social hand hygiene may be achieved with plain soap and warm water or an alcohol hand rub, but antiseptic hand hygiene, such as before patient contact for a surgical procedure, will require an antiseptic hand wash agent.

Hand hygiene preparation should be as follows:
• Nails must be kept short and cut smoothly
• Nail varnish and/or false nails must not be worn
• All wrist and hand jewellery (except plain wedding bands) must be removed
• Sleeves should be short or turned up.

When ordering stock, dental nurses should give careful consideration to choosing a suitable hand hygiene product that has appropriate antimicrobial properties. They should also consider a product that will be tolerated by their skin and not give rise to the risk of any dermatological side effects. Try to choose a good quality liquid soap and use it in conjunction with an emollient-based alcohol rub. Where practicable, microbiocidal gel hand rubs should be made available throughout the practice and staff should adopt a thorough handwashing technique.

Use of face masks
With some occupations (such as dental nursing) there is an increased likelihood of exposure, especially in a dental practice where exposure to aerosols is significant and the use of masks are recommended.

There are many types of mask available and face masks play an important role in reducing the risk of infection. However, the use of a mask must not decrease the strict application of other infection control measures.

Staff must also follow the procedures for their safe use, paying particular attention to how they are removed and disposed of, to avoid users contaminating themselves from the front of the mask.

In preparation for putting on a face mask, ensure hands have been washed thoroughly. Secure ties or elastic bands and fit the flexible band to the bridge of the nose. Ensure a snug fit to the face and below the chin.

When removing a face mask, assume that the front of the mask is contaminated. Untie or break the ties and remove the mask by handling the ties only. Discard appropriately in a foot-operated clinical waste bin and wash hands thoroughly after touching the mask, avoiding unnecessary hand-to-mouth or hand-to-eye contact.

Facemasks should:
• Cover the nose and mouth
• Not be allowed to dangle around the neck after or between each use
• Not be touched once put on
• Be worn once only. The frequency with which they are changed will depend on the nature of the duties being undertaken and the manufacturer’s instructions
• Appropriately discarded.

Types of face masks
There are different types of face masks available and the type you choose will largely depend upon the clinical procedures that you are involved in.

Fluid repellent surgical masks suffice as a barrier to large projected droplets that are regarded as the main route of transmission of the influenza virus; however, they do not provide full respiratory protection against suspended droplets and aerosols. They are normally worn to protect not only the patient but also the dental nurse from the transfer of microorganisms, bodily fluids and matter generated from any splash or splatter, but they are not regarded as personal protective equipment under the European Directive 89/686/EEC (PPE Regulation 2002).

FFP3 (filtering facepiece) masks are certified to the PPE Regulation and for use in particular by healthcare workers engaged in procedures generating aerosols. They provide a high level of filtering capability and face fit. They will provide an effective barrier to both droplets and fine aerosols.

FFP1 and FFP2 masks are also available, but these provide less respiratory protection than a properly fitting FFP3. Any of these three types of masks would be appropriate for use by a dental nurse as personal protective equipment.

A combined approach to safety
Dental nurses, it is time to reinforce good working practices and not rely solely on face masks or other personal protective equipment as a means as protection.

There is no single approach that can be taken to reduce the spread of influenza H1N1. Proper respiratory etiquette, effective hand hygiene and a high standard of infection control, including self-isolation of any patients or staff (stay at home!) that are showing signs and symptoms of influenza, are the most effective barriers to the spread of the infection. This should be promoted, encouraged and applied to reduce the spread of the flu virus within your workplace.

References
HPSC/SARI Infection Control Subcommittee (2005) Guidelines for hand hygiene in Irish healthcare settings

HSE (2009) Pandemic (HINI) 2009 influenza infection prevention and control precautions for all healthcare facilities

HSE (2009) Standard Precautions Version 1.0

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