INFECTION CONTROL TRENDS newsletter

VOLUME 1 | ISSUE 2 | JAN 2019INFECTION CONTROL TRENDS
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Volume 1 | Issue 2 | January 2019
Circulation: Quarterly | All-India | e-Copy format
CHIEF EDITOR
Dr. Ranga Reddy
EDITOR
Dr. T V Rao
EDITOR & CONCEPT
Dr. Dhruv Mamtora
TEAM MEMBER
Sister Solbymol
ACCREDITATION & QUALITY IN INFECTION CONTROL
newsletter
INFECTION CONTROL TRENDS

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Respected Infection Preventionist,
First of all, a big thanks for making the first edition of newsletter a grand success. It is probably unparalleled
in the medical publishing that the very first edition has been received with such enthusiasm and reached more
than 15,000 readers worldwide. Your excellent feedback has really got us fired up and that has made us work even
harder for the second issue, which is in your hands now.
We thank all authors and members of this team who are always there to share their independent views and
opinions.
The newsletter’s second edition is themed on Accreditation. The topic meets with contemporary needs of
all stakeholders in healthcare system. The awareness and demand for quality in quality in healthcare is rising.
Patients, statutory bodies, insurers and others are keenly observing and demanding for safer and economical care.
Patient safety has become cornerstone of quality improvement and accreditation programs. This compels all of
us to learn, share and comply with all accreditation requirements. In order to facilitate better understanding, we
have guest editorial CEO of NABH. We have one article about industry collaboration to make informed choices
about selection of optimal disinfection and antiseptic agents to ensure good IPC standards.
We are also offering several other interesting articles including one from WHO functionary.
There is content for students as well who are torchbearers of future IPC.
We sincerely hope this edition too will make a difference and will continue to be an open source for many to
learn and improve the knowledge & skills.
We take this opportunity to wish you and your families a very happy, healthy and prosperous 2019.
Best wishes
Dr TV Rao
Dr Ranga Reddy Burri
Dr DhruvMamtora
Sister Solby
Respected Infection Preventionist,
Modern science is evolving beyond belief. However, while saving millions of lives through several advanced
healthcare interventions, we also witness an unintended consequence: Healthcare Associated Infection (HAI).
This inaugural edition of Infection Control Trends introduces some important issues regarding healthcare workers,
patients and healthcare infections.
HAI can be avoided, and healthcare workers in particular are critical in making this happen. By better
understanding HAI contributing factors, healthcare professionals can apply measures which will contribute to the
safe care that patients expect and deserve.
It has been amazing to see so many accomplished professionals very passionately supporting this project.
We thank and congratulate one and all for their contributions in making this journal see the light.
Our vision is to bring all latest trends in Infection Control in a simple, straightforward and actionable format.
Please send your comments, suggestions and contributions to help make this journal richer with each passing
edition.
Warm regards,
Dr. Ranga Reddy Burri
Dr. Dhruv Mamtora
Sister Solby
Statutory disclaimer: In no event shall Infection Control Trends be liable for any special, incidental, indirect or consequential damages
of any kind, or any damages whatsoever resulting from loss of use, data or profits, whether or not advised of the possibility of damage,
and on any theory of liability, arising out of or in connection with the use or performance of this information. The ideas and opinions
expressed in Infection Control Trends do not necessarily reflect those of Editorial team members. Infection Control Trends neither
endorses nor takes responsibility for any products, goods or services offered by outside vendors through its services or advertisements.
PREFACE
FOREWORD

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Dr. T. V. Rao is former Professor of Microbiology qualified with
MD Microbiology from Andhra Medical College Visakhapatnam (AP).
He has chosen the specialty not accidentally but with determination
to be part of the system, his experiences in Zambia seeing many
dying with infections and having few resources is great challenge
and practically patients to be treated blindly. Certainly he believes
much of the progress of Microbiology started with onset of AIDS
pandemic many and the new era of Diagnostic Microbiology
started , and his association with scientific Microbiologists at ICMR
( NICED Calcutta) taught what all we all doing is many times not
right, and it needs dedication and sincerity and just teaching
unpracticed knowledge will detoriate profession unless one actually
involved with the Diagnostic Laboratory and bed side medicine. His
observation is Darwin’s theory is working well with Microbes and
they posing a real challenges, However, it is time to rethink ones role
as Medical Microbiologists/Clinical Microbiologists and certainly the
Society awakened to the present needs and demands making one
to realize ANTIBIOTICS ARE NOT MAGIC BULLETS, but soft weapons
to destroy the progress of Medicine. Today, he has created content
to help many in the developing country, to his satisfaction he has
more than 5 million followers globally.
EDITORIAL TEAM
Dr. Ranga Reddy Burri is Health policy enthusiast focused on
public health awareness, education and training. He is committed
to improvement of patient safety in India and other low resource
settings. His vision is to improve professional practice standards
for infection prevention and control across India and the setting
of standards and framework for credentialing of infection control
professionals.
Dr. Reddy is Physician, Public Health specialist and Social
Entrepreneur with interest in business verticals of high social
impact. He graduated from Minsk Government Medical Institute,
Belarus with MD (Physician) degree; subsequently he did his PG
Diploma in management from Pondicherry University and Advanced
Management from IESE, Barcelona, Spain with specialization in
Strategy & Business Development.
Dr. Reddy is the founder trustee of Infection Control Academy
of India (IFCAI). The organization is a result of his leadership skills,
knowledgeandexperiencegainedfromworkinginbothdomesticand
international MNCs. Yet, the Academy’s most valuable strength lies
in the strong sense of empathy for humans and their health imparted
by Dr. Reddy and his colleague trustees. His effort has translated
into creating several long term programs in IPC segment. His current
responsibility includes leading Sanmed Healthcare, a startup with
world class manufacturing capabilities in external preparations.
Additionally, he supports several non-profit organizations in the
capacity of advisor including Neelam Rajasekhar Reddy Research
Center for Social Progress, e-learning center of Hyderabad Central
University & Indian Institute of Public Health.
His flair for entrepreneurship has led him to mentor through
imparting knowledge to NGO’s, startups & micro-small enterprises.
Dr. Ranga Reddy
President IFCAI and Chief Editor
“Infection Control Trends”
Email: dr.rangareddy@ifcai.in
Dr. T. V. Rao
Former Professor of Microbiology
Email: doctortvrao@gmail.com

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Dr. Dhruv Mamtora is a clinical microbiologist and infection
control officer at S. L. Raheja Hospital, A Fortis associate, Mahim,
Mumbai since 2015. Before joining in private sector, he has worked
with government sector both in Maharashtra state as assistant
professor at RCSM GMC Kolhapur and GMC Latur as assistant
professor and AIIMS, Jodhpur as senior resident.
He has passed out MBBS from L. T. M. Medical College (Sion
Hospital) and done MD in microbiology from Government medical
college, Miraj. He has done his healthcare administration EPGDHA
from TISS, Mumbai and he is a New York state certified infection
control professional.
He is member of multiple professional bodies like IAMM, IATP,
IMA, HIS-MF (institutional), society of clinical microbiologists (SCM)
and ISID (international society of infectious diseases).
He has number of publications in peer reviewed journals, both
national as well as international and he is also faculty and speaker
for various national and international, conferences. He has also
organized many training activities and a national level conference
on “Systemic Approach to Hospital Hygiene and Infection Control”
in Mumbai in year 2018.
He is also a media subject expert on subjects like hospital
acquired infection, infection control and infectious diseases.
He is subject expert on infection control for Clean India journal.
He has also guided as well as multiple projects related
to healthcare which is in field of infection control and clinical
microbiology namely national survey on infection control practices
in collaboration with Clean India journal and POCD in infection
control in collaboration with IITB.
He has been awarded multiple times in his organization and at
national level.
His topics of interest are implementing and improving quality
in healthcare, hospital and laboratory accreditation, clinical
microbiology, infection control, antimicrobial stewardship and
improving medical education to a minimum basic standard which
is suitable for current healthcare scenario in country and on
international level.
Sister Solbymol P S is a PICU Nurse with 19 years of experience.
She has worked as In-charge PICU Rainbow Children’s Hospital,
Hyderabad and Vikrampuri, senior staff at Ernakulam Medical
Centre Kochi. She is now working as Coordinator Quality and
Infection Control Nurse at Kinder Women’s Hospital and Fertility
Centre, Cherthala, Alappuzha.
Dr. Dhruv Mamtora
Consultant Microbiologist
and Infection Control Officer
Email: dhruv_mamtora@yahoo.com
Solbymol P S
GNM, ICCP
Email: solbyps@gmail.com

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Theme is dedicated to Accreditation and its role in infection control. Include NABL, NABH or any other accreditation
related topic.
Articles on current infections of National importance as Tuberculosis, Dengue and any other emerging infectious
diseases are welcome.
Article on laboratory quality control, quality assurance, Antimicrobial stewardship, therapeutic drug monitoring,
critical care, transplant care, immunosuppressive therapy, hand hygiene, isolation precautions, disinfection and
sterilization, housekeeping, laundry and kitchen practices are also welcome.
Article related to nursing best practices, role model and healthcare associated costs are also desired.
Or
Any other topic of relevance can be published with consent of editorial team members.
Thefundamentalruleforcreatinganemailnewsletteristomakeitinteresting,relevantandup-to-dateinformation
that is enjoyable to read and practice.
Hope that it meets the expectations of the knowledge seekers. Motto behind e-newsletter format was to be
informed about things which are otherwise difficult to be able to find out about with general searches. People share
the real time experiences, challenges and solutions through this accessible and free platform.
Stick to the Topic you have chosen and elaborate on the theme in mind for each so idea doesn’t get jumbled.
Authorship is for clinical microbiologists, consultants both medical, surgical and dental fields, teaching
professionals, infection control and prevention experts, clinical pharmacists, hospital quality personnel, administrator
and also members of recognized professional bodies. The person has to be associated with medical field in direct or
indirect way. International authors are also welcome and resource poor settings like African region and other Asia
pacific region low and middle income countries will be given special encouragement for authorship.
1. Allow for some flexibility in the length of the content. After all, this is not a print publication that has to fit on a
certain paper size 500 words mean can be 100 words + or 100 words less.
2.TodaymanyareshortoftimeDevisecreativeandinformativesubjectlinesEnsurecontentiseducational,informative,
and concise.
Article to be written with scientific language and references are to be added in Vancouver style only. Mention all
scientific names in italics. Follow font size of 11 with times new roman style with 1.15 line spacing. Article submission
to be done in MS word format only.
We have not many editorial reviewers yet all the articles to be submitted with scientific spirit to be checked for
plagiarism, spell check and grammatical errors by the authors declaring the CONFLICT OF INTEREST IF ANY?
If any comparative or invasive tests are done on humans or animal studies then the scientific work must accompany
the Ethical committee approval/IRB (institutional review board) approval.
Article can be accepted or rejected for lack of place or not suiting the purpose of the topic chosen and will retuned
at the earliest and decision of editorial members is final in approving or rejecting the articles for publication.
Dr. Dhruv Mamtora
Dr. T. V. Rao MD
Dr. Ranga Reddy Burri
OBJECTIVES OF E -NEWSLETTER
ON INFECTION CONTROL TRENDS
MEETING THE OBJECTIVES OF E-NEWSLETTER

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INDEX
Editorial - Role of Disinfectant Manufacturing Industry in Strengthening Infection
Prevention and Control Practices
Dr. Ranga Reddy
07
Guest Editorial - Hospital Infection Control and Hospital Accreditation
Dr. Harish Nadkarni
Dr. Kashipa Harit
10
Guest Editorial - Airborne Infection Control in Health Facilities Warrants More
Attention
Dr. Rakesh PS
12
Investigating an Outbreak - The Right Way
Dr. Nazia Khanum
15
Surveillance versus Audits: Tools for Quality Improvement of Infection Prevention and
Control (IPC) Practices
Dr. Aruna Poojary
18
Hospital Accreditation Assessment: Challenges & Pitfalls
Dr. Dhruv Mamtora
19
How to Train Nursing Professionals in Prevention of Hospital/Community Associated
Infections
Dr. Ashish Jitendranath
22
How Green is My Valley... Er... Hospital?
Dr. Sourav Maiti
23
Antibiotic Stewardship: A Beginner for the Nursing Team!!
Dr. Ankit Gupta
25
Curricular Changes inUndergraduate Medical Education (MCI - 2018)
- Impact on Microbiology
Dr. T V Rao
28
Challenges Faced in the Laboratory Diagnosis of Anaerobic Infections
Dr. H Srinivasa
30

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EDITORIAL
Dr Ranga Reddy Burri
MD, PGDPhM, AMP
President Infection Control Academy of India
Director Sanmed Healthcare
Advisor Indian Institute of Public Health (PHFI)
Faculty e-learning course in IPC at University of Hyderabad
Email: dr.rangareddy@ifcai.in
ROLE OF DISINFECTANT MANUFACTURING INDUSTRY IN
STRENGTHENING INFECTION PREVENTION AND CONTROL PRACTICES
Background:
We often use word stakeholders while talking about Healthcare Associated Infections (HAI) and Infection
Prevention & Control practices. While stakeholders like Healthcare Workers, Hospitals, Laboratories, National and
International Health agencies etc. invariably find mention in most articles, guidelines, presentations, the role of
disinfectant manufacturers rarely find place among stakeholders. Manufacturing industry plays a crucial role in assisting
healthcare community with timely introduction of innovative, optimized solutions for alarmingly escalating infections
and challenges posed by ever changing profile of microorganisms.
At Global level WHO has involved manufacturers of disinfectants/infection control products under umbrella
of Private Organizations for Patient Safety with an objective “to harness industry strengths to align and improve
implementation of WHO recommendations”. In India impact of this initiative is minimal, hence Infection Control
Academy of India (IFCAI) is forging an alliance of manufacturers to improve awareness and reduce health-care
associated infections through improvements in practices based on WHO recommendations.
Keywords: Healthcare Associated Infections (HAI), Infection Prevention and Control (IPC), Disinfectant, Stakeholders,
Manufacturer, Test Standards, Efficacy, Safety.
With increasing complexity in healthcare delivery, challenging clinical procedures, variety of medical devices
make of varied materials, congested healthcare settings, lack of natural light and air within healthcare institutions
due to space & design constraints and emergence of MDR/ XDR pathogens the choice and utilization of appropriate
disinfectant products has become exceedingly important.
The contribution of disinfection processes to prevent health risks is evident, provided that they have been proven
effective. The infections causing mortality are changing, if a century back medical community faced challenge of
plague, cholera, typhus etc. today the challenges are emanating from Ebola, SARS, H1N1, multi drug resistant microbes.
Disinfectants too evolved from chlorinated lime prescribed by Semmelweis to advanced nanochemistries, made
possible by technical progress, better knowledge of microorganisms, experience and rapidly growing pharmaceutical
and disinfectant manufacturing industry.
The choice of the disinfectant shouldn’t jeopardize Infection Control team goals and shouldn’t burden even
otherwise stressed & understaffed HIPC to repeatedly test the products for label claim compliance for safety & efficacy
parameters. Manufacturers of Disinfectants and the standards followed by them play a vital role in assuring the quality
of the products and strengthening Infection Prevention and Control practices in healthcare settings.
Though antimicrobial efficacy is an essential factor when using disinfectants, considering the complex nature
of healthcare system today, there is much more to consider than simply if the product carries effectiveness against a
particular organism. In our opinion, three criteria will probably make the Infection Prevention based on facts devoid of
trial & error:
- Right Chemistry – to ensure safety with intended efficacy

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-RightProduct–toensurerightchemistryisformulatedfordesiredefficacycomplaintwithexistingregulatorystandards
in given country which in turn should lead to products that are more respectful of both user and environment.
- Right Manufacturer- to ensure sustainable supplies with traceable, consistently reproducible quality compliance.
Chemistry is talked about in most articles and Infection Prevention & Control training sessions. Hence, in this
article author shall be focusing on parameters for ascertaining Right products and Right manufacturers.
RIGHT PRODUCT
Once chemistry (active ingredient) is chosen, the team can start looking for the products with the given active
ingredient. Different manufacturers may supply the same active ingredient with different combinations and added
components/excipients. The highest concentration or a combination with wide range of active ingredients may not
always be the best. In this case follow the Centers for Disease Control and Prevention (CDC)’s “Guideline for Disinfection
and Sterilization in Healthcare Facilities” (2008) which has identified several of the key criteria that should be carefully
measured when evaluating a disinfectant product or chemistry. These criteria alongwith study of label claim of the
manufacturer should help to identify “ideal” disinfectant for given healthcare setting:
1. Speed of Disinfection
2. Spectrum of Microbicidal Efficacy or kill claims for the most prevalent healthcare pathogens
3. Cleaning Ability
4. Ease of use
5. Material Compatibility
6. Personnel Health and Safety
7. Responsible Environmental Profile
Therefore, an ideal disinfectant should excel in all of the major decision-making criteria. “The disinfectant should
effectively clean, thereby removing dirt and soil from the surface. It should be effective against a broad spectrum of
microorganisms (bacteria, viruses, etc.) in a rapid and ultimately, realistic contact time and the product’s chemistry
profile should be sustainable. Finally, it should be safe for the users and the occupants of the environment as well as
the environment itself post-use”.
RIGHT MANUFACTURER
Coming to manufacturer, the supplier responsible for marketing is required to provide proof of effectiveness
justifying all claims made for a given disinfectant. All manufacturers licensed in India for manufacturing should comply
with Good Manufacturing Process (GMP) as basic minimum and in addition if the manufacturer is accredited with GLP,
WHO GMP, ISO9001, ISO13485 ensuring higher compliance and ultimately instills confidence that disinfection will be
achieved.
Amanufacturerwith well-equipped in-house dry,wetand microbiology lab and following WHOGMPnormsusually
tests all raw material and finished goods for all stated quality parameters. Different companies may follow different
standards for testing the products but they had to be reliable and reproducible. For microbiological testing different
standards and techniques are used across the world to assess antimicrobial activity of antiseptics and disinfectants.
Following are popular systems:
- European- this standardization is provided by the “European committee for standardization CEN TC 216 for chemical
antiseptics and disinfectants”
- AFNOR France – replicates above
- OECD – published 5 guidelines concerning assessment of bactericidal, fungicidal, virucidal, mycobatericidal and
sporicidal efficacy of biocidal products
- AOAC & ASTM - these American organizations promote microbiological analysis methodologies applicable to
disinfectants
- DGHM & VAH – these German organizations promote methods similar to standards recommended by the CEN (ex
EN1500 method for Hygienic Hand Rubbing)
- India – doesn’t have a separate standard for disinfectants. Some chemical and microbiological tests are covered in
Indian Pharmacopeia.
Irrespective of the system or standards followed the testing had to be reliable and reproducible resulting in a
certificate of analysis for each lot.

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Conclusion: Disinfectant manufacturing industry is one of the key stakeholders to strengthen infection prevention
and control practices in Indian healthcare settings. Infection preventionists, healthcare quality managers and
administrators should constantly improve their knowledge base about disinfectants and criteria to select them to
optimally deploy for safer care.
References
1. Agency for Healthcare Research and Quality. 2010 National Healthcare QualityReport: Patient Safety. Rockville [MD]: US
Department of Health and HumanServices; 2010.
2. Private Organizations for Patient Safety (POPS) http://www.who.int/gpsc/pops/en/
3. Efforts in India for HIPC awareness http://portal.ifcai.in/portal/home
4. Klevens RM, Edwards JR, Richards CL Jr, Horan TC, Gaynes RP, Pollock DA, et al.Estimating health careeassociated infections and
deaths in US hospitals,2002. Public Health Rep 2007;122:160-6.
5. Jarvis WR. The Lowbury lecture. The United States’ approach to strategies inthe battle against healthcare-associated infections,
2006: transitioning frombenchmarking to zero tolerance and clinician accountability. J Hosp Infect2007;65(Suppl 2):3-9.4. World
Health Organization. Improved hand hygiene to prevent healthcareeassociated infections. Patient Safety Solutions 2007;1 (Solution
9).Available from: http://www.who.int/gpsc/tools/faqs/evidence_hand_hygiene/en/. Accessed January 29, 2012.
6. Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, et al.Infection Control Programme. Effectiveness of a
hospital-wide programme toimprove compliance with hand hygiene. Lancet 2000;356:1307-12.
7. Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infectionprevention. J Hosp Infect 2009;73:305-15.
8. The Joint Commission. Infection Control. Measuring hand hygiene adherenceovercoming the challenges. Oakbrook Terrace [IL]:
The Joint Commission; 2009.11. Pittet D. The Lowbury lecture: behaviour in infection control. J Hosp Infect2004;58:1-13.
9. Glanz K, Rimer BK, Viswanath K, editors. Health behavior and health education:theory, research, and practice. 4th ed. San
Francisco [CA]: Jossey-Bass;2008.
10. Day BA, Smith WA. The Applied Behavior Change (ABC) framework: environmentalapplications. Washington, [DC]: Academy for
Educational Development;1996.
11. Centers for Disease Control and Prevention. CDC guideline for hand hygiene inhealthcare settings. Atlanta [GA]: Centers for
Disease Control and Prevention;2002.
12. World Health Organization. WHO guidelines on hand hygiene in health care.Geneva [Switzerland]: World Health Organization;
2009.
13. How to select an ideal disinfectant https://www.infectioncontroltoday.com/environmental-hygiene/how-select-ideal-
disinfectant
14. Selecting disinfectant https://www.beckershospitalreview.com/quality/selecting-an-ideal-disinfectant.html
15. European disinfectant standards https://standards.cen.eu/dyn/www/f?p=204:105:0:::::
16. Rutala, WA. APIC guideline for selection and use of disinfectants. AmJ Infect Control 1996;24:313-42.

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In India, hospital infection control (HIC) programs are frequently under-resourced. Being an integral part of
patient safety all efforts are being done to strengthen such programs in both public hospitals and private healthcare
settings. Running such program however, require resources in terms of dedicated manpower (Infection Control Nurses,
ICNs) and participatory efforts from all hospital staff with leadership from head of institution. Continuous training and
monitoring of implementation of program is integral part
of any HIC program.
NABH in India is the primary accreditation body for
healthcare institutions in India and has played important
role in increasing awareness and strengthening of
this programs. The dedicated chapter in accreditation
standards for entry level, progressive level certification
of accreditation undermines the importance of infection
control in healthcare. With the participation of insurance
sector and strong will power in government large number
of healthcare institutions are now opting for accreditation.
While preparing for accreditation, healthcare units
implementing the standards on HIC initially find it as uphill
task and resource demanding affair, however, as they
progress in their journey, physicians, surgeons, nursing
staff, patients and visitors can feel the difference. For
care providers, it brings in increase sense of occupational safety and strong surveillance mechanism for exposures
and preventive actions. The significant reduction in healthcare associated infections one hand helps in reduction of
morbidity, mortality for the patients on the other hand it reduces cost of care, risks of litigations and improve branding
for the hospitals.
Infectioncontrolinfrastructurehasalwayshavebeenfoundtobemuchbetterintermsofresourcesandoutcomesin
accredited healthcare settings. Surveillance for healthcare associated infections, hand hygiene compliance, healthcare
worker safety program are implemented more frequently and effectively in hospitals with adequate infection control
staffing. In an study on 77 Australian hospitals published in 2015, it was clearly eastablished that Staphylococcus
aureus bacteremia rates reduced to half over a period of 4-years from 1.34 per 10,000 bed days in 2009 to 0.77 per 10
000 bed days in 2012 (Mumford et al, 2015).
Besides the quality indicators for infections control
program as mandated by NABH namely, Hand hygiene
compliance, Device associated infections and antibiotic
utilisation, prophylactic use of antibiotics and post surgical
infection rate monitoring are instrumental in providing insights
to the success of the program. NABH do collect such data from
all the NABH-accrediated organisations in the country and
provide periodic feedback to the participating organisations.
Author
Dr. Harish Nadkarni
CEO of NABH
Email: ceo@nabh.co
Co-Author
Dr. Kashipa Harit
Assistant Director, NABH
Email: kashipa@nabh.co
GUEST EDITORIAL
HOSPITAL INFECTION CONTROL AND HOSPITAL ACCREDITATION
It has been seen that
accreditated or certified hospitals
do have reduction of HAIs by
atleast 25% from the magnitude
they started implementing the
accreditation program.

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This helps the NABH accredited organisations to
assess their program vis-à-vis other instituions in their
respective state and their position at national level
whencomparedinotheraccreditedorgansation.NABH
in this process helps generated national level data on
healthcare associated infections in India. Accrediation
standards also manadate regular training of hospital
staff and infection control nurses thus has been
instrumental in improving overall awareness towards
healthcare associated infection and prevention among
all stakeholders.
Hospital accreditation helps in systematic implementation of hospital infection prevention and control program
and has a significant impact on hospitals’ infection control infrastructure and performance.
References:
1. Mumford V. et. al. Is accreditation linked to hospital infection rates? A 4-year, data linkage study of Staphylococcus aureus
rates and accreditation scores in 77 Australian acute hospitals. International Journal for Quality in Health Care, 2015;27(6):479–
485, https://doi.org/10.1093/intqhc/mzv078
2. Infection control accreditation program launched in Indian state. Healthcare facility Today. January 24, 2014. https://www.
healthcarefacilitiestoday.com/posts/Infection-control-accreditation-program-launched-in-Indian-state--3846
NABH currently has 563 hospitals accredited
under HCO standards and 180 small healthcare
organisations accredited. Assuming that each such
healthcare organisation is preventing alleast one
death from healthcare associated infections per
month, this translates to prevention of 760 deaths
per month by these NABH accredited/certified
organisations. Thus, accreditation is helping in
preventing over 9000 deaths every year.

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Airborne transmission of infectious disease like tuberculosis (TB), H1N1, severe acute respiratory syndrome (SARS),
corona virus is a major public health concern. India continues to have the highest number of tuberculosis (TB) cases in
the world. The airborne transmission becomes even more prevalent in health-care settings because of overburdened
and overcrowded hospitals and the presence of patients with immunosuppression. Nosocomial outbreaks of air borne
infections in many countries have focused attention on the need to control the transmission of the disease in hospital.
Emerging infectious diseases like Nipah virus disease has caused mortality among health care workers and general
population with substantial nosocomial transmission. The death of a nurse who treated the patients with Nipah virus
disease at recent outbreak in Kerala caught widespread attention. A systematic review of 51 studies conducted in low-
to middle-income countries found that TB incidence among health care workers was high, ranging from 69 to 5780 per
100,000. Evidences show that TB is a significant occupational problem among health care professionals. Nosocomial
outbreaksofairborneinfectionslikeinfluenzaH1N1,drug-susceptible,multidrug-resistantTB(MDRTB),andextensively
drug-resistant TB (XDR TB) have been reported and have been linked to the absence or limited application of airborne
infection-control strategies in health care facilities.
Several factors may facilitate nosocomial transmission in Indian hospitals, although their relative importance in
facilitating transmission is unknown. Risk of transmission is highest when there is a high number of cases with poor
infection control. Undiagnosed cases especially at medical ICUs and emergency rooms pose great threat for nosocomial
transmission. Prevailing infection control practices in India revolve around biomedical waste management and disposal
of sharps; while airborne infection control (AIC) measures has not received adequate attention from the health care
facilities and practices. National Guidelines on Airborne Infection Control in Health Care and other settings in India
were published as the first, formal national guidelines on reducing the risk of airborne infections in health care facilities
and special high-risk settings in India.
The guideline involves recommendations categorized into three main components;
I. Administrative controls.
II. Environmental controls.
III. Use of Personnel protective equipment.
I. Administrative controls: Administrative controls are to classify persons with respiratory symptoms,
separate them into appropriate environment, fast-track them through the health care facility to reduce exposure time
to others, and diagnose/treat them with minimal delay.
AIRBORNE INFECTION CONTROL IN HEALTH FACILITIES
WARRANTS MORE ATTENTION
Dr. Rakesh PS
Medical Consultant, TB Elimination,
WHO-RNTCP Technical Assistance Project,
Kerala
Email: epidklm@gmail.com
GUEST EDITORIAL

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A. Outpatient Setting
a. Screening:
Screening for respiratory symptoms need to occur as early as possible upon patient’s entry at the health care
institution. A separate screening counter may be placed, patients can be encouraged to first visit this counter if they
have suggestive symptoms, by appropriate advertisements, posters or announcements in the registration area. Even if
screening at registration is not possible, screening can occur when patients register at specific clinics or when in waiting
areas.
b. Education on cough etiquette and respiratory hygiene:
Physical method that can prove useful for reducing airborne transmission is the provision for patient education
on cough hygiene and sputum disposal. This education can easily be imparted to patients through posters and other
means in the waiting area. Cough etiquette should be reinforced by all staff members. Masks can be provided to all
respiratory symptomatic. Simple surgical masks may not help health care worker from getting air borne diseases but
are effective when used by the patients to reduce the production of respiratory droplets of all sizes.
c. Patient segregation:
Segregation of patients with respiratory symptoms can be achieved by having a separate waiting area for chest
symptomatics, within the overall outpatient area. This is particularly important in larger institutions with heavy OPD
loads. The outpatient area, more so this segregated area, should be well ventilated to reduce overall risk of airborne
transmission.
d. Fast-tracking of patients with respiratory symptoms:
Those identified as patients with respiratory symptoms can be further fast-tracked in both their clinical and
laboratory evaluation. Patients may be allowed to jump the routine queue and be seen earlier than other patients. The
other important area where these patients can be given priority is while performing chest radiography.
B. Inpatient areas
a. Minimize hospitalization of TB patients:
One of the most effective means to reduce the risk of transmission of airborne pathogens such as M. tuberculosis
in hospital settings is to manage such patients in the outpatient setting whenever possible.
b. Establish separate rooms, wards, or areas within wards for patients with infectious
respiratory diseases:
Patients with infectious respiratory diseases should be physically separated from other patients so that others
are not exposed to the infectious droplet nuclei that they generate. Policies on patient separation inevitably generate
concern about stigma, but with appropriate measures – such as training and public posting of separation rules – stigma
can be minimized. Administrative procedures should ensure that separation happens promptly and automatically,
similar to the automatic separation of men and women during inpatient admission. The best choice for infectious or
potentially-infectious patients is to house and manage them in airborne precaution rooms.
c. Educate inpatients on cough hygiene and provide adequate sputum disposal:
Wards housing infectious patients should display sign boards in the ward demonstrating cough hygiene. All
patients admitted in the ward/area should be issued surgical masks and counseled on their proper use and adequate
measures for safe collection and disposal of sputum.
d. Establish safe radiology procedures:
For patients with infectious respiratory disease like scheduling the procedure during non-busy times.
II. Environmental Controls:
Ventilation should be prioritized to reduce the number of infectious particles in the air. Effective ventilation may be
achieved by natural ventilation where ever possible. When clean or fresh air enters a room, it dilutes the concentration
of airborne particles, such as droplet nuclei, in room air.

14
Unrestricted openings (i.e. those that cannot be closed) on opposite sides of a room provide the most effective
natural ventilation. Openings should constitute at least 20% of the floor areas (10% on either side for effective cross
ventilations). In existing health-care facilities that have natural ventilation, when possible, effective ventilation should
be achieved by proper operation and maintenance of openings, and by regular checks to see that openings remain free
of obstruction at all times.
Mechanical ventilation with or without climate control may appropriate where natural ventilation cannot be
implemented effectively, or where such systems are inadequate given local conditions (e.g. building structure, climate,
regulations, culture, cost and outdoor air quality). If mechanical ventilation is used, the system should be well designed,
maintained and operated, to achieve adequate airflow rates and air exchange. Careful attention must be given to
ensuring adequate ventilation when installing air conditioners. Minimum number of air changes per hour need to be
ensured while using air conditioners. In OPD and registration areas, there should be minimum of 6 air changes per hour
while in high risk setting it should be 12.
In high-risk settings where optimal ventilation cannot be achieved through natural or mechanically-aided means,
properly designed, placed and maintained shielded ultraviolet germicidal irradiation devices should be considered as
a complementary control.
Fig 1. Schematic showing seating arrangement for patient and health care worker (red cross)
In (A), natural ventilation would allow potentially infected air
to cross health care worker. In (B), with this seating arrangement
the chance of such exposure is lessened somewhat. (Picture
adapted from NAIC guidelines, 2010)
III. Personal protective equipment:
Simple surgical masks may not help health care worker from getting air borne diseases but are effective when
used by the patients to reduce the production of respiratory droplets of all sizes. Personal protective equipment (e.g.
particulate respirators certified as N95 or FFP2) should be available as required in high-risk situation, especially during
high-risk aerosol-generating procedures such as bronchoscopy or sputum induction.
Conclusion
Numerous studies have shown that implementation of recommended air borne infection-control strategies has
been associated with reduced outbreaks of air borne infections and preventing its nosocomial transmissions in health
care facilities. It is more important to promote implementation of National Air borne Infection Control guidelines in the
hospitals. It has been revealed that most of the countries where a significant reduction of air borne diseases including
TB has been observed, air borne infection control practices have played a crucial role.

15
INTRODUCTION:
I have chosen writing about investigating an outbreak, the reason being that outbreaks of both infectious and
non-infectious adverse events can occur in any healthcare setting and pose a threat to patient safety. All healthcare
settings face an outbreak most of the time but not all the time it is tackled in a standardized way due to various reasons
1. Not knowing there is an outbreak – outbreak not identified
2. Not knowing what to do if there is an outbreak – lack of knowledge
3. Working to manage it but not in the right direction – unfruitful hard work – due to not assessing possible
contributing factors.
BRIEF OUTLINE OF MANAGEMENT OF OUTBREAK:
How do we know we have an outbreak?
Outbreaks should be suspected when healthcare-associated infections, recovery of specific pathogens, or other
adverse events occur above the background rate or when an unusual microbe or adverse event is recognized. This
implies that even a single case of an unusual disease may constitute an outbreak.
WHAT DO WE DO WHEN WE HAVE AN OUTBREAK?
STEPS IN INVESTIGATING AN OUTBREAK
Outbreaks generally do not unfold in a linear or orderly manner. It is possible, that many steps might have to occur
simultaneously and be repeated multiple times.
Confirming Presence of an Outbreak:
For infectious disease outbreaks, this might be done by reviewing surveillance or microbiology records. For
outbreaks of other adverse events, outbreak investigation might be based on the general perception of clinicians as
historic, comparative data might be more difficult to obtain.
Dr. Nazia Khanum
M.D (Microbiology); MHA (SMU)
Clinical Microbiologist & Assistant consultant Infection
Control Infection Prevention & Control Department
KSMC Riyadh
Email: drnaz.khan@gmail.com
INVESTIGATING AN OUTBREAK – THE RIGHT WAY

16
Alerting Key Partners About the Investigation
Facility administration should be notified so that resources can be made available.
The microbiology laboratory should be notified and asked to alert the infection preventionists of new possible
cases and to save any isolates that might be related to the outbreak.
Local, and, as appropriate, state and federal public health officials should be notified.
Performing a Literature Review
Literature review is a critical early step in any investigation. It will help identify possible sources and might also
provide important insight into optimal investigative methodology.
Establishing an Initial Case Definition
Investigator should develop specific criteria for the definition of a case. The initial case definition should be narrow
enough to focus investigative efforts but broad enough to capture the majority of cases.
Developing a Methodology for Case Finding:
Various methodologies used can be as follows:
Laboratory records (If the case definition includes a laboratory result).
Infection prevention and surveillance records (If the outbreak involves an HAI or adverse event or a multidrug-
resistant pathogen).
Discussions with HCP in affected areas (in outbreaks in which the case definition is primarily clinical).
Preparing an Initial Line List and Epidemic Curve
Information collected on a initial line list can include details about patient signs or symptoms, medications,
procedures, consults, patient locations, contact with HCP, and host factors that might have predisposed the patients to
the adverse event under investigation. It is critical to carefully weigh the benefits of any information to be included on
the line list against the resources required to obtain it.
Data from the line list should also be used to create an epidemic curve. In some instances, the shape of the
epidemic curve will provide information that can help identify the mode of transmission.
Observing and Reviewing Potentially Implicated Patient Care Activities:
In most outbreak investigations, it is the observations of practices that ultimately identify the cause. Initial
observations should generally be free-form, and should focus on practice patterns and workflow that deviate from
good infection prevention practices and facility or unit policies. During these observations, it is important to engage
HCP in a discussion about the outbreak being investigated and the potential contributing factors.
Considering Whether Environmental Sampling Should Be Performed:
In outbreaks of infectious diseases, identifying a contaminated source is often one of the most satisfying and
definitive investigative findings. However, environmental culturing during outbreak investigations can also be the most
frustrating, expensive, and potentially misleading aspect of an investigation. More often than not, these cultures are
negative and leave the investigator to ask why.
Given these challenges, some important recommendations can improve the yield of environmental cultures as
follows:
Perform these cultures after making the line list and doing observations
Environmental cultures should never be the first step in an outbreak investigation.
Before obtaining any environmental cultures, talk with microbiology laboratory personnel to determine
whether they are able to process the cultures that will be obtained and discuss the optimal methods of obtaining them.
Culture the items that make the most sense as the likely reservoir for the organism.
Steps of the Follow-up Investigation
There are instances when outbreaks persist despite the initial measures, in these cases, the follow-up steps can
become important.
Refining the Case Definition based on the information gleaned from the initial cases to make it as focused as
possible.
Continuing Case Finding and Surveillance should continue for some period of time (e.g., 1 month) after the
outbreak has terminated to ensure that it is truly over.

17
Considering Whether an Analytical Study Should Be Performed?
Analytical studies can often help guide further investigations in situations in which the source of an outbreak
remains unclear and control measures have been ineffective. They might be useful in convincing clinicians that the
proposed source is indeed correct. Finally, analytical studies are powerful teaching tools of trainees in healthcare
epidemiology, infection prevention, and public health.
Communication During and After an Outbreak Investigation
Communication within the facility and with public health officials can be critical to the success of an outbreak
investigation.
Clinicians working in the affected areas should be kept abreast of developments and findings, this will provide
important information to help guide the investigation, and it will also help assure Health Care Personal that appropriate
steps are being taken to end the outbreak.
Decisions about whether to notify patients about an outbreak must be made by facility administration.
Facility administration should also be informed and updated on a regular basis. It is vital to ensure the support
and provision of facility resources.
Facility risk management personnel also should be informed as Healthcare-associated outbreaks can result in
lawsuits, and risk management officials are better able to advise facilities on the best course of action.
Finally, the public relations or press officer, if present, should be kept informed during outbreak investigations
because Outbreaks sometimes attract media attention, and the facility must be prepared to handle it.
CONCLUSION:
Outbreaks in healthcare settings may be due to a variety of factors, including lapses in infection prevention or
clinical practices, contaminated or defective products or devices, and colonized or infected healthcare personnel. The
ultimate goal of any outbreak investigation is to identify probable contributing factors and to stop or reduce the risk
for future occurrences. Cooperation between healthcare epidemiologists, infection preventionists, and public health
experts is important in effectively managing outbreak responses in healthcare settings.
References:
Elizabeth A. Campbell; Chapter-12 - Outbreak Investigations; Epidemiology, Surveillance, Performance, and Patient Safety
Measures; APIC Text, 4th edition. Washington, DC 20005; 2014

18
Its not uncommon for us as IPC practitioners to mention audit and surveillance in one breath… as if they were
the same. Are they, we must ask? Let’s first clear the difference before we move on to making them effective quality
improvement tools for the practice of infection prevention and control.
An audit is defined as the examination of the actual situation and comparing findings of the audit with the written
policy or known standard /benchmark/yardstick. Surveillance is a systematic, ongoing collection, collation and analysis
of data with timely dissemination of information to those who require this information in order to act upon. Thus, one
of the fundamental differences between an audit and surveillance is that an audit is always done based on a written
policy or a standard operating document (SOP). That is the reason why an audit can actually be done by anyone, trained
or untrained in the specific process that is being audited. When we write policies, they are based on some reference,
guideline and some practical implications within our own settings. An audit of such practices would therefore mean
understanding whether the policies laid down are working within our institutions. The intention of any IPC audit is to
actually bring out reasons for noncompliance to policies. These could be “real” reasons we may not have perceived
when we laid down the policy. In contrast, surveillance requires trained personnel who already know the whys and
how’s of IPC and can intervene, analyse and communicate to the concerned data coming out of surveillance.
The second important difference between surveillance and audits is that there are many different types of
surveillance processes e.g. active, passive, targeted, prospective, retrospective etc. Our IPC practice normally spans
across every department of the hospital (even accounts – they provide the budget!). Imagine the herculean task of
conducting routine IPC audits for every IPC process across every department of the hospital. Hence most IPC audits
need are targeted to specific areas or processes that need attention.
Surveillance can be performed for both outcome measures as well as for process measures. The results of
surveillance often produce our quality indicator data. Some examples of outcome measure surveillance are as follows:
device or non device associated infection rates, surgical site infections, pyrogenic reaction or vascular access infection
in haemodialysis patients, needle stick injuries etc. Some examples of process measures can be influenza vaccination
ratesamonghealthcareworkers,surgicalantimicrobialprophylaxis,immunityduetoHepatitisBvaccination,medication
errors etc
Some examples of common audits we perform in IPC are hand hygiene audit, device insertion and maintenance
audits for vascular catheters, urine catheters, assisted ventilation, biomedical waste, laundry, central sterile supplies
department and kitchen audits. Audits can be time consuming especially if the process being audited involves “the
whole hospital”. E.g biomedical waste audit or device maintenance audits. Often, the time taken to conduct such audits
delays the identification of non-compliances and their resolution. A practical way to handle such issues would be to
do multiple audits during different times of the year but as a sample rather than one single “whole hospital” audit.
E.g spread your biomedical waste audit across 4 or 5 wards and do it every quarterly in different areas. Usually, the
non-compliances will be common across areas.
To conclude, surveillance and audits are integral to our IPC practice and every attempt must be made to customise
them according to our local institutional needs. The outcome of both surveillance and audits is to bring about a
positive change in IPC practice through training and education of healthcare workers and understanding the reasons
for noncompliance.
Dr. Aruna Poojary
MD, DNB, D(ABMM), DipHIC, CIC
HOD, Dept of Pathology & Microbiology
Breach Candy Hospital Trust, Mumbai
Email: arunapoojary@gmail.com
SURVEILLANCE VERSUS AUDITS: TOOLS FOR QUALITY IMPROVEMENT OF
INFECTION PREVENTION AND CONTROL (IPC) PRACTICES

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Practical advice and tips for successful audit outcome
Accreditation is a third party review for the benefit of organization for multiple purposes or stamping of quality
standards which are practiced in day to day service to the patients. There are multiple agencies for accreditation and
in India; we have NABH and NABL under the quality council of India. Other international accreditation agencies are JCI
for hospitals and CAP for laboratories.
I belong to a tertiary care organization and we are accreditated for both NABH and NABL. We have firsthand
experience of passing through assessments and getting through the whole process.
Here is our take on some important assessment aspects which are reproducible provided you are ready to undergo
these processes for benefit of organization as well as it will challenge you to extremes where in you will shine out
like a gem at the end of same with due polishes and glow. It will additionally be a feather in your cap as this will be a
third party proof that you have followed and achieved standards of accreditation which is ultimately going to benefit
patients who are seeking care.
The organization prepares for accreditation process in a following manner.
1. Assemble all members who are key members for accreditation
2. Define organizational strategy – perform a SWOT analysis
3. Form and monitor performance of committees (there are PTC, Infection control, Transfusion and blood products,
ethics and review, advisory, safety and accreditation committees in any organization depending upon scope of services
offered). Committee must have: core members, an agenda, minutes of meeting are recorded and timelines are given to
members. It is the role of senior administration to ensure that everything is followed in stipulated timelines.
4. Train staff – training can be of multiple things as far as infection control as a discipline is concerned. Formulate
training calendar as per requirement of organization.
Training in infection control has to encompass following areas.
a. Infection control committee, structure, functioning and compliance to standards of accreditation
b. Interaction and communication on day to day basis during rounds of hospitals
c. Biomedical waste
d. Hand hygiene
e. Standard precaution
f. Transmission based precautions
g. Isolation precautions
h. Safe injection and infusion practices
i. Bundle care and prevention of HAIs – CLABSI ,CAUTI, VAP and SSIs.
j. Disinfection and sterilization precautions
k. Occupational safety of healthcare workers
l. Immunization and accident reporting (e.g. needle stick injuries)
m. Surveillance of Hospital acquired infections
n. Microbiology laboratory and sample collection
Dr. Dhruv Mamtora
Consultant Microbiologist infection control officer
S. L. Raheja Hospital, A fortis associate, Mahim, Mumbai.
Co-editor and designer “Infection control trends”
Email: dhruv_mamtora@yahoo.com
HOSPITAL ACCREDITATION ASSESSMENT: CHALLENGES & PITFALLS

20
o. Use of single use devices and policy for same
p. Cleaning protocol for critical, semi critical and non critical areas of hospital
q. Environmental surveillance
r. Other need based training in specific areas e.g. dialysis, radiation safety in radiology and nuclear medicine
s. Housekeeping training
t. Conducting audits in infection control
u. Kitchen and food safety
v. Laundry and linen safety
w. External visits and audits for training
5. Conduct baseline assessment or mock audit to know current gaps in system, procedures, manpower, material and
any other resources.
6. Start documentation procedure and help relevant stake holders in preparation of the policy and procedures that
comply with standards of accreditation.
7. Get all required approvals from higher authorities/ senior management.
8. Start implementation and conduct on site surveillance audit with difficulties with staff
9. Resolve their difficulties with available resources and adjustments in time and modify processes accordingly.
10. Once satisfactory, apply for accreditation process and get assessed.
11. During assessment, there will be certain non compliances which will be, raised. Address them in stipulated time
period given for completion and comply to standards.
12. Follow principles of organizational values at all times and do not stop or subsidize routine patient work.
13. Establish culture of quality in the organization with available resources and available literature of the subject.
14. Some of basic qualities which are essential for infection control officer or for quality are good visionary
leadership, understanding and thorough knowledge of available guidelines, good communication skills at all levels of
organization, understanding organizational structure and function, acceptability and ability to work in team, expert
advice, availability and readiness to participate for larger benefit for patient care. Most importantly ability to adopt
and practice essential components with available resources and upgrading the overall knowledge and understanding
of staff. Another important aspect is patience and keeping a balance between different contradictory arguments
and counter arguments which may occur based upon different temperaments of different people while dealing with
various people at organization level.
15. Transparency in maintaining documents is one of critical success factor for infection control. It is a direct face of
quality of care offered to patients.
Types of assessment to be faced by departments generally under NABH accreditation:
1. Pre assessment
2. Final assessment
3. Verification
4. Surveillance
5. Re-accreditation
Also updates in standards happen from time to time with additional clauses and sub clauses which are to be
complied by organization for which staff and concerned people need to undergo training from providers.
Many times these assessments last for few days and then it is really stretching for the staff because they have to
additionally do work in patient care areas and at same time face assessment.
Many times remarks given (non conformities) are not as per standard guidelines and are biased by personal
experience or subjective. With time, the institutions undergoing accreditation will realizes that two different assessors
also do not have common joint consensus as far as some of areas related to infection control are concerned and
their statements can be contradictory. There can be incidents where two guidelines are contradictory and in such
cases, organization must be given freedom to follow what is best suitable for their scope. The differences of opinion
should not hamper the autonomy of organization and multiple factors which govern the practices like resources and
manpower, material must be taken in account before arriving at conclusion.

21
Resource material for establishing infection control:
There is a lot of literature and guidelines are available from national and international agencies. There are CDC,
IDSA, HICPAC and NICE guidelines and recommendations. There are WHO guidelines on SSI prevention and also for the
hand hygiene. AORN guidelines are available for nursing in operating theatres. There are WHO guidelines available for
cleaning and disinfection.
Additionally some of certification in infection control are offered by international agencies and national level
some of programs are conducted by various organizations like Shankar netralaya, Infection Control Academy of India
(IFCAI), JIPMER, Tata memorial hospital, Mumbai; Care hospitals, Hyderabad and HIS India and other local associations.
National guidelines on infection control and antibiotic policy for nation is available and downloadable from ICMR which
can act as national document and help in forming institutional policy.
HAIS- ICMR-AIIMS program has been initiated by AIIMS, Delhi in collaboration with CDC and is helping to establish
nationwide surveillance in India and currently limited but hopefully we will have a nationwide surveillance initiating in
stepwise manner. NABH and other accreditation agencies are also collecting Indian data on Hospital acquired infections.
There have been other local surveillance networks like MAHASAR etc. which work at regional level.
Accreditation if taken in appropriate manner can definitely change whole scenario of healthcare in any given
area or for that matter for the whole country provided it is functional in a manner and with discipline and principles of
standardization which it must adhere to.
Accreditation is as such a boring exercise for operational managers as it is involving multiple tasks and enormous
documentation by the same people who are actually involved in doing ground work. For top management, it is a luxury
or stamp of their ability and expertise and for the insurance agencies and other third party agencies it is assurance and
for accreditation agencies it has become a sustainable business.
For infection control practices, accreditation is definitely helpful in establishing process and systems which
are essential to prevent hospital acquired infections and also it has helped organization to divert resources towards
prevention which is becoming very important arm of accreditation. However, at same time, duplication and wasteful
expenditure must be prevented and all the process and procedures should be as per guidelines which are already
published in literature.
At same time, government hospitals or public organization are far from practicing standards of infection control
with just basic facilities in spite of so much advances in modern medicine. The infrastructure is insufficient and
inappropriate, the staff sensitization is not enough and there is lot of inertia from senior administration as far as
resources are concerned. There are few only organization which can be counted in this nation who are government
and accreditated.
To conclude,
There is a long way to go for this nation as far as quality and standardization is concerned. However, journey has
been already started for quality standards as far as healthcare sector in India is concerned, there is optimism that with
visionary leadership and committed leaders, it is definitely possible and with more investments from capital equities,
international funding and medical tourism, there is a lot of scope as well as need to prioritize mechanisms to address
unmet needs as far as infection control practices are concerned.
It is time to realise that complete documentation just for the sake of accreditation purpose is not a substitute for
continuous quality of patient care and services offered by healthcare organizations for becoming better.

22
HOW TO TRAIN THE NURSING PROFESSIONALS IN PREVENTION
OF HOSPITAL/COMMUNITY ASSOCIATED INFECTIONS
Hospital acquired infection (HAI) causes increased pain, suffering, and length of stay, disability, financial cost, and
morbidity.
We know all of this. Now, most HAIs are preventable. This infection control people will tell you is very achievable.
To achieve this aim the most important people associated with this are the nurses. Now nurses are the people who are
the soldiers associated with infection control. Their support and endeavor play a crucial role in helping us.
Now if you ask me are they teaching infection control in nursing colleges as part of its curriculum, they are, but as
unfortunately, we have found out subsequently the curriculum which they have been imparted has not kept up with the
times.
This brings to my most important point. I read an article where a hospital had an outbreak of Stenotrophomonas
maltophilia from the ICU. The source they found was the ventilator, which was not routinely cleaned or sterilized.
This leads me to question my Infection control nurse whether it was being done here. I was safely reassured that it
was being followed here because as a routine our nurses undergo infection control training. This kind of confused me
because I was always given an impression that nurses were taught infection control, then why do they require training?
Training of nurses in infection control is so important because it helps to refresh the knowledge and keep them updated
about recent concepts. What should be in these training modules? I firmly believe we need to talk about a few things.
I will like to list out the important points here.
1. The infectious agent - By this, I mean the disease-causing organism. The traditional vs the newer agents. How they
transmit infection and what infections they can cause.
2. What are healthcare-associated infections caused because of these microorganisms?
3. How to deal with MRSA, MDRO
4. Be able to give instructions to housekeeping
5. Basic principles of infection control like isolation protocols etc, where this should be a continuous evaluator model-
based assessment after which hands-on training is undertaken.
6. Standard precautions of the same need to be taught for the condition
7. The nurses should be able to identify the population at greatest risk for infection and needs to take better care of the
same.
8. How bedside nurses can improve antibiotic use, taking the right doses and timely administration
9. How to improve nurses’ participation in antibiotic use and activities – at both the national and hospital level.
10. Education and training for nurses on simple measures, timely identification of infective syndrome.
11. How to engage nursing leaders in antibiotic stewardship efforts
At the end of the training program, the nurse should be able to identify nursing precautions that are to be taken
to prevent Healthcare-associated infections.
Dr. Ashish Jitendranath
Associate Professor, Department of Microbiology
Sree Gokulam Medical College and Research Foundation,
Venjaramoodu, Trivandrum, Kerala
Email: ashishjit11@gmail.com

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Nope! It is not the novel by Richard Llewellyn. But we still are much like the character Huw Morgan; trying to seek
better hospitable hospital than the dangerous coal mines, both as professionals and as customers.
With the advent of time and advancement of technology money-crunch and escalating expectations
disproportionate to the pocket size has forced healthcare sector to dilute itself for maintaining its existence. This is
more evident in the private healthcare settings. Hardly we get fresh air and adequate sunlight in the closed modern
hospital environment. Irony is that we need more electricity, more effort for maintenance and more dedication to run
this artificial environmental system. So concept of GREEN HOSPITAL is lucrative to us. Accreditation bodies like NABH
also encourage energy-efficient green hospital system.
A green hospital may be defined as one healthcare set up which makes efficient utilization of the natural resources
in environment-friendly manner to cater patient needs. Not only does it cut cost of electricity but also works towards
water conservation. Studies have shown that it can reduce patient recovery time and uplift the psychological status. It
should counteract the so-called sick building syndrome which is a grey zone between mycology and psychology. Staff
also need mental satisfaction in fulfilling their assigned jobs. Green hospitality reduces stress level.
Studies have shown that seasonal affective disorder, a mood disorder characterized by depressive symptoms,
occurs during the darker time of the year when sunlight is dimmer. This could be linked to low vitamin D level
affecting serotonin levels in the brain. Dr. Sebastin Straube has published his data in BMC Public Health where it
was demonstrated that prevalence of vitamin D deficiency is the highest among the shift workers followed by indoor
workers and healthcare workers. He emphasized the effect of sunlight deprivation in long working hours putting
people in risk for vitamin D insufficiency and deficiency. Calcitriol receptor NR1I1 is a member of the nuclear receptor
family of transcription factors. It not only regulates transcriptional responses but also performs micro-RNA directed
post-transcriptional modifications. Thus it is involved in immune modulation. Low vitamin D level has been linked
to tuberculosis (Nnoaham & Clarke,2008), influenza (Grant,2008), HIV (Rodriguez,2009) and viral infections of upper
respiratory tract (Ginde,2009).
Architect, particularly hospital architectural science, is often neglected. A good hospital design should maximize
day light and optimize artificial lighting system. Solar systems could be planned for the latter part of the day to save
electricity consumption. Both direct and diffused natural lights need to be handled. Obviously, the critical areas
like operation theatres, indoor corridors and staircases need good artificial lighting. Good infection control gains its
confidence and compensation from this aspect. Designed glazing facades and translucent skylights appeal to both
aesthetics and infection control. Smart solutions to conserve electricity include LED lighting, occupancy sensors and
necessity-driven task lights.
Indoor air quality is an important aspect in infection control. HVAC systems provide good air control but need
timely inspection and maintenance. Infection control team in association with the engineering team should actively
look into the fresh air requirements, air flow dynamics and aerosol generation and dispersal. Permanent entry-way
systems for dust capturing like grilles helps to control dust. Usually indoor plants reduce volatile organic compounds
from indoor air but in healthcare settings, it is better to avoid them particularly near the patient-care areas. Adequate air
change per hour is mandatory. Often, we underscore ethylene oxide exhaust from CSSD. Copper pipe with appropriate
height is necessary. Actually it is not spending less money but judicious and justified money management that matters.
Housekeeping has remained an integral part of healthcare set up and will continue to stay so. Accumulation
of soil and dust particles is potential source of healthcare-associated infections. Not only effective cleaning but also
efficient schedules should be there. The issue starts with choosing a product for floor mopping. There will be financial
HOW GREEN IS MY VALLEY... ER... HOSPITAL?
Dr Sourav Maiti
Chief Consultant & In-Charge,
Department of Infection Prevention & Control,
Institute of Neurosciences Kolkata
Email: smaiti76@gmail.com

24
constraints and debates but one should choose cleaning products which meet environmental standards. Training is
the part and parcel of green housekeeping. And we should also ensure compatibility of the surface to be cleaned
with the agent for cleaning. Hospital surfaces having the property of repelling &/or resisting microbial growth and
re-growth look smarter. Copper surfaces and metallic surfaces are costly but helpful. These materials are best utilized
in accordance to the high-touch surfaces. Regular cleaning of the biometric attendance finger-pad is often forgotten.
Outside of hospital also plays important role. One hospital in Kolkata has a beautiful garden in front of the
isolation room window. So nice! Bliss of solitude in the form of daffodils is perhaps the best for the isolated soul, be it
Wordsworth or else.
We can make change, we must. Whatever shade your hospital is in presently, can be improved to bring it towards
520-560 nm wavelength, the green spectrum of the rainbow! All that one need is to have clean mind, clean conscience
and good will. I used to tell everyone that hospital is your workplace and if you calculate, you will find that most of the
23 hours, 56 minutes and 4 seconds you are spending in hospital environment. If it is hostile, make it hospitable. Or at
least try to do so!

25
ANTIBIOTIC STEWARDSHIP: A BEGINNER FOR NURSING TEAM!!
• WHAT ARE ANTIBIOTICS?
o Antibiotics are molecules that kill, or stop the growth of, microorganisms.
• WHAT ARE THE VARIOUS CLASSES OF ORGANISMS ON WHICH ANTIBIOTIC ACT?
o Bacteria
o Fungi
o Parasites
o Viruses
• WHAT IS THE MECHANISM OF ACTIONS OF ANTIBIOITCS?
o Antibiotics that kill bacteria are called “bactericidal”
o Antibiotics that stop the growth of bacteria are called “bacteriostatic”
• DEFINE PATHOGEN
o Pathogen: a microorganism that causes disease. Virulence: The disease-evoking severity of a pathogen
• DEFINE VIRULENCE
o Virulence: The disease-evoking severity of a pathogen
• WHAT ARE THE VARIOUS CLASSES OF ANTIBIOTICS?
o β-Lactam antibiotics examples: penicillins (e.g. amoxicillin), cephalosporins, carbapenems, monobactams, etc.
o Tetracyclines example: tetracycline
o Macrolide antibiotics example: erythromycin
o Aminoglycosides examples: Gentamicin, Tobramycin, Amikacin
o Quinolones example: Ciprofloxacin (a fluoroquinolone)
o Cyclic peptides examples: Vancomycin, Streptogramins, Polymyxins
o Lincosamides example: clindamycin
o Oxazolidinoes example: Linezolid
o Sulfa antibiotics example: sulfisoxazole
• DEFINE RESISTANCE
o The ability of a micro-organism, by virtue of which an antiobiotic is not able to exert its action.
Dr. Ankit Gupta
MAX Hospital, Vaishali, Ghaziabad.
Associate Consultant (Microbiology) and
Infection Control Officer-MSSH
Email: doc.ankit83@gmail.com

26
• WHY DOES RESISTANCE DEVELOP?
o The large numbers of bacterial cells, combined with the short generation times facilitate the development of mutants.
o In a typical bacterial population of 1011 bacterial cells (e.g. in an infected patient) there can easily be 1000 mutants.
o If a mutant confers a selective advantage upon the bacterium (e.g. the ability to survive in the presence of an antibiotic)
then that resistant bacterium will be selected and continue to grow while its neighbors perish.
o This can happen in a matter of days in patients being treated with antibiotics.
• HOW TO TACKLE DRUG RESISTANCE?
o By effective infection control measures.
BASICS OF ANTIBIOTIC THERAPY
• ANTIBIOTICS ARE USUALLY EITHER
o BROAD SPECTRUM = effective against a wide range of organisms (such as insects or bacteria)
o NARROW SPECTRUM= effective against only a limited range of organisms
• ANTIBIOTICS ARE USUALLY GIVEN FOR
o PROPHYLAXIS= Measures designed to preserve health (as of an individual or of society) and prevent the spread of
disease
o THERAPEUTICS= A branch of medical science dealing with the application of remedies to diseases
• ANTIBIOTICS ARE USUALLY GIVEN FOR
o EMPIRICAL THERAPY = Relying on experience or observation alone often without due regard for system and theory
o FOR DEFINITIVE THERAPY= Serving to provide a final solution or to end a situation
• THE GOLDEN 9 Rs OF ANTIOBIOTIC ARE
DO I SUPPORT RATIONAL USE OF ANTIBIOTICS?
• Do I want to start an antibiotic?
o No
o Yes
If yes
• Why do want to start an antibiotic?
o I want to start it empirically
o My antibiotic selection is based on evidence

27
My antibiotic selection is based on clinical evidence.
• Do you know the aetiology of infection?
o Bacterial
o Viral
o Fungal
o Tubercular
o Parasitic
• Do you know the type of infection
o Blood stream infection
o Respiratory tract infection
o Urinary tract infection
o Skin and soft tissue infection
My antibiotic selection is based on laboratory evidence
o Can you name any supportive evidence?
My antibiotic selection is based on microbiological evidence
• Do you know the kind of bacteria isolated
o Gram positive
o Gram negative
• Have you considered the location of your patient
o IPD
o OPD
o ICU
• Do you have any information about your institutional antibiogram?
o Yes
o No
• Have you considered your antibiotic on the basis of its mechanism of action?
o Yes
o No
• Have you considered your antibiotic on basis of its MIC (minimum inhibitory concentration)?
o Yes
o No
• Have you considered the correct route of antibiotic administration?
o Yes
o No
• Have you decided on the duration of antibiotic therapy?
o Yes
o No
• Are you starting any restricted antibiotic?
o Yes
o No
• Have you filled up the restricted antibiotic form?
o Yes
o No
• Are you aware of any other infection control processes for your patient?
o Yes
o No

28
CURRICULAR CHANGES IN UNDERGRADUATE
MEDICAL EDUCATION (MCI - 2018)
IMPACT ON MICROBIOLOGY
One of the major goals of the Division of Infectious Diseases is to prepare medical students, residents and young
doctors to become outstanding clinicians and investigators, of the infectious diseases.
MOVING FROM PAST TO FUTURE
The lack of coordination and integration among the Para clinical teachers Microbiology, Pathology, and
Pharmacology with clinical practitioners had made many young Doctors as prescribers and not true physicians. The
consequences have led to uncontrolled and unscientific prescriptions leading to increased cost in patient care and
ever-growing drug resistance making several drugs ineffective and many clinical attached have no fundamental
facilities even to diagnose few life-threatening conditions, It is a great move to change the static and didactic teaching
and training methods by the Medical Council of India, (after 2 decades,) there is great revisions to educate the young
medicos to be understanding the infectious disease process and execute the actions to diagnose treat and prevent the
infectious diseases.
NEW OBJECTIVES
The new objectives expressed in the document (Formulated by MCI) focus on the students to improve skills and
academic thinking to ensure medicine remains attractive and sustainable to the changing needs, however, present
syllabus incorporates much of a complex plan but the professionally competent teachers should integrate the
recommendation to make distribution of infectious diseases is covered including:
Community-acquired acute and chronic infections
Opportunistic infections in immunosuppressed, cancer, transplant and HIV infected patients
Hospital acquired infections.
Training on challenges with Tuberculosis, MDR -TB
Rationalistic use of Antibiotics
Basic infection control practices
The new syllabus incorporates integrated teaching with many to empower the learning microbiology in a direction
that the knowledge will make them Practitioners to diagnose the infectious disease, effectively treat the patients with
a sense that the unnecessary antibiotics can the controlled.
Learning Objectives in the modified curriculum emphasizes upon completion of the lesson. Students will be able
to identify and describe the common transmission mechanisms of infectious diseases identify common infectious
diseases describe types of prevention and treatment methods for infectious diseases.
Teaching and training in medical microbiology continues to be greater importance than other subjects with the
rise of SUPERBUGS, and ANTIMICROBIAL MISUSE, almost many institutions are teaching in lecture format as a primary
teaching modality and Curriculum much based on small group teaching.
New curricular changes will Move from Didactic and seminars to small group teaching (Microteaching) it creates
Dr. T. V. Rao
Former Professor of Microbiology
Email: doctortvrao@gmail.com

29
a free discussion group and is participant-centered and requires much more participation from all members of the
faculty and bringing wider interaction and the initiates the participants themselves take the center stage.
OSPE in Microbiology - Objective structured practical examination is a multi-station, multitask process of
assessment is to assess the cognitive, psychomotor and affective domain of medical undergraduates in laboratory
practical. OSPE methods of examination give the students greater chance to express their knowledge and skill
competency. The current studies also showed a positive perception towards OSPE as an innovative, fair, unbiased,
valid, reliable assessment method.
The new syllabus brings in interdisciplinary approach of the clinicians to be part of Microbiology teachings on
how to use of antibiotics with coordinated lectures to be part of the Microbiology training programs on antimicrobial
stewardship programs within health care systems, to train the young doctors on rationalistic use and reduce the
misuse of antibiotics has increasingly become a national priority with SUPERBUGS AND MDR BACTERIAL STRAINS, as
Antimicrobial stewardship programs have been shown to improve patient care, decrease antibiotic use, and decrease
costs.
Importance of integrated teaching reduces inappropriate ordering of diagnostic or laboratory tests in the
ambulatory setting (emergency department), failure to recognize that a test was required and lack of knowledge of
the appropriate test was most important contributing factors to a breakdown in the ordering of appropriate tests.
Formal instruction in laboratory medicine often occurs in an integrated format (e.g., multidisciplinary system courses
or integrated problem-based curricula).
Simulation-based training is an effective and enjoyable way to train ID fellows in antimicrobial stewardship and
stewardship team utilization. We are planning for senior fellows to assist with conducting simulations. Future studies
could evaluate perceptions of the training from graduates and from surveys of graduate involvement in antimicrobial
stewardship activities, as well as expansion to include interprofessional learners.
Our faculty’s dedication is a key determinant in the success of our program. Post-doctoral trainees and clinicians
pursue the division’s fellowship program, an innovative two to a three-year program to prepare individuals as
consultants in infectious diseases, with fundamental training for a career in academic infectious diseases. We must
delete several unnecessary topics. There should be many topics to be included in the implication of antibiotics on
health and diseases.

30
CHALLENGES FACED IN THE LABORATORY DIAGNOSIS OF
ANAEROBIC INFECTIONS
Dr H Srinivasa
MD Microbiology
(AIIMS, New Delhi)
Free lance Consultant Microbiologist & Infection Control Bangalore
Email: dr.srinivasa.micro@gmail.com
Introduction
Clinical microbiologists during their studies in student period study in detail Anaerobes, namely Clostridia which
cause gangrene, tetanus, pseudo membranous colitis etc.
They are also taught that anaerobes like bacteroides, fusobacterium, anaerobic cocci are predominant normal
flora of skin, oral cavity and intestine. In certain situations, they cross the mucosal barrier and cause infections. So,
these infections are endogenous infections like Urinary tract infections.
However when they practice clinical medicine, the recognition and documentation of anaerobic infections is poor
compared to western world. Why? How come clinical microbiologists do not grow them as much as aerobes in clinical
samples? Since anaerobic methods like jar/gas pack not done in many centers, most of the even good laboratories do
not grow and hence do not recognize their importance.
Hence forth anaerobes mean strict or obligate anaerobes in this article.
Background
Anaerobes are the major component of normal microbial flora. They outnumber aerobes and facultative
anaerobes. The presence of anaerobes is beneficial as they do not allow pathogens to invade the skin or mucosa.
Are anaerobes then pathogens?
It is displacement of anaerobes that makes them pathogenic. To an area where there is necrosis and dead and
dying tissue, less or no blood supply, these factors favor their colonization and multiplication. Thus, most anaerobic
infections are endogenous. Even infections like gas gangrene, tetanus though are exogenous; require the above
conditions to cause disease. Other virulence factors are presence of capsule e.g. in C. wechii, Bacteroides fragilis.
The anaerobes like bacteroides also have, LPS but structurally different from bacteria like E.coli. These virulence
factors have shown in experimental animals to favor abscess formation.
How to suspect anaerobic infection?
If anaerobes cause cellulitis, visceral abscesses, septicemia similar to aerobes then how to suspect anaerobic
infections? Certain predisposing factors like necrotic lesions, sterile pus with culture yielding no growth, Patient not
responding to antibiotics, pus foul smelling... Refer full list. Also visceral abscesses like lung, cerebral, liver, and pelvic
are more likely to be anaerobic.
Concept of anaerobe
I am sitting in the garden getting gentle breeze as I am writing this article. I am enjoying literally the oxygen in the
air, if I am sitting in a closed room for long I can’t continue writing this as I am deprived of Oxygen and my brain can’t
function optimally. In this way I am like aerobe. Anaerobes are just opposite. They don’t like oxygen, In fact oxygen is
toxic to them as they lack two vital enzymes namely catalase and superoxide dismutase. One or both of these enzymes
are present in aerobes hence they overcome oxygen toxicity. Thus anaerobes are cultivated in oxygen depleted Jars.
Another growth factor for anaerobes is Eh redox potential, more towards reducing side will help growth of anaerobes.
The media are also specialized with enriched reducing agents.

31
Anaerobic culture is laborious and not rewarding Is this statement true?
The commonly held view is the methods are labor intensive, economically not viable to lab. Is there a way out of
pessimism?
Challenges in the lab diagnosis
Though majority of pyogenic infections are caused by aerobes and facultative anaerobes, strict anaerobes
constitute a significant proportion of pus producing infections as much as 20 to 30 percent. Many microbiology labs do
well when it comes to aerobes but are not equipped to isolate anaerobes and hence isolation rate is zero. Why?
Though literature documents reporting many anaerobic infections, why many labs though performing well in
aerobes isolation perform poorly when it comes to anaerobic cultivation?
With anaerobic jar and Gas Pack the isolation has not become difficult with quality media. Many anaerobes can
be identified at generic level. Still why are laboratories not performing anaerobic cultures?
The reasons for many laboratories not recognizing anaerobic infections are many.
• Convincing clinicians about its importance.
• Lab may be well equipped with anaerobic cultivation but lack of proper sampling by OPD and ward side staff.
• As even lab is fully equipped, they fail to recover anaerobes which gets lost amidst aerobes.
• Delay in transit also kills them easily.
• Lack of motivation among microbiologists.
• Anaerobic culture is labor intensive.
• Even growth comes in a jar one has to rule out facultative anaerobes. Staining by grams of each and every colony is
important as anaerobic Infections are many times poly microbial.
• Microbiologists not trained are ignorant about practical steps which gram staining is little modification is required to
stain anaerobes in smear from colonies (No acetone, alcohol or mix of acetone and alcohol).
• Poorly trained technicians are also becoming major challenge.
(Let alone anaerobic even aerobic cultivation is suffering now days as technicians are reluctant to do Gram staining.)
Skills needed for anaerobic culture and lab diagnosis
1. Be a good infectious diseases consultant & Create awareness among clinicians as when to suspect anaerobic
infection. They can create awareness lecture on anaerobes in one of the CME or clinical meets e.g. surgical, pulmonary,
Orthopedics and general medicine. Most important is to know what samples are not suitable for anaerobic culture.
2. How to collect and send sample for anaerobic culture?
If you/ your technician are exposed to a culture during of days get trained in a lab where anaerobic cultures are
done. Both of you should be motivated. Without learning from an experienced teacher bench side you can’t do good
anaerobic culture Availability of labs willing to train are very few in our country. This is a big challenge. As said earlier,
knowledge of anaerobes is extensively taught in undergraduate and post graduate programs. However when we step
in to practicing arena, microbiologist leans towards aerobes and antibiotic resistant bacteria which are more common.
Bias is such that there is over diagnosis in sepsis, cellulitis and abscess towards aerobic infections and diseases like
Tuberculosis but under diagnosis of anaerobe infections and they are not considered in differential diagnosis.
What happens if anaerobic infections are not diagnosed, they are not treated properly as all antibiotics are not
effective on anaerobes. Inappropriate diagnosis and treatment result in higher morbidity and prolonged unnecessary
antibiotics, more days of hospitalization and cost. Mortality may also be high.
Classical anaerobic diseases like Gas Gangrene and Tetanus caused by Clostridia which are Gram positive spore
bearing anaerobes are becoming rarer. Clostridium difficile is becoming important but few have facility for isolation. It
is heartening to note that toxin assay is now becoming widely used to diagnose the Cl. Difficile colitis.
The infections caused by Gram negative nonsporing anaerobes present as cellulitis, visceral abscesses and
septicemia. Not treated properly they may cause life threatening infections. The recognition of gram negative
nonsporing anaerobes like Bacteroides, Fusobacterium and anaerobic cocci in clinical samples like pus are very poor as
they are difficult to visualize. They are easily mistaken as cell debris or staphylococci respectively. So anaerobic culture
methods become very important in such scenarios.

32
So to summarize the challenges and possible solutions
1. Relearning of anaerobic infections presentation, stressing to include in clinical differential diagnosis, even if culture
of anaerobes is not practiced Infection control specialists assist in suspicion and proper management of anaerobic
infections.
2. Awareness of suitable sample collection for anaerobic culture is most important. Then even if culture is not practiced,
out sourcing samples which fail to grow aerobes to reference labs will be helpful to certain extent.
3. Motivating technicians to do anaerobic culture by Gas pack method. Training technicians in reference labs where
anaerobic bacteriology exists may pay a dividend in the long run.
4. Microbiologists & Infection control practitioners should browse web for Indian publications on clinically significant
anaerobes and their cultivation. I am sure it will act like a catalyst to enthuse young generation of Microbiologists to
take up the challenge. At least they should learn to keep anaerobic infection presentations in the differential diagnosis.

33
UPCOMING NEWSLETTERS HAVE FOLLOWING THEMES.
1. April 2019 issue – theme is Antibiotic Stewardship Program.
You can contribute your articles through email to doctortvrao@gmail.com and dhruv_mamtora@yahoo.com.
The rules and regulations for the Infection Control Trends newsletter are as follows:-
1. Article has to be written with scientific language and references are to be added in Vancouver style. Mention
all scientific names in italics. Follow font size of 11 with times new roman style with 1.15 line spacing. Article
submission to be done in MS word format only.
2. The high quality images of authors are to be submitted along with articles separately.
3. Article must be submitted by authors only. Articles submitted by students and secretaries of authors will not
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4. If the articles are resent by editorial committee for necessary corrections, all necessary corrections shall be
done and resubmitted within 3 days after receipt of email. The only reason being the context and concept in
which the article is written is with author; hence editors can never judge or write in same manner.
5. Article should be sent one month in advance for themed newsletter.
6. We encourage reviewers for upcoming newsletter so you can submit your names along with CV to editorial
team.
7. Any verbal communication with editorial team members should be done in working hours only between
9:00 AM and 5:30 PM.
8. The purpose of newsletter is to promote scientific content and enhancing research and scientific approach
related to infection control and related topic and not publicity for person or product or services.
9. We appreciate Feedback and suggestions which should be conveyed only through official email.
10. Any queries related to newsletter will be addressed directly to editorial team members.
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