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1. Airborne Precaution

2. • An outbreak of 8 healthcare associated TB (6 pts-A-F) and 2 HCWs (G,H)
occurred in a tertiary care hospital. An outbreak investigation was carried out. It
was traced back to pt-A, who was housed at a pulmonary unit 3 months back
with symptoms of chronic productive cough with fever and was noted as an
index case. Pt-B and C were also housed in the same location.
• Pt A was sent for CXR to radiology unit and X-Ray was taken by an X-ray
technician (G).
• On further enquiry, it was found that endotracheal intubation was carried out
for pt-A without any airborne precaution by an intensivist who later was
diagnosed to have TB.
• A provisional diagnosis of bacterial pneumonia was made and Rx was started
for the same. The pt did not show any improvement. 1 week later, appropriate
investigation was carried out following which pt was diagnosed to have PTB.
• Pt-A continued to be housed in the same location which was not well ventilated
without any negative pressure or HEPA filter facility. The HCWs were using
surgical mask while handling the pt. Subsequently (D,E,F) have developed TB.

3. Explanation
The outbreak resulted from airborne cross-transmission of Mtb from an
index pt due to non adherence to airborne precautions.
• Airborne precautions must be initiated when there is a suspicion
(even without confirmation) or infectious agent having airborne
transmission potential.
• However, in this situation, pt-A was admitted with chronic cough, but
airborne precaution was neither initiated at the stage of suspicion,
nor at the confirmation of diagnosis

4. • Inappropriate use of PPE: Pt was not put on surgical mask. HCW was
wearing surgical mask instead of N95
• Improper pt placement: The index case was housed in a location
which was not well ventilated, without any negative pressure or HEPA
filter facility
• Improper transport: Pt was transported to X-ray unit without surgical
mask and X-ray technician also did not wear N95 mask. The
transferring unit was not informed about the infectious status of the
patient
• Improper precaution during aerosol generating procedure:
Endotracheal intubation was carried out without proper airborne
precaution. N95 mask was not worn by the intensivist

5. Droplet precaution

6. • A cluster of cases of URTI occurred in a long-term care facility,
following a group activity held in a common food area of the hospital.
All cases who attended the group activity had food, sitting close to
each other at the dining table. One of the individual who attended the
group activity was already suffering from URTI since 4 days. Due to
the lack of waste-bins in the dining room, used tissues were placed on
the dining room tables. The shared bathrooms were far from the
dining area, therefore hand-hygiene was not performed during the
event. 8 individuals reported symptoms consistent with influenza,
which was later confirmed by molecular test. The annual vaccination
coverage for influenza for the current year was 27.1%

7. Explanation
A cluster of URI cases occurred ina long-term facility following a group activity
where one of the attendants was already suffering from URTI. The factor which
promoted the spread include:
• Overcrowding: Group activity held in a common food area and individuals
had food, sitting close to each other at the dining tables
• Lack of droplet precaution by the index case: The index case did not follow
any measures of droplet precaution such as wearing surgical mask, hand
hygiene etc. He shouldn’t have attended any group activity when suffering
from URTI.
• Inappropriate respiratory hygiene: Due to the lack of waste-bins in the dining
room, used tissues were placed on dining room tables
• Inadequate hand-hygiene due to hand-hygiene facility was far away from the
dining area
• Poor vaccination coverage: The vaccination coverage for influenza was only
27.1%

8. Contact Precaution

9. • A 70 year-old woman after surgery for total knee replacement, is
transferred to the post-op ward. 4 days later, pt develops erythema
and pus discharge at the wound site. Wound swab sent for culture
shows growth of MRSA sensitive only to vancomycin and linezolid.
Total of 10 patients are housed in the same ward and only 2 nurses
are posted. Hand rub is available only at the entrance and at the
nursing station. There is only one stethoscope, BP apparatus and
thermometer in the ward. It is a practice in the ward to use same
gloves continuously due to the shortage of supply. After 2 days,
another pt following appendectomy develops discharge from the
wound site and MRSA grows on culture with the same AST pattern.
• Identify the risks of transmission and type of transmission-based
precaution applicable?

10. Explanation
A cluster of cases of SSI occurred with MRSA infection which resulted
from lack of standard and contact precautions of the index case.
• Inadequate staffing: 10 pts are there in the ward and only 2 sisters
are posted there for their care
• Inaccessibility to hand-rub: Hand-rub are available only at the
entrance and nursing station but not at the bedside
• No pt dedicated equipment: There was only one stethoscope, BP
apparatus, thermometer etc; in the ward
• Inappropriate use of gloves: HCWs are using the same gloves in
multiple occasions without changing them when indicated
• Pt placement not followed: Pt isolation or cohorting are not followed