Rao MD
Dr.T.V.Rao MD 1
A Tribute to
Ignaz Semmelweiss (1818-1865)
Dr.T.V.Rao MD 2
History of infection control and
hospital epidemiology in the USA
Pre 1800: Early efforts at wound prophylaxis
1800-1940: Nightingale, Semmelweis, Lister, Pasteur
1940-1960: Antibiotic era begins, Staph. aureus nursery
outbreaks, hygiene focus
1960-1970’s: Documenting need for infection control
programs, surveillance begins
1980’s: focus on patient care practices, intensive care
units, resistant organisms, HIV
1990’s: Hospital Epidemiology = Infection control, quality
improvement and economics
2000’s: ??Healthcare system epidemiology
Dr.T.V.Rao MD 4
What is Nosocomial Infection
Any infection
that is not
present or
incubating at the
time the patient
is admitted to
the hospital
Dr.T.V.Rao MD 5
Consequences of Nosocomial
Infections
Additional morbidity
Prolonged
hospitalization
Long-term physical,
developmental and
neurological sequelae
Increased cost of
hospitalization
Death
Dr.T.V.Rao MD 6
Florence Nightingale
It may seem a
strange principle to
enunciate as the
very first
requirement in a
hospital that it
should do the sick
no harm"
Dr.T.V.Rao MD 7
Links to the Chain of
Infection
• Portal of Entry
• Susceptible Host
• Causative Agent
• Reservoir
• Portal of Exit
• Mode of Transmission
Dr.T.V.Rao MD 8
Hospital Infections are Emerging
challenges in Health Care
Hospital-associated infections represent a serious
and growing health problem. The Centers for
Disease Control and Prevention (CDC) estimates
that 2 million people acquire hospital-associated
infections each year and that 90 000 of these
patients die as a result of their infections. A
variety of hospital-based strategies aimed at
preventing such infections have been proposed.
Dr.T.V.Rao MD 9
Modern Hospital Infection
Control
Modern hospital infection control programs first began in
the 1950s in England, where the primary focus of these
programs was to prevent and control hospital-acquired
staphylococcal outbreaks. In 1968, the American Hospital
Association published "Infection Control in the Hospital,"
the first and only standards available for many years. At
the same time, the Communicable Disease Center, later to
be renamed the Centers for Disease Control and
Prevention (CDC), began the first training courses
specifically about infection control and surveillance
Dr.T.V.Rao MD 10
CHAIN OF INFECTION
Dr.T.V.Rao MD 11
Beginning of Accreditation
In 1969, the Joint
Commission for
Accreditation of Hospitals--
later to become the Joint
Commission on
Accreditation of Healthcare
Organizations (JCAHO)--
first required hospitals to
have organized infection
control committees and
isolation facilities.
Dr.T.V.Rao MD 12
CDC Initiates Hospital
Infection Branch
In 1972, the Hospital
Infections Branch at the
CDC was formed and the
Association for Practitioners
in Infection Control was
organized. By the close of
the decade, the first CDC
guidelines were written to
answer frequently asked
questions and establish
consistent practice.
Dr.T.V.Rao MD 13
First Data on Infection Control
Efficacy
In 1985, the Study of the
Efficacy of Nosocomial
Infection Control (SENIC)
project was published,
validating the cost-benefit of
infection control programs.
Data collected in 1970 and
1976-1977 suggested that
one-third of all nosocomial
infections could be
prevented
Dr.T.V.Rao MD 14
Committee Suggested
One infection control
professional (ICP) for every
250 beds. An effective
infection control physician.
A program reporting
infection rates back to the
surgeon and those clinically
involved with the infection.
An organized hospital-wide
surveillance system.
Dr.T.V.Rao MD 15
Infection Control Challenges of
Healthcare in 2000
Decreasing reimbursement
Increasing emerging infections
Increasing resistant organisms
Increasing drug costs
Institute of Medicine Report--healthcare-associated infections
Nursing shortage
OSHA safety legislation
Multiple benchmark systems
FDA legislation on reuse of single-use devices
Dr.T.V.Rao MD 16
The nature of infections
Micro-organisms - bacteria, fungi, viruses,
protozoa and worms
Most are harmless [non-pathogenic]
Pathogenic organisms can cause infection
Infection exists when pathogenic
organisms enter the body, reproduce and
cause disease
Dr.T.V.Rao MD 17
Modes of spread
Two sources of infection:
Endogenous or self-infection - organisms
which are harmless in one site can be
pathogenic when transferred to another
site e.g., E. coli
Exogenous or cross-infection - organisms
transmitted from another source e.g.,
nurse, doctor, other patient, environment
Dr.T.V.Rao MD 18
(Peto, 1998)
Spread - entry and exit routes
Natural orifices - mouth, nose, ear, eye,
urethra, vagina, rectum
Artificial orifices - such as tracheostomy,
ileostomy, colostomy
Mucous membranes - which line most natural
and artificial orifices
Skin breaks - either as a result of accidental
damage or deliberate inoculation/incision (May,
2000)
Dr.T.V.Rao MD 19
HAI - common bacteria
Staphylococci - wound, respiratory and gastro-
intestinal infections
Escherichia coli - wound and urinary tract
infections
Salmonella - food poisoning
Streptococci - wound, throat and urinary tract
infections
Proteus - wound and urinary tract infections
(Peto, 1998)
Dr.T.V.Rao MD 20
HAI - common viruses
Hepatitis A - infectious hepatitis
Hepatitis B - serum hepatitis
Human immunodeficiency virus
[HIV] - acquired immunodeficiency
syndrome [AIDS] (Peto, 1998)
Dr.T.V.Rao MD 21
Components of Infection
Control Programme
The important components of the infection control programme
are:
·Basic measures for infection control, i.e. standard and
additional precautions; · education and training of health care
workers; · protection of health care workers, e.g.
immunization; identification of hazards and minimizing risks;
· routine practices essential to infection control such as aseptic
techniques, use of single use devices, reprocessing of
instruments and equipment, antibiotic usage, management of
blood/body fluid exposure, handling and use of blood and
blood products, sound management of medical waste;
Dr.T.V.Rao MD 22
Need For
Control programme?
Effective work practices and procedures, such as
environmental management practices including
management of hospital/clinical waste, support
services (e.g., food, linen), use of therapeutic
devices; surveillance; · incident monitoring;
outbreak investigation; infection control in
specific situations; and research.
Dr.T.V.Rao MD 23
Developing Infection Control
Programme
Every infection control program should develop a well-
defined written plan outlining the organizational
philosophy regarding infection prevention and control.
The plan should take into account the goals, mission
statement, and an assessment of the infection control
program. It should include a statement of authority, and
should review patient demographics including geographic
locations of patients served by the healthcare system
Dr.T.V.Rao MD 24
Administrative control measures
Assignment of responsibilities
Administrator
Infection
control
nurse/Engineer
Personnel
Responsibility on implementing, monitoring, enforcing, evaluating, and revising
infection control programs on a routine basis including linkage to TB diagnostics 25and
Dr.T.V.Rao MD
other communicable Infections
Infection control
committee
An infection control committee provides a forum for
multidisciplinary input and cooperation, and information
sharing. This committee should include wide
representation from relevant departments: e.g.
management, physicians, other health care workers,
clinical microbiology, pharmacy, sterilizing service,
maintenance, housekeeping and training services. The
committee must have a reporting relationship directly to
either administration or the medical staff to promote
programme visibility and effectiveness.
Dr.T.V.Rao MD 26
Prevention of Hospital
Infection-Planning
LIFECYCLE OF IC PLAN and
Implemented, monitored
enforced IC plan
Educated and trained
Develop
HCW to ensure good work
practices
Counselling and
Evaluate Revise
screening HCW
Implement periodically
Evaluated and revised
plan 4 times
Dr.T.V.Rao MD 27
The Infection Control
Team
Consist of at least an
infection control practitioner
who should be trained for
the purpose; carry out the
surveillance programme;
develop and disseminate
infection control policies;
monitor and manage critical
incidents; coordinate and
conduct training activities.
Dr.T.V.Rao MD 28
Infection Control Committee
Purpose
Advisory
Review ideas from infection control team
Review surveillance data
Expert resource
Help understand hospital systems and policies
Decision making
Review and approve policies and surveillance plans
Policies binding throughout hospital
Education
Help disseminate information and influence others
29 Dr.T.V.Rao MD
Infection Control Committee -
Represented
Committee Representatives
Hospital Epidemiologist
Infection Control Practitioners
Administrator
Ward, ICU and Operating room Nurses
Medicine/Surgery/Obstetrics/Pediatrics
Central Sterilization
Hospital Engineer
Microbiologist
Pharmacist
30 Dr.T.V.Rao MD
Identify problems with polices and procedures
Example: Pre- and Post-Operative Care
create your protocols
Problem Recommendation
Area
Skin shaved the night
Eliminate shaving of skin the
before surgery night before surgery
Inappropriate peri-op Single dose peri-op antibiotic
antibiotic prophylaxis prophylaxis guidelines
Instruments used for Use individual sterile packs of
dressing changes wound care instruments
submerged disinfectant Use small containers of
Large containers of antiseptics; clean and dry
antiseptics, no routine for containers before refilling
cleaning and refilling
31 Dr.T.V.Rao MD
Aims of Infection Control
To review and approve a yearly programme of activity
for surveillance and prevention; to review
epidemiological surveillance data and identify areas for
intervention; to assess and promote improved practice at
all levels of the health facility; to ensure appropriate staff
training in infection control and safety management,
provision of safety materials such as personal protective
equipment and products; and training of health workers.
Dr.T.V.Rao MD 32
Education is the Real Strength of
Infection Control programme
Education programs for employees and volunteers are
one method to ensure competent infection control
practices. It is a unique challenge since employees
represent a wide range of expertise and educational
background. The ICP must become knowledgeable in
adult education principles and use educational tools and
techniques that will motivate and sustain behavioral
change. Much has been written about the education of
healthcare workers (HCWs).
Dr.T.V.Rao MD 33
Minimal Needs to Start
Infection Control Unit
1 Organized surveillance
and control activities
2. One infection control
practitioner for every major
Health Facility.
3. A Trained Hospital
Epidemiologist
4. A system for reporting
surgical wound infection
rates and other infection
back to the practicing
surgeons and physicians.
Dr.T.V.Rao MD 34
GUIDELINES for Effective
Control of Infections
Hand washing and Hospital Environmental Control
* Immunization
* Isolation Precautions
Dr.T.V.Rao MD 36
Your Unwashed Hand a Great
Concern to Your Patient
Dr.T.V.Rao MD 37
Hand Washing is the Foundation
of Infection Control
Hand washing is the single most
important procedure for preventing
nosocomial infections. Hand
washing is defined as a vigorous,
brief rubbing together of all surfaces
of lathered hands, followed by
rinsing under a stream of water.
Although various products are
available, hand washing can be
classified simply by the nature of the
products used:
plain soap
detergents
Antimicrobial containing products
Dr.T.V.Rao MD 38
Hand Washing is the Foundation
of Infection Control
Hand washing with plain soaps
or detergents (in bar, granule,
leaflet or liquid form) suspends
microorganisms and allows them
to be rinsed off; this process is
often referred to as mechanical
removal of microorganisms. In
addition, hand washing with
antimicrobial containing
products kills or inhibits the
growth of microorganisms; this
process is often referred to as
chemical removal of
microorganisms.
Dr.T.V.Rao MD 39
Hand washing Technique
For routine hand
washing, a vigorous
rubbing together of all
surfaces of lathered hands
for at least 10 seconds,
followed by thorough
rinsing under a stream of
water, is recommended.
Dr.T.V.Rao MD 40
Hand washing
Single most effective action to prevent HAI -
resident/transient bacteria
Correct method - ensuring all surfaces are cleaned - more
important than agent used or length of time taken
No recommended frequency - should be determined by
intended/completed actions
Research indicates:
poor techniques - not all surfaces cleaned
frequency diminishes with workload/distance
poor compliance with guidelines/training
Dr.T.V.Rao MD 41
Hand washing – Areas Missed
Taylor (1978)
identified that 89% of
the hand surface was
missed and that the
areas of the hands
most often missed
were the finger-tips,
finger-webs, the
palms and the
thumbs.
Dr.T.V.Rao MD 42
Successful Promotion
in Hand Washing
Education
Routine observation & feedback
Engineering controls
Location of hand basins
Possible, easy & convenient
Alcohol-based hand rubs available
Patient education
(Improving Compliance with Hand Hygiene in Hospitals. Didier Pittet. Infection Control and Hospital
Epidemiology. Vol. 21 No. 6 Page 381)
Dr.T.V.Rao MD 43
Successful Promotion
can Improve Hand Washing
Reminders in theworkplace
Administrative sanctions ??
Change in hygiene agent (not in Winter)
Promote and facilitate skin care
Avoid understaffing and excessive
workload
Dr.T.V.Rao MD 44
Hand Hygiene Techniques
Many Ways
1. Alcohol hand rub
3. Aseptic procedures 1
minute
Dr.T.V.Rao MD 46
Antibiotic resistance
Not a new problem - Penicillin in 1944
Hospital “superbugs”
Methicillin Resistant
Staphylococcus Aureus
[MRSA]
Vancomycin
Intermediate
Staphylococcus Aureus
[VISA]
Tuberculosis - antibiotic
resistant an Emerging
Global Concern
Dr.T.V.Rao MD 47
MRSA
Discovered in 1981
Found on skin and in the
nose of 1 in 3 healthy
people - symptomless
carriers
Widespread in hospitals
and community
Resistant to most
antibiotics
When fatal - often due to
septicaemia
Dr.T.V.Rao MD 48
Hospital Acquired Infections and
Consequences
Incidence of 10%
5,000 deaths per year - direct result of HAI
15,000 deaths per year linked to HAI
Delayed discharge from hospital
Expensive to treat [£3,500 extra]
Cost to NHS - £1 billion per year
Effective hand washing is the most effective preventative
measure
Dirty wards and re-use of disposable equipment also blamed
Dr.T.V.Rao MD 49
The nature of infection
Micro-organisms -
bacteria, fungi, viruses,
protozoa and worms
Most are harmless [non-
pathogenic]
Pathogenic organisms can
cause infection
Infection exists when
pathogenic organisms
enter the body, reproduce
and cause disease
Dr.T.V.Rao MD 50
Staff health
Risk of acquiring and transmitting infection
Acquiring infection
immunisation
cover lesions with waterproof dressings
restrict non-immune/pregnant staff
Transmitting infection
advice when suffering infection
Report accidents/untoward incidents
Follow local policy (May, 2000)
Dr.T.V.Rao MD 51
Waste disposal
Clinical waste - HIGH risk
potentially/actually contaminated waste including
body fluids and human tissue
yellow plastic sack, tied prior to incineration
Household waste - LOW risk
paper towels, packaging, dead flowers, other waste
which is not dangerously contaminated
black plastic sack, tied prior to incineration
Follow local policy (May, 2000)
Dr.T.V.Rao MD 52
Spillage of body fluids
PPE - disposable gloves, apron
Soak up with paper towels, kitchen roll
Cover area with hypochlorite solution e.g.,
Milton, for several minutes
Clean area with warm water and detergent,
then dry
Treat waste as clinical waste - yellow plastic
sack
Follow local policy (May, 2000)
Dr.T.V.Rao MD 53
Standard Precautions
Hand hygiene
Respiratory hygiene and cough etiquette
Personal protective equipment (PPE)
Based on risk assessment to avoid contact with blood, body
fluids, excretions, secretions
Safe injection practices
Environmental control
Patient placement
Dr.T.V.Rao MD 54
Nosocomial Infections are great concern in
Immune compromised Patients
Immunocompromised patients vary
in their susceptibility to nosocomial
infections, depending on the severity
and duration of immunosuppression.
Use of the two tiered system essential
to break the “Chain of Infection”.
Dr.T.V.Rao MD 55
Strengthen the Epidemiology
Epidemiology is the scientific
process applied to the
control of infections in the
healthcare setting.
Dr.T.V.Rao MD 56
Areas of interest to a hospital
epidemiologist
Surveillance for nosocomial
infection
bloodstream infections
Employee health
Disinfection and
pneumonia sterilization
urinary tract infections
Hospital engineering and
surgical wound infections environment
Patterns of transmission of
water supply
nosocomial infections
air filtration
Outbreak investigation
Isolation precautions Reviewing policies and
procedures for patient
Evaluation of exposures
care
57 Dr.T.V.Rao MD
Areas of interest to a Hospital
Epidemiologist
Antibiotic use
Antibiotic resistant
pathogens
Microbiology support
National regulations on
infection control
Infection control
committee
Quantitative methods in
epidemiology
Dr.T.V.Rao MD 58
What is the role of healthcare
epidemiology?
Eliminate or minimize risks to a patient’s
health
organize care to minimize risk
eliminate risk factors
work around risk factors
develop improved policies and procedures
educate physicians and nurses regarding
risks
study risk factors to learn more about them
and how to eliminate them
Dr.T.V.Rao MD 59
Responsibilities of the Infection
Control Program
Surveillance of nosocomial Education of hospital
infections staff on infection
Outbreak investigation control
Develop written policies for Ongoing review of all
isolation of patients aseptic, isolation and
Develop written policies to sanitation techniques
reduce risk from patient care Eliminate wasteful or
practices unnecessary practices
Cooperation with occupational
health
Dr.T.V.Rao MD 60
Key elements of surveillance
Defining as precisely as possible the event to be
surveyed (case definition)
Collecting the relevant data in a systematic, valid way
Consolidating the data into meaningful arrangements
Analyzing and interpreting the data
Using the information to bring about change
61
adapted from R. Haley
Dr.T.V.Rao MD
Areas of interest to a
healthcare epidemiologist
Surveillance for Employee health
nosocomial infection Disinfection and
Patterns of transmission sterilization
of nosocomial infections Hospital engineering and
Outbreak investigation environment
Isolation precautions water supply
Evaluation of exposures air filtration
Reviewing policies and
procedures for patient
care
Dr.T.V.Rao MD 62
Organizing for Infection
Control
Requires cooperation, understanding and
support of hospital administration and
medical/surgical/nursing leadership
There is no simple formula:
Every facility is different
Every facility’s problems are different
Every facility’s personnel are different
The facility must develop its own unique
program
Dr.T.V.Rao MD 63
Methods to reduce cost of
Nosocomial Infections
Reduce incidence
Reduce morbidity
Shorten hospital stay
Reduce costs of treating infections
Reduce costs of preventative measures
Stop ineffective control measures
64 Dr.T.V.Rao MD
Universal infection control
precautions
Devised in US in the 1980’s in response to
growing threat from HIV and hepatitis B
Not confined to HIV and hepatitis B
Treat ALL patients as a potential bio-hazard
Adopt universal routine safe infection control
practices to protect patients, self and
colleagues from infection
Dr.T.V.Rao MD 65
Universal Precautions
Include
Hand washing
Personal protective equipment [PPE]
Preventing/managing sharps injuries
Aseptic technique
Isolation
Staff health
Linen handling and disposal
Waste disposal
Spillages of body fluids
Environmental cleaning
Risk management/assessment
Dr.T.V.Rao MD 66
Personal protective equipment
PPE when contamination or splashing with blood or
body fluids is anticipated
Disposable gloves
Plastic aprons
Face masks
Safety glasses, goggles, visors
Head protection
Foot protection
Fluid repellent gowns (May, 2000)
Dr.T.V.Rao MD 67
Personal protective equipment
PPE when contamination or splashing with blood
or body fluids is anticipated
Disposable gloves
Plastic aprons
Face masks
Safety glasses, goggles, visors
Head protection
Foot protection
Fluid repellent gowns (May, 2000)
Dr.T.V.Rao MD 68
Eliminate waste:
Unnecessary microbiologic monitoring
Routine environmental cultures of walls, floors, air,
sinks, or other hospital surfaces
Routine cultures of healthcare workers nose and hands
Clinical cultures which are not available to clinicians in
time to help with decision making
Also: Failure to generate annual summary of culture data to
provide clinicians with data for empirical selection of
antibiotics
69 Dr.T.V.Rao MD
Practice Aseptic techniques
Sepsis - harmful infection by bacteria
Asepsis - prevention of sepsis
Minimise risk of introducing pathogenic
micro-organisms into susceptible sites
Prevent transfer of potential pathogens
from contaminated site to other sites,
patients or staff
Follow local policy (May, 2000)
Dr.T.V.Rao MD 70
Antibiotic Prophylaxis in
Surgery
Potentially an important part of surgical wound infection
prevention
May also be a significant expense for the hospital
What is the cost-benefit of prophylactic antibiotics?
What is cost of wound infection? In money? In
suffering?
How effective is prophylaxis?
How much can we spend to prevent a case of wound
infection ?
71 Dr.T.V.Rao MD
Sharps injuries
Prevention
correct disposal in appropriate container
avoid re-sheathing needle
avoid removing needle
discard syringes as single unit
avoid over-filling sharps container
Management
follow local policy for sharps injury (May, 2000)
Dr.T.V.Rao MD 72
Protecting Yourself from
Blood-Borne Pathogens
Dr.T.V.Rao MD
HIV: 3 Infections per 1,000 Sticks with a
HIV+ Needle
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Dr.T.V.Rao MD
Hepatitis C: 18 Persons per 1,000
Needle-sticks
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Dr.T.V.Rao MD
Hepatitis B is Most Infectious
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Dr.T.V.Rao MD
Protect Yourself! Get a Hepatitis B Vaccination
and keep your Vaccine Record
3 doses of Hepatitis B
vaccine protect most
people for a lifetime in
Majority of Indivuasls
But HCW blood banks,
and dialysis should
follow the updated
Instructions
The next dose at this
facility will be given on
Dr.T.V.Rao MD Slide 77
Safe Handling of Sharps
Wear gloves when drawing
blood or handling sharps—
double glove for surgery
Don’t recap!
Don’t bend or break needles
Never place used sharps on
tables, beds, furniture
Put used sharps
immediately into a sharps
container
Dr.T.V.Rao MD 78
Disposal of Sharps: The Ideal
Immediately after
use, put sharps in a
leak- proof and
puncture-proof
container
The container should
be within arm’s
length
Sharps Disposal (cont’d)
Disposal containers should be placed at all points
of use
Disposal bin should be rigid and should be leak and
puncture proof
Separate sharps from other waste so laundry workers or
waste disposal staff do not get needlesticks
Dr.T.V.Rao
Slide 80MD
Danger!
Open containers of
used needles like this
put staff at risk each
time they put a hand
in to pick up one
Keep your ward free
of used sharps
Remember this Procedure…
When Injures with a Needle
If a needle pricks you or blood and/or body
fluids
enter your eye(s) or mouth
Wash wounds with soap and water
Flush eyes and mouth with water
Check the patient record to see if the patient is HIV+,
HIV- , or untested
Check patient record for Hepatitis B or C infection
Call the medical duty officer
Slide 82MDimmediately
Dr.T.V.Rao
Protecting Yourself from Blood-Borne
Pathogens (cont’d)
Wear gloves
Dispose of sharps
immediately after use to
Don’t recap needles
minimise handling that
Complete 3 doses of increases risk of
Hep B vaccine needlesticks
Eliminate Substitute safer devices
unnecessary injections or tools whenever
possible
Report needlesticks
Dr.T.V.Rao
Slide 83MD
Prion diseases
Prions [“pree-ons”] - proteinaceous infectious particles
Corrupted form of a normally harmless protein found in
mammals and birds
Causes fatal neurodegenerative diseases of animals and
humans
Animals: scrapie - sheep, bovine spongiform
encephalopathy [BSE or Mad Cow Disease]
Humans: Creutzfeldt-Jakob disease [CJD]
Prions found in blood, tonsil and appendix tissue
Dr.T.V.Rao MD 84
Prions and surgery
Prions cannot be
destroyed by
sterilisation
Theoretical risk of
cross infection from
contaminated
instruments and
blood transfusion
Dr.T.V.Rao MD 85
Wish to be Better Informed Internet
sites
http://www.icna.co.uk/
http://www.nursing-standard.co.uk/
http://www.medscape.com/
http://www.anes.uab.edu/medhist.htm
http://www.shef.ac.uk/~nhcon/
http://medweb.bham.ac.uk/nursing/
http://www.healthcentre.org.uk/hc/library/defa
ult.htm
Dr.T.V.Rao MD 86
Resources: Where to get more
information or help
Training Courses
Society of Hospital Epidemiologists of America (SHEA)
Association of Professionals in Infection Control (APIC)
National courses and congresses
Books
Textbooks: Bennett and Brachman - Wenzel - Mayhall
APIC Curriculum and Guidelines
CDC Guidelines
Journals
Infection Control and Hospital Epidemiology
Journal of Hospital Infections
American Journal of Infection Control
Consulting services
National: CDC, Ministry of Health
Colleagues
Dr.T.V.Rao MD 87
Created by Dr.T.V.Rao MD for ‘e’
Learning resources to Medical and
Paramedical Health Care Workers in
the Developing World
Email
doctortvrao@gmail.com
Dr.T.V.Rao MD 88