bodily fluids or aerosols that may carry infectious materials such as hepatitis c, hiv, or other blood borne or bodily fluid pathogen. ppe prevents contact with a potentially infectious material by creating a physical barrier between the potential infectious material and the healthcare worker. the united states occupational safety and health administration (osha) requires the use of personal protective equipment (ppe) by workers to guard against blood borne pathogens if there is a reasonably anticipated exposure to blood or other potentially infectious materials. components of ppe include gloves, gowns, bonnets, shoe covers, face shields, cpr masks, goggles, surgical masks, and respirators. how many components are used and how the components are used is often determined by regulations or the infection control protocol of the facility in question, which in turn are derived from knowledge of the mechanism of transmission of the pathogen(s) of concern. many or most of these items are disposable to avoid carrying infectious materials from one patient to another patient and to avoid difficult or costly disinfection. in the us, osha requires the immediate removal and disinfection or disposal of a worker's ppe prior to leaving the work area where exposure to infectious material took place. for health care professionals who may come into contact with highly infectious bodily fluids, using personal protective coverings on exposed body parts improves protection. breathable personal protective equipment improves user-satisfaction and may offer a similar level of protection. in addition, adding tabs and other modifications to the protective equipment may reduce the risk of contamination during donning and doffing (putting on and taking off the equipment). implementing an evidence-based donning and doffing protocol such as a one-step glove and gown removal technique, giving oral instructions while donning and doffing, double gloving, and the use of glove disinfection may also improve protection for health care professionals. guidelines set by the ana and anaa for proper use of disposable gloves include, removing and replacing gloves frequently and when they are contaminated, damaged, or in between treatment of multiple patients. when removing gloves, “grasp outer edge of glove near wrist, peel away from hand turning inside out, hold removed glove in opposite gloved hand, slide ungloved finger under wrist of gloved hand so finger is inside gloved area, peel off the glove from inside creating a ‘bag’ for both gloves, dispose of gloves in proper waste receptacle”. the inappropriate use of ppe equipment such as gloves, has been linked to an increase in rates of the transmission of infection, and the use of such must be compatible with the other particular hand hygiene agents used. research studies in the form of randomized controlled trials and simulation studies are needed to determine the most effective types of ppe for preventing the transmission of infectious diseases to healthcare workers. there is low quality evidence that supports making improvements or modifications to personal protective equipment in order to help decrease contamination. examples of modifications include adding tabs to masks or gloves to ease removal and designing protective gowns so that gloves are removed at the same time. in addition, there is weak evidence that the following ppe approaches or techniques may lead to reduced contamination and improved compliance with ppe protocols: wearing double gloves, following specific doffing (removal) procedures such as those from the cdc, and providing people with spoken instructions while removing ppe. antimicrobial surfaces main article: antimicrobial copper-alloy touch surfaces microorganisms are known to survive on non-antimicrobial inanimate 'touch' surfaces (e.g., bedrails, over-the-bed trays, call buttons, bathroom hardware, etc.) for extended periods of time. this can be especially troublesome in hospital environments where patients with immunodeficiencies are at enhanced risk for contracting nosocomial infections. products made with antimicrobial copper alloy (brasses, bronzes, cupronickel, copper-nickel-zinc, and others) surfaces destroy a wide range of microorganisms in a short period of time. the united states environmental protection agency has approved the registration of 355 different antimicrobial copper alloys and one synthetic copper-infused hard surface that kill e. coli o157:h7, methicillin-resistant staphylococcus aureus (mrsa), staphylococcus, enterobacter aerogenes, and pseudomonas aeruginosa in less than 2 hours of contact. other investigations have demonstrated the efficacy of antimicrobial copper alloys to destroy clostridium difficile, influenza a virus, adenovirus, and fungi. as a public hygienic measure in addition to regular cleaning, antimicrobial copper alloys are being installed in healthcare facilities in the uk, ireland, japan, korea, france, denmark, and brazil. the synthetic hard surface is being installed in the united states as well as in israel. vaccination of health care workers health care workers may be exposed to certain infections in the course of their work. vaccines are available to provide some protection to workers in a healthcare setting. depending on regulation, recommendation, the specific work function, or personal preference, healthcare workers or first responders may receive vaccinations for hepatitis b; influenza; measles, mumps and rubella; tetanus, diphtheria, pertussis; n. meningitidis; and varicella. surveillance for infections main article: disease surveillance surveillance is the act of infection investigation using the cdc definitions. determining the presence of a hospital acquired infection requires an infection control practitioner (icp) to review a patient's chart and see if the patient had the signs and symptom of an infection. surveillance definitions exist for infections of the bloodstream, urinary tract, pneumonia, surgical sites and gastroenteritis. surveillance traditionally involved significant manual data assessment and entry in order to assess preventative actions such as isolation of patients with an infectious disease. increasingly, computerized software solutions are becoming available that assess incoming risk messages from microbiology and other online sources. by reducing the need for data entry, software can reduce the data workload of icps, freeing them to concentrate on clinical surveillance. as of 1998, approximately one third of healthcare acquired infections were preventable. surveillance and preventative activities are increasingly a priority for hospital staff. the study on the efficacy of nosocomial infection control (senic) project by the u.s. cdc found in the 1970s that hospitals reduced their nosocomial infection rates by approximately 32 per cent by focusing on surveillance activities and prevention efforts. isolation and quarantine main article: isolation (health care) further information: pandemic § management, and epidemiology § population based health management in healthcare facilities, medical isolation refers to various physical measures taken to interrupt nosocomial spread of contagious diseases. various forms of isolation exist, and are applied depending on the type of infection and agent involved, and its route of transmission, to address the likelihood of spread via airborne particles or droplets, by direct skin contact, or via contact with body fluids. in cases where infection is merely suspected, individuals may be quarantined until the incubation period has passed and the disease manifests itself or the person remains healthy. groups may undergo quarantine, or in the case of communities, a cordon sanitaire may be imposed to prevent infection from spreading beyond the community, or in the case of protective sequestration, into a community. public health authorities may implement other forms of social distancing, such as school closings, when needing to control an epidemic. barriers and facilitators of implementing infection prevention and control guidelines barriers to the ability of healthcare workers to follow ppe and infection control guidelines include communication of the guidelines, workplace support (manager support), the culture of use at the workplace, adequate training, the amount of physical space in the facility, access to ppe, and healthcare worker motivation to provide good patient care. facilitators include the importance of including all the staff in a facility (healthcare workers and support staff) should be done when guidelines are implemented. outbreak investigation further information: epidemic, pandemic, and syndemic when an unusual cluster of illness is noted, infection control teams undertake an investigation to determine whether there is a true disease outbreak, a pseudo-outbreak (a result of contamination within the diagnostic testing process), or just random fluctuation in the frequency of illness. if a true outbreak is discovered, infection control practitioners try to determine what permitted the outbreak to occur, and to rearrange the conditions to prevent ongoing propagation of the infection. often, breaches in good practice are responsible, although sometimes other factors (such as construction) may be the source of the problem. outbreaks investigations have more than a single purpose. these investigations are carried out in order to prevent additional cases in the current outbreak, prevent future outbreaks, learn about a new disease or learn something new about an old disease. reassuring the public, minimizing the economic and social disruption as well as teaching epidemiology are some other obvious objectives of outbreak investigations. according to the who, outbreak investigations are meant to detect what is causing the outbreak, how the pathogenic agent is transmitted, where it all started from, what is the carrier, what is the population at risk of getting infected and what are the risk factors. training in infection control and health care epidemiology practitioners can come from several different educational streams: many begin as registered nurses, some as public health inspectors (environmental health officers), some as medical technologists (particularly in clinical microbiology), and some as physicians (typically infectious disease specialists). specialized training in infection control and health care epidemiology are offered by the professional organizations described below. physicians who desire to become infection control practitioners often are trained in the context of an infectious disease fellowship. training that is conducted "face to face", via a computer, or via video conferencing may help improve compliance and reduce errors when compared with "folder based" training (providing health care professionals with written information or instructions). in the united states, certification board of infection control and epidemiology is a private company that certifies infection control practitioners based on their educational background and professional experience, in conjunction with testing their knowledge base with standardized exams. the credential awarded is cic, certification in infection control and epidemiology. it is recommended that one has 2 years of infection control experience before applying for the exam. certification must be renewed every five years. a course in hospital epidemiology (infection control in the hospital setting) is offered jointly each year by the centers for disease control and prevention (cdc) and the society for healthcare epidemiology of america. standardization australia in 2002, the royal australian college of general practitioners published a revised standard for office-based infection control which covers the sections of managing immunisation, sterilisation and disease surveillance. however, the document on the personal hygiene of health workers is only limited to hand hygiene, waste and linen management, which may not be sufficient since some of the pathogens are air-borne and could be spread through air flow. since 1 november 2019, the australian commission on safety and quality in health care has managed the hand hygiene initiative in australia, an initiative focused on improving hand hygiene practices to reduce the incidence of healthcare-associated infections. united states currently, the federal regulation that describes infection control standards, as related to occupational exposure to potentially infectious blood and other materials, is found at 29 cfr part 1910.1030 bloodborne pathogens.