Shazia Irum, MSC, MBA, RN, CIC, CPHQ, CBIC Ambassador in Saudi Arabia, infection control specialist at King Salman Center for Kidney Diseases Ministry of Health, Kingdom of Saudia Arabia, in Riyadh, Saudia Arabia. 

Shazia Irum, MSC, MBA, RN, CIC, CPHQ

Shazia Irum, MSC, MBA, RN, CIC, CPHQ, FAPIC, a new member of Infection Control Today®’s (ICT®’s) Editorial Advisory Board, answers a quick question about emerging respiratory viruses.
Irum is also a Certification Board of Infection Control and Epidemiology, Inc, Ambassador, located in Riyadh, Saudi Arabia.

: If you were advising hospital leadership or public health agencies today, what practical investments or policy changes would you recommend to better prepare for emerging respiratory viruses that may already be circulating under the radar?


Shazia Irum, MSc, MBA, RN, CIC, CPHQ, FAPIC: 

From my perspective, effective preparedness for emerging respiratory viruses requires a deliberate transition from episodic emergency response to sustained, evidence-based system strengthening. 

A critical priority is the investment in integrated surveillance infrastructures that link clinical syndromic data, laboratory diagnostics, genomic sequencing, and environmental surveillance, including wastewater monitoring. Such integrated platforms enhance the capacity to detect atypical transmission signals early, often before they manifest as increased health care utilization, thereby enabling timely, data-driven interventions.
Equally important is the strategic development of the health care workforce. Preparedness policies should mandate continuous competency-based training in infection prevention and control, respiratory pathogen management, and appropriate use of personal protective equipment. 

These competencies must be reinforced through routine drills and simulation-based exercises embedded within standard operational planning, rather than activated solely during declared outbreaks. In parallel, workforce sustainability should be recognized as a core preparedness asset, as staff fatigue, burnout, and attrition significantly compromise surge response capabilities.


Targeted investments in health care infrastructure are also essential. Modernization of ventilation systems, expansion of adaptable isolation capacity, and deployment of rapid, scalable diagnostic technologies strengthen day-to-day clinical operations while providing critical flexibility during periods of emerging respiratory threats. These measures support both infection mitigation and continuity of care.


At the policy level, robust and standardized data-sharing frameworks between health care institutions, public health agencies, and international partners are indispensable. Early exchange of epidemiological and virological information facilitates coordinated risk assessment and response across jurisdictions. 

Furthermore, strengthening risk communication policies grounded in scientific transparency is vital to maintaining public trust and adherence to preventive measures.

In my view, true preparedness is not defined by emergency plans alone, but by the integration of surveillance, workforce readiness, infrastructure resilience, and governance into routine health system function, ensuring adaptive capacity for respiratory viruses circulating below the threshold of immediate detection.





Articles

Shazia Irum, MSC, MBA, RN, CIC, CPHQ, FAPIC, a new member of Infection Control Today®’s (ICT®’s) Editorial Advisory Board, answers a quick question about emerging respiratory viruses.

What Is Effective Preparedness for Emerging Respiratory Viruses? Shazia Irum, MSC, MBA, RN, CIC, CPHQ, FAPIC, answers

(Adobe Stock 867731678 by Penn/peopleimages.com)

The immunocompromised host is a person with impairments in the body’s normal defense mecha­nisms against infection.

 Patients who are immunocompromised are suscep­tible to bacterial, fungal, viral, and par­asitic infections that healthy immune systems usually overcome. They are also more susceptible to complications from common infections.

Unfortunately, many patients requiring dialysis are at a higher risk for acquiring infection due to critical illness and multiple comorbidities such as diabetes, heart disease, and immuno­suppression. Along with comorbidities, these patients will also require some form of invasive access into their vas­cular system or peritoneal cavity.

 Any failure along the spectrum of dialysis treatment, from staff education and hand hygiene to machine and station disinfection, will increase a patient’s risk for infection or adverse reaction.

Patients with end-stage kidney dis­ease (ESKD) treated with hemodialysis (HD) are at substantially increased risk of life-threatening infections. Most bloodstream infections are related to vascular access, of which 70% are associated with using a central venous catheter (CVC).

 Infections result in sig­nificant morbidity and are second only to cardiovascular diseases as a cause of mortality in patients with ESKD. In addition, lapses in infection control practices, such as hand hygiene and environmental cleaning, have been associated with bloodstream infections and hepatitis C virus (HCV) outbreaks.

The role of infection preventionists in mitigating the risk of infections in patients undergoing dialysis is highly challenging due to multiple factors such as the immunocompromised state of patients, underlying medical conditions, frequent hospitalizations, exposure to vascular access for cannulation, central line access, contamination of dialysis water, risk of transmission of blood-borne viruses (BBVs), recurrent bloodstream infections, antimicrobial resistant colo­nization of methicillin-resistant 

(MRSA), multidrug-resistant organisms, and many more.

 Infection risk assessment is the keystone of preven­tion for patients who are immunocom­promised and are undergoing dialysis, leading to implementing preventive actions in their treatment plans.

 The following preventive strategies are highly effective and recommended as a compre­hensive approach to combat infections in this vulnerable population.6

Consistent Implementation of Standard Precautions

Effective hand hygiene, glove use, and environmental surface disinfection can prevent contact transmission. An adequate number of easily accessible handwashing sinks should be available (one for every 2 to 4 chairs/beds).

 An alcohol hand rub device (wall-mounted dispenser or desktop pump bottle) should at least be available for every patient’s chair/bed. During HD, expo­sure to blood and potentially contami­nated items is routinely anticipated and gloves are required when caring for a patient or touching the patient’s equip­ment. Wearing fluid-resistant gowns, face shields, protective eyewear, and surgical masks is highly recommended to protect staff during initiation and termination of the dialysis sessions, insertion of a dialysis catheter, manip­ulation of patient’s access at any time, and cleaning of the dialysis station.

Prompt implementation of trans­mission-based precautions for patients at increased risk for transmission of pathogenic bacteria, including antimicrobial-resistant strains (eg, those infected or colonized with MRSA or vancomycin-resistant Enterococci), and additional precautions (ie, con­tact precautions) must be followed during the dialysis session. To prevent the transmission of respiratory infec­tions among patients undergoing HD, including COVID-19, appropriate droplet/ airborne precautions are necessary.

 Patients should be screened through a triage clinic before entering dialysis units and isolated based on their infec­tious status.

Restrict the use of standard sup­plies, medications, instruments, and medication trays, and avoid using a standard medication cart. Single-use medication vials should be used whenever available.6 When a multi­dose vial is used, dedicate it to a single patient whenever possible. If the multi­dose medication is brought to the patient treatment area, it should be discarded and not returned or used for another patient. The vial should be discarded if sterility is compromised or questionable.

Cleaning and Disinfection of Surfaces and Equipment

After each patient treatment session, all surfaces at the dialysis station should be cleaned and disinfected with hospital-approved, US Environmental Protection Agency–registered intermediate-level disinfectant. Special attention and focus should be paid to the control panels on the dialysis machine and other surfaces that are frequently touched and poten­tially contaminated with the patient’s blood. Proper contact time (per manufac­turer) of disinfectant is crucial to ensure maximum efficacy of the product.

Annual immunization against influenza is recommended for patients with ESKD who are at increased risk of complications from influenza. Routine immunization against hepati­tis B virus (HBV) is recommended for all patients with ESKD (ideally before starting HD) and all staff members.

 Hepatitis B surface antigen (HBsAg) and hepatitis B surface antibody (HBsAb) titers should be obtained before starting dialysis, and HBsAg titers should be checked monthly if HBsAb titers are not at the desired level (nonresponders)

Additionally, vaccinations for pneumo­coccal pneumonia, shingles, and SARS-CoV-2 are highly recommended for all patients undergoing dialysis.

The transmission of HBV and HCV in HD units has been documented. Compliance with hand hygiene practices and glove use continues to be the most effective way to prevent the transmis­sion of BBVs in dialysis units. Dedicated separate rooms for treatment of patients infected with HBV are mandatory. Des­ignated machines, equipment, instru­ments, medications, and supplies should be used exclusively for patients infected with HBV (ie, they will not be used by patients susceptible to HBV-suscepti­ble patients). There is no consensus to segregate patients with HCV and those with HIV; transmission between patients within the dialysis environment can be prevented by strict compliance with the infection control precautions (ie, stan­dard precautions) recommended for all patients undergoing HD.

Prevention of Vascular Access and Bloodstream Infections

Arteriovenous fistula (AVF)/arterio­venous graft access should be encouraged to reduce central line–associated blood­stream infections. Sterile preparation of the skin over the fistula site (creation of sterile field, use of sterile barriers and sterile gloves) is not more effective in pre­venting infection than clean technique (clean barriers and clean gloves with strict attention to aseptic technique).

 All patients should be encouraged to wash their access site with soap and water daily before the HD session. If a catheter must be used for access for longer than 3 weeks, a tunneled, cuffed CVC should be used (if possible, it should not be placed on the same side as a maturing AVF access point).

 The preferred insertion site is the right internal jugular vein. Cathe­ters should be inserted using maximal sterile barrier precautions. Emphasis should be placed on the principles of asepsis when accessing or caring for central venous access. Chlorhexidine is highly recommended as an antiseptic for cleaning and disinfecting the vascular access of patients undergoing dialysis.

Measuring and tracking infection rates and using this information are essential to infection prevention in patients undergoing dialysis. This surveillance occurs in outpatient HD centers where patients are monitored and reported for 3 defined events: use of intravenous antimicrobials, positive blood culture results, and pus, redness, or increased swelling at the vascular access site.

 Reviewing dialysis event data and running analysis reports should be done regularly to prevent bloodstream and vascular access infections and be used for quality improvement initiatives.

The incidence of serious infections among patients receiving maintenance HD remains unacceptably high. Acquisition of infections in HD facilities is often due to suboptimal infection control practices, and 100% use of recommended infection control guidelines is essential to prevent infections in this vulnerable population.

Prevention efforts may require that HD organizations devote more significant resources to ensure the implementation of infection control practices. To lead these efforts successfully, medical directors and other nephrologists must understand and champion the CDC infection control practice guidelines. When nephrologists lead by example and collaborate closely with nursing management and staff, we may achieve our target of zero preventable infections and reduce infection-related morbidity and mortality.

1. Flood A. The immunocompromised host. In: 

Association for Professionals in Infection Control and Epidemiology; 2014. Accessed January 23, 2025. https://text.apic.org/toc/microbiology-and-risk-fac­tors-for-transmission/the-immunocompromised-host

2. Bula-Rudas FJ. Infections in the immunocom­promised host. Medscape. Updated May 22, 2024. Accessed January 23, 2025. https://emedicine. medscape.com/article/973120-overview

3. Garcia-Houchins S, Rindels J. Dialysis. In: 

Association for Professionals in Infection Control and Epidemiology; 2014. Accessed January 23, 2025. https://text.apic.org/toc/infection-preven­tion-for-specialty-care-populations/dialysis

4. Vijayan A, Boyce JM. 100% use of infection control procedures in hemodialysis facilities: call to action. 

. 2018;13(4):671-673. doi:10.2215/CJN.11341017

5. Guidelines, recommendations and resources. CDC. January 21, 2024. Accessed January 23, 2025. https://www.cdc.gov/dialysis-safety/hcp/recom­mendations-resources/index.html

6. Alkelany A, Tawfeeq S, Al Slaleh A, Assiri Y, Alshawaiqi A. 

Infection Control Guidelines in Hemodialysis Units. 

Ministry of Health of Saudi Arabia. November 2020. Accessed January 23, 2025. https://jed-s3.bluvalt.com/psj1-ifn-s3-ifn01/files/03/ Guidelines/Infection-Control-Guidelines-in-Hemo­dialysis-Units.pdf

National Healthcare Safety Network. January 2024. Accessed January 23, 2025. https://www.cdc.gov/nhsn/pdfs/ pscmanual/8pscdialysiseventcurrent.pdf

Patients undergoing dialysis are especially vulnerable to infection due to weakened immunity, invasive access procedures, and frequent hospitalizations, making stringent infection control essential.

Silent Threat: The Overlooked Infection Crisis in Dialysis Patients

Infection Control written on a keyboard button 

In a world where competition for jobs, pay increases, and academic success continues to increase, certifications offer hope because they are a credible, third-party assessment of one’s skill and knowledge for a given subject.

Certification in infection prevention and control is a standardized measure of the basic knowledge, skills, and abilities expected of infection prevention and control (IPC) professionals.

 The main purpose of certification is to protect the public by providing a standardized measure of knowledge required for IPC professionals. In addition, it encourages individual growth and study.

The Certification Board of Infection Control and Epidemiology (CBIC) independently sets the standard for infection prevention competency, accrediting the certified in infection control (CIC) credential, recognized as the profession's benchmark.

 Using real-world practice data, CBIC ensures alignment with industry standards through ongoing research and testing.

The importance of certification could be determined by evaluating the relationship between certified infection preventionists (IPs) and the quality of patient care. Certified IPs are well-versed in interpreting evidence and acting as champions for key infection prevention practices within their health care facilities. 

Many infection preventionists have a nursing degree, but it isn't required. 

Additionally, certified IPs may have a stronger understanding than other practitioners of the evidence for certain infection prevention and control activities.3Health care facilities with certified IP leads significantly reduce their health care-associated infections.

 Also, performance organizations recognize that credentialed staff is a vital indicator to patients and employers that their professionals are qualified and proficient.

The demand for certification is increasing daily in the growing infection prevention and control field.

 For IPC professionals, obtaining certification is instrumental in their professional growth and career advancement, such as recognition of expertise, professional development, enhanced job performance, higher salary compensation, and improved patient outcomes.

 There are more opportunities for those with the CIC credential than for those without the credential.

One study found that certified IPs make an average annual salary of $85,911 compared with noncertified IPs, who make an average annual salary of $68,817.5,

 The certification of IPs in health care settings represents the individual’s and their institution’s dedication and commitment to infection prevention and control practices.

 Additionally, acquiring a CIC increases the marketability of IPs in the job market.

Results from one study found that at least 46% of IP job openings in the US required a CIC. State legislation in many states now requires certified IPs in hospitals and long-term care facilities, increasing a certified IP's marketability. In 2007, Goldrick reported that 30% of employers required the CIC credential to apply for or maintain employment.

Currently, CBIC offers 3 different levels and varieties of certification: CIC, a-IPC, and LTC-CIP.

 The most popular and significant certification in infection control, with certain eligibility criteria of educational background and experience to be combatted before applying for the examination. Additionally, the individual must be directly responsible for implementing infection prevention activities in their facilities, which are based on exam content outline and competencies to be covered, such as 

 Identification of Infectious Disease Processes, 

. Surveillance and Epidemiologic Investigation, 

ontrolling the transmission of infectious agents, 

Cleaning, disinfection, sterilization, asepsis, and at least 2 of the remaining 3 components: 

 This is a basic and entry-level certification that does not necessarily require specific job experience in infection prevention and control. It is specifically designed for those who want to gain knowledge and expertise in the IPC field and embrace infection control as a career path.

This certification is offered particularly to those working in long-term care facilities.

The trend of obtaining infection control certification has increased in recent years, especially in Middle Eastern countries like Saudi Arabia, which is at the top in having certified IPs working among others outside North America. A survey analysis conducted by the CIC Academy (virtual study group) in Saudi Arabia showed that more than 20% of the respondents shared that certification was compulsory for them to get a job in a reputable organization. However, more leadership support is needed to strengthen the collaboration between ministries and organizations to support and acknowledge their professionals to pursue certification and to be accredited for their skills.

As an IP, my beliefs and experience clearly show that certification offers several benefits at the personal and facility levels. After my CIC, I gained so much confidence in making the right evidence-based decisions for the safety of my patients, staff, and others in my facility. I found that certification is the best opportunity to validate professional skills and expertise.

To explain the career path of an IP, APIC has announced its new 

Infection Preventionist Career Development & Advancement Guide.

To ensure the safety of patients and staff in health care settings, it is essential to keep up with the most up-to-date safety and prevention strategies for infection control and the reduction of communicable diseases. Moreover, certification in infection control can help you stand out from the competition by showing your commitment to education and excellence in the field, which is indispensable in today’s competitive job market.

Certification: The Defining Difference. Association for Professionals in Infection Control and Epidemiology. Accessed on May 9, 2024. 

https://apic.org/policy-priorities/certification-the-defining-difference/

Crist KS, Russell BS, Farber, MR. The Value of Certification and CIC Credential. 

What is Certification in Infection Control (With Benefits). Indeed. Accessed on May 9, 2024. 

https://ca.indeed.com/career-advice/career-development/certification-in-infection-control

Marx JF, Callery S, Boukidjian R. Value of certification in infection prevention and control. 

Knighton SC, Gilmartin HM, Reese SM. Factors affecting annual compensation and professional development support for infection preventionists: implications for recruitment and retention. 

 2018;46(8):865-869. doi:10.1016/j.ajic.2018.03.009

Benefits of Achieving Certifications and Trainings in the field of Infection Prevention and Control. 

https://www.infectioncontroltoday.com/view/benefits-achieving-certifications-training-field-infection-prevention#

Reesem SM. The benefits of achieving certifications and training in the field of infection prevention. 

Guidelines for CIC Certification. Certification Board of Infection Control and Epidemiology, Inc. Accessed May 14, 2024. 

https://www.cbic.org/CBIC/Candidate-Handbook/Eligibility-Guidelines.htm

Certification in infection prevention and control is essential for career growth, higher salaries, and improved patient outcomes. Learn why certification matters from Shazia Irum, MSC, MBA, RN, CIC, CPHQ, CBIC Ambassador in Saudi Arabia.


The Value of Certification in Infection Prevention and Control: Why Is it important?

Vascular access-related infection is a second major cause of mortality among end-stage renal disease patients undergoing hemodialysis (HD). Dialysis patients require vascular access to deliver their renal failure treatment. Commonly used vascular accesses are arteriovenous fistula (AVF), arteriovenous graft (AVG), and central lines.

 Vascular access-related infection is highest when central venous dialysis catheters are employed. Native arteriovenous fistulas carry the lowest risk of infection.

 Unfortunately, prosthetic arteriovenous grafts, which represent the most common type of HD access in the United States, have been repeatedly shown to be a risk factor for bacteremic and nonbacteremic infections. High proportions of infections related to vascular access are caused by staphylococcal organisms, which carry high mortality rates, recurrence, and metastatic complications.



Several studies have attempted to define catheter-related bacteremia (CRB) risk factors.

 Both the insertion site and the use duration influence the infection rate. Femoral catheters are more susceptible to infections than thoracic catheters. This may relate to the accumulation of sweat and moisture around the exit site. The type of catheter and site of insertion significantly impact the involvement of catheter-related infections, such as tunneled and cuffed catheters, are considered as a low incidence of bacteremia compared to non-tunneled catheters.

 Similarly, temporary HD catheters placed in the internal jugular vein are associated with higher infection rates than those placed in the subclavian vein.



However, these outcomes should not justify the routine use of subclavian veins for HD catheters for 2 reasons. First, these findings may not apply to tunneled catheters. Second, the subclavian location carries the highest rate of catheter-associated central venous stenosis. The duration of catheter use is also essential as the risk of infection increases linearly with time.



Nurses, medical providers, dialysis technicians, and others who work in dialysis facilities face the difficult task of managing the complex circumstances affecting their patients while concurrently focusing on reducing the risk of infection for these at-risk individuals. CDC’s core interventions have been proven to reduce dialysis bloodstream infections and can help to improve the quality of vascular access in dialysis patients.



Staff Education and Training
Educating health care providers regarding the appropriate need and use of intravascular catheters and the proper insertion techniques can significantly reduce the risk of vascular infections in dialysis patients. Periodic competency assessment and appropriate staffing ratio is another supportive intervention in preventing infections.

Selection of Vascular Access
The use of fistula and graft in chronic kidney disease patients for their dialysis treatment is highly recommended.

 Subclavian sites in dialysis and chronic kidney disease patients should be avoided as much as possible to prevent the long-term complication of central venous stenosis. Avoiding using femoral sites for central line insertion in adult patients also significantly reduces bloodstream infections.

Use of Aseptic Technique
Performing hand hygiene procedures and following strict aseptic measures are core considerations in preventing vascular access-related infections. Wearing either clean or sterile gloves when changing dressings on central lines is acceptable; however, to ensure maximal barrier precautions, cap, sterile gloves, sterile gown, and sterile full body drape are highly recommended during the insertion of central lines.

Antibiotic Lock Prophylaxis
Using prophylactic antimicrobial lock solution in patients with long-term catheters who have a history of multiple catheter-related bloodstream infections (CRBSI) despite optimal maximal adherence to aseptic technique is a recognized approach to reduce the incidence of BSI among dialysis patients.



Patient Education and Engagement
Provision of standardized education to all patients on infection prevention topics, including vascular access care, hand hygiene, risks related to catheter use, recognizing signs of infection, and instructions for access management when away from the dialysis unit is one of the highly impactful preventive measures. Patients with fistulas should be instructed to wash their access site with soap and water before cannulation during each dialysis session. Patients dialyzed through central lines need to be instructed not to change their dressings at home. Also, they should avoid merging the catheter insertion sites in water. Prompt reporting of local site infections around vascular access, such as pus, increased swelling, and redness, is required.

Catheter Skin Preparation
According to CDC, >0.5% chlorhexidine preparation with alcohol before central venous catheter insertion and during maintenance care is advisable. If there is a contraindication to chlorhexidine, a tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives.



Reduction
One of the highly effective core interventions is to reduce the number of central lines in dialysis patients. Early initiation of fistulas is highly recommended during stages 4 and 5 of end-stage renal disease. Incorporate efforts (eg through patient education, vascular access coordinator) to reduce catheters by identifying and addressing barriers to permanent vascular access placement and catheter removal.



Surveillance and Feedback Using NHSN
Conducting monthly surveillance for BSIs and other dialysis events using the 

National Healthcare Safety Network (NHSN)—Dialysis Surveillance

 Calculating facility rates and comparing them with other NHSN facilities. Actively sharing results with front-line clinical staff is a highly effective strategy to ensure maximum staff compliance to reduce vascular access infections in dialysis patients. Another source is CDC audit tools and checklists for BSI prevention in dialysis patients.



References
1. Gulati S, Sahu KM, Avula S, Sharma RK, Ayyagiri A,  Pandey CM. Role of vascular access as a risk factor for infections in hemodialysis. 

. 2003;25(6):967-973. doi:10.1081/JDI-120026031
2. Nassar GM, Ayus JC. Infectious complications of hemodialysis access. 

10.1046/j.1523-1755.2001.00765.x
3. Kairaitis LK, Gottlieb T. Outcome and complications of temporary haemodialysis catheters. 

. 1999;14(7):1710-1714. doi:10.1093/ndt/14.7.1710
4. Dialysis component. Centers for Disease Control and Prevention. March 30, 2023. Accessed August 22, 2023.
5.  Summary of recommendations. Centers for Disease Control and Prevention. February 2017. Accessed August 22, 2023. https://www.cdc.gov/infectioncontrol/guidelines/bsi/recommendations.html
6. Audit Tools and Checklists. Centers for Disease Control and Prevention. January 11, 2023. Accessed August 22, 2023.
7. Shahar S, Mustafar R, Kamaruzaman L, Periyasamy P, Pau KB, Ramli R. Catheter-related bloodstream infections and catheter colonization among haemodialysis patients: prevalence, risk factors, and outcomes. 

2021:5562690. doi:10.1155/2021/5562690
8. Kumbar L, Yee J. Current concepts in hemodialysis vascular access infections. 

 2019;26(1):16-22. doi:10.1053/j.ackd.2018.10.005
9. Health Services Advisory Group. Reducing dialysis related infections and hospitalizations. Susan Moretti. End-stage renal disease network 15. September 19, 2018. Accessed August 22, 2023. https://health.wyo.gov/wp-content/uploads/2018/09/Moretti-ReduceDialysisRelatedInfHos508.pdf








Staphylococcal organisms, which have high mortality rates and can cause recurrence and metastatic complications, are responsible for a significant proportion of infections related to vascular access.

Shazia Irum, MSC, MBA, RN, CIC, CPHQ

Articles

What Is Effective Preparedness for Emerging Respiratory Viruses? Shazia Irum, MSC, MBA, RN, CIC, CPHQ, FAPIC, answers

Silent Threat: The Overlooked Infection Crisis in Dialysis Patients

The Value of Certification in Infection Prevention and Control: Why Is it important?

How to Prevent Risk of Vascular Access-Related Blood Stream Infections in Patients Undergoing Hemodialysis