Hospital Communicable Diseases Surveillance Protocols Primer. Key Infec:on Preven:on and Control Lapses in the Clinical Office

Transcription

1 OEMAC 33 rd Scien/fic Conference September 29, 2015; 2:50-3:15 Hospital Communicable Diseases Surveillance Protocols Primer Key Infec:on Preven:on and Control Lapses in the Clinical Office Dr. Maureen Cividino FCFP DOHS CCBOM CIC SJHH, IPAC Physician, PHO

2 Learning Objec/ves Describe updates to hospital based communicable disease surveillance protocols, including changes in recommended immuniza/on, surveillance and post- exposure prophylaxis based on the OHA/OMA Communicable Disease Surveillance Protocols for Ontario Hospitals Recommend safe injec/on prac/ces in the clinical office sesng to avoid bacterial and blood- borne pathogen outbreaks Outline cri/cal infec/on preven/on and control best prac/ces in an office sesng, including basic parameters for reprocessing medical equipment 2

3 Communicable Diseases Surveillance Protocols (CDSPs) CommiXee Recent events have proven that disease and viral outbreaks in Ontario remain a real and serious threat CommiXee involves collabora/on between OHA member hospitals, the Ontario Medical Associa/on and the Ministry of Health and Long- Term Care In accordance with Regula/on 965, Sec/on 4 of the Public Hospitals Act, the CommiXee produces protocols which apply to all people who carry out ac/vi/es within hospitals 3

4 CDSPs Adenovirus Protocol Revised February 2014 An:bio:c Resistant Organisms Protocol Revised May 2015 Blood Borne Diseases Protocol - Reviewed Revised March 2015 Cytomegalovirus Protocol Revised May 2015 Enteric Diseases Revised February 2014 Group A Streptococcal - Dec 2014 Herpes Simplex October 2014 Influenza Protocol - Revised July

5 CDSPs Measles Protocol revised July 2015 Meningococcal Disease Protocol Revised February2014 Mumps Protocol Revised July 2015 Parvovirus Oct 2014 Pertussis Protocol Revised February 2014 Rubella Protocol Revised July 2015 Scabies Protocol Revised Nov 2014TB Protocol Revised Aug 2014 Varicella Protocol - revised Aug

6 Adenoconjunc/vi/s Conjunc/vi/s ( pink eye )caused by bacteria and viruses, but adenovirus primary cause of outbreaks of conjunc/vi/s in health care sesngs Nosocomial outbreaks occur primarily in eye clinics/offices, but occasionally in NICUs and LTC homes Onset typically sudden with pain, watery discharge, photophobia, blurred vision, low grade fever, malaise and preauricular lymphadenopathy. Corneal infiltrates may interfere with vision for weeks to months; in severe cases, permanent scarring may result Bacterial conjunc/vi/s usually presents with muco- purulent or purulent discharge and crus/ng 6

7 Adenoconjunc/vi/s Incuba/on period 5-12 days; viral shedding from late incuba/on period to 14 days aeer onset Transmission by direct contact with eye secre/ons or indirect contact with contaminated surfaces, instruments or solu/ons; Trauma or eye manipula/on increases infec/on risk Adenovirus may survive on surfaces for prolonged periods No effec/ve an/viral therapy available Acute Disease: cannot provide pa/ent care from the /me of onset for 14 days.if the second eye becomes infected must wait an addi/onal 14 day Purulent conjunc/vi/s restricted from pa/ent care for the dura/on of symptoms and instructed on proper hand hygiene. 7

8 An/bio/c Resistant Organisms (AROs) Resistant to mul/ple an/bio/cs; treatment op/ons can be more limited, more toxic, and/or more expensive Healthcare associated AROs are generally not more virulent or more transmissible than an:bio:c suscep:ble strains HCWs more likely to be colonized than acutely ill Methicillin resistant Staphylococcus aureus (MRSA) that are community associated (CA- MRSA) contain virulence factors that allow them to cause serious illness in otherwise healthy individuals 8

9 AROs Methicillin- resistant Staphylococcus aureus (MRSA) S. aureus resistant to all the beta- lactam classes of an/bio/cs Vancomycin- resistant enterococcus (VRE) defined as Enterococcus faecalis or E. faecium with acquired resistance to vancomycin* Extended- spectrum beta- lactamases (ESBL) are enzymes that may be produced by some strains of Enterobacteriaceae that hydrolyse all cephalosporins* Carbapenemase- producing Enterobacteriaceae (CPE) are Enterobacteriaceae resistant to carbapenem an/microbials (e.g. imipenem, meropenem, ertapenem) through produc/on of carbapenemase enzymes that hydrolyse carbapenems)* * Note these organisms are rarely transmixed to HCWs 9

10 MRSA Decoloniza/on Not rou:ne: only indicated if strain isolated from HCW is same genotype as strain isolated from pa/ent(s), and HCW is epidemiologically linked to ongoing transmission 4% chlorhexidine bath daily (avoid contact with eyes and ears); plus 2% mupirocin cream or ointment to anterior nares 3 /mes/ day; plus trimethoprim/sulfamethoxazole one DS tab orally twice daily, or doxycycline 100 mg orally twice daily; plus rifampin 300 mg orally twice daily all for a total of 7 days One week aeer treatment, swab anterior nares and any other previously posi/ve sites; repeat swabs weekly X2 HCW clear aeer 3 consecu/ve nega/ve sets of swabs If swabs remain posi/ve aeer the above treatment, consult with an infec/ous diseases physician 10

11 Bloodborne Pathogens Hepa//s B Vaccine preventable: 3 doses a 0, 1 month and 6 months Test for hepa//s B an/body > 10 IU/L If immunity documented at any :me life- long immunity Exposure risk in suscep/ble individual 6 30% HCW Exposure protocol: non- responder to two courses of hepa//s B vaccine (6 doses), administer hepa//s B immune globulin (HBIG) and repeat in 1 month non- responder to one course of hepa//s B vaccine, administer HBIG and ini/ate the second course of vaccine 3 doses of vaccine but immunity unknown, test for an/body to HBsAg not immune, give HBIG and 1 dose of vaccine; test for an/body to HBsAg at 6 months to allow HBIG an/bodies to wane no vaccine or one or two doses of vaccine- - test for an/body; if result non- immune or not available, give one dose HBIG and begin or complete the vaccine series as scheduled 11

12 Hepa//s C Known Exposure: risk 1.8% No vaccine or prophylaxis currently available Counsel exposed HCW to report any signs of hepa//s- like illness Test for an/body to HCV; if nega/ve, test again 3 and 6 months Test baseline ALT and repeat at 3 and 6 months Quan/ta/ve PCR tes/ng can be done 8 to 12 weeks post- exposure Excellent early treatment is available; a treatment naïve op/on is interferon- free ledipasvir- sofosbuvir 8-12 weeks 12

13 HIV Known Exposure: risk 0.3% percutaneous; 0.09% mucosal Basic 2 drug regimen (Combivir) discon/nued 3 drug regimen: raltegravir 400 mg PO twice daily + Truvada (tenofovir DR 300mg /emtricitabine 200 mg) once daily for 28 days Note that drug regimens change over /me Consulta/on with an infec/ous disease specialist should occur ideally within 24 hours 13

14 Cytomegalovirus Pregnant women are at no increased risk of primary CMV infec/on compared with non- pregnant women Incidence rate approximately 2.1 per 100,000 live births There is no preven/on for reac/va/on of virus during pregnancy in previously infected individuals Symptoms usually greater in infant born to mother with primary infec/on vs reac/va/on deafness and neurological complica/ons can occur Because of the poten/al risk to the fetus, and the wide prevalence of this virus in pa/ents body fluids, pregnant women must adhere closely to rou/ne prac/ces/hand hygiene 14

15 Enteric Diseases HCWs with vomi:ng/diarrhea generally should be symptom- free for 24 hours prior to return to work Norovirus (Norwalk- like Disease): must remain off work un/l symptom- free for 48 hours In outbreaks pa/ent- staff cohor/ng should be implemented; persons working in the affected unit should not work in other units or facili/es for 48 hours aeer the last exposure Salmonella typhi and paratyphi: Carriers of these organisms must be excluded from food handling and pa:ent care ac:vi:es un:l the carrier state is eradicated un/l 3 consecu/ve stool specimens collected at least 1 week apart and at least 24 hours aeer cessa/on of symptoms are nega/ve 15

16 Group A Strep An:microbial prophylaxis is not indicated for most HCWs who have been in contact with an infected pa:ent If fluid from the nose, mouth or wound of the infected case did not contact a HCW s mucous membranes or non- intact skin, that HCW was not exposed and does not need prophylac:c an:bio:cs An/microbial prophylaxis recommended for HCW unprotected exposure to case of igas including necro/zing fascii/s, toxic shock syndrome, meningi/s, pneumonia, or any other form of severe igas Choose first genera:on cephalosporin in divided doses for 10 days; give as soon as possible, preferably within 24 hours and up to 7 days aeer the last contact with an infected case All exposed HCWs should be advised of the signs and symptoms of GAS disease and seek medical axen/on if fever or other signs or symptoms develop within 30 days of exposure 16

17 All HCWs regardless of year of birth must be provide proof of immunity; 1970 exemp:on removed Immunity is 2 doses of measles- containing vaccine or serology Measles Serologic not recommended either before or aeer receiving measles- containing vaccine Infec/ous 4 days before onset of rash un/l 4 days aeer onset of rash Suscep:ble exposed HCWs must be excluded from any work in the hospital from 5 days aher the first exposure un:l 21 days aher the last exposure, regardless of whether they received MMR or immune globulin aeer the exposure HCW must be excluded from work while wai:ng for serology results if they are s:ll within the period of work exclusion defined above 17

18 Meningococcal Nosocomial transmission of N. meningi9dis is uncommon TransmiXed through direct contact with respiratory tract secre/ons or handling of laboratory cultures on rare occasions HCWs who have had intensive, direct exposure without wearing facial protec:on to pa:ents treated for <24 hours should receive an:microbial prophylaxis (Ciprofloxacin 500 mg po, single dose or Rifampin 600mg po q12h x 4 dose or Ceeriaxone 250 mg IM) Secondary cases occur rapidly (i.e. within a week) aeer exposure so give prophylaxis as soon as possible, and up to ten days post- exposure Laboratory personnel who may be rou/nely exposed to prepara/ons or cultures of N. meningi8dis should receive quadrivalent meningococcal A,C,Y,W- 135 conjugate vaccine 18

19 Mumps Immunity: documenta/on of receipt of two doses of mumps- containing vaccine or serology Exposure: contact of the oral or nasal mucous membranes of a suscep/ble HCW with infec/ous saliva from 7 days before to 5 days aeer onset of paro/d swelling in source pa/ent Work Restric:on: Suscep/ble exposed HCWs must be excluded from any work in the hospital from the 10th day aeer the first exposure through the 26th day aeer the last exposure, regardless of whether they received vaccine aeer the exposure Workers who have had one dose of vaccine may receive the second dose and con/nue to work 19

20 Parvovirus Erythema infec/osum common in children; characterized by fever followed by intensely erythematous facial rash ( slapped cheek appearance) Once the rash is present, the infec:ous period has ended 70% of women of childbearing age have an/bodies to parvovirus B19; suscep/ble pregnant women can have adverse fetal outcomes including fetal anemia/ hemolysis, fetal hydrops, and fetal death Pregnant HCWs who acquire parvovirus B19 infec/on usually acquire it from their own children; if acquired occupa/onally should be referred to OB/Gyn specialist; fetal blood transfusion can improve outcome 20

21 Pertussis Immuniza:on: Adult dose of Tdap, in addi/on to any dose received prior to 18 th birthday No concern regarding interval of tetanus booster (eg) if tetanus booster received two days ago can safely receive Tdap Incuba:on period: commonly 7-10 days, range of 4-21 days with 3 stage clinical course catarrhal; paroxysmal cough; convalescent Significant recent increase in outbreaks; high risk to neonates HCWs with symptoms of pertussis must be excluded from work for the first 5 days of an:microbial treatment High risk close contacts in a health care sesng are pregnant HCWs in their third trimester or parents of infants (<12months) Chemoprophylaxis of all high- risk contacts is recommended; azithromycin 500 po one dose Day 1 then 250 po Day

22 Tuberculosis History of BCG vaccine not a contra- indica/on for TB skin tes/ng No need to repeat CXR unless clinically indicated IGRA can be useful adjunct for decision for treatment of LTBI Contact tracing changed from baseline week post- exposure to single test 8 weeks post- exposure As per the Canadian Tuberculosis Standards, aeer 2 or more years of annual screening, if conversion rate in those screened less than 0.5%, consider reducing frequency of screening to every other year or restrict annual screening to fewer workers who are at higher risk, and post- exposure 22

23 Varicella Immunity: 2 doses of varicella vaccine at least 4 weeks apart or serology Work Restric:on: Suscep/ble HCW must be furloughed from Day 10 to Day 21 post- exposure 23

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25 Canadian Journal of Anaesthesia

26 Image Source: hxp:// waterloo/endoscope- didn- t- cause- hepa//s- c- outbreak- at- kitchener- clinic

27 Toronto Star 27

28 Toronto Star 28

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30 GUIDELINES REGARDING REUSE OF SYRINGES ARE NOT NEW

31 Because reuse of syringes and mul9dose vials con9nues to cause disease Used with permission from the Southern Nevada Health District 31

32 Reuse of syringes on individual pa/ents and use of single- use medica/on vial on mul/ple pa/ents; 40,000 no/fied; 6 confirmed cases 32

33 Alberta pa/ents followed up 33

34 HBV and HCV Transmission in a Pain Clinic 6 pa/ents with suspected acute HCV infec/on Oklahoma 2002 Reuse of needles and syringes done rou:nely by cer/fied registered nurse anaesthe/st Single needle and syringe to administer each of midazolam, fentanyl and propofol to up to 24 sequen/ally treated pa/ents administered through heparin locks connected to IV cannulas In follow- up of 793 of 908 pa/ents tested; 69 HCV and 31 HBV infec:ons 34

35 HCV Transmission in a Hematology/Oncology Clinic 4 pa/ents with recent HCV infec/on reported All had received chemo at same hem/onc clinic Nebraska Follow- up iden/fied 10 cases available genotyping in 6/10 was HCV 3a, rare in US Rou:ne use of same syringe to draw blood from pa:ents CV catheters and to draw catheter- flushing solu:ons from 500 cc saline bags used for mul:ple pa:ents 486/613 tested for HCV 99 clinic- acquired iden:fied all 3a genotype; higher evidence of transmission in those with implantable CV catheter 35

36 Healthcare- Associated Hepa//s B and C Outbreaks reported to CDC 2008 to outbreaks of viral hepa//s, 33 (94%) occurred in non- hospital se@ngs Hepa::s B 19 outbreaks; 153 associated cases; >10,000 no:fied for screening Hepa::s C 16 outbreaks; 160 outbreak- associated cases; >90,000 at- risk persons no:fied for screening Two outbreaks due to drug diversion by HCV infected HCWs 36

37 Safe Administra/on of Injectables: Single Dose Vials Single dose vials are preferred Do not reuse single dose vials. They should be entered once and then immediately discarded Cleanse diaphragm using fric/on and 70% alcohol. Allow to dry before inser/ng a needle into the vial Always use a new sterile syringe and needle when entering a vial The lehover contents of single dose vials should never be combined or pooled 37

38 All needles are SINGLE PATIENT USE ONLY All syringes are SINGLE PATIENT USE ONLY Mul:- dose vials NEVER re- enter a vial with a used needle OR used syringe Use MDV for a single pa/ent whenever possible and mark the vial with pa/ent name Mark MDV with the date first used, to facilitate discarding at the appropriate /me 38

39 MDV cont d Once medica/on is drawn up, needle should be IMMEDIATELY withdrawn A needle should NEVER be leh in a vial to be amached to a new syringe Discard the MDV immediately if sterility is ques/onable or original entry date not marked Discard opened MDV according to manufacturer s instruc/ons or within 28 days, whichever is shorter. 39

40 Lancets, hubs, glucometers and insulin pens Lancets must be SINGLE USE ONLY Lancet hubs (holds the lancet) SINGLE USE ONLY Insulin pens must be SINGLE PATIENT USE ONLY Blood glucose monitoring devices (Glucometers) and other blood tes/ng devices, should not be shared between pa/ents If they must be shared, device must be designed for mul/- pa/ent use and cleaned and disinfected aher each use, per manufacturer s recommenda:on If the manufacturer does not specify how the device should be cleaned and disinfected then the device cannot be shared 40

41 Blood Collec/on Devices SINGLE USE Blood collec/on tube holders are PREFERRED If blood tube holder must be reused, it MUST be designed for reuse and must be cleaned and disinfected aeer each use as per manufacturer s instruc/ons 41

42 Tonometers Tonometers and other ophthalmologic equipment that touch the eye must undergo high- level disinfec/on (e.g. glutaraldehyde) between pa/ent use Cleaning with alcohol is not sufficient 42

43 Reprocessing absolute musts: A designated, segregated area for reprocessing medical equipment/devices Reprocessing does not occur in the procedure room The reprocessing work area shall be physically separated from clean areas by cleanable walls or par//ons Surfaces in the reprocessing area must be easily cleaned and disinfected 43

44 Safety Issues Wherever chemical disinfec/on/steriliza/on is performed, air quality must be monitored when using products that produce toxic vapours and mists An eyewash sta:on must be located in the reprocessing area A dedicated hand washing sink must be located in the reprocessing area There shall be appropriate PPE for staff involved in reprocessing 44

45 Steriliza/on Logs Steriliza/on logs required for all office/desktop autoclaves Logs must document /me, temperature and pressure (physical indicators) at comple/on of each load External chemical indicator must be used with every packaged item to indicate the item has been sterilized Internal chemical indicator must be placed inside every packaged item to be sterilized Daily tes/ng of biological indicator (BI) is required when a sterilizer is in use 45

46 Summary and Resources Reviewed: updates on OHA/OMA CDSPs Google Ontario Hospital Associa/on CDSP Top 5 high risk prac:ces in clinic offices Main emphasis reuse of syringes Importance of careful reprocessing/steriliza/on Resources: PIDAC Best Prac:ce Documents hxps:// Pages/PIDAC_Documents.aspx Infec/on Preven/on and Control for Clinical Office Prac/ce Rou/ne Prac/ces and Addi/onal Precau/ons The Best Prac/ces for Hand Hygiene Cleaning Disinfec/on and Steriliza/on of Medical Equipment/Devices 46

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