Interim infection control precautions to minimise transmission of respiratory tract infections (RTIs)

Transcription

1 Interim infection control precautions to minimise transmission of respiratory tract 1. INTRODUCTION This document outlines the infection prevention and control advice for health and social care providers who are involved in receiving and/or caring for individuals who are suspected or confirmed to have a respiratory infection. This guidance is an update of, and supersedes, the HPS 2010 guidance General information and infection control precautions to minimise transmission of respiratory tract and incorporates the latest international guidance for the control of RTIs. 2-9 This guidance can be applied in the absence of pathogen specific guidance to any RTI, including those caused by novel or emerging pathogens e.g. pandemic influenza. If available, pathogen specific guidance should be consulted (see Appendix 2). 2. GENERAL INFORMATION Common causes of an RTI include viruses such as: rhinovirus,*coronavirus, adenovirus, influenza and Respiratory Syncytial Virus (RSV); and bacteria such as Streptococcus pneumoniae and Haemophilus influenzae. S. pneumoniae and H. influenza are components of the normal upper respiratory tract flora; infections with these organisms are often secondary to a prior viral infection. An RTI is an infectious process of any of the components of the upper and/or lower airway. Lower respiratory tract infections tend to be more serious and have higher mortality. Symptoms of RTI can include any of the following: rhinorrhoea (runny nose), sore throat and cough to limb or joint pain, headache, lethargy and breathing difficulty. The majority of RTIs are self-limiting viral infections of the upper respiratory tract and although they can occur at any time, they are most common during the autumn and winter months, from September until March. *Coronaviruses typically cause mild illness however, the coronaviruses SARS and MERS-CoV can cause severe respiratory illness and even death in susceptible individuals. Patients infected with SARS or MERs-CoV may also have gastrointestinal symptoms such as diarrhoea and/or vomiting. Gastrointestinal symptoms can also occur during infection with other respiratory viral pathogens; this is more common in children than adults. 2.1 Incubation period and period of communicability Incubation period Different infections have varying time of onset from when the organisms enter the body to when symptoms occur (incubation period). Some of the common pathogens causing RTIs and their respective incubation periods are: Version: 1.0 September 2015 page 1 of 16

2 Rhinoviruses: 1-5 days Adenoviruses :3-10 days Pneumococcal and haemophilus infections: 1-5 days Respiratory Syncytial viruses (RSV): 7 days Bordetella pertussis (whooping cough): 7-21 days Influenza and parainfluenza viruses: 1-4 days SARS: 2-7 days MERS-CoV: 2-14 days 10 Period of communicability The period of communicability for the most common respiratory viruses (e.g. rhinovirus, coronavirus, adenovirus, influenza, RSV, and parainfluenza virus) is usually between hours before to 5 days after clinical onset. However, for some organisms the period of communicability may be significantly longer e.g. around 21 days for whooping cough. Children, the elderly and immune compromised patients may shed virus for an extended period of time; however, the latest WHO guidance states that, in the case of influenza, this does not appear to increase transmission. 3;11; Persons most at risk of developing complications Some people will be at greater risk of developing complications (including pneumonias) from RTIs and becoming more seriously ill e.g.: People aged 6 months to 65 years with chronic: lung disease; heart disease; kidney disease; liver disease; neurological disease; Immuno-suppression (whether caused by disease or treatment); Diabetes mellitus; Asplenia; or Morbid obesity (BMI of 40 or over). Pregnant women Young children under 5 years old People aged 65 years and older 2.3 Routes of transmission The pathogens that cause RTIs are spread through the following routes; typically more than one route is involved: By droplet transmission: Droplets greater than 5 micrometres (µm) in size (large droplets) may be generated from the respiratory tract during coughing, sneezing or talking. If droplets from an infected person come into contact with the mucous membranes (mouth or nose) or surface of the eye of a recipient individual, they can cause infection. Droplets can penetrate the respiratory system to above the alveolar level. These droplets do not remain in the air HPS. Version: 1.0: September 2015 page 2 of 16

3 for long and do not travel more than one metre in distance, so closeness is required for transmission. By contact transmission (direct and indirect): Direct contact transmission occurs during skin-to-skin or oral contact. Infectious agents are passed directly from an infected person (for example after coughing into their hands) to a recipient person who then transfers the organism into their mouth, nose or eyes. Indirect contact transmission takes place when a recipient person has contact with a contaminated object, such as bedding, furniture or equipment which is usually in the environment of an infected person. Again, the recipient person transfers the organisms from the object to their mouth, nose or eyes. By the airborne route Airborne transmission is the transmission of infectious airborne particles (aerosols) of small size (<5μm diameter). Particles of this size can remain suspended in the air for long periods of time and may be dispersed over large distances by air currents. Aerosols can penetrate the respiratory system to the alveolar level. RTIs are typically transmitted by more than one of these routes. Aerosol Generating Procedures (AGPs): Aerosol generating procedures (AGPs) are medical and patient care procedures that result in the production of airborne particles (aerosols) and create the potential for airborne transmission of infections that may otherwise only be transmissible by the droplet route. A list of AGPs can be found in Section INFECTION CONTROL PRECAUTIONS This section describes specific actions that should be taken when applying standard infection control precautions (SICPs) and transmission-based precautions (TBPs) in the care of a person known or suspected to have an RTI. All health and social care providers should be familiar with standard infection control precautions (SICPs) and transmission based precautions (TBPs) as set out in the National Infection Prevention and Control Manual. Standard infection control precautions (SICPs) SICPs are the basic infection prevention and control measures necessary to reduce the risk of transmission of infectious agents from both recognised and unrecognised sources of infection. Sources of (potential) infection include blood and other body fluids secretions or excretions (excluding sweat), non-intact skin or mucous membranes and any equipment or items in the care environment that could have become contaminated. SICPs are to be used by all staff, in all care settings, at all times, for all patients. HPS. Version: 1.0: September 2015 page 3 of 16

4 Transmission-based precautions (TBPs) TBPs are applied when SICPs alone are insufficient to prevent cross transmission of an infectious agent. TBPs must be applied in addition to SICPs when a person is known or suspected to be colonised or infected with an infectious agent. There are three categories of Transmission-Based Precautions (TBPs): Droplet Precautions Contact (direct and indirect) Precautions Airborne Precautions Interrupting transmission of a respiratory infection requires more than one TBP category: The use of droplet and contact precautions at all times The addition of airborne precautions is required whilst undertaking an AGP, for confirmed airborne respiratory pathogens (e.g. MDR Tb) or any *novel or emerging pathogen of uncertain transmission mode (e.g. MERS-CoV) in a hospital setting *Novel or emerging pathogens are typically associated with higher levels of mortality, there are typically no vaccination, prophylaxis or treatment options available and as such a precautionary approach should be applied until further information on transmission mode is available. 3.1 Patient assessment and placement Identification of cases: Patients must be promptly assessed for infection risk on arrival at the care area. The early symptoms of infection with a novel or emerging pathogen are likely to be non-specific, obtaining any relevant travel or exposure history from the patient will assist in differentiating these infections from endemic RTIs (e.g. seasonal influenza). Guidance for cohorting patients: If a single/isolation room is not available, cohort confirmed respiratory infected patients with other patients confirmed to have the same RTI. If single/isolation rooms are in short supply, and cohorting is not yet possible (awaiting laboratory confirmation), prioritise patients who have excessive cough and sputum production for single room placement. Ensure patients are physically separated (i.e. at least 3 feet (one metre) apart) from each other. Draw the privacy curtains between the beds to minimise opportunities for close contact. Display signage to control entry into cohort areas. HPS. Version: 1.0: September 2015 page 4 of 16

5 Placement and transfer of patients with a known or suspected RTI caused by an endemic pathogen (e.g. seasonal influenza): Isolation within a care home for a known/suspected infection can be achieved in the persons bedroom in most cases. In a hospital setting, place patient in a single room en-suite, if available or cohort area if multiple cases. Special environment controls such as negative pressure rooms are not necessary to prevent droplet transmission. Limit transport and movement of patients outside of their room to medicallynecessary purposes. If patient movement or transport is necessary, the patient may wear a fluid-resistant surgical face mask (if tolerated) to minimise the dispersal of respiratory secretions and reduce environmental contamination. Placement and transfer of patients with a known or suspected RTI caused by an airborne (e.g. TB) or novel or emerging pathogen (e.g. pandemic influenza): If a person presents in a primary care setting with an RTI suspected to be caused by a novel or emerging pathogen they should be separated from other patients during assessment and initial management. If transfer to an acute care setting is required the receiving hospital and any ambulance personnel should be notified of the infection risk. Negative pressure rooms should be used for patients with a suspected or confirmed airborne pathogen (e.g. TB) or a novel or emerging pathogen (e.g. MERS-CoV) Avoid moving patients with a confirmed infection caused by a novel or emerging pathogen out of the isolation room or area unless medically necessary. Designated, portable equipment may make this easier. If transfer is necessary ensure that the receiving ward/department is notified in advance. Display signage to control entry into isolation areas. HPS. Version: 1.0: September 2015 page 5 of 16

6 Table 1 isolation requirements for respiratory tract infections Precaution Pathogen RTI Pulmonary or laryngeal Seasonal caused by endemic pathogen e.g. RSV Tuberculosis influenza Single en Yes If negative pressure Yes Suite room Isolation room (negative pressure) Summary of Precautions (excluding AGPs) No isolation room unavailabl Yes Until the patient has received 14 days of appropriate antibiotic or If patient has MDR or XDR TB SICPs SICPs SICPs SICPs droplet - droplet - contact contact contact contact - airborne - airborne No Novel or emerging pathogen e.g. pandemic influenza*, MERS- CoV If negative pressure isolation room unavailab Yes *The transmission mode of pandemic influenza is likely to be similar to seasonal influenza, however higher mortality is usually a feature of pandemic strains and a precautionary approach should be followed until the transmission mode is further defined. 3.2 Respiratory and Cough Hygiene Some patients (e.g. elderly, children) may need assistance with containment of respiratory secretions. Staff should promote respiratory and cough hygiene as follows: Use a disposable, single use tissue to cover mouth and nose when coughing, sneezing, wiping or blowing noses. Dispose of tissues promptly and then wash hands. Wash hands frequently with soap and water, especially after coughing, sneezing and using tissues. Keep contaminated hands away from the nose and mouth. Fluid resistant-surgical masks can be worn by the patient (if tolerated) to help contain respiratory secretions. 3.3 Management of Patient care equipment Reusable (communal) equipment should as far as possible be allocated to the individual patient or cohort of patients This must be decontaminated between each patient and after patient use, after blood and body fluid contamination and at regular intervals as part of equipment cleaning. Refer to Appendix 7 of the National Infection Prevention and Control Manual. HPS. Version: 1.0: September 2015 page 6 of 16

7 Avoid use of fans that re-circulate the air 3.4 Management of the Care environment Survival in the environment/persistence on inanimate surfaces varies widely between organisms from 1-2 hours to several months (see Table 2) and will also vary depending on the type of material and exposure to environmental stresses such as temperature, humidity and UV exposure. 14 Infectious influenza virus may be transferred from environmental surfaces to hands, for up to 24 hours after contamination takes place. 15;16 Infectious organisms can also be deposited on and subsequently transferred from soft materials e.g. pyjamas, magazines and tissues. Regular, effective hand hygiene and environmental cleaning are essential to disrupt or minimise this route of transmission. Table 2 survival of organisms in the environment Organism Persistence on dry inanimate surfaces Coronavirus (not SARS or MERS-CoV) Influenza Respiratory Syncytial Virus Rhinovirus Haemophilus influenzae Streptococcus pneumoniae Mycobacterium tuberculosis 3 hours 1-2 days Up to 6 hours 2 hours to 7 days 12 days 1-20 days 1 day to 4 months Environmental measures: Ensure that the rooms of patients with infection are cleaned (at least daily) with a focus on increased cleaning for frequently-touched surfaces (e.g. over-bed tables, lockers, lavatory surfaces in patient bathrooms, door knobs) and equipment in the immediate vicinity of the patient. Frequently touched surfaces must be decontaminated at least daily as well as after any AGP and immediately if visibly contaminated/soiled. Use a combined detergent/disinfectant at a dilution of 1000 parts per million (ppm) available chlorine (av.cl.) or a neutral detergent in a solution of warm water followed by disinfection with 1000ppm av.cl. Keep environment clean and clutter free. Terminal clean all isolation/cohort rooms following discharge or transfer of a patient. 3.5 Management of linen Treat all linen as infectious: bag linen inside patient room into a water soluble (alginate) bag followed by a clear polythene outer bag; HPS. Version: 1.0: September 2015 page 7 of 16

8 place into an infectious linen hamper. 3.6 Safe disposal of waste If patient is suspected or confirmed to have an RTI caused by a novel or emerging pathogen dispose of all waste as healthcare waste (orange stream), otherwise use procedures for the safe disposal of waste set out in the National Infection Prevention and Control Manual Literature review -'Safe Management of Waste'. The patient should use toileting facilities if able, if using a commode liquid waste may be flushed down the toilet with the lid closed. 3.7 Personal Protective Equipment (PPE) All staff should be trained in the proper use of any PPE it is anticipated they will be required to wear. It is mandatory that all members of staff who may be required to wear an FFP3 respirator have been fit-tested for the make and model of respirator they intend to wear and perform a fit-check before commencing patient care activities. 1 PPE for droplet and contact precautions (endemic RTI): Single-use disposable gloves. Single-use disposable plastic apron. Fluid-resistant (Type IIR) surgical face mask. Consider eye protection (e.g. goggles or a visor) if there is a risk of splash or spray (prescription spectacles are not considered eye protection). Additional requirements/considerations: Change plastic apron and gloves and perform hand hygiene between contacts with patients (even when they are in the same room). Surgical face masks do not need to be worn continuously and should not be seen as a substitute for respiratory and hand hygiene practices. Surgical face masks should be removed and disposed of inside the patient room when at least 3 feet (1 metre) from the patient(s). However - When patients with RTIs are cohorted in one area and multiple patients require care, it may be more practical to put on a fluid-resistant (Type IIR) surgical face mask on entry to the area and keep it on for the duration of all care activities or until the mask requires replacement (when it becomes moist or damaged). HPS. Version: 1.0: September 2015 page 8 of 16

9 PPE for airborne precautions (for performing AGPs, airborne pathogens, novel or emerging pathogens, pandemic influenza)*: Single-use disposable gloves Long-sleeved fluid-resistant disposable gown Correctly fitted filtering face piece (FFP3) (EN149:2001), respirator. Eye protection (correctly fitting goggles or a full face visor) If preferred, a respirator hood may be used in place of an FFP3 respirator and eye protection. Hoods must not compromise the function of other PPE used i.e. gowns, and the manufacturer s guidance for appropriate use should be followed. FFP3 respirator should be disposed of out with the patient care area (e.g. isolation room) and should be the last item of PPE removed *This level of PPE will not generally be required for novel or emerging pathogens in primary or residential care settings as patient interactions are likely to be short and non-invasive. NB. The majority of PPE will be single-use disposable, any PPE considered reusable (e.g. visors) should have a decontamination schedule in place with responsibility assigned. 3.8 Aerosol generating procedures (AGPs) AGPs should only be carried out when essential. These procedures should be carried out in a negative pressure isolation room if available or a well-ventilated single rooms with the doors shut Only those healthcare workers who are needed to undertake the procedure should be present A long-sleeved fluid-resistant disposable gown, gloves, eye protection and an FFP3 respirator should be worn by all staff present during the procedure A risk assessment should be performed to determine the rate of clearance of aerosols from rooms used to perform AGPs. This will determine when it is safe to enter the room without an FFP3 respirator (for patients on droplet and contact precautions). This will also determine the optimum time for environmental cleaning to avoid recontamination from aerosol fallout. The following procedures are currently considered to be AGPs: Intubation and extubation; Manual ventilation; Open suctioning; Cardiopulmonary resuscitation; Bronchoscopy; HPS. Version: 1.0: September 2015 page 9 of 16

10 Surgery and post-mortem procedures involving high-speed devices; Some dental procedures (e.g. drilling); Non-invasive ventilation (NIV) e.g. Bi-level Positive Airway Pressure (BiPAP) and Continuous Positive Airway Pressure ventilation (CPAP); High-Frequency Oscillating Ventilation (HFOV); and Induction of sputum (not including chest physiotherapy). 3.9 Duration for the requirement of TBPs In general patients should remain in isolation/cohort and TBPs continued until the resolution of fever and respiratory symptoms or completion of treatment. The duration of TBPs may require modification based on available pathogenspecific guidance and patient information (e.g. Children and immune compromised patients may remain infectious for a longer period of time). The decision to modify the duration of, or stand down TBPs should be based on clinical judgement of the patients condition and agreement with the ICT Care of the deceased The principles of SICPS and TBPs should continue to be followed while the deceased individual is in the care environment, follow the guidance set out in Chapter 2 of the National Infection Prevention and Control Manual Mortuary staff and funeral directors must be advised of the infection risk before transferring the deceased 4. GUIDANCE FOR VISITORS AND OCCUPATIONAL EXPOSURE Visitors: Should be advised not to attend if they have RTI symptoms. Should be limited if appropriate (consider the wellbeing of the patient). Are encouraged for vulnerable or paediatric cases provided it is possible to ensure effective hand hygiene and correct use of PPE. Should be made aware of the risks and be offered PPE as recommended for staff. Visiting may be suspended during outbreaks if considered appropriate. Visitors should not be present during AGPs. Occupational exposure: Staff should be offered immunisation (e.g. seasonal influenza vaccine). HPS. Version: 1.0: September 2015 page 10 of 16

11 Regardless of whether staff have had and recovered from or have received vaccination for a specific respiratory pathogen they should continue to follow the infection control precautions including PPE. In the event of a breach in infection control procedures e.g. incorrectly worn FFP3 respirator during an AGP, staff should be reviewed by Occupational Health and an incident form completed All HCWs should be vigilant for any respiratory symptoms during the incubation period following last exposure to a confirmed case and should not come to work if they have a fever or cough. They should seek advice from their ICT/occupational health department as per the local policy. Their hospital ICT and/or local HPU will advise on where they should be medically assessed. During this period, symptomatic HCWs should avoid contact with people both in the hospital and in the general community. HPS. Version: 1.0: September 2015 page 11 of 16

12 Reference List (1) Health and Safety Executive. Respiratory protective equipment at work. A practical guide. Fourth Edition (2) WHO. Infection prevention and control during health care for probable or confirmed cases of novel coronavirus (ncov) infection. Intermim guidance (3) WHO. Infection prevention and control of epidemic- and pandemic-prone acute respiratory infection in healthcare (4) Centers for Disease Control and Prevention (CDC). Prevention Strategies for Seasonal Influenza in Healthcare Settings (5) Centers for Disease Control and Prevention (CDC). Interim guidance for infection control within healthcare settings when caring for confirmed cases, probable cases, and cases under investigation for infection with novel influenza A virus associated with severe disease (6) Public Health England. Infection Control Advice. Middle Eastern respiratory syndrome coronavirus (MERS-cov) (7) Public Health England. Supplementary guidance for health protection teams involved in prevention and control of influenza and other respiratory viral infections among care home residents (8) Health Protection Agency. Managing Outbreaks of Acute Respiratory Illness in Care Homes. Information and Advice for Health Protection Units (9) Health Protection Scotland. General information and infection control precautions to minimise transmission of respiratory tract infections (10) Lessler J, Reich NG, Brookmeyer R, Perl TM, Nelson KE, Cummings DA. Incubation periods of acute respiratory viral infections: a systematic review. [Review] [83 refs]. The Lancet Infectious Diseases 2009 May;9(5): (11) Lee N, Chan PK, Hui DS, Rainer TH, Wong E, Choi KW, et al. Viral loads and duration of viral shedding in adult patients hospitalized with influenza. Journal of Infectious Diseases 2009 Aug 15;200(4): (12) Ryoo SM, Kim WY, Sohn CH, Seo DW, Oh BJ, Lee JH, et al. Factors promoting the prolonged shedding of the pandemic (H1N1) 2009 influenza virus in patients treated with oseltamivir for 5 days. Influenza & Other Respiratory Viruses 2013 Sep;7(5): (13) WHO. World Health Organization. WHO guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care. Geneva (14) Kramer A, Schwebke I, Kampf G. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. [Review] [126 refs]. BMC Infectious Diseases 2006;6:130. HPS. Version: 1.0: September 2015 page 12 of 16

13 (15) Bean B, Moore BM, Sterner B, Peterson LR, Gerding DN, Balfour HH, Jr. Survival of influenza viruses on environmental surfaces. Journal of Infectious Diseases 1982 Jul;146(1): (16) Thomas Y, Boquete-Suter P, Koch D, Pittet D, Kaiser L. Survival of influenza virus on human fingers. Clinical Microbiology & Infection 2014 Jan;20(1):O58- O64. (17) WHO. Inadequate plumbing systems likely contributed to SARS transmission HPS. Version: 1.0: September 2015 page 13 of 16

14 Appendix 1 - Putting on and removing Personal Protective Equipment Putting on (donning) PPE PPE should be put on before entering a side room. If full PPE is required, for example for a potentially infectious aerosol generating procedure, all staff in the room or entering within one hour of the procedure should wear the following PPE put on in the following order: 1. Gown or Apron 2. FFP3 respirator or fluid-resistant (Type IIR) surgical face mask 3. Eye protection, i.e. goggles or full face visor (if required) 4. Disposable gloves. The order given above is practical but the order for putting on is less critical than the order of removal given below. Removal of (doffing) PPE PPE should be removed in an order that minimises the potential for crosscontamination. Before leaving the side room gloves, gown and eye protection should be removed (in that order, where worn) and disposed of as healthcare (including clinical) waste. After leaving the area, the respirator can be removed and disposed of as healthcare (including clinical) waste. Guidance on the order of removal of PPE is as follows: 1. Gloves Grasp the outside of the glove with the opposite gloved hand; peel off. Hold the removed glove in gloved hand. Slide the fingers of the un-gloved hand under the remaining glove at the wrist. Peel the second glove off over the first glove and discard appropriately. 2. Gown or apron Unfasten or break ties. Pull gown/apron away from the neck and shoulders, touching the inside of the gown/apron only. Turn the gown/apron inside out, fold or roll into a bundle and discard. HPS. Version: 1.0: September 2015 page 14 of 16

15 3. Eye protection To remove, handle by headband or earpieces and discard appropriately. 4. Respirator or fluid-resistant (T ype IIR) surgical face mask Untie or break bottom ties, followed by top ties or elastic, and remove by handling ties only and discard appropriately. To minimise cross-contamination, the order outlined above should be applied even if not all items of PPE have been used. Perform hand hygiene immediately after removing all PPE. HPS. Version: 1.0: September 2015 page 15 of 16

16 Appendix 2 Pathogen specific guidance HPS has produced pathogen specific guidance documents and algorithms for the assessment and management of patients with RTIs cause by: MERS-CoV Influenza (Seasonal, pandemic (H1N1) and Avian) Infection control guidance for severe respiratory illness from novel or emerging pathogens: MERS-CoV and avian influenza (e.g.a/h7n9, A/H5N1) is also available and can be used in conjunction with this guidance document. In addition, HPS has produced outbreak tools such as cribcards and posters as well as generic hospital outbreak investigation and management tools, these are available at HPS. Version: 1.0: September 2015 page 16 of 16