Final Document Ratification. Date Ratified 28 July 2016 Authorisation Authoriser Mary Edwards. Signature

Transcription

1 Management of Chickenpox and Shingles Policy HH(1)/IC/648/16 Previous document(s) being replaced Location Policy No Policy Name HHFT HH(1)/IC/648/13 Management of Chickenpox and Shingles Policy Document Summary This document provides healthcare workers with necessary information in relation to: the transmission of Varicella zoster virus (VZV) the infection control management of patients the management of non immune patient and staff contacts pre employment staff screening vaccination Ownership Author Sheryl Lucero Job Title Infection Control Nurse Document Type Level Level 1 Trustwide Related Documents Document Details Cleaning, disinfection and sterilisation Policy Environment cleaning Policy Hand Hygiene Policy Health and Safety Risk Assessment Policy Health Clearance and Vaccination of Staff against Infectious Diseases Policy Health4Work Service Immunisation and screening for new HHFT healthcare workers HHFT Adult Antimicrobial Guide Learning and Development Policy Linen Policy Standard precautions (Incorporating Personal Protective Equipment) Policy Waste Management Policy Relevant Standards CQC Outcome 8 Equality Analysis Completed by Lorraine Amos Date Completed 10 November 2016 Final Document Approval Committee Policy Approval Group Date Approved 25 July 2016 Specialist committee(s) Committee(s) N/A recommending approval Date Recommended Final Document Committee Executive Committee Ratification Date Ratified 28 July 2016 Authorisation Authoriser Mary Edwards Job Title Chief Executive Signature Page 1 of 29

2 Date Authorised 15/11/2016 Dissemination Target Audience All Trust Staff Dissemination and Implementation Plan Action Owner Due by Publicise detail of new document via Intranet and Midweek message IPCT and Communication Team Within 1 week of publication Communication to all Senior Managers to advise publication of policy BNHH Healthcare Library On publication The policy will be available on the intranet and web site Review Expiry date 25 July 2019 Review date 25 April 2019 BNHH Healthcare Library and Communication Team Within 1 week of authorisation Page 2 of 29

3 Document Control Document Amendments Version No. Details Key amendments to note By whom Date 1 Review of policies to produce harmonised HHFT policy Karen Davis Blues March Information amended on advice for women of child bearing age receiving VZV vaccine. 2 Information amended on contraindication for vaccination in breastfeeding women 2 Information amended on frequency of cleaning the environment. 2 Amended clinical matrons duties in Section 5. 2 New information added on healthcare workers pre employment screening Women of childbearing age should be advised to take adequate precautions to prevent pregnancy occurring between the two doses and for 1 month (previous advice was 3 months) after the second dose. There is evidence to show that the vaccine virus is not transferred to the infant through breast milk and therefore breast feeding women can be vaccinated if indicated. Frequency of cleaning the environment (isolation room) occupied by a patient with VZV infection has been changed to twice daily. This has been amended to include responsibility for referring known members of staff who may be suspected/ diagnosed to have VZV infection to Health4Work and liaising with Health4Work and Infection Prevention & Control Team (IPCT) when member of staff may be safe to resume work. A history of chickenpox in individuals from temperate countries or vaccination is required. For those individuals who do not have such a history, a blood test to confirm immunity will be undertaken. Those healthcare workers who were born or raised in tropical or sub tropical counties will have serological screening unless they are able to provide documentary evidence of immunization. Sheryl Lucero June 2016 Sheryl Lucero June 2016 Sheryl Lucero June 2016 Sheryl Lucero June 2016 Sheryl Lucero June 2016 Page 3 of 29

4 2 New information added on definition of healthcare worker. 2 New information added on site for administration of Varicella vaccine when given with other live attenuated vaccine 2 Information added on routine postvaccination serological testing in pre exposure vaccination. Healthcare workers include all staff who have patient contact (direct and indirect e.g. contact with patient environment including catering staff, staff who work in estates and facilities) whether employed directly by the Trust or through contract. If varicella vaccine is given at the same time as other live vaccines (e.g. MMR), the vaccine should be given at a separate site, preferably in a different limb or at least 2.5cm apart if given on the same limb. The site of each vaccine must be noted on the individual s records. Post vaccination serological testing is not routinely recommended but is advisable for HCW in units dealing with highly vulnerable patients (e.g. transplant units). Sheryl Lucero June 2016 Sheryl Lucero June 2016 Sheryl Lucero June 2016 Page 4 of 29

5 Contents 1. Introduction Purpose Scope Explanation of Terms Duties Chickenpox Shingles Transmission Complications Diagnosis Treatment Assessing immunity to VZV Management of Patients with Suspected or Confirmed VZV Management of VZV in Maternity/Neonatal Unit Management of Patients Infected with VZV going to Theatre Management of contacts of patients with chickenpox or shingles Infection Control Precautions Varicella Vaccine Stakeholders Engaged During Consultation Dissemination and Implementation Training Monitoring Compliance with the Document References Associated Documentation Contributors Appendix A Equality Impact Assessment Appendix B Procedure for vaccinating healthcare workers Appendix C Management of VZV occurring in the ward Appendix D Management of immune compromised patients exposed to VZV Appendix E Management of neonates exposed to VZV Appendix F Management of pregnant women exposed to VZV Page 5 of 29

6 1. Introduction Varicella zoster virus (VZV) is a member of the herpesvirus family. Humans are the only reservoir of the virus, and disease occurs only in humans. After primary infection as varicella (chickenpox), the virus remains dormant in the sensory nerve ganglia and can reactivate at a later time, causing herpes zoster (shingles) (Marin & Bialek, 2015). Chickenpox is predominantly a childhood illness; its incidence highest before 10 years of age. Ninety percent of adults raised in the UK are immune (DoH, 2006). It is usually self limiting in healthy children, and complications are rare. In adults, however, chickenpox can be more serious and 25 times more likely to lead to complications and admission to hospital. Certain groups of people such as those who are immune compromised, pregnant women and neonates are more at risk of developing serious complications (Marin & Bialek, 2015). Shingles is less common than chickenpox and the incidence is highest in older people. The incidence of shingles increases with age and around 1 in 4 adults may experience an attack in their lifetime (PHE, 2015). Chickenpox is not a notifiable disease in England and Wales although it is notifiable in Scotland and Northern Ireland. It is essential that all staff are aware of their responsibilities in the prompt reporting, diagnosis and management of patients and staff with chickenpox or shingles and that adequate isolation facilities and the necessary support services and resources are provided to maintain effective and safe care of both patients and staff. 2. Purpose The purpose of this policy is to provide healthcare workers with the necessary information in relation to: the transmission of Varicella zoster virus (VZV) the infection control management of patients the management of non immune patient and staff contacts pre employment staff screening vaccination 3. Scope This policy and procedure will be applied fairly and consistently to all employees and service users regardless of their protected characteristics as defined by the Equality Page 6 of 29

7 Act 2010 namely, age, disability, gender reassignment, race, religion or belief, gender, sexual orientation, marriage or civil partnership, pregnancy and maternity. For employees this policy also applies irrespective of length of service, whether full or part time or employed under a permanent or a fixed term contract, irrespective of job role or seniority within the organisation. Where an employee or service user has difficulty in communicating, whether verbally or in writing, arrangements will be put in place as necessary to ensure that the processes to be followed are understood and that the individual is not disadvantaged during the application of this policy. The application of this policy is completely clinically based and ensuring prompt testing/treatment would be the priority, however the Trust would endeavour to continue to meet patients individual needs as far as is practicable. In line with the Equality Act 2010, the Trust will make reasonable adjustments to the processes to be followed where not doing so would disadvantage an individual with a disability during the application of this policy. This policy complements professional and ethical guidelines and The Code Professional standards of practice and behaviour for nurses and midwives (NMC 2015). 4. Explanation of Terms Disseminated widely spread or scattered Immune compromised a patient whose immune system efficiency has been reduced and has an increased risk of acquiring an infection Incubation period the period from entry of infection to the appearance of infection Index case the initial person or first occurrence of the disease Maculopapular presence of non palpable localised change in skin colour (macules) and raised palpable spots (papules) Malaise feeling of illness and discomfort Post herpetic neuralgia neuralgia (pain in the distribution of a sensory nerve) following an attack of herpes zoster (shingles) Varicella zoster immunoglobulin (VZIG) contains high concentrations of varicella zoster antibody and used to convey passive immunity to varicella Vesicle a fluid filled blister less than 5 mm in diameter Page 7 of 29

8 5. Duties 5.1 Post holders with duties The Chief Executive (CE) has overall responsibility for the strategic and operational management of the Trust ensuring there are appropriate strategies and policies in place to ensure the Trust continues to work to best practice and complies with all relevant legislation in regard to the management of patients with Varicella zoster virus (VZV) infections. The Director of Infection Prevention and Control (DIPC) is the Trust Director responsible to the Board of Directors for the delivery of Infection Prevention and Control (IPC) standards. The DIPC and/or the duty Consultant Microbiologist will advise the medical teams on the management of susceptible in patient contacts, including post exposure prophylaxis. The Director of Nursing will ensure that the Divisional Directors take clinical ownership of the policy. The Divisional Operational Directors will ensure that all healthcare workers comply with this policy and that all healthcare workers attend mandatory infection prevention and control training. They are responsible for ensuring adequate facilities and resources are available to adhere to this policy. The Clinical Matrons/Clinical Directors/ Departmental Managers will ensure that the current version of this policy is available in all of their areas. They will ensure that all healthcare workers comply with this policy and that all healthcare workers attend mandatory IPC training. They are also responsible for referring known members of staff who may be suspected/diagnosed to have VZV infection to Health4Work and liaising with Health4Work and Infection Prevention & Control Team (IPCT) when member of staff may be safe to resume work. The duty nurse in charge of the ward is responsible for contacting the IPCT in the event of a patient developing clinical signs of chickenpox or shingles. They are responsible for informing the clinical matron (when applicable) and contacting the site coordinator to request an isolation room for the patient if one is not already provided. They are responsible for ensuring that patient/staff contact list is completed and sent to the IPCT and Health4Work within 24 hours of the list being requested. All Trust employees will comply with this policy and inform the Infection Prevention and Control Team about any issues or concerns relating to the policy. All staff will attend mandatory IPC training annually. Infection control is the responsibility of ALL staff associated with patient care. A high standard of infection control is required on ALL wards and units, although the level of risk may vary. It is an important part of total patient care. 5.2 Committees and Groups with duties Page 8 of 29

9 The Health4Work (H4W) department will assess and conduct vaccination and immunization screening for all new healthcare staff and maintain a database in order to protect vulnerable patients from acquiring VZV from members of staff. They will act as a resource for information, and support and consult with managers, the IPCT and healthcare workers regarding the use of personal protective equipment. They are responsible for ensuring that healthcare workers are vaccinated against VZV according to Department of Health guidance. They will follow up staff contacts (list to be supplied by the ward staff) as appropriate. The Infection Prevention and Control Team (IPCT) will act as a resource for information and support. They will provide education in relation to this policy within the yearly mandatory infection prevention and control training. The Health and Safety Team will act as a resource for information, and support and consult with managers, the IPCT and healthcare workers regarding the use of personal protective equipment. 6. Chickenpox Clinical Signs and Symptons The illness usually starts with 1 to 2 days of fever and malaise although this may be absent, particularly in young children. Vesicles begin to appear on the face and scalp, spreading to the trunk and abdomen and eventually to the limbs. After 3 to 4 days the vesicles start to dry and scab and are followed by another crop of fresh vesicles. In some cases, the vesicles are very few and may not be noticed; whilst in others they may cover most of the body. The virus is plentiful in the naso pharynx in the first few days and in the vesicles before they dry up. Modified chickenpox, also known as breakthrough chickenpox, can occur in vaccinated people. This is usually mild with less than 50 lesions, low or no fever, and shorter duration of rash. The rash may be atypical in appearance with fewer vesicles and predominance of maculopapular lesions. Modified chickenpox is contagious, although less so than chickenpox in unvaccinated people. Period of Infectivity The incubation period ranges from 2 3 weeks. The virus is shed from the nasopharynx for up to five days. It is infectious from 1 2 days before the rash appears and ends when all the lesions are crusted (typically 4 7 days). The period of infectivity may be prolonged in people who are immune compromised. 7. Shingles Clinical Signs and Symptoms In shingles, the virus is shed from the skin lesion vesicles. The causes of reactivation of the VZV are unknown, but medical conditions that suppress the normal immune system seem to be a main contributing factor. Page 9 of 29

10 The early signs of shingles begin usually with pain in the affected nerve area, most commonly on the chest. A rash of fluid filled blisters will then appear in the affected area, typically on one side of the body. The rash usually lasts for seven days but the neuralgic pain may persist much longer. Persistent pain known as post herpetic neuralgia is common amongst the elderly; it often lasts for 3 to 6 months, sometimes even years. Period of Infectivity The person is considered infectious for approximately 1 week after the appearance of the lesions although this may be prolonged in individuals who are immunecompromised. Crusted vesicles are no longer infectious. It is possible to develop chickenpox after exposure to a person with shingles but it is not possible to develop shingles from exposure to a person with chickenpox. 8. Transmission Varicella zoster virus is spread from person to person via the upper respiratory route or conjunctiva by three modes of transmission: direct contact with vesicle fluid from skin lesion or possibly infected respiratory tract secretions contact with articles (e.g. clothes and bedding) soiled by vesicle fluid or infected respiratory secretions inhalation of large droplet particles or smaller airborne particles from vesicle fluid or skin lesions 9. Complications Children In children younger than 5 years of age, bacterial skin infection is the most common complication. Adults Adults, particularly those who smoke and pregnant women with chickenpox may develop more severe complications. Around 5 14% of adults with chickenpox develop lung involvement of varying severity. Pregnancy Up to 1 in 10 pregnant women with chickenpox develop pneumonia. Pregnant women are at particular risk of complications affecting the foetus/neonate which arise as a result of the mother contracting the infection. Congenital abnormalities and/or foetal death can occur if the mother contracts chickenpox during the first 20 weeks of pregnancy. Page 10 of 29

11 Maternal infection in the week before and the week after delivery can cause severe and even fatal disease in the neonate. Neonates Mother to infant transfer of antibodies is limited before weeks of gestation. Therefore, infants that are delivered at less than 28 weeks of gestation will usually be protected against chicken pox by maternal immunity. If the baby is born up to 7 days before or 7 days after the onset of the mother s rash, it is more likely to develop chicken pox of the newborn. Severe infection is more likely if the maternal onset of rash is 5 days before to 2 days after delivery. Immune compromised people Severe disseminated chickenpox with pneumonia, encephalitis, hepatitis, and hemorrhagic complications, as well as secondary complications caused by bacterial super infection of skin lesions (e.g. septicaemia, bacterial pneumonia, and meningitis) are more common in immune compromised people than other populations. Significant exposure to Varicella zoster virus An exposure to VZV is significant if: The index case has chickenpox, disseminated zoster or an exposed localised lesion (e.g. ophthalmic zoster). If the index case is immunosuppressed then a local lesion anywhere may be significant as shedding is greater from these individuals Timing of exposure occurs between 48 hours before onset of a rash up to crusting of all lesions (chickenpox) or from the day of onset of rash to crusting of all lesions in shingles Contact with index case is in the same room (e.g. in a house or classroom or hospital bay) for at least 15 minutes or direct face to face contact (e.g. when having a conversation). In the case of large open wards, airborne transmission at a distance has occasionally been reported and giving VZIG to all susceptible high risk contacts should be considered (particularly in paediatric wards where the degree of contact may be difficult to define) and discussed with the Consultant Microbiologist. 10. Diagnosis Chickenpox In most cases, the diagnosis of chickenpox can be made clinically from the characteristic chickenpox rash. A history of recent exposure to chickenpox or shingles or cases occurring in close contacts may help to confirm the diagnosis. Page 11 of 29

12 Laboratory tests can be used for confirmation but are rarely required. If confirmation is needed in pregnant women, chickenpox can be detected by virus, antigen, or DNA detected in vesicle fluid. Shingles Similarly, diagnosis of shingles is usually made on clinical grounds based on the individual s history of burning, tingling, numbness, or itchiness in the affected skin 1 4 days before the rash appears. This painful rash (lasting 7 10 days) develop into vesicle lesions (most commonly in the thorax) and lasts between 7 10 days. 11. Treatment There is no specific treatment for chickenpox, but acyclovir may occasionally be used in patients at high risk of complications. It is a viral infection which will not respond to antibiotics. Oral acyclovir can also be used to treat shingles under the clinician s guidance. Treatment should be aimed at relieving the symptoms of the fever and itchiness. People at high risk of developing serious complications from chickenpox may be given Varizella zoster immunoglobulin (VZIG) after exposure to a case (but not as a treatment). This includes: pregnant women immune compromised patients those who have recently been on steroids neonates whose mothers develop chickenpox within 7 days before and 7 days after delivery neonates who are VZV negative (VZ virus not detected in serum sample test) and exposed to chickenpox or shingles in the first seven days Refer to HHFT Adult Antimicrobial guide for treatment of Skin and Skin Structure Infections (SSSI)/ Viral infections/ Herpes zoster (Chicken pox) & Varicella zoster (Shingles) and /or consult the Microbiologist for high risk patients. 12. Assessing immunity to VZV Immunity to VZV may be indicated by a reliable history of past infection with chickenpox or shingles or detection of VZ antibody (VZ antibody positive) from a serum sample. The majority of adults and a substantial proportion of children without a definite history of chickenpox will be VZ antibody positive. This, however, excludes bone marrow transplant patients who must be considered non immune regardless of previous history and be tested for VZ antibody to assess immunity. Healthcare Workers Pre employment Screening Page 12 of 29

13 Healthcare workers (HCW) include all staff who have patient contact (direct and indirect e.g. contact with patient environment including catering staff, staff who work in estates and facilities) whether employed directly by the Trust or through contract. Health4Work will conduct a vaccination and immunization screening for all new healthcare staff and maintain a database in order to protect vulnerable patients from acquiring VZV from members of staff. Varicella vaccine is recommended for non immune healthcare workers who work in primary care and in hospitals and who have direct patient contact. A history of chickenpox in individuals from temperate countries or vaccination is required. For those individuals who do not have such a history, a blood test to confirm immunity will be undertaken. Those HCWs who were born or raised in tropical or sub tropical counties will have serological screening unless they are able to provide documentary evidence of immunization. Staff who are found not to be VZV immune must never care for patients with VZV. Staff who acquire chickenpox/shingles Staff members diagnosed by their General Practitioner must inform their manager and/ or H4W immediately so that necessary actions may be instituted where required including informing IPCT. Any staff member suspected to have either chickenpox or shingles must be excluded from work and referred to H4W immediately by their department manager. Pregnant Staff Staff who may be pregnant and have no history of VZV infection or are VZ virus IgG antibody negative must avoid all contact with staff or patients with VZV. Varicella virus infection can be particularly severe in pregnancy. Any non immune, pregnant staff member who comes into contact with a patient with Varicella infection should seek advice from the H4W immediately. Refer to Appendix B for procedure for vaccinating healthcare workers. 13. Management of Patients with Suspected or Confirmed VZV Patients with suspected or confirmed chickenpox or shingles must not be nursed on oncology units (i.e. Wessex at BNHH) or in the vicinity of other patients who are categorised as susceptible or high risk (e.g Nick Jonas unit at RHCH). Potentially high risk /susceptible patients: Those who have received oral or parenteral steroids (other than replacement therapy) in the previous three months Patients with leukaemia and lymphoma or bone marrow transplant recipients Page 13 of 29

14 Patients who have had solid organ transplants Patients who have had radiotherapy in the past three months Patients with immunosuppression due to HIV infection Critically ill patients, i.e. long stay on ITU Pregnant women Infants under one month old Immune compromised Patients If a patient is immune compromised and contracts VZV then the decision regarding where the patient should be nursed and whether the patient should be given VZIG will be made in consultation with the clinician responsible for their care and the IPCT/consultant microbiologist. Information leaflet for patients, relatives and carers on chickenpox and shingles can be found and printed off from the Trust intranet. Refer to Appendix C for management of VZV occurring in the ward. 14. Management of VZV in Maternity/Neonatal Unit Women with chickenpox must not be admitted to the maternity unit unless there is an overriding obstetric need. If the mother develops chickenpox less than seven days before delivery or up to seven days after, her baby must be given VZIG. Please contact a Consultant Microbiologist. Refer to Appendix E for management of neonates exposed to VZV. If a mother has or develops chickenpox whilst on the maternity unit, she must be isolated from other mothers, babies, neonates and those known to be susceptible until non infectious. She should not visit the Neonatal Unit. A mother who has chickenpox should be allowed to breastfeed. If lesions are close to the nipple, milk should be expressed from the affected side until lesions have crusted. The milk can be fed to the baby if the baby is covered by VZIG and/or acyclovir. The immune status of mothers in close contact should be assessed. Refer to Appendix F for algorithm in management of pregnant women exposed to VZV. Further guidance in management of chickenpox and shingles in pregnancy can be found on Green top Guidelines No.13 by the Royal College of Obstetricians and Gynaecologists. Page 14 of 29

15 15. Management of Patients Infected with VZV going to Theatre Non urgent elective surgery should be re scheduled for when the VZV infection has cleared. If the surgery could not be re scheduled due to overriding clinical needs of the patient: The clinical team should discuss the case with the consultant microbiologist as soon as possible. The nurse responsible for the patient s care must alert the theatre manager as soon as possible. All staff caring/treating the patient must have immunity to VZV. Areas of skin affected by shingles must be covered with a semi occlusive dressing. Gloves and aprons must be worn by all staff who have direct contact with the patient. Theatre Reception/Anaesthetic Room The patient must go straight into the operating theatre. Anaesthetic circuits and bacterial filters must be used and changed following the case.. Theatre Air conditioning/ultra clean air systems must be working. Theatre personnel must be kept to a minimum. Recovery The patient should be recovered in theatre and returned directly to the ward isolation room. Exposed surfaces should be disinfected with 1,000 ppm solution of Actichlor Plus. 16. Management of contacts of patients with chickenpox or shingles Managing contacts of patients with chickenpox or shingles involves three steps: 1. Deciding if the contact is non immune and therefore at risk of acquiring chickenpox 2. Preventing non immune contacts spreading infection to others 3. Preventing or ameliorating severe disease in non immune contacts using VZIG Refer to Appendix C for management of VZV occurring on a ward. Refer to Appendix D for management of immune compromised patients exposed to VZV. Refer to Appendix E for management of neonates exposed to VZV. Refer to Appendix F for management of pregnant women exposed to VZV. Page 15 of 29

16 17. Infection Control Precautions Patients with chickenpox infection should not be admitted to hospital unless absolutely necessary due to the risk they pose to other patients. Non immune persons who have been exposed to VZV within the previous 21 days are at risk of developing chickenpox and they should also avoid admission to hospital if possible. Staff Immunity Only staff who are known to be immune are allowed to look after patients with VZV infection. Staff who may be pregnant and have no history of VZV infection or are VZV IgG antibody negative must avoid all contact with staff or patients with VZV infection. Isolation Patients who are suspected or known to have chickenpox or shingles must be nursed into a single room, preferably with its own toilet facilities. If designated toilet facilities are not available, the patient should be provided with their own commode. If the room has negative pressure facility, this should be switched on. If the patient was identified to have chickenpox/shingles while in a bay, the bay must be closed to admissions and transfers and the patient isolated in a single room, preferably with en suite facilities. The vacated bed area must be deep cleaned before the bay can re open. If several patients have chickenpox they could be cohort nursed following discussion and agreement with the IPCT or Consultant Microbiologist. Patients should be isolated until all of the skin lesions are crusted. Personal Protective Equipment (PPE) & Hand hygiene During the period of isolation, disposable aprons and gloves must be worn by anyone entering the isolation room where the patient is being barrier nursed. Hands must be decontaminated with soap and water after removal of gloves. Strict compliance with hand washing techniques and 5 moments for hand hygiene must be observed at all times. Refer to Standard precautions (Incorporating Personal Protective Equipment) and Hand hygiene policy. Refer to Appendix D (Personal Protective Equipment (PPE) Guidance Sheet) of the Health and Safety Risk Assessment Policy. Disposal of clinical waste All waste from the room should be disposed of in the clinical waste stream for the duration that the patient is being barrier nursed. Refer to Waste Management policy. Cutlery/Crockery Page 16 of 29

17 Normal ward issue can be used but must be cleaned by washing in a dishwasher only; they must not be hand washed. Management of linen All linen must be disposed of as infected/ contaminated and be placed into a water soluble (alginate) bag before being placed into a white plastic bag. Refer to Linen policy. Cleaning and disinfection Where possible, the patient must be provided their own equipment (e.g. blood pressure machine/cuff). All equipment must be cleaned and disinfected using 1,000 ppm solution of Actichlor plus solution before re use for non infected patients. The environment must also be cleaned and disinfected using 1,000 ppm solution of Actichlor plus. A deep clean (Amber clean) must be carried out when the patient vacates the room. The curtains must be changed and sent to be cleaned as infected linen. Refer to Cleaning, disinfection and sterilisation policy and Environment cleaning policy. Patient visits to other departments Visits to other departments should be planned and kept to a minimum time. The following guidance must be observed where visits to other departments could not be avoided or delayed: Inform the receiving department and porters/transport personnel prior to the planned visit so that immune members of staff are made available to attend to the patient Where possible, plan the visit at the end of the working session Coordinate with the porters/transport and the receiving department to avoid patient waiting in common areas with other potentially susceptible patients. Ensure the receiving department is ready before transferring/transporting the patient. Visitors Visitors must be informed of the risks. Susceptible visitors must be advised to avoid contact. 18. Varicella Vaccine Pre exposure vaccination Varicella vaccine contains live attenuated Varicella zoster (Oka strain) virus; it provides protection for about 80% of recipients. Two vaccines are currently available: Varilix and Varivax. Only 75% of people seroconvert after one dose of the vaccine; hence a second dose is given four to eight weeks later. Page 17 of 29

18 If a healthcare worker is exposed to chickenpox or shingles between the first and second dose of the vaccine, the second dose should be given immediately. Storage In the dry state at 2 8 C Check expiry date before use Reconstitute with the diluents supplied by the manufacturer and use within one hour Dose 0.5mls administered by subcutaneous injection (Varivax can also be administered as intramuscular injection) total of 2 doses given at an interval of 4 8 weeks The upper arm (deltoid region) is the usual site of injection. If varicella vaccine is given at the same time as other live vaccines (e.g. MMR), the vaccine should be given at a separate site, preferably in a different limb or at least 2.5cm apart if given on the same limb. The site of each vaccine must be noted on the individual s records. Adverse reactions Up to 10% of vaccines may develop a vaccine associated rash, either localised or generalised, within 4 6 weeks of immunisation; the rash may be papular or vesicular Other adverse reactions include pain and redness at the injection site (20% of vaccines), fever, fatigue, and headache Rare side effects include seizures, encephalitis, pneumonia, thrombocytopenia, and anaphylaxis Contraindications Acute illness (vaccination should be postponed) Immunodeficiency states, such as individuals with leukaemia, lymphomas, blood dyscrasias, clinically manifest HIV infection, or patients receiving immunosuppressive therapy (including high dose steroids) Receipt of antibodies passively (immunoglobulin or blood transfusion) within three months may neutralise the live vaccine virus (not an absolute contraindication, vaccination should be postponed) Receipt of another live vaccine, including BCG, within three weeks Pregnancy Hypersensitivity to Neomycin Hypersensitivity reaction following the first dose Concurrent treatment with Acyclovir Advice Page 18 of 29

19 There is evidence to show that the vaccine virus is not transferred to the infant through breast milk and therefore breast feeding women can be vaccinated if indicated. Women of childbearing age should be advised to take adequate precautions to prevent pregnancy occurring between the two doses and for 1 month after the second dose. Salicylates (aspirin containing compounds) should be avoided during the period between the two doses of the vaccine and for six weeks after the second dose. It is possible to transmit the virus if rash develops after vaccination. Therefore pregnant non immune household contacts should be advised to seek medical advice from their GP, as they will need to have their Varicella status determined (serology testing) and (VZIG) immunoglobulin administered if indicated. Transmission in the absence of a post vaccine rash has not been documented. If a HCW develops symptoms suggestive of mild Varicella (few spots +/ fever), localised rash, or generalised rash following vaccination, they must be excluded from work immediately until all lesions have crusted and the scab has been shed naturally from all exposed lesions. The line manager must be informed and H4W contacted for advice on return to work. A few (approximately 20%) of people after vaccination may still develop chickenpox on subsequent exposure to Varicella, however it will not be severe i.e. an attenuated disease (few spots +/ fever). Post vaccination serological testing is not routinely recommended but is advisable for HCW in units dealing with highly vulnerable patients (e.g. transplant units). Post Exposure Prophylaxis The aim of post exposure prophylaxis is to protect individuals at high risk of suffering from severe Varicella infection. VZIG is recommended for individuals who fulfil either of the following criteria: No antibodies to VZ virus Significant exposure to chickenpox or shingles (see page 9) A clinical condition that increases the risk of severe Varicella (pregnant women, neonates and immune compromised individuals) on discussion with the consultant microbiologist There is some evidence that Varicella vaccine administered within three days of exposure may be effective in preventing chickenpox. 19. Stakeholders Engaged During Consultation Stakeholder Infection Prevention and Control (Lead Infection Prevention & Control Nurse) Date of Consultation 20/06/2016 Page 19 of 29

20 Health and Safety Health, Safety and Risk Officer 20/06/2016 Safeguarding (Trust Safeguarding Lead) 20/06/2016 Information Governance (Information Governance Manager) 20/06/2016 Assistant Risk and Compliance Manager (Risk and Compliance) 20/06/2016 Divisional Directors and Divisional Directors (Operational) 20/06/2016 Equality and Diversity Lead (Equality & Diversity) 20/06/2016 Head of Health4Work 20/06/2016 Infection Prevention and Control Committee 20/06/2016 Consultant Microbiologists 20/06/2016 Clinical Service Managers/Leads 20/06/2016 Operational Service Managers 20/06/ Dissemination and Implementation The policy will be disseminated in the following ways: Action(s) Publicise detail of new document via Intranet and Midweek message Communication to all Senior Managers to advise publication of policy The policy will be available on the intranet and web site Owner IPCT and Communication Team BNHH Healthcare Library BNHH Healthcare Library and Communication Team 21. Training Individuals in the Trust should comply with their yearly mandatory infection prevention and control training to ensure they are aware of their responsibilities. Education and Training will be provided in accordance with the Trust Training Needs Analysis (Learning and Development Policy). 22. Monitoring Compliance with the Document NHSLA Minimum requirements Compliance with policy Requirement Reviewed by Ward staff and IPCT Method of Monitoring Audit of cases Frequency of Review Case by case basis Committee where Monitoring is Reported to Reported at ward level Page 20 of 29

21 23. References References Brooker, C. (ed) (2010) Mosby s dictionary of medicine, nursing & health professions UK Edition. Elsevier Ltd: London Damani, N. (2012) Manual of infection prevention and control (3 rd ed). Oxford University Press: Oxford National Instutute for Health and Care Excellence (NICE) (2015) Chickenpox. Available at Accessed 14 April 2016 Marin, M. & Bialek, S. (2015) Chapter 3: Infectious diseases related to travel. Centres for Disease Control and Prevention. Available at diseases related totravel/varicella chickenpox Accessed 04 April 2016 NHS choices (2016) Chickenpox (Varicella) vaccine. Available at vaccine.aspx Accessed 15 June 2016 Guidance from other organisations Public Health England (PHE) (2015), Immunisation against infectious disease Chapter 34 Varicella Update. Available at /Green_Book_Chapter_34_Patch_v3_0.pdf Accessed 14 April 2016 Public Health England (PHE) (2015), Varicella, the green book chapter 34. Available at the green book chapter 34 Accessed 14 April 2016 Royal College of Obstetricians and Gynaecologists (2015) Chickenpox in pregnancy Green top Guideline No.13. Available at Accessed 25 July Associated Documentation Cleaning, disinfection and sterilisation Policy Environment cleaning Policy Hand Hygiene Policy Health and Safety Risk Assessment Policy HH(1)/HS/614/15 Health Clearance and Vaccination of Staff against Infectious Diseases Policy Health4Work Service Immunisation and screening for new HHFT healthcare workers HHFT Adult Antimicrobial Guide Learning and Development Policy Page 21 of 29

22 Linen Policy HH Standard precautions (Incorporating Personal Protective Equipment) Policy Waste Management Policy 25. Contributors Contributor Job Title Infection Prevention and Control Nurse Contributor Name Karen Davis Blues Page 22 of 29

23 Appendix A Equality Impact Assessment Document Title: Management of Chickenpox and Shingles Policy PART 1 Policy Author to complete and forward on to an EA Lead for sign off 1. Could the application of this document have a detrimental equality impact on individuals with any of the following protected characteristics? (See Note 1) a Age No b Disability No c Gender reassignment No d Race No e Religion or belief No f Sex No g Sexual orientation No h Marriage & civil partnership No i Pregnancy and maternity No 2. If Yes to question 1, do you consider the detrimental impact to be valid, justifiable and lawful? If so, please explain your reasoning. Yes/No /NA Summarise the equality and diversity related elements within the policy 3. Specify with which, if any, individuals and groups you have consulted in reaching your decision. PART 2 Equality Analysis Lead to complete and forward back to the Policy Author Provide a brief summary of the potential impact of the policy and whether sufficient consideration has been given to the Equality Duty. The policy advices on all aspects of the management of; infected individuals, contacts and preemployment screening of staff. 1. Is this document recommended for publication? Y If yes go to question 3 if No complete number 2 below. 2. This document is not recommended for publication because: Page 23 of 29

24 A Amendments are suggested as follows: B A more detailed equality analysis should be undertaken as follows: C Other (please specify) 3. Specify with which, if any, individuals and groups you have consulted in reaching your decision. Name: Lorraine Amos Job Title: Pathology Business Manager Date: PART 3 Policy Author to complete on receipt of part 2 and before forwarding for final policy approval 1. I have reviewed the Part 2 assessment and have made the necessary amendments to the policy. If you have answered no, please explain why not none required Name: Sheryl Lucero Job Title: Infection Control Nurse Date: Note 1 Under the terms of the Equality Act 2010 s public sector Equality Duty, the Trust has a legal responsibility to think about the following three aims of the Equality Duty as part of our decision making and policy development. Eliminate unlawful discrimination, harassment and victimisation; Advance equality of opportunity between people who share a protected characteristic and people who do not share it; and Foster good relations between people who share a protected characteristic and people who do not share it. Page 24 of 29

25 Appendix B Procedure for vaccinating healthcare workers Page 25 of 29

26 Appendix C Management of VZV occurring in the ward Page 26 of 29

27 Appendix D Management of immune compromised patients exposed to VZV Page 27 of 29

28 Appendix E Management of neonates exposed to VZV N.B. Refer to Green top Guideline No.13 for further guidance on management of chickenpox and shingles in neonates. Page 28 of 29

29 Appendix F Management of pregnant women exposed to VZV N.B. Refer to Green top Guideline No.13 for further guidance on management of chickenpox and shingles in pregnancy. Page 29 of 29