1 of 9 Policy Objective To ensure that Healthcare Workers are aware of the actions and precautions necessary to minimise the risk of outbreaks and the importance of diagnosing patients clinical conditions promptly. This policy applies to all staff employed by NHS Greater Glasgow & Clyde and locum staff on fixed term contracts. Document Control Summary Approved by and date Board Infection Control Committee16/06/2008 of Publication 17/06/2008 Developed by Infection Control Policy Sub- Group. 0141 201 4931 Related Documents NHSGGC Transmission Based Precautions Policy NHSGGC Standard Precautions Policy Distrubution/Availablity NHSGGC Infection Prevention and Control Policy Manual and the Internet Implications of Race This policy must be implemented fairly and without Equality and other diversity prejudice whether on the grounds of race, gender, disability, duties for this document sexual orientation or religion. Equality and diversity Yes 11/06/2008 Impact Assessment Completed Lead Responsible Director/Manager Nurse Consultant Infection Control Board Infection Control Manager
2 of 9 Contents 1. Responsibilities 2. General Information on Whooping Cough (Pertussis) 3. Transmission Based Precautions for Whooping Cough (Pertussis) 4. Audit 5. Evidence Base Appendix 1 - Management of contacts of a clinically suspected or laboratory confirmed case of Pertussis.
3 of 9 1. Responsibilities Health Care Workers (HCW) must : - Follow this policy. Inform a member of the Infection Control Team (ICT) if this policy cannot be followed. Clinicians & Microbiologists must:- Notify the NHS Greater Glasgow & Clyde Public Health Protection Unit 0141 201 4917 if they diagnose a clinical case of whooping cough. Laboratory staff must notify NHS Greater Glasgow & Clyde Public Health Protection Unit 0141 201 4917, if they make a laboratory diagnosis of whooping cough. Managers must: - Support HCWs and ICTs in following this policy. Infection Control Teams must: - Keep this policy up to date. Audit compliance with this policy. Provide education opportunities on this guideline.
4 of 9 2. General information on Whooping cough Communicable Whooping cough or Pertussis, is caused by a gram negative disease / Alert bacillus - Bordetella pertussis. Incidence is higher in infants less Organism than 6 months of age. Neither infection nor immunisation provides life long immunity. Clinical condition Begins with a mild upper respiratory tract infection which develops into a cough. The cough can become paroxysmal and is characterised by inspiratory whoop. Fever is absent or minimal. Classic infection can last typically 6 to 10 weeks in children. Severity of disease is closely associated with age. Infants under 1 year have the highest mortality rate and are more likely to be hospitalized. They are also most likely to suffer complications. These can include; bronchopneumonia and cerebral complications such as seizures, cranial nerve abnormalities and encephalitis. Mode of spread Droplet transmission: Close direct contact with an infected person via aerosolized droplets from the respiratory tract. Incubation period Usually 6 to 10 days with a range of 5 to 21 days. Notifiable Disease Period of communicability Persons most at risk Yes Individuals are infectious for 5 days after initiation of effective therapy. Where treatment is not given, individuals are infectious for 3 weeks after the onset of symptoms Infants under 1 year have the highest mortality rate 3. Transmission based precautions for patients with Whooping cough Accommodation Single room until after 5 days of appropriate antibiotic therapy Care plan No Clinical waste During period of isolation, all non-sharp waste should be placed in a yellow/orange clinical waste bag within the room. Contacts Please refer to appendix 1. Decolonisation Not applicable Domestic advice Advise general services/domestic assistants to clean single room last, following SOP for twice daily cleaning of isolation rooms. Equipment Where practicable, the patient should be designated their own equipment. See Decontamination of Equipment Policy. Exposures Prevent further cases by isolating all patients suspected or diagnosed with whooping cough in a single room. Furniture Keep clean by use of detergent and water and drying thoroughly. Hand hygiene Hands must be decontaminated before and after each direct patient contact and contact with patient equipment/environment regardless of whether personal protective equipment is worn. Alcohol hand gel will be effective if hands are visibly clean. Last offices No special requirements Linen Used linen should be placed in a red alginate bags and then a secondary bag as per Linen policy.
5 of 9 Marking notes Moving between wards, hospitals and departments (including theatres) Notice for the door Outbreak Patient clothing Personal protective equipment Precautions required until Procedure restrictions Screening on admission Screening staff Specimen required Specimens marked as Danger of Infection Terminal clean of room Vaccination Visitors Not applicable Patient movement should be restricted, however, if deemed necessary by the clinical team they in consultation with the ICT should inform the receiving department before transfer of the need for special precautions. Staff transferring the patient do not need to wear protective clothing during the transfer, but should decontaminate hands once transfer is complete. Transfer to other departments, i.e. radiology, should occur at the end of the day, unless in a clinical emergency. Yes Unlikely if transmission based precautions are followed. Follow Outbreak Policy http://library.nhsggc.org.uk/mediaassets/infection%20control/micros oft%20word%20-%20outbreak%202007%20final.pdf No special precautions Aprons should be worn for direct contact with the patient and their immediate surroundings. Gloves should be worn to prevent direct contact with respiratory secretions. Perform hand hygiene after removing personal protective equipment. 5 days after initiation of appropriate antibiotic therapy or three weeks after start of symptoms. None. Yes, if whooping cough suspected. All staff that have been exposed and are unsure of their immune status should contact the Occupational Health Department for advice. A nasal swab should be taken to confirm whooping cough. Rapid results are achieved by PCR but culture will also be carried out. No As per SOP Please refer to green book Immunisation against infectious disease. (2006) http://www.dh.gov.uk/en/policyandguidance/healthandsocialcaretopics/greenbook/d H_4097254 Only parents or close relatives who have been immunised or given chemoprophylaxis may visit. Interpreters/advocate regularly involved with the patient and their family must also be considered in this category.
6 of 9 4. Audit Criteria Guide Score 1. Patients suspected of or diagnosed with pertussis on admission, are accommodated in a single room. Check on admission diagnosis or positive specimen result 2. Hand hygiene facilities are available within the patient s room. 3. Gloves and aprons are readily available for use when caring for the patient with pertussis. 4. The isolation room is clearly identified Check there is a hand wash basin, with supplies of liquid soap and paper towels and alcohol hand gel. Check gloves and aprons are available at the entrance to the single room Check that there is a sign at entrance to single room Audit undertaken by: : Ward: Hospital: Action Plan: Results reported to: This audit may be undertaken by ward staff, or by an ICN as part of their annual audit programme.
7 of 9 5. Evidence Base UK guidelines for use of erythromycin chemoprophylaxis in persons exposed to pertussis H. Dodhia, N.S. Crowcroft, J.C. Bramley and E. Miller. Journal of Public Health Medicine 2002;Vol 24:No 3:pp 200-206. http://www.hpa.org.uk/infections/topics_az/whoopingcough/guidelines.htm American Academy of Pediatrics. 2006 Red Book: Report of the Committee on Infectious Diseases, 27th ed. (Elk Grove Il) 308. Centres for Disease Control. Guideline for Isolation Precautions: Preventing transmission of Infectious Agents in Healthcare Settings 2007. http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/isolation2007.pdf
8 of 9 Appendix 1 Management of contacts of a clinically suspected or laboratory confirmed case of pertussis. (Presumption that the initial case has been commenced on treatment) One or more case(s) of clinically suspected* or laboratory confirmed* pertussis Has the onset of the disease occurred within the past 21 days YES NO Identify if any member of the household is defined as a vulnerable close household contacts * No further action required NO YES Treat all close household * contacts with erythromycin chemoprophylaxis and complete pertussis vaccination as appropriate (up to 10 years of age). *Definitions: Suspect case: an acute cough lasting 14 days (with at least one of the following symptoms; post-tussive vomiting, apnoea or whoop) or a paroxysmal cough lasting 7 days.
9 of 9 Confirmed case: a symptomatic case with positive laboratory result by culture, PCR or serology where available. Close household contacts : person living within the same household or institutional setting (e.g. ward, residential home). Vulnerable close household contact : newborn infants born to symptomatic mothers; neonates, infants and children with no or incomplete protection from vaccine (see below); presence of other chronic illness; asthma, congenital heart disease; Immunocompromised. Persons considered to have no or incomplete protection from vaccination: fewer than 3 doses of vaccine or > 5 years old and not received a pre-school booster. Anyone born before Nov 1996 will not routinely have received a preschool booster, nor some born in to May 1998. Erythromycin chemoprophylaxis: the dose and duration of erythromycin chemoprophylaxis should be 125mg 6 hourly for children up to 2 years of age; 250mg 6 hourly for children 2-8 years of age; and 250-500mg 6 hourly for children over 8 years of age and adults. The duration of treatment and chemoprophylaxis should be for 7 days. Erythromycin treatment: Treat the first and other clinically suspected case(s) with onset <21 days to reduce transmission risk. There is no evidence of benefit in cases with onset >21 days. Pregnant women with suspected or confirmed pertussis should be given treatment for 7 days and started at least 3 days prior to delivery if feasible. Dosage as per erythromycin chemoprophylaxis above. Note: Erythromycin has only limited effectiveness in preventing transmission even if given before 21 days of exposure. Furthermore, there is good evidence on the adverse effects of erythromycin, which include gastrointestinal effects (i.e nausea, vomiting and abdominal pain), which may lead to non-compliance. There is evidence that neonates receiving erythromycin may be at increased risk of developing infantile hypertrophic pyloric stenosis. Its use should therefore be restricted to circumstances where it can be given before 21 days and: (1) likelihood of transmission is high (i.e. close contacts); (2) the contact is in a vulnerable group; (3) vaccination cannot be relied upon to protect the vulnerable contact. Taken from UK guidelines for use of erythromycin chemoprophylaxis in persons exposed to pertussis, H. Dodhia, NS Cowcroft, JC Bramley, E Miller, Journal of Public Health Medicine, 2002