Transcript Chickenpox outbreak among the staff of

14.06 - 24.06.2012
Alshallali ICU
 Main ICU at
Omdurman military
teaching hospital
 Capacity of 17 beds:
8 medical, 4 surgical,
4 HDU and
one isolation bed
 4 ICU consultants
 6 registrars of anesthesia
 6 medical registrars
 16 medical officers
 60 staff nurse
 18 aid nurses
 12 dietitian
 One clinical pharmacist
 14th June -------------------> 24th June 2012
 ICU setting before 14th April 2012
Before 14 April 2012
No: isolation room, receptionist area, clean utility
rooms, visitors waiting room, on call rooms and staff
offices
Equipment
storage


Old ALshallali ICU
New extension
 17 beds (3% of the total hospital beds)
 Missing facilities
New extension 17 beds
( 3% of the total hospital beds)
Old ICU
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Isolation room
(-ve)
14.4.2012
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Medical ICU
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HDU
On call room
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On call room
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Surgical ICU
Old ICU
Receptionist Area
Clean and Dirty Utility Rooms.
Equipment Storage.
Visitors Waiting Room
Staff offices
Plasmapheresis
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Equipment Storage
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Medical ICU
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HDU
On call room
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On call room
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Surgical ICU
 Two possible index cases
 The first patient was 22 years
immunocompetant male presented to the
A&E with chickenpox complicated by
chickenpox pneumonia
 29th of may 2012.
 Admitted to the A&E hospital for 24 hours
 The dept of communicable was aware of the
case
 Admitted to the ICU on 30/may/2012
 Indication : respiratory distress with severe
hypoxemia, with ? need for assisted
ventilation.
Where in ICU ?
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Equipment Storage
30.5.2012
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Medical ICU
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HDU
On call room
Surgical ICU
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On call room
30.5.2012
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INFECTION CONTROL PRECAUTIONS
 Standard precautions
 Disposable gloves
 Surgical masks
 Instructions : nursed by staff with H/O
childhood chickenpox
 Exclusion of susceptible staff from attending
the affected patient
 Transported to radiology department
without any infection control precautions
Patient improved on :
 Oxygen therapy
 I.V acycloviar
 I.V steroids
 Discharged on the 7th of June
 On the 8th of June the second possible
index patient was admitted
 55 years old diabetic female presented with
herpes zoster ophthalmicus complicated
by secondary bacterial infection
 Indication for ICU: swelling of the tongue
and lips, and the risk of upper airway
obstruction.
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Equipment Storage
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Medical ICU
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HDU
On call room
Surgical ICU
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On call room
8.6.2012
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 No infection control precautions !!!!!
 Discharged on 11th of June
 3 days after discharging the second patient.
 14th of June
 The first secondary case, was staff nurse
 15th June : one medical officer
 16th June : one medical officer
 17th NO case reported
 18th June : one case staff nurse
 19th June : one case staff nurse
 20th : 4 staff + one patient
 The infection prevention and control team
was informed on the 20th of June
 21 June : 4 cases HCWs
 22 June : 4 cases HCWs
 23 June : 3 cases HCWs
 24 June : 2 cases HCWs
6
5
4
NO. of case 3
2
1
0
14
15 1
16
17
18
DAYS
20
21
22
23
24
 Secondary cases continued till 24th of June
 Diagnosis of varicella was based on clinical
appearance, namely an acute generalized
maculo-papulo-vesicular rash, without
other apparent cause.
Staff Age/
gender
PH of
Preg. Previous
similar
expo. to
illness
CK case
Incub.
period,
days
Direct
contact
with the
patient 1
Direct
contact
with the
patient 2
Aware of
the
patient
∆
N1
25 F
NO
NO
NO
14
YES
NO
YES
N2
26 F
NO
NO
Unknown
16
NO
YES
YES
N3
25 F
NO
NO
NO
20
NO
NO
YES
N4
24 F
NO
NO
NO
20
YES
YES
YES
N5
23 F
NO
NO
NO
21
NO
NO
YES
N6
24 F
NO
NO
NO
24
YES
NO
YES
N7
23 F
NO
NO
YES
22
YES
YES
YES
N8
25 F
NO
NO
NO
22
YES
NO
YES
N9
24 M
NO
----
NO
22
NO
NO
YES
N10
24 F
NO
NO
YES
24
YES
YES
YES
Dr 1
26 F
NO
NO
NO
15
NO
YES
YES
Dr 2
25 F
NO
NO
YES
21
YES
NO
YES
Dr 3
25 F
NO
NO
NO
23
NO
NO
YES
Staff
Age/
gender
PH of
Preg Previous
similar
exposure
illness
to CK
case
Incub. Direct
period, contact
days
with the
patient 1
Direct
contact
with the
patient 2
Aware of
the
patient
∆
A.N1
40 F
NO
NO
Unkonwn
21
NO
NO
YES
A,N2
28 M
NO
---
YES
19
YES
NO
YES
A.N3
31 M
NO
----
NO
18
YES
YES
YES
A.N4
25 F
NO
NO
NO
23
NO
NO
YES
A.N5
26 F
NO
NO
YES
20
YES
NO
YES
A.N6
23 F
NO
NO
NO
20
NO
NO
YES
D1
27 F
NO
NO
NO
21
YES
YES
YES
D2
24 F
NO
NO
YES
22
NO
NO
YES
D3
24 F
NO
NO
NO
23
NO
NO
YES
Pt 1
24 M
NO
---
NO
20
NO
NO
YES
 Total NO. secondary cases : 23
- 22 HCWs
- One patient
 Age range : 24-40yr
 19 females (non was pregnant)
 4 males
 All reported no prior history of chickenpox
or VZV vaccination.
 6 reported PH of contact with close relative
with chickenpox.
 2 were not sure.
 11 of HCWs who developed chickenpox
reported contact with the index patient NO1
 7 reported contact with the index patient
NO2.
 5 HCWs reported contact with both index
patients.
 All infected staff reported awareness of the
high infection rate of chickenpox
 Only 2 staff (physician) were aware that
shingles is infectious
 None has any education about the mode of
transmission and the additional precautions
required to prevent exposure to, and spread
of VZV.
 No written guidelines
 Only one patient infected with chickenpox,
20th of June.
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Equipment Storage
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Medical ICU
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On call room
On call room
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Surgical ICU
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HDU
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Possible Infection routes
 Direct contact form the patient
1st or 2nd ?
 Direct contact from infected staff ?
 Air borne transmission from the first
patient ?
Outbreak management
 The infection prevention and control team
was informed on the 20th of June
 The staff were excluded from work until
they became no longer infectious.
 They were given sick leave (range, 10–15
days) until the entire rash crusted and they
became well.
 Evacuate the ICU for 72hr. : disinfection.
 Using Formaldehyde (formalin )
 No admission to ICU : for two weeks
 All patients were shifted to the Medical ICU
 HDU & SICU : disinfected with chlorine
based disinfectant (intermediate level DI)
 Visitors continued to be allowed with no
precautions
Limited resources
 Varicella zoster antibody testing
 Varicella zoster vaccine
 Respirator masks : N95, P2 and P3 masks
 -Ve pressure isolation room : 9/7/2012
Summary of the out break
 Total number of secondary cases were 22
unvaccinated ICU staff who developed
chickenpox 15–24 days following exposure :
- 9 staff nurses : 15% of total staff
- 6 aid nurse : 30%
- 4 medical officers : 25% of total staff
- 3 dietician : 25%
 A total of 276 person-days of work were lost.
 Complications of chickenpox in
secondary cases :
-Staff ?
-Patient ?
 Why this has happened ?
 What have we done since then to prevent
recurrence of similar outbreak or
outbreaks of other communicable
disease ?

approach
References
. Practical Guidelines for Infection Control in
Health Care Facilities ©World Health
Organization 2004
 Immunization of Health-Care Personnel:
Recommendations of the Advisory Committee on
Immunization Practices (ACIP). MMWR, 2011;
60(RR-7).
 Guideline for Disinfection and
Sterilization in Healthcare Facilities,
2008
Ideal approach
 NOTIFICATION REQUIREMENTS
 EDUCATION
 STAFFING
 AIRBORNE PRECAUTIONS
 CONTACT PRECAUTIONS
 TRANSPORTATION
 VISITORS
 VZV EXPOSURES
 STAFF WITH VZV INFECTION
 Modes of transmission of VZV
 Communicability
 The incubation period
TRANSMISSION
 The most common modes of transmission
of VZV are the following:
 Person to person from infected respiratory
secretions
 Respiratory contact with airborne droplets
 Direct contact with aerosols
 Inhalation of aerosol from vesicular fluid of
skin lesions of patient with acute Chicken or
Herpes Zoster (Shinges)
COMMUNICABILITY
 Patients with Chickenpox or Herpes Zoster
(Shingles) are infectious from 1-2 days
before the onset of rash, through the first
4-5 days until the lesions have formed
crusts.
 Chickenpox is highly contagious.
 Secondary attack rates in household
contacts are as high as 90%.
 Staff who develop Chickenpox or Herpes
Zoster (Shingles) are a source of infection to
other non-immune or
immunocompromised patients or staff.
INCUBATION PERIOD
 The incubation period is from day 10 to day
21 post exposure to either Chickenpox or
Herpes Zoster (Shingles).
 Up to 85% of non-immune people exposed
to Chickenpox become infected.
NOTIFICATION REQUIREMENTS
-All staff MUST notify Infection Control
of any suspected or confirmed cases of:
 Chickenpox
 Disseminated Zoster in an
immunocompromised patient
 Herpes Zoster (Shingles).
Staff education
 Staff education should be a central focus
of the infection control program.
 Clearly written policies, guidelines, and
procedures are needed in many
instances for uniformity, efficiency, and
effective coordination of activities.
STAFFING
 Only staff who have had Chickenpox (or
a blood test confirming chickenpox),
Herpes Zoster (Shingles) or 2 doses of
the Varicella Zoster vaccine should care
for patients with Chickenpox,
Disseminated Zoster or Herpes Zoster
(shingles).
 An employee’s health programme must
be in place to prevent and manage infections
in hospital staff.
 Varicella is highly contagious
 Adults are at high risk of developing
complications
 Vaccination of hospital staff against varicella
is recommended.
 Practical Guidelines for Infection Control in
Health Care Facilities ©World Health
Organization 2004
 The CDC and many infectious diseases
experts recommend the varicella vaccine for
healthcare workers.
 Varicella For HCWs who have no
serologic proof of immunity, prior
vaccination, or history of varicella
disease, (chickenpox) give 2 doses of
varicella vaccine, 4 weeks apart.
CDC. Immunization of Health-Care Personnel:
Recommendations of the Advisory Committee on
Immunization Practices (ACIP). MMWR, 2011; 60(RR-7).
 Healthcare workers should be screened for
varicella immunity at the time of
employment.
 Routine vaccination for all healthy persons
aged >13 years is recommended for those
without evidence of immunity.
Advisory committee on immunization practice.
Recommended adult immunization shedule: USA. Ann
intern med 2007.
Airborne and Contact Precautions
 Are intended to reduce the risk of
transmission of the infectious agent VZV
to staff, patients and visitors who have
no immunity to the disease or have not
been vaccinated against the disease.
AIRBORNE PRECAUTIONS
 PATIENT PLACEMENT
 CHICKENPOX AND DISSEMINATED
HERPES ZOSTER
 MUST be cared for in a negatively
ventilated room.
 HERPES ZOSTER (SHINGLES)
 MUST be cared for in a single room in a
ward with no immunosuppressed
patients.
RESPIRATORY PROTECTION
 Masks are not required when entering
the room as only staff that have had
Chickenpox, Herpes Zoster (Shingles) or
2 doses of the Varicella Zoster vaccine
and are not immunosuppressed are to
care for the patient.
CONTACT PRECAUTIONS
 Wear gloves for contact with lesions on the
patient or potentially infective material or
surfaces in the patient’s environment.
 Change gloves after contact with infective
material.
 Hand wash or disinfect hands immediately
after removing gloves.
 Cover localised lesions to contain vesicle
exudate.
 Wear a gown whenever it is anticipating
that clothing may have direct contact with
infective or potentially infective lesions,
material or surfaces.
TRANSPORTATION
 Limit patient movement outside the room to
medically necessary/essential procedures.
 Wherever possible, use portable equipment
to perform x-rays and other procedures in
the room.
 If procedures are medically
necessary/essential the following must be
implemented:
 Before the patient is transferred, the
ward/unit in which the patient is isolated
MUST notify the accepting area that the
patient has VZV infection and requires
additional AIRBORNE AND CONTACT
PRECAUTIONS.
 During transport/transfer non-ventilated
patients MUST wear a mask (N95 if
possible or a surgical mask).
 During transport/transfer support staff
MUST wear gloves and a gown if direct
patient contact is anticipated.
VISITORS
 Staff MUST check if visitors have had
chickenpox or Herpes Zoster (Shingles)
before they enter the room.
 What Personal Protective Equipment (PPE)
visitors will be required to wear will depend
on their immunity and degree of contact
with the patient.
 Notification
 Negative pressure room
 Vaccination of staff
Conclusion
 This outbreak highlights the importance
and benefit of occupational health
programs in developing countries and
the need for rapid involvement of infection
control experts to target and prevent the
spread of emerging and reemerging
infectious agents.
 Infection control team should ensure all
staff are aware of their immune status in
relation to Varicella Zoster Virus, the mode
of transmission and the additional
precautions required to prevent exposure to,
and spread of VZV.
 Adherence to isolation precautions,
education, pre-employment anti-VZV-IgG
screening and vaccine coverage of staff
could have prevented the occurrence of
this outbreak.
 Complications of chickenpox in
secondary cases :
 All recovered without complications
Thank
You!
Responsibilities of the infection
control team
 Advise staff on all aspects of infection
control and maintain a safe environment for
patients and staff
 Provide educational programmes on the
prevention of hospital infection for all
hospital personnel
 Provide a basic manual of policies and
procedures and ensure that local written
guidelines based on these are in existence.
 Establish systems of surveillance of hospital
infection in order to identify at-risk patients
and problem areas that need intervention.
 Methods for surveillance may include case
finding by ward rounds and chart reviews,
reviews of laboratory reports, and targeted
prevalence or incidence surveys.
 Advise management of patients requiring
special isolation and control measures.
 Investigate and control outbreaks of
infection in collaboration with medical and
nursing staff.
 Ensure that an antibiotic policy is in
existence.
 Liaise with the hospital doctors and
administration (managerial and nursing),
community health doctors and nurses, and
infection control staff in adjacent hospitals.
 Provide relevant information on infection
problems to management and the ICC.
 Perform other duties as required, e.g.,
kitchen inspections, pest control, waste
disposal.