Case 2: Infection Control Precautions

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The paediatric ward informs you of a child admitted last night with a maculopapular rash. The child is currently in a single room; however, the staff are requesting you review the type of infection control precautions required. There is no history of contact with measles, mumps or rubella, however, the child has never been immunized. Clinically the child has a dry cough, coryza and a pink maculopapular rash – the parents are unsure of where the rash started. The paediatrician suspects measles or rubella.
Case Two Questions:
1. What are your recommendations regarding infection control precautions for this child?

Suspected measles=airborne precations.

Patients with suspected measles should be placed under airborne precautions (Lautenbach, p. 57).

Airborne precautions “prevent disease transmission by aerosols containing droplet nuclei or contaminated dust particles” (Lautenbach, p. 57). Droplet nuclei are less than 5um in size and may remain suspended in the air allowing them to migrate for long periods of time.

The patient is already in a private room but should be in an airborne infection isolation room, AIIR, which is a private room with negative air pressure and at least 6 air exchanges per hour (preferrably 12). Room air being exhausted directly outside or through a high efficiency particulate air, HEPA, filter. The room door should be kept closed at all times. (Lautenbach, p. 57).

Patient transport: a surgical mask should be worn by the patient.

Visitors and staff entering the room: wear a respirator. The N95 mask filters out 95% or particles.

Suspected rubella=droplet precautions

Droplet precautions “prevent the transmission of micro-organisms by particles larger than 5um. Droplets are produced when the patient talks, coughs, or sneezes. (Lautenbach, p.58.)

The patient should also be placed on contact precautions to prevent spread of disease from contaminated surfaces (Lautenbach, p. 59). Measels mode of transmission is through “airborne by aerosol and droplet spread, direct contact with nasal or throat secretions of infected persons; less commonly by articles freshly soiled with nose and throat secretions.” (BCCDC, 2014). Healthcare workers should gown and glove when entering the room and change gloves if touching materials with high concentration of micro-organisms.

Considering the patient has a rash that is not yet known to be rubella or measles it is best to place the patient in the more extensive and encompassing precautions – airborne isolation with contact precautions until a definite diagnosis can be made (Lautenbach, p. 59).

Once definitive diangosis is made, isolation precaution continuation and removal will follow CDC guidelines for the pathogen-specific illness (Lautenbach, p. 59).
2. What laboratory tests would help in the diagnosis and why is it important to confirm your suspicions?

Lab tests for measels:

  • Submit a nasopharyngeal swab and urine sample for measles virus isolation and PCR testing.
  • isolation of measles virus from an appropriate clinical specimen
  • detection of measles virus RNA
  • seroconversion or a significant (e.g. fourfold or greater) rise in measles IgG titre by any standard serologic assay between acute and convalescent sera
  • positive serologic test for measles IgM antibody using a recommended assay in a person who is either epidemiologically linked to a laboratory-confirmed case or has recently travelled to an area of known measles activity.
  • Epidemiologically-linked: • Clinical illness (fever≥ 38.3oC and cough, coryza or conjunctivitis and generalized maculopapular rash for at least 3 days) in a person with an epidemiologic link to a laboratory-confirmed case. (BCCDC, 2014)

Lab tests for rubella:

  • “Nasopharyngeal or throat swab specimens and/ or urine should be taken for virus isolation. Virus may be isolated 1 week before to 2 weeks after rash onset” (BCCDC, 2014)
  • isolation of rubella virus from an appropriate clinical specimen
  • detection of rubella virus RNA
  • seroconversion or a significant (i.e., fourfold or greater) rise in rubella IgG titre by any standard serologic assay between acute and convalescent sera
  • detection of rubella IgM antibody using a recommended assay in a person with an epidemiologic link to a laboratory- confirmed case or who has recently travelled to an area of known rubella activity
  • Epidemiologically-linked: Clinical illness (fever and rash, and at least one of the following: arthralgia/arthritis, lymphadenopathy, conjunctivitis) in a person with an epidemiologic link to a laboratory confirmed case (BCCDC, 2014)

Importance of confirming suspicions:

Due to infectious nature of disease, morbidity and mortality confirming cases promplty is of great importance. “Investigate all confirmed, probable, and suspect cases of measles within 24 hours”. For rubella “Confirming the diagnosis is particularly important in pregnant women, cases who have contact with pregnant women, suspected cases of CRS, and during outbreaks.” (BCCDC, 2014) as the virus has significant implications on the developing fetus.

Case reporting to the following is necessary along with contact tracing for tratment and containment of the outbreak.

  • Complete the individual case report in iPHIS (Integrated Public Health Information System)/ Panorama or PARIS.
  • Public health action, including contact management, may commence at any level of the case definition, including for a suspect case.
  • Inform the local Medical Health Officer and initiate control measures immediately.” (BCCDC, 2014)
  • Viral detection methods (e.g., RT-PCR followed by sequencing) enable a definitive diagnosis, allow the laboratory to distinguish vaccine virus type from wild virus type
  • DNA viral testing can determine if there are single or multiple genotypes of virus circulating in a community.
  • Genotyping of the virus is helpful in understanding transmission patterns
  • Genotying faciliates outbreak investigation when there is no epidemiological links between cases because such results can indicate whether the origin of the virus is the same or different. (CDC, 2014)
  • “Clinical diagnosis of rubella is challenging and may be inaccurate because symptoms and signs are not unique to this disease. ” (BCCDC, 2014). The virus has significant implications on the developing fetus therefore confirming a case is crucial for the pregnant woman and her GP to make informed decisions regarding pregancy care and carrying the fetus to term (BCCDC, 2014)

3. How would you perform a risk assessment to determine the extent of contact tracing for possible exposed individuals?

Risk Assessment: “An evaluation of the interaction of the health care provider, the client/patient/resident and the client/patient/resident environment to assess and analyze the potential for exposure to infectious disease.” (PIDAC pdf, p12)

“The risk of transmission of microorganisms between individuals involves factors related to:
 the client/patient/resident infection status (including colonization)

 the characteristics of the client/patient/resident

 the type of care activities to be performed

 the resources available for control

 the health care provider immune status.” (PIDAC pdf p.24)
I would start by determine if correct PPE was used and protocols followed as soon as measles or rubella was suspected. Determine at first encounter, if any staff were not yet following appropriate precautions (this would be prior to suspicion of rubella or measles). Consider all unimmunized staff, patients, and visitors waiting in ER, hallways, elevators at the time this patient was brought in and then transferred to the paediatric unit. Then all unimmunized hospital staff, patients, visitors within this suspected infected patient’s air space prior to the patient being place place in a negative pressure room and under correct isolation precautions for rubella/measles. (PIDAC pdf, p40)

Contact tracing would then extend beyond the hospital into the community (the child’s school, church, community/rec centre, library etc) for all unimmunized potentially exposed individuals – ensure these individuals get tested to contain outbreak.

Post exposure follow-up:
“ identification of exposed staff
 assessment and immunization history

 post-exposure prophylaxis and follow-up including:

 collection and analysis of exposures

 a program for prompt response to sharps injuries16, 77

 policies to deal with spills and staff exposure to blood or body fluids

 education regarding preventive actions that may be put into place to improve practices and prevent recurrence.” (PIDAC pdf, p64)
4. What is the difference between Airborne and Droplet Precautions? What is a bioaerosol?

Airborne Precautions “prevents disease transmission via aerosols containing droplet nuclei or contaminated dust particles.” (Lautenbach p. 57.) Droplet nuclei are particles less than 5um and may remaining suspended in the air for long periods. Airborne precautions therefore consist of a negative pressure, single patient room with at least air exchanges per hour exhausted to the outside or through HEPA filters and room doors must be closed. N95 or portable respirators must be worn by those entering the room and the patient must wear a surgical mask on transport outside the room. (Lautenbach, P57, Table 6-3)

Droplet precautions “prevent the transmission of microorganisms by particles larger than 5um”, produced when the patient talks, coughs or sneezes or during certain procedures. (Lautenbach p. 58) Droplet precautions consist of a single patient room where the door may remain open. Surgical or isolation mask must be worn by those entering the room and the patient must wear a surgical or isolation mask if transported outside the room. (Lautenbach, P57, Table 6-3

Bioaerosols: are “Small droplet of moisture that may carry microorganisms. Aerosols may be light enough to remain suspended in the air for short periods of time, allowing inhalation of the microorganism.” (PIDAC, p. vii)
5. You are asked to provide an education session to the staff on Infection Control Precautions. What principles would you use in your approach to planning and carrying out the session?

Adults learn best when convinced of the need for knowing the information. Often a life experience or situation stimulates the motivation to learn” (medscape article)

Therefore provide relevance, emphasizes how what the group is learning will help protect them as well as their patients.

“former experiences can assist the adult to connect the current learning experience to something learned in the past. ” (Russel, 2011).
Draw on the group’s experiences, have them give examples of past cases they have used various infection control methods relevant to this suspected measles/rubella case. Eg. Have any of them cared for a patient in a negative pressure room? When was the last time they cared for a patients under droplet precautions?

Facilitate the learning group process:

“The learner participates completely in the learning process and has control over its nature and direction.

It is primarily based upon direct confrontation with practical, social, or personal problems.

Self-evaluation is the principal method of assessing the progress or success.” (Medscape article)

Engage the group with a practically relevant trial runs by having them set up an infection control room for droplet precautions, a negative pressure room etc. have them volunteer ideas and critique the scenarios.

Understand there are different learning styles amongst the group: kinaesthetic, auditory and visual. Teach to all these styles. Provide hands-on activities such as the scenarios above for the kinaesthetic learners, use the visual aides (infection control signs/posters with steps on) for the visual learners and discuss material with repetitions during the session for the auditory learners. (Russel, 2011).

References:

1. Lautenbach, E., Woeltje, K., and Malani, P. 2010. Practical HealthcareEpidemiology, 3rd ed.

2. BCCDC. (2014). Communicable Disease Control Manual Chapter 1 – Management of Specific Diseases Measles. Section 6.1 Laboratory Testing. http://www.bccdc.ca/resource-gallery/Documents/Guidelines and Forms/Guidelines and Manuals/Epid/CD Manual/Chapter 1 – CDC/MeaslesSeptember2014.pdf

3. BCCDC. (2014). Communicable Disease Control Manual Chapter 1 – Management of Specific Diseases Rubella. Section 6.1 Laboratory Testing. http://www.bccdc.ca/resource-gallery/Documents/Guidelines and Forms/Guidelines and Manuals/Epid/CD Manual/Chapter 1 – CDC/RubellaSeptember2014.pdf

4. Provincial infectious diseases advisory committee (PIDAC). (2012). Routine practices and additional precautions in healthcare settings. http://www.publichealthontario.ca/en/eRepository/RPAP_All_HealthCare_Settings_Eng2012.pdf

5. Russell, SS. (2011). An overview of adult learning processes. http://www.medscape.com/viewarticle/547417_print

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