Case 7: Paediatric Issues in Infection Control (practice/redo)

You were informed by one of the patient service managers that one of her staff (a 26 year-old female) has just been diagnosed by her family practitioner as having chicken pox. She works on the general paediatric ward and her last day of work was three days ago, the same day the rash developed. The nurse had worked with three patients in adjacent rooms for five days prior to her last day of work, although she had been giving break relief to other nurses throughout that period. The unit has twelve patients on the one wing. The children range from age 2 to 13.

Case Seven Questions:

1.What precautions should be taken, if any, to protect patients on the ward? Would you recommend prophylactic therapy for any of the patients? Justify your response.

Precautions for patients:

  • Varicella zoster can be transmitted through air or contact from persons (Lautenbach, p. 301) Therefore all patients with symptoms should be placed on airborne and contact precautions.
  • Patients who have contracted varicella zoster should remain on precautions until lesions have dried and crusted to prevent hospital exposures (Lautenbach, p. 301).
  • Non-immune exposed patients should be placed on airborne precautions for the period from day 10 through day 21 after their exposure or through day 28 if the patient is immunocompromised or has received Varicella zoster immunoglobulin
  • Varicella zoster is rarely spread through air from individuals with localized herpes zoster so patients, visitors and healthcare workers with this disease entity do not need to be restricted so long as their lesions are covered (Lautenbach, p. 301)

Prophylactic therapy:

  • Patients and staff who are non-immune should receive the varicella zoster vaccine as it results in milder outbreak and is cost effective for the hospital given costs associated with secondary cases (Lautenbach, p301)
  • All patients on the unit are a high risk for complications therefore if they can safely receive varicella vaccine, and it is within 3 to 5 days after exposure, give the vaccine (BCCDC, 2004)
  •  For immunocompormized patients give Varicella zoster immune globulin (VZIG) given within 96 hours of exposure (BCCDC, 2004)

2. What, if any, infection control measures should be considered for the hospital workers.

  • non-immune workers could be incubating the infection and could spread it to others
  • all healthcare workers who might have been exposed should not work in patient care capacity during the incubation period (Lautenbach, p. 301)
  • staff members who develop varicella zoster must not work until all lesions have crusted over(Lautenbach, p. 301)
  • non-immunized exposed staff should be considered potentially infectious 8 to 21 days following exposure (28 days if VZIG was given (BCCDC, 2004)

  • Staff who are pregnant or have immunocompromizing conditions such as corticosteroid treatments should receive VZIG  (BCCDC, 2004).
  • immunization status of current staff should be known or sought (BCCDC, 2004)

  • Lab results for Serology for VZV IgG should be determined for non-immune staff before immunization (i.e.unknown or no history of chickenpox) (BCCDC, 2004).

  • staff who are immunized are considered to be immune (4 weeks after the second dose) and no special precautions need to be taken if they are exposure

  • If susceptible staff is not eligible for immunization, or if serology results can not be promptly obtained, refer to a physician for clinical management, which may include prophylaxis with antiviral and VZIG if the HCW is at high risk for complications of varicella disease.

  • susceptible non-immunized HCW/students from work from days 8 through days 21 post-exposure. Extend the exclusion to 28 days, if VZIG is given.

3. What are the tests available to confirm a diagnosis of chicken pox? Is laboratory confirmation always necessary – why or why not?

Laboratory confirmation from Isolation of varicella virus from an appropriate clinical specimen or significant rise in serum varicella IgG antibody level by any standard serologic assay (BCCDC, 2004).

Laboratory confirmation not always necessary in cases where clinical illness arises in an epidemiologically linked person where the link individual has lab confirmed chicken pox.

4. How effective is Varicella zoster vaccination in children? In adults? What are the potential complications?

  • In immunocompetent children 12 months to 12 years of age, a single univalent varicella vaccine dose results in a seroconversion rate of 98% at 4 to 6 weeks after vaccination, with antibodies persisting in 98% at 5 years and 96% at 7 years after vaccination.
  • A second dose of a univalent varicella vaccine in children produces an improved immunologic response that is correlated with improved protection (Government of Canada, 2016).
  • In immunocompetent adults and adolescents 13 years of age and older, 2 vaccine doses administered 4 to 8 weeks apart result in seroconversion rates of 99% at 4 to 6 weeks after the second dose, with persistence of antibodies 5 years later in 97% of vaccine recipients(Government of Canada, 2016).

Potential Complications:

  • injection site pain
  • swelling and redness in 10% to 20% of recipients
  • A low-grade fever has been documented in 10% to 15% of vaccine recipients.
  • A varicella-like rash occurs at the injection site or is generalized in 3% to 5% of vaccine recipients after the first dose.
  • The rash usually appears within 5 to 26 days after immunization.
  • As varicella-like rashes that occur within the first 2 weeks after immunization may be caused by wild-type virus (varicella virus circulating in the community), health care providers should obtain specimens from the vaccine recipient to determine whether or not the rash is due to a natural varicella infection or to the vaccine-derived strain (Government of Canada, 2016).

5. This nurse, as the case turns out, is pregnant and delivers the day following her visit to her family practitioner. The baby is admitted to the neonatal intensive care unit. What measures should be taken?

References:

  1. Lautenbach, E., Woeltje, K., and Malani, P. 2010. Practical HealthcareEpidemiology, 3rd ed.
  2.  BCCDC. 2004. Communicable disease control Varicella zoster.  http://www.bccdc.ca/resource-gallery/Documents/Guidelines%20and%20Forms/Guidelines%20and%20Manuals/Epid/CD%20Manual/Chapter%201%20-%20CDC/Epid_GF_VaricellaZoster_July04.pdf
  3. Government of Canada. 2016. Canadian Immunization guide. https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-24-varicella-chickenpox-vaccine.html#p4c23a4
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