Introduction: The Wyoming Department of Health receives numerous inquiries from Long Term Care Facilities around the state regarding facility outbreaks and isolated infections of concern. Many times these outbreaks and isolated infections manifest themselves as skin infections like MRSA, diarrheal diseases like norovirus, and respiratory diseases of either viral or bacterial origin. In response to these inquires this document (Infection Control in Long Term Care) was created to serve as a resource to LTCF staff. The document should help assist in answering many frequently asked questions, but certainly will not answer every question so please continue to call Epidemiology at (307-777-3593) if your questions are not answered by this informational guideline. Infection Control in Long Term care is broken up into six sections; Infection Control, Diarrheal diseases, Drug-Resistant Infections, Respiratory Diseases, Varicella, and Scabies. The Infection control section at the beginning serves as a guide to what your facility should be doing. The specific disease section includes infection control recommendations and guidelines for specific disease categories. The infection control issues and the diseases addressed here are common to the LTCF in the state of Wyoming. Infection Control The implementation and execution of proper infection control practices in LTCF’s is essential to the well being of residents. Therefore, adherence to infection control guidelines by medical staff should be strictly enforced at all times. The purpose of the infection control section is to assure that the LTCF has an infection control program which is effective at investigating, controlling, and preventing infections. Infection Control Surveillance 1. The facility must have an Infection Control system to monitor and investigate infectious diseases (both nosocomial and community acquired) 2. Surveillance system should also be able to determine the how the disease is spread. 3. Maintain a separate record for each patient who is infected and include • the date of infection, • the causative agent • the origin or site of infection • measures taken to prevent the spread of infection 4. The surveillance system must be able to • analyze clusters • recognize changes in prevalent organisms • and recognize an increase in the rate of infection quickly. 5. Surveillance data should be analyzed routinely and recommendations should be made based on this data to prevent and control disease. Infection Control Standards: (guidance for evaluating a facilities program) 1. Call the State Epidemiologist’s office at 307-777-3593 to report non-sporadic, facilitywide infections that are difficult to control. 1

2. Do risk assessments of occurrence of communicable diseases for both residents and staff that is reviewed annually or more frequently if needed. 3. Methods for identifying, documenting and investigating nosocomial infections and communicable diseases. The methods should be able to • Identify new infections quickly • Pay special attention to residents at high risk of infection – residents who are/have o are immobilized, o invasive devises or procedures, o pressure sores o recently been discharged from the hospital to the LTCF o MI or MR o Decreased mental status o Nutritionally compromised o Compromised immune systems. o 4. Early Detection of residents who have signs and symptoms of TB • A referral protocol to the Wyoming Department of Health where TB can be evaluated and managed properly 1-307-777-3593 5. Measures for prevention of infections, especially those associated with • Intravascular therapy • Indwelling urinary catheters • Tracheostomy care • Stoma care • Respiratory care • Immunosuppresion • Pressure sores • Bladder and bowel incontinence • And other infections which may compromise a residents resistance to infection. 6. Measures for the prevention of communicable disease outbreaks, including TB, Flu, hepatitis, scabies, MRSA, Norovirus, and other respiratory, and diarrheal diseases. 7. Isolation procedures and requirements for infected and at risk or immunosuppressed nursing home residents. 8. Use of in-service education regarding standard precautions, universal precautions/body substance isolation. 9. Proper use of disinfectants, antiseptics, and germicides in accordance with manufacturers instructions • Follow EPA and FDA label specifications to avoid harm to staff, residents, and visitors and to ensure it’s effectiveness 10. Orientation of all new facility personnel to the infection control program and periodic updates for all staff. 11. Measures for the screening of health care workers for communicable diseases • For the evaluation of workers exposed to residents with communicable diseases including TN and blood born pathogens 12. Work restriction guidelines for an employee that is infected or ill with a communicable disease. 2

13. Measures which address the prevention of infections common to nursing home residents which includes • Vaccination for influenza and streptococcus pneumoniae as appropriate • TB screening and testing 14. Sanitation of tubs, whirlpools, and multiple use equipment to be performed according to manufacturers recommendations.

3

Summary of the Guidelines for Isolation Precautions in Hospitals: HICPAC Recommendations for Isolation Precautions in Hospitals (Reference 15: Infection Control and Hospital Epidemiology 1996;17(1):53-80) Standard Precautions Standard Precautions are designed to incorporate the protection against blood-borne pathogens achieved by Universal Precautions and the protection against other pathogens achieved by Body Substance Isolation. Standard Precautions are to be used on ALL patients, regardless of their diagnosis or presumed infectious status, when coming into contact (or risk of contact) with any of the following: (1) blood, (2) all body fluids, secretions and excretions except sweat, (3) non-intact skin, or (4) mucous membranes. Standard Precautions consist of the following nine components: (1) Routine hand washing (2) Consistent and correct glove use (i.e., glove changing with hand washing between patients) (3) Appropriate use of masks, eye protection, and face shields (4) Appropriate use of gowns (when necessary) (5) Routine cleaning or disposal of patient care equipment (6) Regular cleaning of all environmental surfaces (7) Appropriate handling of contaminated linen (8) Strict adherence to occupational safety requirements (9) Effective management of patients with poor hygienic practices Transmission-based Precautions Summary Transmission-based precautions consist of additional measures designed to be used with Standard Precautions to further reduce the risk of disease transmission. Transmissionbased precautions are divided into the three categories listed below. Specific use of a category of transmission-based precautions is based upon the disease(s) of the patient. Example diseases are listed below each category; for a complete list of diseases, refer to Infection Control and Hospital Epidemiology 1996;17(1):53-80, Appendix A. Airborne Precautions (1) Place patient in private room or cohort. (2) Use respiratory protection when appropriate. (3) Limit patient transport within the facility. (4) Use additional precautions with tuberculosis.* Example Disease: TB-pulmonary or laryngeal Measles Chickenpox Droplet Precautions 4

(1) Place patient in a private room or cohort; when not possible, maximize distance between patients. (2) Wear mask when working closely with the patient. (3) Limit patient transport within the facility. Example Diseases: H. influenza meningitis N. meningitidis meningitis S. pneumoniae pneumonia Diphtheria, Pertussis, Influenza Contact Precautions (1) Place patient in a private room or cohort; when not possible, consult the infection control practitioner (ICP). (2) Wear gloves upon entrance to room and at all times. (3) Wash hands with antimicrobial soap upon leaving the room taking care not to touch environmental surfaces. (4) Wear a gown when entering the room if contamination is at all possible. (5) Limit patient transport within the facility. (6) Dedicate the use of personal, non-critical medical equipment to a single patient. (7) Use additional precautions for preventing the spread of Vancomycin resistance. Example Diseases: MRSA/VRE infection or colonization** C. difficile with diarrhea Shigellosis if diapered or incontinent Scabies

5

Guidelines for the Epidemiological Investigation of Gastroenteritis Outbreaks in Long Term Care Facilities Introduction Definitions Surveillance Single Case Management Outbreak Management Introduction: Outbreaks of gastroenteritis occur in nursing homes and other long term care facilities (LTCFs) each year, most commonly in the winter. Risk factors in these settings include the close proximity of ill residents and staff in close living quarters and the decreased personal hygiene among some residents due to incontinence, immobility, or reduced alertness. Viruses, such as Norwalk-like agents, are the most common agents causing nursing home outbreaks of gastroenteritis. Viral gastroenteritis is a self-limiting intestinal illness with symptoms of diarrhea and/or vomiting. Additional symptoms may include nausea, abdominal pain, headache, muscle ache, and low grade fever. The incubation period is 12 to 48 hours and gastrointestinal symptoms usually last 12 to 60 hours. The virus is passed from person to person through the fecal-oral route (fecal matter to mouth); contaminated food and water have also been implicated as vehicles for transmission in outbreaks. Additional information can be found in the reference: Centers for Disease Control and Prevention (CDC), Morbidity and Mortality Weekly Report (MMWR), Norwalk-Like Viruses: Public Health Consequences and Outbreak Management. 2001;50 (RR-9). For LTCF residents, gastroenteritis is important because it can lead to more serious illnesses and complications, such as dehydration, debilitation, hospitalization, and death. The symptoms, course, treatment, and control measures for gastroenteritis outbreaks in a LTCF will vary depending on whether the agent is probably viral or bacterial (such as Salmonella or Shigella). In order to facilitate investigations of gastroenteritis outbreaks and implementation of control measures, the following guidelines have been established. These guidelines are divided into four sections: • • • •

Section 1 provides a working case definition and an outbreak definition. Section 2 addresses the use of surveillance to detect cases. Section 3 outlines the management of an individual case of gastroenteritis. Section 4 outlines the management of an outbreak.

Section 1. Definitions

6

A. Case Definition A case of gastroenteritis is defined as a person with diarrhea or vomiting. Diarrhea is defined as two or more loose stools per day or an unexplained increase in the number of bowel movements. B. Outbreak Definition An outbreak of gastroenteritis is defined as three or more residents from a single ward or unit, or 3% or more of the entire facility, who develop diarrhea and/or vomiting within a 7 day period. Section 2. Surveillance Each LTCF should have its designated infection control practitioner (ICP) routinely maintain records on the occurrence of diarrhea and vomiting among all residents and staff. When a person meeting the case definition is identified, the case management procedures described below should be followed. Any employee with gastrointestinal illness should be instructed to report it to Employee Health or the ICP. Section 3. Single Case Management Each time a case of gastroenteritis is recognized in a resident or employee, the following measures should be implemented: A. Residents • •

•

• • •

Restrict the case to his/her room and restrict from participating in group activities for 2 days after the last episode of diarrhea or vomiting. Wear gloves. Direct patient care providers should wear disposable gloves when handling feces or fecally-soiled articles or equipment (e.g., cleaning or changing an incontinent patient, cleaning feces from a bed or bedpan, etc.). Wash hands. Employees and residents must WASH THEIR HANDS carefully after contact with any feces or fecally-soiled material. Employees should wash their hands after removing gloves. Dispose of feces or fecally-soiled material in the sanitary sewer (toilet), or place in plastic bags for disposal as special medical waste. Clean environmental surfaces (toilets, bedpans, fecally-soiled beds, etc.) with cleaning products and procedures normally used by the facility. Practice infection control precautions. Each LTCF should practice the Standard Precautions recommended by the CDC Hospital Infection Control Practices Advisory Committee at all times, regardless of the presence of an outbreak

B. Employees When a case of gastroenteritis is recognized in an employee, reassign the employee to non-patient care and non-food handling duties or exclude until 2 days after the resolution of diarrhea and/or vomiting. If salmonellosis, shigellosis, or E. coli infection is diagnosed, the local health officer may recommend additional control measures. 7

Section 4. Outbreak Management A. Reporting LTCFs should report gastroenteritis outbreaks to the local health department and to the Wyoming Department of Health within 24 hours. In the event of an outbreak on a weekend or holiday, please contact your local health department for the telephone number used to contact them at those times. B. Outbreak Control Measures Control measures for an outbreak of gastroenteritis should focus on stopping person-toperson spread and on removing any ongoing common sources of infection (ill food handler, ill patient care provider, or contaminated food or drink). When an outbreak is identified, the LTCF should institute the following control measures • Follow the recommendations for management of individual cases • Assign employees to care for the same group of patients during a shift if possible. • Stop new admissions; readmissions to the facility are allowed, preferably to an unaffected ward. • Exclude symptomatic employees from direct patient care and food handling until 2 days after the resolution of diarrhea and/or vomiting. • Restrict ill residents from group activities, including group dining, until 2 days after the resolution of diarrhea or vomiting. • Institute visitor precautions (e.g., post a sign to alert visitors that an outbreak is occurring and that hand washing is recommended). A visitor ban is not necessary. • Wear masks when cleaning areas grossly contaminated by feces or vomitus (since spattering or aerosols of infectious material of viral gastroenteritis may be involved in disease transmission). • Handle soiled linen and clothes as little as possible; transport laundry in an enclosed and sanitary manner. Unless otherwise indicated, all control measures for presumed viral gastroenteritis can be lifted when there are no new cases for 4 days after onset of the last case. C. Specimen Collection In all outbreaks of gastroenteritis, specimen collection for bacterial enteric pathogens should be done to rule out Salmonella, Shigella, and E. coli as causative agents. Stool specimens of no more than 10 residents should be collected. Process specimens through a commercial laboratory following their instructions, or use an "enteric pathogen kit" if sending the specimen to the Wyoming Public Health Laboratory (WPHL). This kit is a jar containing a buffered glycerol saline solution. Store and transport at +4 C to the WPHL. If Salmonella, Shigella, or E. coli causes the outbreak, the epidemiologic and laboratory investigation will be different from an outbreak presumed to be caused by a virus. In outbreaks of salmonellosis, shigellosis, or E. coli infection additional specimens 8

and questionnaires from food handlers and patient care providers, as well as additional information on residents (e.g., food history) may be needed. Stool specimen analysis for viral studies is not available at the WPHL, but will be referred to a reference laboratory. There should be communication with the LTCF and the Epidemiology department prior to planning viral studies. When the epidemiology suggests a viral etiology, please refer to the guidelines for the submission of stool samples for viral studies (see Attachment A). Stool samples should be submitted in a sterile stool jar (either the “miscellaneous kit” or the “Norwalk study kit”). WPHL can provide stool collection kits, including stool jars, upon request. All samples should be delivered to the Wyoming Public Health Laboratory for processing. D. Data Collection and Summary Report 1. Data Collection Pertinent information regarding each resident and employee case should be entered into the ICP' s surveillance log. This log should be updated daily. Once an outbreak has been identified, cases should be placed on a "line list" (see attached line listing form for gastroenteritis - Attachment B). 2. Epidemic Curve Plot an epidemic curve ("epi curve") of the resident and employee cases (a graph of the number of cases by date of onset). The epi curve is a useful tool to track the progress of the outbreak and is helpful in determining whether a common foodborne source was present. 3. Summary Report At the conclusion of the outbreak, the health department investigator and the involved facility should work together to complete a summary report. A copy should be submitted to the epidemiology program. The report may be narrative in format or Attachment C may be completed instead of the narrative report. Regardless of which report format is chosen, please include the epi curve with the report. E. Health Department Responsibilities Once notified of a gastroenteritis outbreak the health department should take the following steps: • • • • • •

Verify the existence of an outbreak of gastroenteritis by reviewing facility records. Notify the State Epidemiologist of the outbreak. Verify that outbreak control measures have been properly implemented and residents with diarrhea have been cultured to rule out enteric pathogens. Inspect the facility to assess: General cleanliness Availability of soap, towels, running water in rest rooms and in all patient care 9

• •

areas Food preparation areas and food handling procedures when foodborne transmission is suspected Arrange for the collection of data on resident and employee cases as indicated in the line list

When additional employee information is desired, Attachment D is a standardized questionnaire for investigation of gastrointestinal illness. It can be administered to all or only symptomatic employees at the facility, depending on investigation needs. The questionnaire may be modified as appropriate to the outbreak and facility, duplicated, and distributed as needed. If the local health department or the LTCF distributes the questionnaire, be sure to fill in the LTCF name (on line 1 on the questionnaire) and the appropriate date for assessing symptoms (on line 10) before duplication.

10

Guideline for Control of Methicillin-Resistant Staphylococcus aureus (MRSA) In Long Term Care Facilities Introduction and Background Virulence of MRSA Identifying MRSA Colonization and Infection Risk Factors for MRSA Procedures for obtaining cultures to identify MRSA Standard Precautions Termination of Precautions Communication MRSA FAQ References

Introduction and Background The term “Methicillin-Resistant Staphylococcus aureus” (MRSA) refers to those strains of Staphylococcus aureus bacteria that have acquired resistance to the antibiotics methicillin, oxacillin, nafcillin, cephalosporins, imipenem, and/or other beta-lactam antibiotics. The incidence of MRSA has increased in health care facilities in the United States since the mid-1970s. Approaches to the control of MRSA vary widely, primarily because studies establishing the efficacy of specific infection control measures are lacking. This guideline recommends the most widely used approaches to the control of MRSA in long term care facilities, including nursing homes, chronic care and rehabilitation hospitals, extended care facilities, assisted living facilities, etc. These approaches include: • • • •

Recognition of infected or colonized residents; Appropriate infection control measures; Communications between acute care and long term care facilities; and Personnel policies related to MRSA.

Once MRSA has become firmly established in a facility, it is rarely eliminated. A variety of control measures have been reported, and many of these reports cite beneficial results. It should be emphasized, however, that the efficacy of most measures used for 11

surveillance, prevention, and control of MRSA has not been established in controlled studies. As a result, recommendations in this guideline are based on general infection control principles and on review of published articles dealing with the epidemiology and control of MRSA in hospitals and long term care facilities. Virulence of MRSA MRSA is not a “super bug.” While Staphylococcus aureus itself is a virulent (disease causing) pathogen, methicillin resistant strains are NOT more virulent than methicillin sensitive strains. Many health care workers (HCWs) incorrectly assume that MRSA strains are more virulent because of the special isolation precautions implemented. MRSA is of special concern because it is often multi-drug resistant, thus limiting treatment options. Identifying MRSA MRSA is identified by a bacterial culture and antibiotic sensitivity of the suspected site of infection or colonization (e.g., blood, sputum, urine, wound, exudate, pressure ulcer material). Two criteria are necessary for the organism to be identified as MRSA. First, the organism is identified as Staphylococcus aureus or coagulase-positive Staphylococcus species. Second, the antibiotic sensitivity test will show that the organism is resistant to oxacillin, methicillin, nafcillin, cephalosporins, imipenem, and/or other beta-lactam antibiotics. Colonization and Infection •

•

Colonization is the presence, growth, and multiplication of the organism in one or more body sites without observable clinical symptoms or immune reaction. A ‘carrier’ refers to an individual who is colonized with MRSA. MRSA colonization can occur on the skin surface, wound or pressure ulcer surface, in the sputum, or in the urine. One of the most common sites of colonization in both HCWs and residents is the anterior nares. While personnel may become colonized with MRSA, they rarely develop infections with the organism. MRSA infection is a condition whereby the bacteria has invaded a body site, is multiplying in tissue, and is causing clinical manifestations of disease, such as fever, suppurative wound, pneumonia or other respiratory illness or symptoms, or other signs of inflammation (warmth, redness, swelling). Infection is confirmed by positive cultures from sites such as blood, urine, sputum, or wound.

Reservoirs of MRSA •

Colonized and infected residents serve as the major reservoir of MRSA in long term care facilities. Contaminated environmental surfaces have not been shown to play a significant role during outbreaks in long term care facilities. Asymptomatic colonization of residents’ noses with MRSA is common in long term care facilities. Point prevalence studies have found that 23% - 35% of residents in Veterans’ Affairs affiliated units may become colonized over a period of one to two years. In the few prevalence surveys performed in freestanding long term care 12

facilities located in areas where MRSA is common, 9% - 12% of residents were colonized. MRSA colonization may disappear with treatment and reappear weeks or months later. Transmission of MRSA •

•

The main mode of transmission of MRSA is person to person via hands, usually of HCWs. Colonization of hands of personnel may be either transient, such as a single day, or of longer duration, such as several weeks. Colonization of the HCW may occur if proper handwashing and barriers (such as gowns and gloves) are not used appropriately. MRSA may be aerosolized in the droplet nuclei from a coughing resident or from a ventilator exhaust port of an intubated resident who has MRSA in his or her sputum. The organism may also be aerosolized during the irrigation of a wound containing MRSA. However, the role of aerosolization in the transmission of MRSA is not known. Although MRSA has been isolated from environmental surfaces, transmission to residents is thought to be minimal, except in burn units.

Risk Factors for MRSA The following factors have been identified as increasing the risk that a resident will have an MRSA infection: • • • • •

Prior prolonged hospitalization Preceding antimicrobial therapy Close proximity to a resident colonized or infected with MRSA Presence of open wounds and/or pressure ulcers Presence of invasive devices, such as gastrostomy tubes, tracheostomy tubes, intravascular lines, indwelling urinary catheters, etc.

Procedures for Obtaining Cultures to Identify MRSA Surface cultures of broken skin or weeping lesions If a culture is needed from broken skin, a pressure ulcer, etc., gently wipe area with a sterile gauze pad moistened with saline. The site should then be swabbed with the culture swab, using a rolling motion. If a Gram stain is indicated, an additional swab should be taken from the site for the Gram stain. If the site is suppurative (pus producing) or shows tissue destruction, culture the area most heavily involved. Indicate the anatomical location of the site that was cultured on the culture requisition form. Gloves must be worn while obtaining cultures. Gloves should then be removed, placed in the appropriate waste disposal unit, and hands should be thoroughly washed with soap and water. •

Cultures of residents with confirmed or suspected deep tissue infections, urinary tract infections, and respiratory infections

13

Follow facility protocols for obtaining sterile specimens for culture from these sites. •

Routine nares cultures of asymptomatic residents or HCWs are not indicated. DO NOT culture nares when obtaining cultures for MRSA at other body sites unless the resident or HCW is epidemiologically implicated in an MRSA outbreak. For questions as to whether or not a resident or HCW might be linked to an outbreak and thus warrant nares cultures for MRSA, contact the Wyoming Department of Health Epidemiology Section at (307-777-3593).

•

Nares (Nostrils) If a culture of the nares is warranted, the culture should be taken with a sterile swab moistened with sterile saline or culture tube transport medium. The swab should be placed gently in one nostril and allowed to remain seconds. The same swab can be used for each nostril. The culture swab is then placed in the transport medium and labeled appropriately. The laboratory should be instructed to screen only for MRSA.

Surveillance 1 The long term care facility should maintain a line listing of the names and other appropriate information of residents and admissions that are found to be colonized or infected with MRSA.4 2. Do not include on the line listing residents who are colonized with MRSA in the nares ONLY. These colonized patients should be tracked separately. 3. Facilities should regularly monitor and record endemic MRSA case rates using incidence or incidence density ratio (e.g., percent cases or cases per 1,000 resident-days). Definition of an outbreak An outbreak of MRSA in the facility represents an increase in the incidence of MRSA cases in the facility above the baseline level, or a clustering of new MRSA cases that are epidemiologically linked. For the purposes of this guideline, an outbreak consists of either: • •

1) an increase in the average monthly incidence of MRSA of 25% above the baseline, or 2) three or more new MRSA cases within a two month period on any ward or unit.

If an outbreak has been identified, notify the local health department. Management of the outbreak should be conducted in consultation with the local health department and the Department of Health. 14

Infection Control Measures Standard Precautions These precautions must be used for ALL residents, regardless of diagnosis or presumed infection status, when contact is anticipated with blood; all body fluids, secretions, excretions, including feces and urine but excluding sweat; non-intact skin; and mucous membranes. Standard precautions consist of the following components: •

•

•

• • • •

•

Routine handwashing, using soap, running water, and friction must be strictly adhered to. In certain circumstances, hands may be cleansed with an alcoholbased waterless hand cleaner (containing at least 60% alcohol) between washing with soap and water. Single use, disposable gloves must be used when touching blood and all body fluids, non-intact skin, and mucous membranes. Those employees who are sensitive to latex may use latex-free gloves. The gloves may be sterile or nonsterile, depending upon the task to be performed. Masks, eye protection, or face shields must be worn when it is anticipated that splashing with body fluids might occur, such as during suctioning of the respiratory tract or irrigation of a large wound. Gowns must be worn when soiling of the health care worker’s clothes is possible during care, such as giving a resident a bath. Routine cleaning of resident care equipment must be performed according to facility protocol. Routine cleaning of environmental surfaces must be performed according to facility protocol. Linen must not be separated on the nursing unit. ALL linen, regardless of the diagnosis of the resident, should be collected and bagged at the bedside. If linen is wet, or saturated with urine or feces, it should be collected in a plastic or fluid impervious bag. The concept of “isolation linen,” in which linen is collected and handled separately according to the diagnosis of the resident, is no longer practiced. All linen is treated in the same manner, i.e., as if it were potentially infectious. Safe disposal of sharps, including needles, must be accomplished according to facility protocol, the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogen Standard, and State and local regulations

Contact Precautions Contact precautions must be used when a resident is colonized or infected with MRSA in any site other than the nares. Nasal colonization of a resident with MRSA does not warrant precautions other than standard precautions unless that resident is considered to be epidemiologically linked, either as a source or as a spread case, to an outbreak of MRSA in the facility. Contact precautions consist of the following components:

15

Contact precautions must be used when a resident is colonized or infected with MRSA IN ANY SITE OTHER THAN THE NARES. Nasal colonization of a resident with MRSA does not warrant precautions other than standard precautions unless that resident is considered to be epidemiologically linked, either as a source or as a spread case, to an outbreak of MRSA in the facility. Contact precautions consist of the following components: 1. Room Placement and Activities • • •

•

•

• •

A resident who is colonized or infected with MRSA at any body site should be placed according to the following scheme: Most Desirable: A private room or cohorting with another resident who is colonized/infected with MRSA. Less Desirable: A room with another resident who has intact skin and no “tubes” (invasive feeding tubes, tracheotomy tubes, any type of intravascular line, any type of indwelling urinary drainage tube, or any other tube or device that breaks the skin or enters into a normal body orifice). A resident with MRSA should not be placed with another resident who has another antibiotic resistant organism, e.g., vancomycin-resistant enterococcus (VRE). A resident may attend activities as long as any colonized or infected body site, other than the nares, can be securely covered, and the resident observes acceptable hygiene and washes his/her hands. A resident who is unable to control secretions should not attend group activities. A resident with nasal colonization of MRSA does not need to wear a mask outside of the room and may attend all activities. If the resident has a "cold" with significant nasal discharge, they do not need a mask if they can control their secretions and cover their nose and mouth when coughing and sneezing.

IF IT IS ALREADY KNOWN THAT A RESIDENT HAS MRSA ONLY IN THE NOSE, IT IS PREFERABLE TO FOLLOW THE ABOVE PLACEMENT GUIDELINES WHEN POSSIBLE, EVEN THOUGH THE RESIDENT DOES NOT NEED TO BE PLACED ON CONTACT PRECAUTIONS. Special emphasis should be placed on handwashing for these residents. If the resident’s cognition is less than normal, the nursing personnel caring for them should be responsible for ensuring that the resident washes his/her hands regularly and especially after coughing and sneezing. A resident who is colonized with MRSA in the sputum does not need to wear a mask outside of the room if he/she can cover his/her mouth and nose with a tissue when coughing. If they have a chronic, uncontrollable cough, they should wearmask when outside of the room. If they have a tracheostomy tube, the tube can be covered with a “trach collar.” Again, special emphasis on handwashing should be maintained on these residents. Placement of these residents should follow the guidelines previously stated.

16

A resident who is infected (not colonized) with MRSA in the respiratory tract, such as pneumonia or bronchitis, should wear a mask when leaving the room. 2. Gloves Nonsterile exam gloves (latex or latex-free) must be worn when physical contact with the resident is anticipated and discarded when soiled, before touching a clean surface and before leaving the room. 3. Handwashing Hands must be washed with an antimicrobial soap or alcohol-based waterless hand cleanser after removing gloves and before leaving the room. Care should be taken not to touch environmental surfaces in the room before leaving, unless a disposable paper towel is used to touch the surfaces. 4. Gowns Gowns must be worn if physical contact with the resident will occur, and changed between residents. Dispose of according to facility protocol. 5. Masks HCWs must wear a mask when the possibility of splashing in the worker’s face is present, such as when suctioning respiratory secretions or irrigation of large wounds. Residents who are infected (not colonized) with MRSA in the respiratory tract, e.g. pneumonia or bronchitis, should wear a mask when leaving the room. Those residents who are colonized with MRSA in their sputum and who have a chronic, uncontrollable cough should wear a mask when leaving the room. 6. Equipment Where possible, dedicate the use of personal, noncritical medical equipment, such as thermometers and blood pressure apparatus, to the resident with MRSA. 7. Cleaning The resident’s room must be cleaned per protocol with the facility’s hospital disinfectantdetergent. No special cleaning methods are necessary. Decolonization Because colonized or infected residents represent the major reservoir of MRSA, eradicating the organism from all such residents should theoretically reduce the reservoir of MRSA in the facility. Decolonization generally involves the use of topical and/or systemic antibiotic treatment to eliminating MRSA carriage in an individual. While this approach has been used in a number of hospitals and long term care facilities, it has resulted in emergence of antibiotic resistance in some cases. 17

Eradication of MRSA colonization may be desired by the physician and the resident in situations where isolation may interfere with the resident’s well being. Eradication may also be used during MRSA outbreaks to help control the spread of the organism. Since the use of single antimicrobial agents to eradicate MRSA may be unsuccessful and may result in the emergence of resistance, MRSA eradication should only be attempted in consultation with an infectious disease physician. Termination of Precautions A resident may be considered free of MRSA after two cultures of the colonized or infected body site is negative (except for nares). The first culture should be taken 72 hours or more after antibiotic treatment has been discontinued. The second culture should be taken one week after the first. If the first or second of these cultures remains positive for MRSA, cultures should continue to be taken one week apart until two consecutive negative cultures have been documented. If a sputum specimen cannot be obtained from a resident who has been colonized/infected with MRSA in the sputum, the resident’s throat may be cultured as a surrogate for sputum. If a wound site is healed, the healed site itself may be cultured with a moist swab, according to procedures stated elsewhere in this guideline. When two consecutive negative cultures have been obtained, contact precautions may be discontinued and standard precautions should be followed for the resident. Using cultures of a resident’s nares as criteria for discontinuing contact precautions is not necessary and should not be done. Negative nares culture from a resident does not necessarily provide adequate evidence that the MRSA has been eradicated from that resident. Prevalence surveys have shown that residents may be colonized with MRSA in the absence of infection and without the knowledge of the health care staff. Therefore, a resident’s nares should ONLY be cultured if the resident is implicated in a MRSA outbreak situation and NOT as a condition for termination of contact precautions. Communication Long term care facilities may NOT arbitrarily refuse to accept a resident with MRSA colonization or infection, as long as the facility is able to place the resident according to the room placement scheme mentioned previously. .” Long term care facilities should have some system in place for alerting HCW’s and visitors that a resident is on contact precautions, such as labeling the chart or the door of the room, without compromising that resident' s privacy. Long term care facilities should inform hospitals or other nursing facilities if they transfer a resident who is known to be colonized or infected with MRSA.

18

Hospitals and other nursing facilities that transfer a resident known to be colonized or infected with MRSA to a long term care facility should inform that facility that the resident has MRSA. The transferring facility should also note, if it can be determined, that the resident was infected or colonized with MRSA during the hospitalization. An MRSA patient in an hospital or other nursing facility who transfers to a long term care facility does NOT need to have two negative MRSA cultures before transfer can occur. Negative cultures serve as criteria for discontinuing contact precautions only. Training and Education Certified nursing assistants (CNAs) and other HCWs in the facility should receive basic instruction in performing infection control procedures. Each facility must also periodically present continuing education on handwashing, standard and transmissionbased precautions, and the OSHA Bloodborne Pathogen Standard. When a resident acquires MRSA, appropriate infection control procedures should be reviewed with all HCWs who will have contact with the resident. Employee Health Surveillance cultures of HCWs for MRSA carriage is not recommended as a general control measure. Such cultures should be done only if employees are epidemiologically implicated as the source of an outbreak, as directed by WDH personnel. Personnel who have staphylococcal infection should be treated with antibiotics. Personnel with skin lesions or dermatitis should be removed from direct resident care until the lesions are healed. Personnel with respiratory infections and cough should not be assigned to direct resident care. MRSA Guidelines for LTCFs – Page 1 Definition of Terms • Carrier: An individual who has been found to be colonized (culture growing MRSA) at one or more body sites but who has no signs or symptoms of infection. • Cohort: A cohort consists of two or more residents sharing the same room in a facility and/or physically separated from other residents by their location. • Cohort staffing: The practice of assigning specified personnel to care only for residents known to be colonized or infected with MRSA. Such personnel should not participate in the care of residents whose cultures do not grow (or who have not had cultures obtained for) MRSA. • Contact isolation: A method of isolation recommended by the Centers for Disease Control and Prevention that requires barrier precautions such as gloves and gowns for direct contact with substances and residents known to contain MRSA or another pathogen. This method includes hand washing after removal of barrier precautions. • Decolonization: Topical and/or systemic antibiotic treatment administered for the purpose of eliminating MRSA carriage in an individual.

19

• Endemic: A baseline rate or an ongoing frequency at which MRSA infection or colonization occurs in a facility. • Incidence: The number of cases of MRSA colonization or infection identified in a specific population during a given time period. • Infection: The condition of a resident when MRSA has entered a body site, is multiplying in tissue, is causing the clinical manifestations of disease, such as fever, suppurative wound, or pneumonia, and is documented by positive cultures, such as from blood, sputum, wound, or urine cultures. • Outbreak: An increase in the incidence of MRSA cases in the facility above the baseline level, or a clustering of new MRSA cases that are epidemiologically linked. For the purposes of this guideline, an outbreak consists of either: 1) an increase in the average monthly incidence of MRSA of 25% above the baseline, or 2) three or more new MRSA cases within a two month period on any ward or unit. Standard Precautions: A system of precautions to be applied to all residents, regardless of the known or perceived diagnosis. These precautions synthesize the elements of universal blood and body fluid precautions and body substance isolation. They are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infections in facilities. FREQUENTLY ASKED QUESTIONS 1. We have always screened new admissions to our facility for MRSA colonization in their nares. Should we continue this? Routine nares cultures for MRSA of residents are not indicated unless the resident is epidemiologically implicated in an MRSA outbreak. See,“Procedures for Obtaining Cultures to Identify MRSA”) 2. What drug(s) should we use to treat (decolonize) a resident with MRSA in their nares? Decolonization of MRSA from residents should only be done in consultation with an infectious disease physician and only in an outbreak situation to decrease the possibility of promoting further antimicrobial resistance. (see,“Decolonization”) 3. Do we still need to place a resident with MRSA colonization in the nares on contact precautions? A resident who is known to have MRSA in the nares ONLY does not need to be placed on contact precautions. However, this individual should, if possible, be placed with another resident with MRSA colonization or infection or with a resident with no tubes or wounds. (see, “Room Placement and Activities”) 4. When discontinuing contact precautions, we have always obtained two negative nares cultures along with two negative site cultures. Do we still need to do this? It is no longer necessary to obtain negative nares cultures in order to discontinue contact precautions on a resident. Two negative cultures of the infected body site, obtained no less than one week apart, are sufficient. (see, “Termination of Precautions”) 5. Do these residents have to stay in their rooms? Even if they are on contact precautions, those residents who are colonized or infected with MRSA may, if they feel like it, go anywhere in the facility and attend activities as long as the infected site is covered, and the resident observes meticulous

20

handwashing. An alcohol-based waterless hand cleaner may be given to the resident to facilitate handwashing. (see, “Room Placement and Activities”) 6. Which residents should be included on the MRSA line listing? Include any resident who is colonized or infected with MRSA at any site OTHER THAN the nares. A resident who is known to have MRSA in the nares only does not need to be included on the line listing, but should be tracked separately (see, “Surveillance”) 7. Under what circumstances should we culture our healthcare workers for MRSA in the nares?Nares cultures for MRSA from healthcare workers should not be done unless there is an outbreak situation and the culturing has been recommended by hospital infection Control staff. References •

•

•

•

•

•

•

• • • •

•

Wenzel R, et al. Methicillin-resistant Staphylococcus aureus outbreak: A consensus panel’s definition and management guidelines. American Journal of Infection Control. 1998;26:102-110. Goetz A, Muder R. The problem of methicillin-resistant Staphylococcus aureus: a critical appraisal of the efficacy of infection control procedures with a suggested approach for infection control programs. American Journal of Infection Control. 1992;20:80-84. Methicillin-resistant Staphylococcus aureus Task Force, American Hospital Association. Methicillin-resistant Staphylococcus aureus (MRSA): a briefing for acute care hospitals and nursing facilities. The AHA Technical Panel on Infections within Hospitals. Infection Control and Hospital Epidemiology. 1994;15:105-113. Boyce J. Methicillin-resistant Staphylococcus aureus in hospitals and long term care facilities; microbiology, epidemiology, and preventive measures. Infection Control and Hospital Epidemiology. 1992:13:7725-737. Spindel S, Strausbaugh L, Jacobson C. Infections caused by Staphylococcus aureus in a Veterans’ Affairs nursing home care unit: a 5-year experience. Infection Control and Hospital Epidemiology. 1995;16:217-223. Straubaugh L, Jacobson C, Yost T. Methicillin-resistant Staphylococcus aureus in a nursing home and affiliated hospital: a four-year perspective. Infection Control and Hospital Epidemiology. 1993;14:331-336. Strausbaugh L, Crossley K, Nurse B, Thrupp L. SHEA Long-term Care Committee. Antimicrobial resistance in long term care facilities. Infection Control and Hospital Epidemiology. 1996;17:129-140. Strausbaugh L, et.al. Methicillin-resistant Staphylococcus aureus in extended care facilities. Infection Control and Hospital Epidemiology. 1991;12:36-45. Bradley S, et al. Methicillin-resistant Staphylococcus aureus: colonization and infection in a long term care facility. Annals of Internal Medicine. 1991;115:417-422. Storch G, et al. Methicillin-resistant Staphylococcus aureus in a nursing home. Infection Control. 1987; 8:24-29. Thomas J, et al. Transmission and control of methicillin-resistant Staphylococcus aureus in a skilled nursing facility. Infection Control and Hospital Epidemiology. 1989;10:106-110. Hsu C. Serial survey of Staphylococcus aureus nasal carriage among residents in a nursing home. Infection Control and Hospital Epidemiology. 1991;3:901-913.

21

•

•

• •

Centers for Disease Control and Prevention, Hospital Infections Program. Methicillin-resistant Staphylococcus aureus. Web page: CDC Hospital Infections Program, www.cdc.gov/nciod/hip, Jun 4, 1999. Bennett M, Thurn J, Klicker R, et al. Recommendations from a Minnesota task force for the management of persons with methicillin-resistant Staphylococcus aureus. American Journal of Infection Control. 1992;20:42-48. Centers for Disease Control and Prevention. HICPAC recommendations for isolation precautions in hospitals. Infection Control and Hospital Epidemiology. 1996;17:53-80 Bradley, S. Issues in the management of resistant bacteria in long term care facilities infection Control and Hospital Epidemiology. 1999;20:362-366.

22

Guidelines for the Prevention and Control VRE in Long Term Care Facilities

Introduction Background Goals of VRE Control in the LTCF Prevention and Control Measures Avoidance of Unnecessary Restrictions Tracking Notification of Providers Control of VRE Outbreak Situations Identification of Vancomycin-Resistant Staphylococci

I. Introduction Vancomycin-resistant enterococci (VRE) have emerged in the past few years as epidemiologically important pathogens. VRE pose a unique public health threat because: • •

A. Treatment of infection is quite challenging, since VRE are often resistant to multiple antibiotics, B. The potential exists for VRE to transfer genetic vancomycin resistance to other gram-positive organisms, including Staphylococcus aureus. This transfer has not yet occurred clinically.

All health care institutions must become aware of the threat and involved in the control of these pathogens. Long term care facilities (LTCFs) may be especially challenged by VRE because of their at-risk patient population and frequent patient transfers to and from acute care institutions. II. Background Enterococci are gram-positive bacteria which are found normally in the gastrointestinal and female genital tracts. They may be identified on laboratory reports by several different names: Enterococcus faecium, Enterococcus faecalis, or Enterococcus species. Enterococci can also be found without causing infection along catheter sites and in the urine.

23

Most enterococcal infections occur when enterococci are introduced into normally-sterile body sites (e.g., blood or urine). Clinical infections may include: endocarditis, urinary tract infections, intra-abdominal or pelvic infections, vascular line sepsis, and wound infections. Many enterococcal infections are mixed infections in which the role of enterococci is uncertain. All enterococci have intrinsic low-level resistance to some antibiotics. In recent years, however, some strains of enterococci have acquired high-level resistance to multiple antibiotics including aminoglycosides, ampicillin, and vancomycin. Virtually all VRE are E. faecium. Vancomycin resistance is of special concern because it makes treatment difficult, and because of the potential for this plasmid-mediated vancomycin resistance trait to be transferred to other microorganisms (although this has occurred in one experimental laboratory study to date). If methicillin-resistant S. aureus (MRSA) were to acquire vancomycin resistance, this pathogen would become virtually untreatable with current antibiotics. A dramatic increase in the incidence of VRE has been seen in the past few years. Although most outbreaks of VRE have occurred in acute care settings (especially intensive care units), all health care institutions have the potential to be affected. Risk factors for acquiring VRE infection or colonization include: • • • • • •

severe underlying illness or immunosuppression, indwelling urinary or central venous catheters, recent abdominal or cardiothoracic surgery, prolonged hospital stays, stay on an ICU, oncology, or transplant ward, treatment with vancomycin, cephalosporins, metronidazole or clindamycin, or multiple antimicrobial agents and the number of days treated.

Most enterococcal infections probably arise from bacteria in the patient' s own gastrointestinal tract. People who are colonized with the bacteria in their gastrointestinal tract may be colonized for long periods of time. Nosocomial spread has been documented to take place as well. Direct contact (person-to-person) and indirect contact (via equipment or hands of personnel) can both transmit the organism. Because of the serious nature of these infections, it is imperative to take steps to prevent such transmission. III. Goals of VRE Control in the LTCF The goals of VRE control in the LTCF should include: A. Preventing the transmission of VRE: • • •

to residents within the facility, to staff and visitors of the facility, and to those outside the facility when residents are transferred;

24

B. Allowing for admission or readmission of patients with VRE; and C. Preventing the potential transfer of vancomycin resistance to other gram- positive microorganisms (including S. aureus and S. epidermidis) within the facility and the community. IV. Prevention and Control Measures A. Staff Education All staff working in a LTCF should receive education and training regarding the importance of VRE control. Education should be provided regularly, at least annually, and may be incorporated into a larger infection control training program. In addition, refresher training in infection control practices should be provided in response to any increase in VRE frequency within the facility. B. Prescriber Education The overuse of vancomycin has been implicated in promoting an increase in VRE. Education of antibiotic prescribers is also important in VRE control. LTCFs can distribute information on vancomycin use to their prescribers. The Centers for Disease Control and Prevention (CDC) has provided recommendations for the prudent use of vancomycin; these are included in a sample provider handout (Appendix A). Especially note that vancomycin use should be discouraged for: treatment in response to a single blood culture positive for coagulase-negative staphylococcus, if other blood cultures drawn in the same time frame are negative (#3), continued empiric use for presumed infections in patients whose cultures are negative for beta-lactam-resistant gram-positive organisms (#4), and primary treatment of antibiotic-associated colitis (C. difficile and others) (#8). C. Identification of Patients with VRE 1. Case Definition - A VRE case is defined as a resident who has been identified by culture to be currently infected or colonized with VRE. A notation should be made in the resident' s record (e.g., problem list and care plan) when he/she is identified as a VRE case. 2. Culturing - Culturing for VRE should be performed according to clinical criteria established at the LTCF. Routine screening of all residents, staff personnel, and environmental surfaces is not recommended. When culturing is performed, the LTCF should ensure that the laboratory: •

a. tests all enterococci-positive cultures for vancomycin resistance,

25

• •

b. is capable of detecting both high and moderate levels of vancomycin resistance, and c. reports VRE findings to the LTCF expeditiously

D. Infection Control Practices Consistent application of sound infection control practices will reduce the spread of many nosocomial pathogens, including VRE. Such practices do not depend on the identification of VRE cases, and should be applied in all patient care situations. Specific practices which should be especially followed when caring for VRE cases include:

1. Hand Washing, Gloves, and Gowns • • •

•

•

a. Antiseptic soap is recommended for hand washing. b. Staff and visitors should wash hands after any contact with a VRE case prior to leaving the resident' s room. c. A resident identified as a VRE case should wash his/her hands after any personal hygiene activities (e.g., toileting) and prior to leaving his/her room for group activities. A resident who cannot wash his/her own hands should be assisted with hand washing in these instances. d. Staff should wear gloves when providing care which involves any personal contact (e.g., changing clothes, bathing). In the course of resident care, gloves should be changed before further contact with clean surfaces, the resident, or staff if they have become soiled with potentially infectious material (e.g., stool, urine). After such care, staff should remove gloves and wash hands. Care should be taken to avoid touching environmental surfaces or other residents or staff after caring for a VRE case and prior to washing hands. e. Gowns should be worn if the provider' s clothing is likely to have substantial contact with a VRE case in the course of care. Gowns should be removed

2. Environmental Surface Precautions •

• •

Rooms of VRE cases should be cleaned daily; frequently touched surfaces (e.g., bed rails, bedside tables, doorknobs) should be cleaned with an EPA-approved hospital grade disinfectant-detergent, in accordance with the manufacturer' s instructions. It should be noted that, although VRE is difficult to treat in the individual, it is not more difficult to eradicate from environmental surfaces than other enterococci or similar bacteria. Patient-care equipment with which a VRE case has contact should be cleaned and disinfected prior to use on another resident. Upon discharge or transfer, the room of a VRE case should undergo "terminal cleaning" with an EPA-approved hospital grade disinfectant-detergent.

3. Room Placement

26

A VRE case should receive special consideration for room placement within the LTCF. The order of preference for room placement is: A private room; A room with other resident(s) known to be VRE cases (i.e., cohorting); or A room with other resident(s) who are not at increased risk for infection (e.g., residents without vascular lines, catheters, stomas, decubiti, or other wounds), and who do not have MRSA infection or colonization. b. A resident identified as a VRE case who is incontinent of either urine or feces (regardless of the site of documented infection or colonization) or who is unreliable in personal hygiene should be placed in a private room or cohorted in a room with another VRE case. c. A VRE case should never be placed in the same room as a resident with current MRSA infection or colonization d. Termination of Special Infection Control Practices A VRE case should be considered to carry the pathogen indefinitely, unless: •

•

three consecutive cultures, taken after antibiotic treatment has ceased and at least one week apart, from the original culture-positive site(s) are negative for VRE, and three consecutive cultures, taken after antibiotic treatment has ceased and at least one week apart, from stool or rectal swabs are negative for VRE. Once these negative cultures are documented, the individual can be considered VRE-free and special infection control practices may be terminated.

V. Avoidance of Unnecessary Restrictions A. Activities within the LTCF A VRE case should not be excluded from therapeutic or group activities as long as reasonable personal hygiene is maintained. Care should be taken to prevent stool, urine, and other body fluids from contacting environmental surfaces outside of the resident' s room. B. Admission and Transfer of VRE Cases A VRE case may be admitted to or retained in a LTCF. Also, the presence of VRE infection or colonization should not in itself preclude transfer of patients between health care facilities. Transferring facilities should notify receiving facilities as far in advance as possible and again upon transfer whenever a VRE case is transferred. VI. Tracking 27

All cases of VRE should be documented in a line-listing which is reviewed by professionals responsible for infection control at the LTCF. An example of a line-list format is included in Appendix B VII. Notification of Providers A resident' s primary care providers should be notified when the resident is newly identified as a VRE case. All primary care providers who admit residents to the LTCF should be notified whenever there is concern for increased transmission of VRE within the facility. VIII. Control of VRE Outbreak Situations When three or more VRE cases (not including newly admitted residents who have VRE or residents being readmitted after a hospitalization who have VRE) are identified in a six month period, the LTCF should report this finding to the Local Health Department. Consultation should occur whenever there is evidence of an increase in VRE rates or transmission between residents. IX. Identification of Vancomycin-Resistant Staphylococci If the LTCF becomes clinically suspicious or receives laboratory notification of a case of vancomycin-resistant Staphylococcus aureus (VRSA) or Vancomycin-resistant Staphylococcus epidermidis (VRSE), the LTCF should immediately contact the The Wyoming Department of Health –Epidemiology Section, (307) 777-3593, for infection control guidance. Local health departments if applicable should also be notified if vancomycin resistance is suspected in these pathogens. The LTCF should have the laboratory contact the WDH-Epidemiology section for guidance on where to submit the isolate for confirmatory testing Acknowledgment: These recommendations were reviewed by the individuals listed below. We appreciate their comments. • • • • • • •

John G. Bartlett, M.D., Johns Hopkins Hospital J. Mehsen Joseph, Ph.D., Maryland Department of Health and Mental Hygiene J. Glenn Morris, Jr., M.D., M.P.H.&T.M., University of Maryland Medical Center Trish Perl, M.D., M.Sc., Johns Hopkins Hospital Louis B. Polish, M.D., D.T.M.&H., University of Maryland Medical Center Harold C. Standiford, M.D., Baltimore Veterans Administration Medical Center Dorothea Stern, M.D., Maryland Department of Health and Mental Hygiene

28

Guidelines for the Prevention and Control of Upper and Lower Acute Respiratory Illnesses (including Influenza and Pneumonia) in Long Term Care Facilities Introduction Section 1 discusses prevention of influenza and pneumococcal disease Section 2 provides definitions and characteristics of respiratory illnesses Section 3 addresses the use of surveillance to detect cases Section 4 outlines management of single cases Section 5 outlines the management of respiratory illness outbreaks in LTCFs (includes a flow chart). Section 6 outlines instructions for collecting Viral Throat Culture Section 7 Data Collection and Summary Introduction These guidelines cover all long term care facilities (LTCFs) within Maryland except those designated as assisted living centers. These guidelines, however, may be tailored for alternative settings such as assisted living centers. Each year outbreaks of respiratory illness including pneumonia occur in LTCF such as nursing homes. Because of their immunologically declining health status, residents in LTCFs are at high risk for developing serious complications or dying when they become ill. Historically, specific emphasis has been placed on influenza. In the United States, influenza is associated with an average of 20,000 deaths yearly, and an even larger number of hospitalizations. Not only are morbidity and mortality a problem, but because people are in close proximity to one another, once the influenza virus is introduced into the LTCF, it can spread rapidly. During some nursing home outbreaks over half of the residents have been affected. In addition to the burden of influenza, other respiratory viruses that cause the common cold and bacterial pathogens causing respiratory illness affect residents and staff of LTCFs each year. Because infection with these agents can compromise an already declined health status of the LTCF resident, control of these agents in the LTCF is also critical.

29

In order to facilitate respiratory disease outbreak investigations and implementation of control measures, the following guidelines have been established. These guidelines emphasize priorities regarding prevention of influenza and pneumococcal disease including pneumonia: • • • • • •

to prevent pneumococcal disease through immunization to prevent outbreaks through influenza immunization and antiviral drug use to detect the occurrence of an outbreak early to stop transmission of the influenza virus through control measures to measure the level of morbidity and mortality to identify the strain of influenza virus responsible for the outbreak

Section 1. Prevention: Influenza: Two measures are available in the United States to minimize the impact of influenza: vaccination and use of antiviral drugs, such as amantadine and rimantidine. Annual vaccination of high risk persons and employees, volunteers, and family members in contact with those at high risk before the influenza season is the most important way of reducing the impact of influenza. Antiviral drugs are effective only against influenza type A infections and are used in both prevention and treatment. Additional information can be found in the annually updated Centers for Disease Control and Prevention (CDC), Morbidity and Mortality Weekly Report (MMWR), Prevention and Control of Influenza. Attached is a copy of the latest edition (1997). Pneumococcal pneumonia: Neumococcal vaccine (usually a one time shot) is available to prevent illness due to Streptococcus pneumoniae. Pneumococcal pneumonia is a common complication of influenza. Receipt of one dose of pneumococcal vaccine should be documented in the chart of each resident of a LTCF. If the vaccination status is unknown to the facility, vaccinate the resident after obtaining appropriate consent. The physician is responsible for educating the resident or their guardian on the availability of pneumococcal vaccine and administering the vaccine to individuals who have not already been immunized with pneumococcal vaccine or referring the individual to a health care provider who will administer the vaccine. Further information regarding the vaccine can be found in the CDC MMWR Recommendations of the Immunization Practices Advisory Committee, Prevention of Pneumococcal Disease (MMWR 1997; Vol. 46, No.RR-8). Section 2. Case Definition, Clinical Characteristics, and Outbreak Definitions A. Case Definitions

30

A case of acute respiratory disease is defined as a person with mild to moderate symptoms of one or more of the following; rhinitis, pharyngitis, laryngitis, bronchitis, and cough. These symptoms are usually caused by a rhinovirus, of which there are more than 100 recognized subtypes. The incubation period is between 12 hours and 5 days but usually 2 days. Getting freshly shed virus particles from one person on to the mucous membranes of another is thought to be the most important mode of transmission. Inhaling virus particles by the airborne route is another way to spread rhinoviruses. The duration of illness is normally 2-7 days. A case of acute febrile respiratory disease is defined as a person with one or more of the above symptoms (see acute respiratory disease) in the presence of a temperature of 37.8EC (100EF) or greater orally or 38.3EC (101EF) rectally. Acute febrile respiratory diseases are caused by numerous agents including viruses and bacteria. The incubation period is 1 to 10 days. While influenza is spread via airborne transmission, the chief mode of transmission for non-influenza agents is contact with infectious secretions either directly or indirectly through contaminated hands or environmental surfaces (bed rails, telephones, etc.). A person with one of these agents can spread the agent from a few days prior to symptom onset and throughout the course of active disease. A case of influenza or influenza-like illness (ILI) is defined as a person with temperature of 37.8EC (100EF) or greater orally or 38.3EC (101EF) rectally PLUS cough during the influenza season (October 1 through May 31). A person with laboratory confirmed influenza is also considered a case even if the person doesn' t have all of the above symptoms and fever. The incubation period for influenza is short, usually 1 to 3 days. Communicability includes the period immediately prior to clinical onset and throughout the course of active disease. A case of pneumonia is defined as a person with clinical symptomatology PLUS X-ray findings of pneumonia. For the purposes of these Guidelines, specific emphasis is placed on Streptococcus pneumoniae (the Apneumococcus@), respiratory viruses, Haemophilus influenzae, aerobic gram-negative bacilli, and Staphylococcus aureus. Pneumococcal pneumonia is characterized by a fever, chills, cough, and pleuritic pain. The case-fatality rate remains 20% to 40% among patients with substantial underlying disease. The organism is spread by droplet, direct, or indirect inoculation. Person-toperson transmission is common, but illness among casual contacts and attendants is uncommon. The incubation period may be as short as 1 to 3 days. Appropriate antibiotic therapy will render patients noninfectious within 1 to 2 days. B. Outbreak Definitions An outbreak of acute respiratory disease in a LTCF is defined as the presence of 10% or more of the residents or 10% or more of the staff meeting the case definition for acute respiratory disease over a 7 day period. An outbreak of acute febrile respiratory disease, influenza, or ILI is defined as 3 or more clinically defined cases or one laboratory proven case of influenza in a facility within a 7 day period. Unless indicated by laboratory results, influenza and ILI are applicable only 31

between Oct. 1 and May 31. An outbreak of pneumonia is defined as two or more cases of pneumonia in a facility within a 10 day period.

Section 3. Surveillance Each LTCF should have their designated infection control practitioner (ICP) routinely maintain records on the occurrence of fever in all facility residents and illness among employees. Employees should report respiratory illness (as well as other acute illnesses such as diarrhea) to the appropriate staff person at the LTCF throughout the year. The one-time pneumococcal vaccination and yearly influenza vaccination status of all current residents should also be recorded in the residents charts and in employee records. This will enable rapid assessment of susceptible individuals in the event of an outbreak. Influenza and/or ILI (instead of acute respiratory illness) should be suspected during the influenza season from Oct. 1 through May 31. When a person who meets the case definition is identified, the case management procedures as described below should be followed unless the fever is known to have another cause. Section 4. Single Case Management A stepped-care approach has been developed for case and outbreak management of respiratory illness in LTCFs. This section covers single cases among LTCF residents and employees. Acute Respiratory Disease A. Residents • •

Observe case for signs/symptoms that suggest need for physician consult Encourage the case to limit contact if possible by limiting group activities while ill, washing hands, and using tissues to cover mouth and nose while coughing and sneezing

B. Employees •

Exclude from direct patient care (if possible) and review vigilance for hand washing and covering the mouth when coughing or sneezing

Acute Febrile Respiratory Illness, Influenza, or ILI A. Residents •

Observe case for signs/symptoms that suggest need for physician consult. 32

• •

• •

• •

Restrict the case to his/her room (i.e.,. restrict the case from participating in group activities) until patient no longer has active symptoms. Consider confirmation of diagnosis with appropriate viral throat culture and/or rapid antigen test, bacterial throat or sputum culture, or consultation with a physician. If between October 1 and May 31, suspect influenza or ILI. Give antiviral treatment to the case within the first 48 hours of illness when a physician has a high suspicion of an influenza type A diagnosis and when the Wyoming Department of Health has determined that influenza type A is in the community. Give influenza vaccine to any unvaccinated roommates of a case and to other unvaccinated residents and staff during the influenza season. Observe the roommates of a case and others in the facility closely for similar signs and symptoms of influenza-like illness.

B. Employees •

When a case of acute febrile respiratory disease, influenza or ILI is recognized in an employee, exclude until the employee is no longer symptomatic.

Pneumonia A. Residents • • • •

Perform diagnostic testing to establish the diagnosis and to determine the cause of pneumonia (e.g., chest X-ray, sputum and/or throat culture). Consult with a resident=s physician regarding appropriate antibiotic treatment. Restrict case to his/her room until completion of first 48 hours of antibiotic therapy if treated with antibiotics. Report individual case of pneumonia caused by Legionellae pneumophila to your local health department.

B. Employees •

Exclude from the facility until completion of first 48 hours of antibiotic therapy if given and/or until the employee is no longer symptomatic.

Section 5. Outbreak Management A. Nursing homes and other LTCFs should report single cases and outbreaks of disease of public health importance including cases and outbreaks as defined in these guidelines. Reporting should be made within 24 hours to a local health department. Please contact your local health department for an emergency telephone number where they can be reached during weekends and after work hours in the event of an outbreak. Section 6. Specimen Collection If influenza is suspected based on clinical symptoms, laboratory testing will confirm the 33

diagnosis. A case of influenza can be laboratory confirmed by three techniques. Most commonly, a viral throat culture is used to detect influenza; however, influenza infection can be confirmed using serology, as well as a rapid antigen detection method. A. Viral Throat Culture A throat culture should be collected on 10 to 12 cases within 72 hours of illness onset (a "viral throat swab" kit should be used if submitting samples to the WDH Laboratory). The following steps should be followed closely when preparing to submit viral throat swabs for laboratory culture: Procedures for Collection and Transport of Viral Throat Specimens (from DHMH Guidelines, January 1996) • • • • •

•

Obtain viral throat kits from Wyoming Public Health Laboratories Administration, Specimen Mailing Assemblies (Outfit Room) at 307-777-7431. Complete the accompanying laboratory form including clinical diagnosis. Note "influenza" if influenza is suspected as the clinical diagnosis. Open sterile cotton-tipped swabs. Hold two swabs together and swab the posterior pharynx and tonsillar areas vigorously with swabs. Immerse swab-tips in media and break off the top portion of the wooden swab to allow the swabs to fit into the tube. Refrigerate specimen immediately after collection unless transporting immediately. Alternatively, the specimen can be frozen at -70 degrees C; this requires a specialized freezer. Do not freeze in a regular freezer (-15 degrees C). Refrigerated specimens should be transported on wet ice or cold packs to Wyoming Public Health Lab 5th Floor Hathaway Building, 2300 Capitol Avenue, Cheyenne, WY 82002."Wet ice" is a mixture of ice with a small amount of water. Specimens should be placed into the water portion of the "wet ice." Frozen specimens should be shipped on dry ice.

Failure to follow the above procedures will render the specimens unsatisfactory and they will not be processed by the WPHL. B. Rapid Antigen Detection Techniques have been developed to allow the rapid detection of influenza type A and type B antigens in as little as 15 minutes. These techniques vary greatly and include several different detection systems, such as the immunofluorescence assay (IFA) and the enzyme immunoassay (EIA). In addition, these systems are available as commercially sold kits. When compared to viral cultures (which are thought to be the "gold standard@ for influenza detection), these rapid testing methods were able to detect from 87 to 99 percent of all positive influenza cases. As with many laboratory tests, there is always a potential for a false-positive result. However, use of rapid detection methods in conjunction with viral throat culture should minimize false-positive rates. In addition, use of both methods allows a more efficient administration of antiviral medications and infection control measures, while also 34

permitting the identification and typing of circulating strains of influenza virus. Decision regarding the choice of rapid detection method should be made in conjunction with the clinical laboratory used by the LTCF. Cost, technical support, and resources available for testing may all factor into the choice of rapid influenza detection methods. DHMH will perform a rapid antigen detection test on any viral throat kit specimen submitted for influenza detection between October 1 and April 30. C. Serology Serological specimens do not need to be routinely collected. If serological specimens are recommended by DHMH then two blood specimens (acute and convalescent) are needed to demonstrate a significant rise in anti-influenza antibody titer. The first specimen should be collected as early as possible after onset of illness, and the second specimen three weeks later. In either instance, obtain 5-8 ml of blood in a RED TOP TUBE. Do not freeze whole blood since this will result in complete hemolysis and renders the specimen unsatisfactory for testing. Serum or clotted blood specimens may be transported unrefrigerated to the laboratory. Section 7. Data Collection and Summary Pertinent information regarding each resident and employee case should be entered into the LTCF Infection Control Professional' s surveillance log and updated daily. Once an outbreak has been identified, cases should be placed on a "line list" (see line listing form for influenza, page 12). A summary sheet should be filled out by the local health department at the conclusion of an outbreak and a copy should be forwarded to the Division of Outbreak Investigation (see outbreak summary form for influenza, page 10).

35

Guidelines for Control of Severe Acute Respiratory Syndrome (SARS) Clinical Case Definition Surveillance of Health Care Personnel Infection Control Measures for Residents Infection Control Measures for Healthcare Workers

Case Definition • The Exclusion Criteria have been revised to allow exclusion of cases with a convalescent-phase serum sample (i.e., collected >28 days after symptom onset) that is negative for antibody to SARS-associated coronavirus (SARS-CoV). Testing results from serum previously collected between 22 and 28 days after symptom onset are acceptable and will not require collection of an additional sample >28 days after symptom onset. •

The Case Classification has been revised to exclude probable and suspect SARS cases with convalescent-phase serum samples that are negative for antibody to SARS-CoV.

Clinical Criteria • •

•

Asymptomatic or mild respiratory illness Moderate respiratory illness o Temperature of >100.4°F (>38°C)*, and o One or more clinical findings of respiratory illness (e.g., cough, shortness of breath, difficulty breathing, or hypoxia). Severe respiratory illness o Temperature of >100.4°F (>38°C)*, and o One or more clinical findings of respiratory illness (e.g., cough, shortness of breath, difficulty breathing, or hypoxia), and radiographic evidence of pneumonia, or respiratory distress syndrome, or autopsy findings consistent with pneumonia or respiratory distress syndrome without an identifiable cause

Epidemiologic Criteria •

•

Travel (including transit in an airport) within 10 days of onset of symptoms to an area with current or previously documented or suspected community transmission of SARS (see Table below),or Close contact§ within 10 days of onset of symptoms with a person known or suspected to have SARS. 36

The last date for illness onset is 10 days (i.e., one incubation period) after removal of a CDC travel alert. The case patient’s travel should have occurred on or before the last date the travel alert was in place. Laboratory Criteria¶ •

•

•

Confirmed o Detection of antibody to SARS-associated coronavirus (SARS-CoV) in a serum sample, or o Detection of SARS-CoV RNA by RT-PCR confirmed by a second PCR assay, by using a second aliquot of the specimen and a different set of PCR primers, or o Isolation of SARS-CoV. Negative o Absence of antibody to SARS-CoV in a convalescent–phase serum sample obtained >28 days after symptom onset.** Undetermined o Laboratory testing either not performed or incomplete.

Case Classification*** •

•

Probable case: meets the clinical criteria for severe respiratory illness of unknown etiology and epidemiologic criteria for exposure; laboratory criteria confirmed or undetermined. Suspect case: meets the clinical criteria for moderate respiratory illness of unknown etiology, and epidemiologic criteria for exposure; laboratory criteria confirmed or undetermined.

Exclusion Criteria A case may be excluded as a suspect or probable SARS case if: • • • •

A case may be excluded as a suspect or probable SARS case if: An alternative diagnosis can fully explain the illness.**** The case has a convalescent-phase serum sample (i.e., obtained >28 days after symptom onset) for which is negative for antibody to SARS-CoV.** The case was reported on the basis of contact with an index case that was subsequently excluded as a case of SARS, provided other possible epidemiologic exposure criteria are not present.

Infection Control Precautions for Aerosol-Generating Procedures on Patients with Severe Acute Respiratory Syndrome (SARS) Worldwide, several health-care workers (HCWs) have been reported to develop severe acute respiratory syndrome (SARS) after caring for patients with SARS. Multiple hospitals have reported cases among HCWs who were present during aerosol-generating procedures performed on patients with SARS, suggesting that aerosol-generating procedures may increase the risk of SARS transmission. 37

Procedures capable of stimulating cough and promoting the generation of aerosols include: administration of aerosolized medication treatment; diagnostic sputum induction; bronchoscopy; airway suctioning; endotracheal intubation; positive pressure ventilation via facemask (e.g.,BiPAP,CPAP), during which air may be forced out around the facemask; and high frequency oscillatory ventilation (HFOV). CDC is recommending healthcare facilities to review their strategies to protect HCWs during these procedures, including the use of personal protective equipment and safe work practices, and to alert HCWs performing such procedures that there may an be increased risk for transmission of SARS. The following recommendations apply to the performance of aerosol-generating procedures in patients with suspect or probable SARS. These recommendations should be considered interim in nature, and may be revised as more information becomes available. Limit opportunities for exposure. •

•

Limit the use of aerosol-generating procedures on SARS patients to those that are deemed medically necessary. Use clinically appropriate sedation during intubation and bronchoscopy to minimize resistance and coughing during the procedure. Limit the number of HCWs present in the room during an aerosol-generating procedure to those who are essential for patient care and support.

Perform aerosol-generating procedures in an airborne isolation environment • •

If the patient is in an airborne isolation room, perform the procedure in that environment. If an airborne isolation room is not available, the procedure should be performed in a private room, away from other patients. If possible, steps should be taken to increase air exchanges, create a negative pressure relative to the adjacent room or hallway, and avoid recirculation of the room air. If recirculation of air from such rooms is unavoidable, the air should be passed through a HEPA filter before recirculation as recommended for Mycobacterium tuberculosis. Air cleaning devices such as portable HEPA filtration units may be used to further reduce the concentration of contaminants in the air. Doors should be kept closed except when entering or leaving the room, and entry and exit should be minimized during the procedure.

Use of filters on ventilation exhaust valves. •

Some hospitals caring for SARS patients have used bacterial/viral filters on exhalation valves of mechanical ventilators to prevent contaminated aerosols from entering the environment. Although the effectiveness of this measure in reducing the risk of SARS transmission is unknown, the use of such filters may be prudent during HFOV of patients with SARS.

38

Wear personal protective equipment appropriate for standard, contact and airborne precautions with consideration for additional personal protection based on the potential for higher level of contact with respiratory secretions The optimal combination of personal protective equipment (PPE) for preventing transmission of SARS during aerosol-generating procedures has not been determined. PPE must cover the arms and torso, and fully protect the eyes, nose and mouth; additional PPE to protect all exposed areas of skin should be considered. The following personal protective equipment is recommended for those present during aerosol-generating procedures on patients with SARS: •

• • • •

Single isolation gown to protect the body and exposed areas of the arms. A disposable full-body isolation suit may be considered in this setting as it provides greater protection for the neck area; some suits also have an attached hood to cover the hair. Another alternative for providing full head, neck, face and respiratory protection is a disposable surgical hood with an attached face shield in combination with a disposable respirator. It is unknown whether covering exposed areas of skin or hair of the head and neck will further reduce the risk of transmission. A single pair of disposable gloves that provide a snug fit over the wrist. Eye protection consisting of goggles should be worn to protect the eyes from respiratory splash or spray. Goggles should fit snugly around the eyes. A face shield may be worn over goggles to protect exposed areas of the face but should not be used as a primary form of eye protection for these procedures. Respiratory protection for aerosol-generating procedures must ensure that HCWs are protected from exposure to aerosolized infectious droplets through breaches in respirator seal integrity. Healthcare facilities should consider the following options: o Disposable particulate respirators (e.g. N-95, N-99, or N-100) are sufficient for routine respiratory protection for airborne precautions and are the minimum level of respiratory protection for HCWs who are performing aerosol-generating procedures. To ensure adequate protection, HCWs must be fit-tested to the respirator model that they will wear (see TB Respiratory Protection Program In Health Care Facilities: Administrator' s Guide), and also know how to check their facepiece seal. A fit-check should be performed each time the respirator is put on, prior to entering the patient room. If disposable respirators cannot be fit-tested to the individual, a higher level of respiratory protection should be used. o Healthcare facilities in some SARS affected areas have used higher levels of respiratory protection for persons present during aerosol-generating procedures on SARS patients. Higher levels of respiratory protection include: Powered air purifying respirator (PAPRs) designed with loosefitting facepieces that form a partial seal with the face; PAPRs with hoods that completely cover the head and neck and may also cover portions of the shoulder and torso; PAPRs with tight-fitting facepieces (both half and full facepiece);

39

Full facepiece elastomeric negative pressure (i.e. non-powered) respirators with N, R, or P100 filters. At this time there is inadequate information to determine whether these higher levels of respiratory protection will further reduce transmission. Factors that should be considered in choosing respirators in this setting include availability, impact on mobility, comfort, (TB Respiratory Protection Program In Health Care Facilities: Administrator' s Guide), the potential for exposure to higher levels of aerosolized respiratory secretions, and the potential for reusable respirators to serve as fomites for transmission. All HCWs offered respiratory protection must be included in a respiratory protection program that meets the minimum requirements of the OSHA Respiratory Protection Standard (29CFR1910.134) if within the United States, or other applicable requirements for workplaces outside the U.S. Safe work practices •

•

•

HCWs must be careful to contain the area of contamination. Aerosol-generating procedures may produce high concentrations of virus in the air and on environmental surfaces. HCWs should avoid touching their face and personal protective equipment on their face with contaminated gloves. They also should avoid contaminating surfaces around the patient and room. HCWs should use care when removing personal protective equipment to avoid contaminating skin, clothing, and mucous membranes. Standard procedures for removal of personal protective equipment that minimize the potential for selfcontamination should be developed based on the equipment used, and healthcare workers should be trained in these procedures. Hand hygiene should be performed following the removal of PPE and leaving the patient’s room.

Decontaminating, cleaning, and disinfecting personal protective equipment and environmental surfaces • A disinfectant should be available for decontaminating reusable personal protective equipment. Clean gloves should be worn when wiping surfaces of equipment to render them safe for handling. Manufacturer’s guidelines for cleaning and disinfection of reusable protective equipment should be followed. • Horizontal surfaces in the environment around the patient should be cleaned and disinfected as soon as possible following an aerosol-generating procedure. Surveillance of Health-Care Personnel Surveillance of health-care personnel is necessary to ensure that workers who are ill receive appropriate care and are isolated to prevent transmission. Health-care facilities that care for SARS patients should implement surveillance of health-care workers who have any contact with SARS patients or their environment of care. Recommendations for surveillance include:

40

• •

•

Develop and maintain a listing of all personnel who enter the rooms of SARS patients, or who are involved in the patient’s care in other parts of the hospital. Instruct personnel who have contact with SARS patients or their environment of care to notify occupational health, infection control or their designee if they have unprotected exposure to a SARS patient or if they develop any fever or respiratory symptoms. Monitor employee absenteeism for increases that may suggest emerging respiratory illness in the workforce. Notify local and state health authorities of clusters or unusual increases in respiratory illness, including atypical pneumonia.

Management of Asymptomatic, Exposed Health-Care Workers 1. To date, there is no evidence to suggest that SARS is transmitted from asymptomatic individuals. However, according to recent reports health-care workers who developed SARS may have been a source of transmission within health-care facilities during the early phases of illness when symptoms were mild and not recognized as SARS. To minimize the risk of transmission from unrecognized SARS infections among health-care workers, health-care workers who have unprotected high-risk exposures to SARS should be excluded from duty (e.g. administrative leave) for 10 days following the exposure. Unprotected high-risk exposure is defined as presence in the same room as a probable SARS patient during a high-risk aerosol-generating procedure or event and where recommended infection control precautions are either absent or breached. Aerosol-generating procedures or events include aerosolized medication treatments, diagnostic sputum induction, bronchoscopy, endotracheal intubation, airway suctioning, positive pressure ventilation via facemask (e.g.,BiPAP,CPAP), during which air may be forced out around the facemask, and high frequency oscillatory ventilation (HFOV). Health-care workers who are excluded from duty because of their exposure need not limit their activities outside of the healthcare setting, but should undergo active surveillance for symptoms, including measurement of body temperature twice daily and monitoring for respiratory symptoms for 10 days following exposure. 2. Health-care workers who have other unprotected exposures to patients with SARS need not be excluded from duty because of their exposure need not limit their activities outside of the healthcare setting, but should undergo active surveillance for symptoms, including measurement of body temperature twice daily and monitoring for respiratory symptoms for 10 days following exposure. 3. Health-care workers who have cared for or otherwise been exposed to SARS patients while adhering to recommended infection control precautions should be instructed to be vigilant for fever and respiratory symptoms, including measurement of body temperature at least twice daily for 10 days following the last exposure to a SARS patient. These health-care workers should be contacted by occupational health, infection control or their designee regularly over the 10 day period following exposure to inquire about fever or respiratory symptoms. Management of Symptomatic, Exposed Health-Care Workers

41

1. Any health-care worker who has cared for or been exposed to a SARS patient who develops fever OR respiratory symptoms within 10 days following exposure should not report for duty, but should stay home and report symptoms to the appropriate facility point of contact immediately. If the symptoms begin while at work, the health-care worker should be instructed to immediately apply a surgical mask and leave the patient care area. Symptomatic health-care workers should use infection control precautions to minimize the potential for transmission and should seek health-care evaluation. In advance of clinical evaluation healthcare providers should be informed that the individual may have been exposed to SARS so arrangements can be made, as necessary, to prevent transmission to others in the health-care setting. 2. If symptoms improve or resolve within 72 hours after first symptom onset, the person may be allowed after consultation with infection control and local public health authorities to return to duty and infection control precautions can be discontinued. 3. For persons who meet or progress to meet the case definition for SARS (e.g., develop fever and respiratory symptoms), infection control precautions should be continued until 10 days after the resolution of fever, provided respiratory symptoms are absent or improving. 4. If the illness does not progress to meet the case definition, but the individual has persistent fever* or unresolving respiratory symptoms, infection control precautions should be continued for an additional 72 hours, at the end of which time a clinical evaluation should be performed. If the illness progresses to meet the case definition, infection control precautions should be continued as described above. If case definition criteria are not met, infection control precautions can be discontinued after consultation with local public health authorities and the evaluating clinician (see figure). Factors that might be considered include the nature of the potential exposure to SARS, nature of contact with others in the residential or work setting, and evidence for an alternative diagnosis. 5. Persons who meet or progress to meet the case definition for suspected SARS (e.g., develop fever and respiratory symptoms) or whose illness does not meet the case definition, but who have persistent fever or unresolving respiratory symptoms over the 72 hours following onset of symptoms should be tested for SARS coronavirus infection. Collection of appropriate specimens for laboratory testing should be coordinated with and guided by local/state public health authorities and consultation with CDC Prevention of Unprotected Exposures Prevention of unprotected exposures will limit the need for exclusion from duty. Healthcare facilities should address the following: • • •

Review current procedures for early detection and isolation of suspect SARS patients Educate all health-care personnel on signs and symptoms of SARS and recommended infection control practices Review use of personal protective equipment with health-care personnel, including physicians, who may care for SARS patients 42

•

Follow current CDC recommendation for aerosol-generating procedures in suspected or probable SARS patients

Management of Symptomatic, Exposed Visitors Close contacts (e.g., family members) of SARS patients are at risk for infection. Close contacts with either fever or respiratory symptoms should not be allowed to enter the health-care facility as visitors and should be educated about this policy. A system for screening SARS close contacts who are visitors to the facility for fever or respiratory symptoms should be in place. Health-care facilities should educate all visitors about use of infection control precautions when visiting SARS patients and their responsibility for adherence to them. Limit opportunities for exposure. •

•

Limit the use of aerosol-generating procedures on SARS patients to those that are deemed medically necessary. Use clinically appropriate sedation during intubation and bronchoscopy to minimize resistance and coughing during the procedure. Limit the number of HCWs present in the room during an aerosol-generating procedure to those who are essential for patient care and support.

Perform aerosol-generating procedures in an airborne isolation environment • •

If the patient is in an airborne isolation room, perform the procedure in that environment. If an airborne isolation room is not available, the procedure should be performed in a private room, away from other patients. If possible, steps should be taken to increase air exchanges, create a negative pressure relative to the adjacent room or hallway, and avoid recirculation of the room air. If recirculation of air from such rooms is unavoidable, the air should be passed through a HEPA filter before recirculation as recommended for Mycobacterium tuberculosis. Air cleaning devices such as portable HEPA filtration units may be used to further reduce the concentration of contaminants in the air. Doors should be kept closed except when entering or leaving the room, and entry and exit should be minimized during the procedure.

Use of filters on ventilation exhaust valves. •

Some hospitals caring for SARS patients have used bacterial/viral filters on exhalation valves of mechanical ventilators to prevent contaminated aerosols from entering the environment. Although the effectiveness of this measure in reducing the risk of SARS transmission is unknown, the use of such filters may be prudent during HFOV of patients with SARS.

Wear personal protective equipment appropriate for standard, contact and airborne precautions with consideration for additional personal protection based on the potential for higher level of contact with respiratory secretions 43

The optimal combination of personal protective equipment (PPE) for preventing transmission of SARS during aerosol-generating procedures has not been determined. PPE must cover the arms and torso, and fully protect the eyes, nose and mouth; additional PPE to protect all exposed areas of skin should be considered. The following personal protective equipment is recommended for those present during aerosol-generating procedures on patients with SARS: •

• • • •

Single isolation gown to protect the body and exposed areas of the arms. A disposable full-body isolation suit may be considered in this setting as it provides greater protection for the neck area; some suits also have an attached hood to cover the hair. Another alternative for providing full head, neck, face and respiratory protection is a disposable surgical hood with an attached face shield in combination with a disposable respirator. It is unknown whether covering exposed areas of skin or hair of the head and neck will further reduce the risk of transmission. A single pair of disposable gloves that provide a snug fit over the wrist. Eye protection consisting of goggles should be worn to protect the eyes from respiratory splash or spray. Goggles should fit snugly around the eyes. A face shield may be worn over goggles to protect exposed areas of the face but should not be used as a primary form of eye protection for these procedures. Respiratory protection for aerosol-generating procedures must ensure that HCWs are protected from exposure to aerosolized infectious droplets through breaches in respirator seal integrity. Healthcare facilities should consider the following options: o Disposable particulate respirators (e.g. N-95, N-99, or N-100) are sufficient for routine respiratory protection for airborne precautions and are the minimum level of respiratory protection for HCWs who are performing aerosol-generating procedures. To ensure adequate protection, HCWs must be fit-tested to the respirator model that they will wear (see TB Respiratory Protection Program In Health Care Facilities: Administrator' s Guide), and also know how to check their facepiece seal. A fit-check should be performed each time the respirator is put on, prior to entering the patient room. If disposable respirators cannot be fit-tested to the individual, a higher level of respiratory protection should be used. o Healthcare facilities in some SARS affected areas have used higher levels of respiratory protection for persons present during aerosol-generating procedures on SARS patients. Higher levels of respiratory protection include: Powered air purifying respirator (PAPRs) designed with loosefitting facepieces that form a partial seal with the face; PAPRs with hoods that completely cover the head and neck and may also cover portions of the shoulder and torso; PAPRs with tight-fitting facepieces (both half and full facepiece); Full facepiece elastomeric negative pressure (i.e. non-powered) respirators with N, R, or P100 filters.

At this time there is inadequate information to determine whether these higher levels of respiratory protection will further reduce transmission. Factors that should be considered 44

in choosing respirators in this setting include availability, impact on mobility, comfort, (TB Respiratory Protection Program In Health Care Facilities: Administrator' s Guide), the potential for exposure to higher levels of aerosolized respiratory secretions, and the potential for reusable respirators to serve as fomites for transmission. All HCWs offered respiratory protection must be included in a respiratory protection program that meets the minimum requirements of the OSHA Respiratory Protection Standard (29CFR1910.134) if within the United States, or other applicable requirements for workplaces outside the U.S. Safe work practices •

•

•

HCWs must be careful to contain the area of contamination. Aerosol-generating procedures may produce high concentrations of virus in the air and on environmental surfaces. HCWs should avoid touching their face and personal protective equipment on their face with contaminated gloves. They also should avoid contaminating surfaces around the patient and room. HCWs should use care when removing personal protective equipment to avoid contaminating skin, clothing, and mucous membranes. Standard procedures for removal of personal protective equipment that minimize the potential for selfcontamination should be developed based on the equipment used, and healthcare workers should be trained in these procedures. Hand hygiene should be performed following the removal of PPE and leaving the patient’s room.

Decontaminating, cleaning, and disinfecting personal protective equipment and environmental surfaces •

•

A disinfectant should be available for decontaminating reusable personal protective equipment. Clean gloves should be worn when wiping surfaces of equipment to render them safe for handling. Manufacturer’s guidelines for cleaning and disinfection of reusable protective equipment should be followed. Horizontal surfaces in the environment around the patient should be cleaned and disinfected as soon as possible following an aerosol-generating procedure.

Personal Protective Equipment Personnel involved in cleaning and disinfection activities should wear appropriate personal protective equipment. Wear full protective attire as required for contact and airborne precautions (disposable gown, utility gloves, and N95 respirator) plus eye protection (goggles or face shield) (see Interim Domestic Guidance on the Use of Respirators to Prevent Transmission of SARS) as long as the patient is in the room. Once the patient has been transferred or discharged, wear gown and gloves for post-discharge cleaning. Postpone initiation of cleaning to allow time for the ventilation system to remove any residual airborne viral particles. In most general patient care areas in U.S. healthcare facilities, the heating, ventilation and air-conditioning (HVAC) systems are generally engineered to provide approximately 6 air changes per hour (ACH). (See table of time 45

required for particulate removal relative to ACH in a room in Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities, 1994.) Type of Cleaning and Disinfectant Agents Any EPA-registered* hospital detergent-disinfectant currently used by healthcare facilities for environmental sanitation may be used. Manufacturer’ recommendations for use-dilution (i.e., concentration), contact time and care in handling should be followed. Cleaning methods In-patient rooms housing SARS patients should be cleaned and disinfected daily and at the time of patient transfer or discharge. •

Daily cleaning and disinfection should include horizontal surfaces (e.g., over-bed table, night stand), surfaces that are frequently touched by patients and healthcare personnel (e.g., bed rails, phone), and lavatory facilities. To facilitate daily cleaning, the area around the patient should be kept free of unnecessary equipment and supplies.

•

Terminal cleaning and disinfection following transfer or discharge should include the type of surfaces described above plus obviously soiled vertical surfaces, frequently touched surfaces (e.g., light cords and switches, door knobs), and durable patient equipment (e.g., bed, night stand, over-bed table, wheelchair, commode). Curtain dividers also should be changed and laundered as appropriate for the curtain fabric. There is no need to routinely clean and disinfect walls, window drapes, and other vertical surfaces unless visibly soiled; disinfectant fogging for purposes of air disinfection is not recommended.

•

Patient care equipment such as mechanical ventilators, pulse oximeters, blood pressure cuff, should be cleaned and disinfected in accordance with current CDC recommendations, manufacturer’s instructions and facility procedures for critical, semi-critical and non-critical surfaces. See www.cdc.gov/ncidod/hip/isolat/isolat.htm and www.cdc.gov/ncidod/hip/sterile/sterile.htm.

Cubicles or rooms in out-patient areas where patients with suspected SARS are evaluated should be cleaned and disinfected before another patient is seen or cared for in that environment. Areas that should be specifically targeted for cleaning include the examination table and horizontal surfaces that may have been touched by the patient or healthcare provider. Solutions used for cleaning and disinfection should be discarded after use. Thoroughly rinse and clean housekeeping equipment after use in a SARS room or area and allow the equipment to dry. Launder reusable mop heads and cleaning cloths according to current practice. * There are no disinfectant products currently registered by the U.S. Environmental Protection Agency (EPA) specifically for the inactivation of the newly identified viruses associated with SARS. However, related viruses with physical and biochemical properties similar to the possible SARS agents are known to be readily inactivated by EPA46

registered chemical germicides that provide low- or intermediate-level disinfection during general use. Treatment No specific treatment recommendations can be made at this time. Empiric therapy should include coverage for organisms associated with any community-acquired pneumonia of unclear etiology, including agents with activity against both typical and atypical respiratory pathogens (2). Treatment choices may be influenced by severity of the illness. Infectious disease consultation is recommended.

Guidelines for Control of Varicella Zoster Virus Diseases (Chickenpox and Shingles) in Long Term Care Facilities

Introduction Epidemiology and Transmission Definition of Immunity and Exposure Infection Control Measures for Residents Infection Control Measures for Healthcare Workers Treatment of VZV Infections INTRODUCTION These guidelines are intended to assist long term care facilities (LTCFs) with the prevention and control aspects of chickenpox and shingles, two distinct infections caused by the varicella zoster virus (VZV). They apply to nursing homes, chronic care facilities, and assisted living facilities, as well as long term care services for children and/or adults. Chickenpox (Varicella) Varicella zoster virus causes both chickenpox and shingles, but the two diseases are distinguished by the highly contagious nature of chickenpox. In susceptible household 47

contacts, approximately 90% of those exposed may become infected. Chickenpox is characterized by fever and a generalized, pruritic (itchy) rash with fluid-filled vesicles. These vesicles eventually break open and become encrusted. The individual is no longer infectious after the lesions have crusted over. Chickenpox is usually self-limiting and will resolve without treatment in 4 to 5 days among children. This resolution may be prolonged, however, in adults whose immune systems have been compromised by chemotherapy or conditions such as human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS). Shingles (Herpes zoster) After a chickenpox infection, the virus remains dormant in sensory nerve cell bodies. Approximately 15% of those with a history of chickenpox may experience a reactivation of the virus. Such a reactivation is called herpes zoster, or shingles. Shingles is more likely to occur in the elderly and those with a weakened immune system, but many times the reason for the reactivation is unknown. Presenting symptoms include a painful rash usually limited to one side of the body, in a band-like pattern on the skin. The individual is no longer infectious after the lesions have crusted over. Localized shingles, the usual form of the disease, manifests in vesicles that are restricted to skin areas supplied by a dermatome of sensory dorsal root ganglia. These lesions may appear in crops or in an irregular fashion and are unilateral, i.e., only the dermatome on one side of the body is affected. Certain underlying conditions, such as immunosupression, may cause the herpes zoster virus to reactivate in a disseminated fashion, in which a generalized vesicular rash appears on the body, without restriction to a dermatome. EPIDEMIOLOGY AND TRANSMISSION Chickenpox (Varicella) Varicella is one of the most communicable infectious diseases and has a secondary attack rate among exposed susceptible household contacts as high as 90%. It is transmitted primarily by direct contact with large-particle droplets. Less commonly, airborne transmission of VZV may occur via aerosolized droplet nuclei. VZV is very labile and is therefore unlikely to be transmitted by inanimate objects. Varicella may be transmitted for 1 to 2 days prior to the onset of rash and up to 5 days after rash onset, or until all lesions are crusted over. Immunocompromised persons may be contagious as long as new lesions erupt. The incubation period for varicella from exposure to the onset of symptoms is usually 10 to 21 days. The rash usually appears from 14 to 16 days after exposure. Shingles (Herpes zoster)

48

Herpes zoster occurs only in persons who have had varicella or the varicella vaccine. Up to 15 % of those who have had varicella disease will have herpes zoster at some point in their lives. Shingles is most common among the elderly and those who are immunocompromised. According to the Centers for Disease Control, close to 50% of those who live beyond the age of 80 years will develop shingles. Shingles occurs throughout the year with no temporal pattern. Residents with localized herpes zoster may transmit VZV to susceptible persons, usually via direct contact with vesicular lesions. Airborne transmission of skin squames carrying the VZ virus may occur, although it is rare. Residents with disseminated shingles may transmit the VZ virus via both the contact and airborne routes. NOTE: If a nonimmune person is exposed to a resident with shingles, the person MAY develop chickenpox as a result of the exposure, but they will not "catch" shingles. Chickenpox is the initial infection, while shingles is a reactivation of the virus. DEFINITION OF IMMUNITY AND EXPOSURE According to the CDC/Advisory Committee on Immunization Practices (ACIP) "Immunization of Health Care Workers" (December, 1997)," A reliable history of chickenpox is a valid measure of VZV immunity".

Persons are considered susceptible to varicella if they meet the following criteria: • • •

No history of varicella disease No history of varicella vaccination No serologic evidence of varicella immunity

In a long term care or assisted living setting, an exposure is defined as: • • •

Being in the same 2-bed to 4-bed room Being in an adjacent bed in a large ward Having face-to-face contact with an infectious patient, healthcare worker, or visitor for at least 5 minutes

INFECTION CONTROL MEASURES FOR RESIDENTS Residents With Known or Suspected Herpes zoster (Shingles) For residents with localized herpes zoster (shingles), standard precautions are sufficient, as long as any roommates, healthcare workers, and visitors have had a history of chickenpox. For residents with disseminated herpes zoster, contact precautions with a private room should be used, again, as long as any roommates, healthcare workers, and

49

visitors have had a history of chickenpox. These precautions should remain in place until the lesions crust over. If healthcare workers and/or visitors who are nonimmune to varicella zoster will be entering the room of the resident with shingles, the resident must be placed on airborne and contact isolation. Airborne precautions consist of a private room with negative pressure ventilation and at least six air exchanges per hour. Contact precautions consist of gowning and gloving when entering the room. Airborne precautions require the wearing of a mask when entering the room. Because most LTC facilities do not have these types of rooms available for use, the best policy is not to allow nonimmune healthcare workers and/or visitors to enter the room until the resident' s lesions have crusted over. Residents With Known or Suspected Varicella (Chickenpox) If a resident is diagnosed with primary chickenpox, the resident must be placed in a private room with airborne isolation and contact precautions IF there are healthcare workers and visitors who are nonimmune to chickenpox who will be entering the room. As above, because most LTC facilities do not have these types of rooms available, the best policy is to not allow nonimmune healthcare workers and/or visitors to enter the room until the resident' s lesions have crusted over. If all healthcare workers in the facility are immune to chickenpox, the resident with diagnosed chickenpox may be placed in a private room with contact precautions. Susceptible Residents Exposed to Varicella zoster virus Susceptible residents who have been exposed to either chickenpox or shingles should be placed in airborne and contact precautions from days 10 to 21 following exposure. If the resident is given VZIG (varicella immune globulin), the precautions should be continued until 28 days after exposure. If not contraindicated, varicella vaccine should be given within 72 hours after exposure. Postexposure Prophylaxis with VZIG The use of VZIG is indicated in certain situations following exposure to varicella-zoster virus. Criteria for using VZIG include: • •

A susceptible host who is at greater risk than the general population for serious complications. An exposure that is likely to result in transmission, e.g., more than 5 minutes of face-to-face contact

VZIG should be given within 96 hours after exposure. It is administered intramuscularly, and the dosage is 125U/10 kg (22lb) of body weight up to a maximum of 625 U. VZIG is available throughout the United States through the Red Cross. 50

Table 1: Infection Control Recommendations for Residents with either Shingles or Primary Chickenpox Infection

If all roommates, healthcare staff, and visitors are immune to chickenpox:

Shingles

Primary Chickenpox

If localized shingles: Standard precautions

Private room with

If disseminated shingles:

contact precautions

Private room with contact precautions If any roommates, healthcare Airborne and contact isolation in a private, negative staff, and visitors are not pressure room. Visitors must wear mask, gown, and immune to chickenpox: gloves INFECTION CONTROL MEASURES FOR HEALTHCARE WORKERS Health Care Workers with Known Varicella (Chickenpox or Shingles) If a health care worker develops active chickenpox, they must be excluded from patient contact until all of the lesions are dry and crusted. They must spend this time outside of the facility. If a health care worker develops shingles, they must also be excluded from patient contact (outside of the facility) until all of the lesions are dry and crusted because all residents of a long term care facility are considered to be high-risk. Management of Susceptible Healthcare Workers who are Exposed Exposed healthcare workers without a history of chickenpox or varicella immunization must be excluded from duty from days 10 to 21 following exposure, outside of the facility. If chickenpox develops, the lesions must crust over before the HCW may return to work. VZIG is not recommended for exposed, immunocompetent healthcare workers. If HCWs are immunocompromised, HIV infected, or pregnant, VZIG may be considered by their personal physician. Recommendations for Varicella Vaccination of Healthcare Workers All healthcare workers who are employed in a long term care or assisted living facility should be immune to varicella zoster, either by history or vaccination.

51

New employees should be screened for antibody to varicella, and immunized if they are seronegative. Table 2: Management of exposed persons Shingles Susceptible residents

• • •

Susceptible* healthcare workers

• •

Primary Chickenpox

Place in airborne and contact precautions from days 10-21 following exposure. If patient has received VZIG, continue precautions until 28 days after exposure. Consider varicella vaccine within 72 hours after exposure unless contraindicated. 1) Exclude from work at the facility from 10-21 days from exposure. 2) If chickenpox develops, worker may not return to work until lesions have crusted over.

VISITORS Visitors should be informed if a resident has localized or disseminated herpes zoster (shingles). If the visitor is nonimmune, they may visit only if wearing a mask, gown, and gloves. If they are immune by history of chickenpox or vaccination, no specific precautions are needed. SURVEILLANCE The Infection Control Practitioner should maintain a line list of all susceptible (nonimmune) residents, employees, and volunteers. This information can be routinely collected at the time of admission or employment. In the event of an index case of chickenpox or shingles, this list can be reviewed to determine the appropriate control measures that should be taken. TREATMENT OF VZV INFECTIONS Acyclovir (Zovirax) is the only antiviral agent approved by the Food and Drug Administration (FDA) for the treatment of both primary varicella zoster infection (chickenpox) and herpes zoster (shingles). Famcyclovir (Famvir) and Valacyclovir (Valtrex) are approved for the treatment of acute herpes zoster but not chickenpox. REFERENCES •

Centers for Disease Control and Prevention. "Prevention of Varicella: Recommendations of the Advisory Committee on Immunization Practices (ACIP)", Morbidity and Mortality Weekly Report 1996; 45 (No. RR-11). 52

•

• •

Centers for Disease Control and Prevention. "Guideline for Infection Control in Health Care Personnel", American Journal of Infection Control, 1998; 26:289354. Centers for Disease Control and Prevention. "Guidelines for Isolation Precautions in Hospitals", Infection Control and Hospital Epidemiology, 1996; 17(1): 53-80. Centers for Disease Control and Prevention. "Immunization of Health Care Workers", Morbidity and Mortality Weekly Report, 1997; 46 (No. RR-18).

53

Guidelines for Control of Scabies in Long Term Care Facilities Introduction Definitions Diagnosis of Scabies Confirmation of Diagnosis Treatment Environmental Control Measures Protocol For Assessment And Control Of Scabies Outbreaks in Long Term Care Facilities Institutional Treatment Plan: Selective vs Mass Treatment References

Introduction Scabies is a contagious parasitic infestation of the skin caused by the mite, Sarcoptes scabiei var hominis. Although not a reportable disease, scabies outbreaks reported from long term care facilities (LTCFs) have increased in recent years. In Maryland for example, 61 scabies outbreaks were reported from 1986-1995, of which 57% (35/61) occurred in nursing homes. Both care givers and residents of LTCFs are at increased risk of exposure to scabies. The increased risk is attributed to several circumstances of providing and receiving care in a LTCF. Scabies in residents of LTCF may often be atypical in appearance and symptoms, causing a delay in diagnosis as well as heavy infestation. An additional factor contributing to the increased risk of exposure is the opportunity for direct skin contact between staff and residents or residents and other residents. Such contact is increased with LTCF residents who often require assistance with dressing or positioning as well as other nursing care. Further opportunities for transmission can occur through rotation of asymptomatic staff members to various units within the LTCF. Finally, environmental exposure to scabies can occur if residents mistakenly occupy another infested resident' s bed.

Definitions 54

Outbreak: An outbreak of scabies should be reported when a LTCF experiences two or more concurrent cases of scabies affecting residents and/or staff members. Two or more consecutive cases of scabies occurring within four to six weeks of each other should also be considered to be an outbreak. Case: A confirmed case of scabies is defined as a person who has a skin scraping with identified mites, mite eggs, or mite feces. A probable case of scabies is a person with clinical symptoms of a persistent pruritic rash. Contact: A contact is defined as anyone with whom a case has had skin-to-skin contact (e.g., staff member, physical therapist, phlebotomist, family member who is a regular visitor, or other residents with whom the case has had direct skin contact). Sexual partners and roommates are also contacts. Incubation Period: The time between contact with the mite and the appearance of the symptoms of the pruritic rash varies. If the individual has never had a previous infestation, the onset of symptoms occurs two to six weeks following the initial infestation by the mite. If the individual has had a prior infestation symptoms can occur one to four days following mite infestation. Period of Communicability: The infested individual may be asymptomatic yet able to transmit the mite to others. After infestation occurs, the mite deposits eggs under the skin of the human host. After larvae hatch from the eggs, they travel to the surface of the skin. Transmission can occur as early as two weeks after the original infestation of the individual. A person is considered to be no longer communicable 24 hours after start of effective therapy. Diagnosis of Scabies: Typical scabies lesions consist of papules, vesicles, or linear burrows containing the pinpoint mite; however, these may not be present on an elderly or immunocompromised infested person. Erythematous papules, excoriations, or occasionally vesicles are often located between the fingers, on the upper back, wrists, elbows, thighs, breasts, or genitalia. The lesions may also appear as eczematous plaques, pustules, or nodules located in skin folds under the breasts, around the naval, axillae, buttocks, scrotum, or at the belt line on the abdomen. Infested individuals usually complain of severe nighttime itching. The itching is often worse following a hot shower or bath. The location of scabies lesions also differs in the elderly or immunocompromised. Residents and staff should have skin examination by inspection. New residents or those accepted in transfer from another care facility should be examined on the first day of arrival. If a resident is undergoing treatment for scabies but requires transfer to another care facility, the accepting facility must be notified of the current diagnosis of scabies in this resident prior to transfer. Residents of LTCF are at risk for hyperinfestation with the scabies mite. Crusted scabies, known as Norwegian scabies, is extremely contagious. If even a single resident has crusted scabies, the LTCF faces a significant risk of a scabies outbreak. Lesions resemble 55

psoriasis with heavy crusting and scaling. Fingernails and toenails often appear discolored and thickened. Individuals diagnosed with Norwegian scabies may have one of the following characteristics: a history of treatment with steroids, an impaired ability to scratch caused by neurological or psychological illness, or an otherwise impaired immune response secondary to age or illness. Confirmation of Diagnosis: Suspicious lesions should be scraped with a sterile needle or scalpel blade. Health care personnel can be trained to perform skin scrapings according to the following procedure: •

• •

•

Choose lesions without significant excoriation. A magnifying glass may be used to locate burrows. When a possible burrow is detected, mark with a wide felt tip pen. Apply an alcohol pad to remove the surface ink. If a burrow is present, the ink will remain within the burrow. The burrow will then appear as a dark, irregular line. Apply sterile mineral oil to the surface of the lesion to be sampled. With a glass slide held at a 90 angle to the surface of the lesion, scrape the lesion. Collect the scraping on the glass slide. Scrapings from several lesions may be collected onto a single glass slide. Place a coverslip over the scrapings and examine with a microscope under low power. The presence of a mite, eggs of a mite, or mite fecal material confirms the diagnosis of scabies.

Treatment: The recommended treatment for scabies is 5% permethrin cream. Application of this cream to the skin of an infested resident should be supervised by the staff of the LTCF. Usually the cream is best applied prior to bedtime. The cream must cover all skin areas from the neck down. In the case of an incontinent resident, the LTCF staff must ensure that any cream that is removed during bouts of incontinence is promptly replaced. Following 8-14 hours of skin contact, the cream should be removed by shower or bath. Treatment may need to be repeated in seven days if there is evidence of persistent or recurrent lesions. An infested individual should be considered contagious until 24 hours after start of effective treatment. Itching often persists in spite of treatment and may require additional therapy for symptomatic relief. Alternative treatments are occasionally prescribed. These may include 1% lindane cream or lotion, 6% precipitated sulfur in petroleum, or 10% crotamiton cream or lotion. Environmental Control Measures: While scabies is readily transmissible with skin to skin contact, the mite can only survive in the environment for 48 hours without a human host. The bedding and clothing of an infested individual may contain viable mites, but exposure to a human host must occur 56

within a short period of time for transmission to occur. In general, vacuuming and general cleanliness should provide adequate environmental control. Fumigation is not necessary; furniture should not be discarded. Clothing or bedding that were used by an infested individual during the seven days before effective treatment should be laundered and dried with the hot cycle or dry cleaned. Items that cannot be laundered or dry cleaned should be placed in a plastic bag and sealed for seven days to allow time for mites and eggs to die. Cohort Measures: During an identified scabies outbreak, staff members who have been providing care to an identified case should not be rotated to other resident care units until 24 hours after completion of the staff member' s scabicidal treatment. The case should also be isolated from other residents for 24 hours. Treatment of cases and contacts in a coordinated manner according to the attached protocol will minimize the inconvenience of these cohort measures. Protocol For Assessment And Control Of Scabies Outbreaks in Long Term Care Facilities The following protocol provides guidance for surveillance, diagnosis, and treatment of cases and contacts in LTCFs and management of outbreaks. General Actions • • •

Make a line list of all cases and contacts. Include roommates, staff members (permanent and rotating), providing care, and regular visitors as contacts Confirm the diagnosis when possible; refer to dermatologist or physician for diagnostic evaluation. . Institute mass education regarding scabies outbreaks. Educate staff; consider community meetings for residents and family members, printed fact sheets (see attachment), and newsletters to families of staff and residents.

4. Educate staff and residents (if possible) on: • • • • • • •

Mode of transmission Communicability Potential for widespread epidemic if prompt action not begun Need for prophylactic treatment of even asymptomatic contacts Need for coordinated timing of treatment Proper application of treatment medication Environmental control measures: Laundry, dry cleaning, or isolation of clothing in plastic bags for seven days

57

Categorize cases and contacts for treatment assignment as follows: Management: Group I: Confirmed or Suspected Scabies and Contacts 1. Action: Isolate case (Contact precautions) for 24 hours after start of effective therapy. Perform environmental control measures: • • •

Laundry, dry cleaning, or isolation of clothing in plastic bags for seven days. Exclude case from work (or school, day care center, if applicable) until the day after treatment. Do not transfer patient without notifying the accepting facility of the diagnosis of scabies.

2. Treatment: •

• • •

Day 1 (PM) Clip nails. Bathe or shower. Apply 5% permethrin cream to all skin areas from the neck down and under nails. (Staff member should apply permethrin to the skin of the resident.) Day 2 (AM) Bathe or shower to remove the cream. Inform person that itching may persist for weeks. Day 14 Reexamine; retreat if persistent or recurrent lesions. Day 28 Reexamine; retreat if persistent or recurrent lesions.

Group II: Crusted Scabies or Norwegian Scabies (Hyperinfestation) Note: These individuals have a long term rash and are very heavily infested. They are very contagious. Repeat treatments with 5% permethrin cream are usually necessary. 1. Action: • • • • •

•

Isolate case (Contact precautions) until dermatology consult determines that case' s rash is no longer transmissible. Perform environmental control measures: Laundry, dry cleaning, or isolation of clothing in plastic bags for seven days. Cohort staff so that only one group cares for a resident/in-patient case until case is no longer transmissible. Exclude symptomatic cases (those with a rash) from work (or school, day care center, if applicable) until dermatologist, in consultation with Health Officer approves resumption based on lack of risk of transmission. Do not transfer patient without notifying the accepting facility of the diagnosis of scabies.

2. Treatment: •

Day 1 (PM) Clip nails. Bathe or shower. Apply 5% permethrin cream to all skin 58

• • • •

areas including scalp, temples, forehead, and under nails. (Staff member should apply permethrin to the skin of the resident.) Day 2 (AM) Bathe or shower to remove the cream after permethrin has been on skin for 8-14 hours). Inform person that itching may persist for weeks. Day 7 (PM) Repeat bath or shower. Repeat application of 5% permethrin cream from the neck down. Day 8 (AM) Bathe or shower to remove cream. Day 14 Reexamine; retreat if persistent or recurrent lesions. Day 28 Reexamine; retreat if persistent or recurrent lesions.

Institutional Treatment Plan: Selective vs Mass Treatment Although scabies frequently presents as a widespread outbreak within a LTCF, there are circumstances in which a more selective treatment plan may be utilized. Selective Treatment Protocol If a single case of scabies (Group I, above) occurs within the population of residents or employees, a selective treatment protocol may be utilized: •

• • • • •

Identify the case and make a line list of all contacts (roommate, care providers including radiologists, physical therapists, etc., sexual contacts, family members, or regular visitors) for the previous two months. Check contacts for rash or itching symptoms. Educate cases and contacts as previously described. Emphasize the rationale for treatment of contacts. Evaluate case and contact for assignment to proper treatment group (Group I or Group II, above). Treat case and contacts to permit simultaneous treatment to prevent re-infection and spread of the infestation Emphasize the need for follow-up / reexamination at 14 and 28 days. Employ environmental control measures for laundry and clothing as previously described.

Mass Treatment Protocol A more extensive treatment plan should be utilized if any of the following occur: •

• •

a single case of crusted or atypical scabies (Norwegian scabies, Group II, above) is diagnosed within the resident population and at least one employee is symptomatic; two or more residents have positive scrapings and at least one employee on the same unit is symptomatic; or one asymptomatic resident has a positive scraping and other residents or employees have exhibited symptoms of infestation for a period exceeding a month.

The following actions should be taken: •

Designate an outbreak control officer. This should be a health care provider or infection control professional who is able to diagnose and treat cases and contacts. 59

• • • • • • •

Make a line list of cases and contacts. Institute a facility-wide screening to detect skin lesions or symptoms that may be present in residents, employees, or close contacts of cases. Cohort employees to designated units until coordinated treatment is completed. Educate the resident community, patients, employees, ancillary personnel, and family members or frequent visitors as previously described. Make assignment to appropriate treatment group (Groups I and II, above). Perform mass treatment within a 24 hour period of all residents and staff members employed within a defined area of the facility . Perform followup examination and retreatment according to Group assignment. 9. Perform environmental cleaning as previously described.

Summary Prompt identification and treatment of scabies cases and potential contacts remains the cornerstone of outbreak control. Education of residents, staff, and family members or regular visitors must be initiated immediately. Finally, treatment of cases, contacts, and the environmental control measures must be coordinated. If case and contact identification is not complete or if treatment of cases and contacts does not occur at the same time, transmission of the mite will continue. Strict surveillance for possible cases should be performed at time of resident admission or during times of skin care or bathing assistance. The unique circumstances of the LTCF provide a population that is extremely susceptible to outbreaks of scabies. Vigilant and ongoing surveillance for cases is of paramount importance within this setting. References • Maryland Electronic Reporting and Surveillance System (Unpublished data). • Jimenez-Lucho VE, Fallon F, Caputo C, Ramsey K. Role of prolonged surveillance in the eradication of nosocomial scabies in an extended care Veterans Affairs medical center. Am J Infec Control 1995; 23:44-49. • Benenson, AS, ed. Control of Communicable Diseases Manual. Washington, D.C.: American Public Health Association, 1995: 415-417. • Maguire JH, Spielman A. Ectoparasite Infestations. In: Isselbacher KJ, Braunwald E, Wilson JD, Martin JB, Fauci AS, and Kasper DL, eds. Harrison' s Principles of Internal Medicine. New York: McGraw-Hill, Inc., 1994: 934-935. • Centers for Disease Control. Scabies in health care facilities-Iowa. MMWR 1988; 37: 178- 179. • Degelau, J. Scabies in Long-Term Care Facilities. Infect Control Hosp Epidemiol 1992; 13: 421-425. • Wilson, BB. Scabies. In: Mandell GL, Bennett, JE, and Dolin R, eds. Mandell, Douglas and Bennett' s Principles and Practice of Infectious Diseases. New York: Churchill and Livingstone, Inc., 1995: 2560-2562. • Yonkosky D, Ladia L, Gackenheimer L, and Schultz MW. Scabies in nursing homes: an eradication program with permethrin 5% cream. J Amer Acad Derm 1990; 16: 60

1133-1136. • Collier, C. Guidelines for Scabies Prevention and Control Missouri Epidemiologist Nov-Dec 1994: 14

61