Management of Varicella Zoster Virus Infection. Contents

Management of Varicella Zoster Virus Infection Classification: Policy Lead Author: Dr Adam Jeans Additional author(s): Authors Division: Clinical supp...
3 downloads 0 Views 228KB Size
Management of Varicella Zoster Virus Infection Classification: Policy Lead Author: Dr Adam Jeans Additional author(s): Authors Division: Clinical support & tertiary medicine Unique ID: TC6(05) Issue number: 3.8 Expiry Date: April 2015

Contents

1 2 3 4 5 6 7 8

Section

Page

Who should read this document Key messages Background & Scope What is new in this version Policy Explanation of terms/ Definitions References and Supporting Documents Roles and Responsibilities

2 2 2 3 3 9 10 10

Document control information (Published as separate document) Document Control Policy Implementation Plan Monitoring and Review Endorsement Equality analysis

Issue 3.8 May 2015

Management of Varicella Zoster Virus Infection

Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue

Page 1 of 12

1. Who should read this document? All clinical staff Health & Wellbeing staff

2. Key Messages 

All patients with clinically suspected chickenpox or shingles must be nursed in a side room and gloves and aprons must be worn for all patient contact.



The patient must be attended only by staff known to be immune to varicella zoster virus (VZV). All patients and staff who have had contact with a case of VZV infection (during the infectious period) should be identified and their history of exposure documented.



Varicella zoster immunoglobulin (VZIG) prophylaxis may be indicated for immunocompromised patients, pregnant women and neonates following exposure to chickenpox or shingles if they have no detectable immunity.

3. Background & Scope Primary infection with varicella zoster virus causes chickenpox. This is generally a benign childhood illness, but it can be life-threatening in neonates, immunocompetent adults and immunocompromised patients. Following chickenpox, VZV becomes latent, but may re-activate after a variable period, usually several decades, causing herpes zoster (shingles). In recent years the potential for transmission of VZV within hospitals and resulting infection of at risk patients and staff, has been increasingly recognised. Significant exposure of vulnerable patients to VZV may require prophylaxis with varicella zoster immunoglobulin (VZIG). VZIG attenuates VZV infection if given within 1 week to 10 days of exposure to the virus, but chickenpox may still develop despite prophylaxis. Transmission of VZV VZV is spread by personal contact or via the airborne route (in the case of chickenpox) or indirectly by hands or fomites (shingles and chickenpox). The incubation period after exposure to VZV infection is 10-21 days but may be shorter in neonates. Individuals with chickenpox are infectious to others from two days before the rash develops until the lesions have formed crusts, approximately five days later. Individuals with shingles are infectious from the development of the rash until crusts form (approximately 5 days). VZV is highly infectious. The infectious period may be prolonged in immunosuppressed patients. Issue 3.8 May 2015

Management of Varicella Zoster Virus Infection

Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue

Page 2 of 12

4. What is new in this version? No major changes from previous version.

5. Policy 5.1 Infection Control Notification and Advice 

Any potential VZV exposure within the hospital or of healthcare workers (HCWs) must be reported to the Infection Control Team by the nurse in charge of the ward/department.



Advice about management of contacts and staff can be obtained during normal working hours from an Infection Control Nurse (extension 65032). Outside normal working hours contact the Infection Control Nurse on call.

5.2 Isolation Precautions 

All patients with clinically suspected chickenpox must be nursed in a side room with the door closed. Inform the Infection Control Team. Patients with shingles should be isolated if the lesions are on an exposed part of the body or if the patient is immunosuppressed (see section 5.3.2).



Gloves and aprons must be used for all activities that involve patient contact and should be discarded into a yellow clinical waste bag before leaving the room.



All staff must wash their hands before and after patient contact and before leaving the room.



To confirm the diagnosis, swabs of vesicle fluid should be obtained, placed in viral transport media and transported to the lab requesting VZV PCR testing. Standards of good laboratory practice should ensure that laboratory workers and others handling/transporting specimens are not at increased risk.



All patients and staff who have had contact with a case of VZV infection (during the infectious period) should be identified and their history of exposure documented by the senior nurse on duty (see section 5.3).



All VZV antibody negative patients who have had significant exposures to VZV should be nursed in a side room for a period between 8 and 21 days after the contact if they remain in hospital. This is because patients will be infectious 2 days before the rash appears. The earliest this could appear is the 10th day. Issue 3.8 May 2015

Management of Varicella Zoster Virus Infection

Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue

Page 3 of 12



Staff who are VZV antibody negative and who have had a significant exposure to VZV (see section 5.3.1) should not have contact with susceptible individuals (i.e. those who have no history of chickenpox or are immunocompromised) for a period between 8 and 21 days after the contact. This may mean remaining off duty for the period and should be discussed with the Health and Wellbeing department (Occupational Health) on an individual basis (see section 5.3.5).



The patient must be attended only by staff known to be antibody positive or with a reliable history of VZV infection. Health and Wellbeing check the immunity of staff on appointment and immunise those who are antibody negative.



Visitors must be informed of the risks. Susceptible visitors (i.e. those who have no history of chickenpox or are immunocompromised) may need to be advised to avoid contact. Contact the Infection Control Team for further advice if needed.



All used linen should be placed in a red alginate bag within the room, which should then be placed in a white linen bag outside the room.



All disposable waste, including hand towels, should be treated as clinical waste and placed in a yellow bag inside the patient’s room. Seal the bag as usual before removing from the room.



On discharge of the patient all laundry and waste should be treated as above. All furniture fittings and horizontal surfaces should be cleaned with Chlor-clean. Medical equipment should be disinfected appropriately prior to re-use. For SSD items, follow the procedure for infected equipment. Wall washing is not necessary.

5.3 Management of VZV Exposures in Patients & Staff 5.3.1 Determination of significant VZV exposures (at risk contacts) Three aspects of the exposure are relevant, and all aspects must apply for the exposure to be determined as significant: 1) Type of infection in the index case.  Chickenpox  Disseminated zoster  Immunocompetent individuals with exposed lesions (e.g. ophthalmic zoster)  Immunosuppressed patients with localised zoster on any part of the body Issue 3.8 May 2015

Management of Varicella Zoster Virus Infection

Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue

Page 4 of 12

2) The timing of the exposure in relation to onset of rash in the index case.  In chickenpox or disseminated zoster, 48 hours before the onset of rash until crusting of lesions  In localised zoster, the day of onset of rash until crusting of lesions 3) Closeness and duration of contact  Contact in the same room or four-bedded bay for 15 minutes or more  Face to face contact, e.g. while having a conversation  In large open wards, all susceptible high-risk contacts may need to be considered to have been exposed to VZV

5.3.2 Determination of immune status of contacts: 

A substantial proportion of patients with a negative history of chickenpox will, in fact, have detectable VZV antibody. Patients who are shown to have antibody (90% of adults) will not require prophylaxis with VZIG.



Staff who have a clear history of chickenpox /shingles or who have been vaccinated against VZV or who are immune on blood testing should be reassured that they are immune to varicella infection and allowed to continue working as there is only a remote risk that they may develop chickenpox. They should be advised to report to the Health and Wellbeing department if they feel unwell, have a fever or develop a rash.



Patients who have a clear history of chickenpox/shingles or who have detectable VZV antibody on blood testing should be reassured that they are immune and are very unlikely to develop chickenpox. If they feel unwell or develop a rash they should be assessed by a doctor.



All patient and staff contacts that have a negative history of chickenpox should be tested for VZV antibody as soon as is practicable (usually within 48 hours). Any immunocompromised patients (as defined below) should be tested regardless of their history. One 7.5 mL brown top serum gel tube of blood should be sent to the Microbiology Laboratory marked urgent. The laboratory should be informed that a specimen is being sent for urgent VZV IgG antibody testing and this should be clearly stated on the request form. This should also be discussed with the on call Medical Microbiologist if necessary.

Issue 3.8 May 2015

Management of Varicella Zoster Virus Infection

Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue

Page 5 of 12



The following categories of individual require special consideration:

1) Patients with evidence of severe primary immunodeficiency, for example, severe combined immunodeficiency (SCID), Wiskott-Aldrich syndrome and other combined immunodeficiency syndromes. (Patients with gamma-globulin deficiencies who are receiving replacement therapy with intravenous normal immunoglobulin do not require VZIG). 2) Current treatment for malignant disease with immunosuppressive chemotherapy or radiotherapy, and for at least six months after stopping such treatment. 3) Patients who have received a solid organ transplant and are currently on immunosuppressive treatment. 4) Patients who have received a bone marrow transplant until at least 12 months after finishing all immunosuppressive treatment, or longer where the patient has developed graft-versus-host disease. 5) Current high dose systemic steroid therapy, or within 3 months of stopping treatment. This includes children who have received prednisolone at a daily dose (or its equivalent) of 2mg/kg/day for at least one week or 1mg/kg/day for one month, and adults who have received prednisolone 40mg/day (or its equivalent) for more than 1 week. 6) Patients receiving other types of immunosuppressive drugs (e.g. azathioprine, ciclosporin, methotrexate, cyclophosphamide, leflunomide and the newer cytokine inhibitors) or within 6 months of stopping treatment. 7) Symptomatic HIV positive patients, asymptomatic HIV positive adults with CD4 < 400 cells/µL and asymptomatic HIV positive children with moderate or severe immunosuppression.5,6 8) Pregnant women, at any stage of pregnancy. 9) Neonates. 5.3.3 Patient Contacts: VZIG for prophylaxis 

VZIG prophylaxis is recommended for individuals who fulfil all of the following three criteria:1 a) significant exposure to chickenpox or herpes zoster (section 5.3.1) b) no detectable antibodies to VZV c) a clinical condition which increases the risk of severe VZV infection; see special consideration (section 5.3.2) Issue 3.8 May 2015

Management of Varicella Zoster Virus Infection

Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue

Page 6 of 12



In immunosuppressed patients VZIG should not be delayed past 7 days after initial contact whilst an antibody test is being done if there is a negative history of chickenpox. In these circumstances VZIG should be given empirically. If the patient has a positive history of chickenpox, wait for the antibody results. VZIG is not indicated if more than 10 days have elapsed since the initial exposure. Aciclovir may be given if more than 10 days have elapsed (see section 5.3.7).



The dosage of VZIG for prophylaxis is: 0-5 years 6-10 years 11-14 years 15 years & over

250mg (one 250mg vial) 500mg (two 250mg vials) 750mg (three 250mg vials) 1000mg (four 250mg vials)

VZIG is given by intramuscular injection. Doses may be divided and given at different sites. 

If a second exposure occurs after 3 weeks a further dose is required.



Contacts with bleeding disorders who cannot be given an IM injection may be given IV normal immunoglobulin (a single dose of 0.2 g/kg body weight).

5.3.4 Pregnant contacts 

In the case of pregnant contacts, staff or patients, administration of VZIG can be delayed up to 10 days after initial contact while awaiting tests results for VZV antibody. VZIG is not indicated if more than 10 days have elapsed since the initial exposure.

5.3.5 Staff contacts 

Department of Health guidance on management of hospital outbreaks of VZV infection recommends that susceptible (VZV antibody negative) staff should be excluded from contact with high-risk patients between 8 and 21 days after exposure to a case of VZV infection. 1 This will be arranged by the Health and Wellbeing department in liaison with the Infection Control Team.



Staff who develop chickenpox/disseminated zoster should be excluded from work until the last crop of lesions has formed crusts.

Issue 3.8 May 2015

Management of Varicella Zoster Virus Infection

Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue

Page 7 of 12



VZIG may be indicated for pregnant staff who come into contact with VZV. Any exposed staff who are pregnant should obtain advice from the Health and Wellbeing department.



HCWs with localised herpes zoster on a part of the body that can be covered with a bandage and/or clothing may, if fit and after consultation with Health and Wellbeing and Infection Control, be allowed to continue working unless in contact with high risk patients, in which case a risk assessment should be made by Health and Wellbeing in conjunction with the Infection Control Team.

5.3.6 Neonates 

VZIG is recommended for infants born to mothers who develop chickenpox (but not herpes zoster) in the period 7 days before to 7 days after delivery. VZIG can be given without antibody testing of the infant.



VZIG is also recommended for: 

VZV antibody negative neonates exposed to chickenpox or herpes zoster (other than in the mother) in the first 7 days of life.



VZV antibody negative infants of any age exposed to chickenpox or herpes zoster while still requiring intensive or prolonged special care nursing.



Note that infants in the latter two exposure groups born at

Suggest Documents