MANAGEMENT OF PATIENTS WITH AN INFECTION, HUMAN INFESTATION, INFECTIOUS DISEASE POLICY
Dr Judith Hooper
NHS Kirklees Infection Prevention and Control Team
NHS Kirklees Governance Committee
1 2 3 4 5 6 6.1
Introduction Associated Policies and Procedures Aims and Objectives Scope of the Policy Accountabilities and Responsibilities Resistant Organisms Meticillin Resistant Staphylococcus Aureus Extended-Spectrum Beta-Lactamase (ESBL) producing Micro6.2 organisms 6.3 Glycopeptide-resistant Enterococci (GRE) 7 Management of patients with multi resistant infections 7.1 Infection prevention and control precautions 8 Blood Borne Viruses 8.1 Infection prevention and control 8.2 New healthcare workers 8.3 Hepatitis 9. Transmissible Spongiform Encephalopathy (including CJD) 9.1 Occupational exposure 9.2 Infection control precautions 10 Tuberculosis 11 Mites 11.1 Scabies mite (Sarcoptes Scabei) 11.2 Atypical Scabies 11.3 Human Lice 11.4 Fleas 12 Other infections / infectious diseases 13 Equality Impact Assessment 14 Training needs analysis 15 Monitoring compliance with this policy 16 References 17 Appendices Appendices A B C D
Definitions Key Stakeholders consulted/involved in the development of the policy/procedure Equality Impact Assessment Tool Table of infectious diseases
3 3 4 4 4 5 6 8 8 8 9 10 10 10 10 13 13 13 14 15 15 16 17 18 18 18 19 19 20 21
21 22 23 24
Policy Statement NHS Kirklees will ensure the safe and effective management of patients who have an infection, infestation or infectious disease by providing up to date information about the range of infections identified within the Health and Social Care Act 2008 Code of Practice for Health and Adult Social Care on the Prevention and Control of Infection and Related Guidance.
Introduction Healthcare Providers are required by the Health and Social Care Act 2008, to provide safe and effective care to patients with an infection ensuring appropriate management in order to minimise the risk of transmission to others. This policy will provide staff with information regarding infections, infestations and infectious diseases. It is intended that this will support staff when caring for patients with these infections, as well as providing information to share with others including patients and their carers. Appendix D provides a table of information on infectious diseases. As part of the patient’s care pathway, it is extremely important to ensure sufficient and suitable information regarding an individual’s infection status is appropriately shared with other healthcare professionals.
Associated Policies and Procedures This policy should be read in accordance with the following Trust policies, procedures and guidance. ●
Hand decontamination policy
Universal standards precaution policy
Health and safety policy
Incident reporting policy
Waste management guideline
Decontamination, disinfectants and antiseptics policy
Records management policy
Medical devices policy
Multi resistant organism policy
Clostridium difficile policy
Management of clinical sharps injuries policy
Creutzfeldt-Jakob Disease (CJD) Policy
Aims and Objectives The key aims are:
To ensure a high standard of care is delivered to patients with a known infection, infestation or infectious disease.
To reduce the associated risks to patients and healthcare workers from the transmission of healthcare associated infections/ infectious disease.
To ensure compliance with the Health and Social Care Act 2008: Code of Practice for health and adult social care on the prevention and control of infections by providing appropriate policy information.
To provide up to date information for patients, staff and the public to promote their understanding of infections, infestations and infectious diseases.
Scope of the Policy This policy must be followed by all NHS Kirklees employees who are developing policy and procedural documents or developing guidance for colleagues. It must be followed by all staff who work for NHS Kirklees and Kirklees Community Healthcare Services, including those on temporary or honorary contracts, bank staff and students. Breaches of this policy may lead to disciplinary action being taken against the individual. Independent contractors are responsible for the development and management of their own procedural documents and for ensuring compliance with relevant legislation and best practice guidelines. Independent contractors are encouraged to seek advice and support as required.
Accountabilities and Responsibilities The Chief Executive (CE) is accountable for ensuring that effective arrangements for the safe management of patients with an infection / infectious disease are in place within NHS Kirklees. The Director of Infection Prevention and Control (DIPC) has responsibility to give assurance to the Board and to have direct accountability for the management of patients with an infection/ infectious disease The infection prevention and control team will: ●
Ensure this policy is reviewed as required and work with Heads of Service to implement necessary changes in practice.
Act as a resource providing expert specialist advice on infections; infestations or infectious diseases.
Act as a link between NHS Kirklees and specialist agencies and networks.
Provide specialist support to promote the thorough investigation of cases of infections.
Heads of Service are responsible for ensuring that healthcare professionals involved in the management and care of patients / clients with an infection, infestation or infectious disease adhere to the policy.
Co-operate and assist with the implementation of the policy, and its associated procedures.
Bring to the notice of management, any problems of failings associated with the safe and effective management of patients with an infection, infestation or infectious disease.
Attend training as required.
Make themselves aware of, and follow safe working practices; including the use of standard infection prevention and control precautions and safe management of equipment provided for their safety and the safety of others.
Promptly report all incidents concerning the management of patients with an infection / infectious disease in accordance with the Trust’s Policy and Procedure on reporting incidents.
Resistant Organisms Antibiotic resistant strains of certain micro organisms have been emerging in the United Kingdom for some time. These micro organisms have become increasingly resistant to the more commonly prescribed antibiotics. For information on resistant organisms see NHS Kirklees Multi Resistant Organism Management Policy. ●
Identification Identification of a patient colonised or infected with a resistant organism is made by the local microbiology laboratory.
Infection An infection is the detrimental invasion and multiplication of disease producing microorganisms in the tissues or the body. This results in the tissues reacting to the invasion causing inflammation, heat and redness. The infection may be caused by pathogenic bacteria, viruses, fungi, protozoa, parasites or prions.
Colonisation Is when bacteria settle at a particular site but signs and symptoms of infection are not present.
Infection prevention and control measures Standard infection control precautions should be applied in all situations, additional precautions may be necessary, and in some cases when patients have a transmissible infection, the infection prevention and control team may advise that they are isolated to prevent or minimise the spread of infection to others. This decision is reached following an individual risk assessment which will take into account: ● ● ●
The susceptibility of the patient. The susceptibility of other patients in that clinical area. The organism involved.
Meticillin Resistant Staphylococcus Aureus Staphylococcus aureus is a gram-positive bacterium that is found in the normal flora of the nose in twenty to thirty percent of healthy people, and on the skin. It can be transiently carried on the hands and survives well in the environment in dust. Some strains of staphylococcus aureus are resistant to certain antibiotics including all Beta Lactamases eg, benzyl penicillin and currently all available cephalosporins are also resistant to meticillin; these are referred to as meticillin resistant staphylococcus aureus (MRSA). Both MRSA and sensitive staphylococcus aureus can colonise a person’s skin. The most common carriage site is the anterior nares (nostrils). MRSA is no more virulent or pathogenic than meticillin sensitive staphylococcus aureus, it is however both difficult to treat, and costly in human and financial terms. MRSA is not a significant risk to healthy individuals including health care workers or family members, but can cause serious infection in vulnerable patients. Some strains of MRSA appear in epidemics, these are known as EMRSA. 6.1.1 Management of patients in the community While the risk of serious infection with MRSA is lower in the community, it still exists, and cases of MRSA bacteraemia are occurring within community settings. People affected with MRSA do not present a risk to the community at large and should continue their normal lives without restriction. The presence of MRSA in an individual is not a refusal to admit to a care home or a reason to exclude an affected person from having a home / social life. In the patient’s own home there should be no restrictions to a normal life and people with MRSA can work and socialise as usual. They do not need to restrict contact with friends, children or the elderly but hand washing must be encouraged if close contact occurs. Hospital / care home admissions - when admitted to hospital or other communal care settings (eg care home) the risk of infection being spread to others is increased, and the accepting unit must be informed of an individual’s infection status so the patient can be risk assessed, screened on admission if required and managed appropriately. 6.1.2 MRSA screening Within the NHS Operating Framework, the Department of Health identifies MRSA screening as a performance target. The objective of MRSA screening is to reduce the risk of infection for MRSA and ultimately the number of infections occurring by routinely screening patients, both elective and all relevant emergency admissions. Within NHS Kirklees screening applies to those patients who attend the preassessment clinic at the day surgery unit at Holme Valley Memorial Hospital and all admissions to Maple Ward at Holme Valley Memorial Hospital. It also includes GP services that undertake enhanced surgical procedures. MRSA screening is currently exempt for the following pre-operative groups: ● ● ● ● ●
Day case ophthalmology Day case dental Day case endoscopy Minor dermatology procedures, eg, warts or other liquid nitrogen applications Maternity / obstetrics but includes elective caesareans.
Screening must take place as near to the procedure as possible, taking into account the five days suppression regime required before the procedure if the patient is found to be positive.
A full screen comprises of both nostrils and groin, plus any lesions, or drain sites, a catheter specimen of urine (if catheter present) and a sputum sample if the patient has a productive cough. The infection prevention and control team will notify healthcare workers if any further sites need to be screened. If a patient is transferred from another hospital to Holme Valley Memorial Hospital, it is the responsibility of the nurse in charge of the patient to ascertain the patient’s MRSA status prior to transfer. There are some parts of the body from which it is difficult to reduce / remove MRSA. If these sites become colonised with MRSA, suppression treatments are much less likely to be successful.
● ● ●
Patients with a urinary catheter Patients with a chronic wound Patients from whom MRSA is known to have been isolated from sputum or urine samples in the past.
If MRSA is isolated from any sample, it is essential that this information is shared with the patient’s GP and other relevant healthcare professionals. 6.1.3 Transfer of patients with MRSA If a patient with MRSA is transferred to another healthcare setting or care provider the management of the patient must be discussed with the receiving facility prior to the transfer occurring. This allows the receiving unit to take necessary measures to protect vulnerable patients. 6.1.4 Booking of patients for ambulance transport Most carriers of MRSA can be transported with other patients with no extra precautions. Arrangements must be made for patients to travel alone if other patients have any of the following: ●
Have open wounds such as skin grafts, or exudating wounds, that cannot be covered by an impermeable dressing;
Are excessively expectorating sputum and cannot effectively dispose of / manage the use of tissues.
The infection prevention and control team should be consulted for further advice. 6.1.5 Patient management prior to travelling in the ambulance / patient transport ●
Ensure catheters are emptied before discharge.
Wounds are covered with an impermeable dressing and the wound checked for visible exudate.
If patients are expectorating sputum, staff must ensure that clean tissues are available for the patient; consider lone transportation if the patient cannot effectively dispose of / manage tissues themselves.
Extended-Spectrum Beta-Lactamase (ESBL) Producing Micro-Organisms Gram negative bacilli are commonly found in the gastrointestinal tract, in water and soil. These bacteria achieve antibiotic resistance by producing an enzyme (beta lactamase) that counters the effects of specific antibiotics. Gram negative bacilli especially Escherichia Coli contains powerful beta-lactamases (ESBLs) that can destroy / inactivate even broad spectrum antibiotics. Gram negative bacilli commonly cause urinary tract infections, pneumonia and surgical site infections.
Glycopeptide-Resistant Enterococci (GRE) Enterococci are bacteria that are commonly found in the bowel of normal healthy individuals. They may also be found in the vagina and urethral meatus. Although not usually harmful, enterococci can cause serious infections in people who are immuno suppressed. Oncology, transplant, renal and intensive care units have been identified as areas of increased risk. Screening of this high risk group in hospitals may be advised by the infection prevention and control team, and prophylactic antibiotics may be advised pre-operatively to reduce the risk of post operative infection. Vulnerable individuals may become infected or colonised with GRE through environmental contact with the organism. The ability of enterococci to survive in the environment cannot be underestimated. GRE can cause a range of illnesses including wound infections, bacteraemia and urinary tract infections. In-patients with GRE will require isolating from others. Management of GRE may include the removal of catheters. Treatment can be difficult due to the limitations in the range of effective antibiotics but prevention of spread is achieved by thorough strict hand washing, cleaning of equipment and appropriate use of standard precautions.
Management of Patients with Multi Resistant Infections Infection control management of a patient with a multi resistant organism must be based on a risk assessment. This will include: ●
Adherence to standard infection control precautions
Known colonised/infected individuals should not share a room with another individual who has a urinary catheter in situ or a wound (in patient or care home settings)
Minimise use of antibiotics
Infection prevention and control precautions Patients colonised or infected with multi-resistant organisms require isolation. The following points reiterate some of the salient aspects of the isolation policy that require implementation to prevent patient to patient transmission of these organisms. 7.1.1
If one individual patient is found to be colonised or infected, they should be isolated in a side-room (ie, standard isolation) with ensuite or designated toilet / washing facilities. A risk assessment needs to be carried out if an isolation room is not available. Non-mobile patients must be allocated their own commode, urinal etc. Adequate handwashing facilities must also be offered to these patients eg, hand wipes.
Hand hygiene Hands must be thoroughly decontaminated before and after any patient contact. Alcohol hand rub can be used as a sole agent for decontamination providing that hands are not visibly soiled or potentially grossly contaminated with dirt or organic material. If this is the case hands must be washed with soap and water then dried. Alcohol hand rubs must not be used if the patient has loose stools as this method of hand decontamination is ineffective.
Protective clothing Disposable aprons and gloves must be put on when entering the patient’s room. These must be discarded as clinical waste after each single use before leaving the patient’s room and hands decontaminated.
Decontamination of equipment
Instruments or equipment (eg, writing materials, sphygmomanometers, stethoscopes, lifting slings and resuscitator beds) should be designated for the affected patient. If possible, single patient use items are to be used. If single use items are not available then equipment / instruments should be decontaminated after use as per manufacturer’s instructions. Where possible, equipment must be ‘singleuse’. All equipment that is not ‘single-use’ must be cleaned thoroughly after use with detergent and water or detergent wipes. If contaminated with blood or body fluids the use of disinfectant (Hypochlorite) is required. ‘Haz Tab’ dilution must be made up to 10,000 parts per million of available chlorine for blood spillage and 1000 parts per million of available chlorine for other body fluid spillages. 7.1.5
Linen Linen from patients with any of the infections discussed must be treated as contaminated / infected and must be placed immediately into a water-soluble bag (red) and removed from the patient’s bed area as soon as possible. To prevent saturated laundry from dissolving the water-soluble bag, it should be wrapped in used linen first. Once three quarters full the laundry bag must be tied off / fastened and placed in a red nylon laundry bag and safely stored.
Environmental cleaning The room / bed area requires a thorough clean daily using hot water and detergent, including high-level damp dusting of all horizontal surfaces. On the patient’s discharge a thorough clean is required of all surfaces of the room / bed area, mattress, bed frames, call bells, duvets and pillows, with hot water and detergent. Care must be taken when cleaning electrical equipment. The use of disinfectants (Hypochlorite) is required when the patient has had diarrhoea or when there is evidence of contamination with blood or body fluids. ‘Haz Tab’ dilution must be made up to 10,000 ppm for blood spillage and 1000 ppm for a body fluid (not containing blood). Window and bed space curtains must be changed for patients infected / colonised with a multi resistant infection on their discharge. Carpets should be steam cleaned on discharge. 9
Blood Borne Viruses 8.1
Infection prevention and control It is important that all Health Care Workers adhere to safe working practices against exposure to blood and body fluids from all patients, in all departments and at all times, regardless of what is or is not known about the HIV status of patients.
New healthcare workers The Department of Health recommends that all healthcare workers including students who have direct contact with blood, blood stained body fluids or patients’ tissues, are offered hepatitis B immunisation and tests to check their response to immunisation, including investigation of non response. Exposure prone procedures are those invasive procedures where there is a risk that injury to the worker may result in exposure of the patient’s open tissues to the blood of the worker. Health clearance is recommended for healthcare workers who will perform exposure prone procedures: ● ● ● ● ● ●
Dental Midwifery Paramedic Ambulance technician Podiatric surgery Medical students
These healthcare workers must have health checks to establish that they are not chronically infected with hepatitis B, hepatitis C or HIV antibody prior to their employment. 8.3
Hepatitis Hepatitis means inflammation of the liver. The most common causes of hepatitis are viral infections. Initial diagnosis may be made according to the presenting symptoms of the patient, but will be confirmed by serological testing. 8.3.1
Hepatitis A virus The disease is generally mild but severity tends to increase with age. Fulminant hepatitis can occur but is rare. There is no chronic carrier state and chronic liver damage does not occur. The virus is usually transmitted by the faecal oral route via person to person spread or contaminated food or drink. The incubation period is usually 28 – 30 days. Outbreaks of hepatitis A have been reported amongst injecting drug users. Poor standards of personal hygiene with possible faecal contamination of shared injecting equipment or drugs are the most likely mode of transmission in this group of individuals. Excellent infection prevention practices must be followed. Protection is available in the form of human immunoglobulin (IgG) for contacts in an outbreak situation.
Hepatitis B virus Hepatitis B is an infection of the liver caused by the hepatitis B virus. The illness starts insidiously with symptoms of – anorexia, nausea, pain / tenderness in right upper abdomen, mild fever, and malaise may be profound. The incubation period ranges from 40 to 160 days, with an average of 60 to 90 days. The virus is transmitted via: ● ● ● ●
Unprotected sexual intercourse – vaginal or anal As a result of blood-to-blood contact, including needlestick injury Perinatal from mother to child Biting incidents from infected person that break the skin (rare)
Chronic infection (carriers) Chronic hepatitis B infection occurs when the surface antigen is still detected in the serum for six months or longer. The risk of developing chronic hepatitis B infection depends on the age at which infection is acquired. All chronic carriers are potentially infectious to others. The risk of chronic infection increases when patients have an impaired immunity. When chronic infection occurs there is a likelihood of progression to permanent liver damage and other serious liver disorders. To prevent the spread of infection, healthcare professionals must adhere to standard precautions to reduce the risk of blood borne viruses. It is important that staff, regardless of vaccination status or the infection status of the patient use safe practices when in contact with blood and body fluids. Hepatitis B Immunoglobulin (HBIg) can be used to provide passive prophylaxis following sharps injury involving a hepatitis B positive patient. For additional information see Policy on Management of Clinical Sharps Injuries and Exposure to Blood and Body Fluids. 8.3.3
Hepatitis C virus A proportion of non A, non B hepatitis and the majority of post transfusion hepatitis is now known to be caused by the hepatitis C Virus. Transmission was originally thought to be transmitted via blood transfusion, however sexual and perinatal transmission can occur. Activities involving IV drug users sharing equipment can also result in transmission. There is currently no vaccine for hepatitis C; adherence to standard precautions will prevent spread.
Hepatitis D, E, F and G A number of other types of hepatitis have been identified within the world including hepatitis D. This is also referred to as the delta virus and requires the presence of hepatitis B virus to survive. Transmission of the virus is the same route as hepatitis B.
Hepatitis E has an average incubation period of four to six weeks. The disease is generally mild in its effect unless the individual has pre existing liver disease. Transmission is via the faecal-oral route. There is no chronic infection status caused by hepatitis E. In pregnant women, there is a risk of the virus causing acute fulminant hepatitis. There is no vaccination programme, and infection control measures are the same as for hepatitis A.
Hepatitis F virus is often referred to as the unidentified agent. The full clinical significance of infection with hepatitis F and G remains unknown. 8.3.5
Human Immuno-Deficiency Virus (HIV) and AIDS HIV is a retrovirus which interferes with the body’s immune response to infection and malignancy. A person infected with HIV may experience an initial acute illness followed by a period in which there are no clinical features, although antibodies to the virus can be detected in the blood. People with HIV infection may remain well for several years. As the immune system becomes increasingly impaired, the chances of opportunistic infections increase.
Acquired Immune Deficiency Syndrome (AIDS) Acquired Immune Deficiency syndrome (AIDS) is diagnosed when a person with HIV infection is found to be suffering from one or more of a number of specific diseases. These diseases include Pneumocystis Carinii Pneumonia (PCP), certain cancers, eg Kaposi’s sarcoma and conditions thought to be due to the direct effect of HIV, eg HIV encephalopathy. (This list is not exhaustive.) Transmission of HIV Transmission of HIV can occur through the following routes: ●
Sexual contact – where blood or body fluids are exchanged.
Blood-to-blood contact – through sharing contaminated needles, syringes and other equipment used for injections. Blood-to-blood contact – through sharing contaminated needles, syringes and other equipment used for injections.
Mother to baby
through transplacental transmission during the birth process through breast milk
There is no evidence of other modes of transmission. The virus is not transmitted through coughing and sneezing, sharing utensils or kissing. The prime risk of infection to health care workers is parenteral transmission by accidental needlestick injury or entry of infectious material through broken skin (eg cuts, abrasions and skin conditions such as eczema) or mucous membranes. It is, therefore, essential that the utmost care is taken to avoid sharps injury and contamination of wounds and mucosal surfaces with blood or tissue fluids. Refer to: the Policy on the Management of Clinical Sharps Injuries and Exposure to Blood and Body Fluids Testing for antibodies
It is important that HIV testing is not performed indiscriminately. Consent must be obtained from the patient prior to testing. A person should only be tested for HIV with adequate pre-test counselling and advised when the results of the test are available; its disclosure to the person must be accompanied by post-test counselling. A negative test result means that antibodies to HIV were not found. This does not exclude exposure to HIV as antibodies may take up to three months to appear (window period). A person can be recently infected by HIV and have a negative result and still be capable of transmitting the HIV virus to another person. A positive result means that antibodies to HIV were detected, but does not give an indication of when the infection occurred. 9.
Transmissible Spongiform Encephalopathy (including CJD) Transmissible Spongiform Encephalopathy (TSE) also known as prion disease results in degeneration of brain tissue. The diseases which occur in humans and certain other animal species are fatal. The common feature of all TSE’s is the appearance of microscopic holes in the grey matter of the brain, giving a sponge-like appearance, from which the conditions derive their names. The pre-clinical phase of CJD may last for years, followed by rapidly progressive dementia, loss of memory and intellect, personality changes and progressive unsteadiness and drowsiness. New variant CJD (vCJD) is characterised by behavioural changes, poor co-ordination (ataxia), progressive cognitive impairment and often a relatively long duration of illness, up to two years in people of a young age. 9.1
Occupational exposure Incident reports must be completed and sent to the risk management team within the Trust for all incidents of exposure with infectious or potentially infectious material. All employees must have a clear understanding of identifiable risks to their health arising from work, and the action to be taken in dealing with situations in which exposure may occur. If there is any incident with a known exposure of staff to potentially infectious materials, infection prevention and control team must be contacted as a matter of urgency. A meeting may then be convened by the Health Protection Agency and infection prevention and control team to consider up-to-date evidence on treatment options. Incident reports must be completed and sent to the risk management team within the Trust for all incidents of exposure with infectious or potentially infectious material.
Infection prevention and control precautions Normal social or routine clinical contact does not present a risk to healthcare workers, families or others. Staff who work with patients known to be suffering from CJD, or who are thought to be suffering from CJD, and are likely to come into contact with infected tissue, must be informed of the risk. Tissues that present the highest risk if exposed are: Staff who work with patients known or thought to be suffering from CJD, and who are likely to come into contact with infected tissue, must be informed of the risk. Tissues that present the highest risk if exposed are: ● ● ●
Brain Spinal cord Eyes 14
Lymphoreticular tissue in new variant CJD has been suggested as a possible high risk material.
Patients with CJD may be cared for on an open ward or at home, with no special precautions other than standard infection control practice that would apply to any patient. All pathological specimens must be labelled with Danger of Infection. Specific advice from the laboratory must be sought before specimens are sent for investigation. Routine autoclave processes and disinfectants are not sufficient to deal with TSE agents, the following advice must be followed: ● Single-use disposable equipment should be used where practicable. Instruments which are not disposable must either be discarded or undergo special decontamination procedures. Contact the infection prevention and control team for details.
Equipment not in direct contact can be covered with coverings or shields to protect from decontamination.
Items for disposal by incineration should be isolated in a rigid clinical waste container and transported as soon as possible for incineration.
Tuberculosis Tuberculosis (TB) is an infectious disease caused by bacteria belonging to the mycobacterium tuberculosis complex. Bacteria may affect almost any part of the body. The symptoms of TB are varied and depend on the site of infection. Transmission of pulmonary tuberculosis occurs through coughing of infectious droplets, and usually requires prolonged close contact with an infectious case. The initial infection may: ● ● ●
Be eliminated Remain latent Progress to active TB
Untreated disease may eventually be fatal. Symptoms may include: ● ● ● ●
Persistent cough, for more than three weeks, which may be associated with sputum, breathlessness and or haemoptysis Loss of weight Fever and night sweats Lethargy
Antibiotic treatments are highly effective for drug sensitive cases, but need to be continued for a minimum period of six months to cure the disease. Where patients do not continue to take their medication correctly, multi-drug resistant TB may occur. Contact tracing of patients is undertaken by the TB Nurse Specialists, and those people identified at risk will be offered screening and follow up treatment if necessary. Pre-employment screening for healthcare workers who will be working with patients or clinical specimens is undertaken by Occupational Health Services prior to the commencement of employment. Routine BCG vaccination for all children is no longer offered within the UK, and selective immunisation to those at risk is now government policy throughout England. The aim of the BCG immunisation programme within the UK is to immunise those at increased risk of developing severe disease and / or of exposure to TB infection. BCG immunisation should be offered to:
All infants (aged 0 to 12 months) living in areas of the UK where the annual incidence of TB is 40/100,000 or greater
All infants (aged 0 to 12 months) with a parent or grandparent who was born in a country where the annual incidence of TB is 40/100,000 or greater
Previously unvaccinated children aged one to five years with a parent or grandparent who was born in a country where the annual incidence of TB is 40/100.000 or greater. These children should be identified at suitable opportunities, and can normally be vaccinated without tuberculin testing.
Previously unvaccinated, tuberculin-negative children aged from six to under 16 years of age with a parent or grandparent who was born in a country where the annual incidence of TB is 40/100,000 or greater. These children should be identified at suitable opportunities, tuberculin tested and vaccinated if negative.
Previously unvaccinated tuberculin-negative individuals under 16 years of age who are contacts of cases of respiratory TB.
Previously unvaccinated, tuberculin-negative individuals under 16 years of age who were born in or who have lived for a prolonged period (at least three months) in a country with an annual TB incidence of 40/100,000 or greater.
People in the following occupational groups are more likely than the general population to come into contact with someone with TB: ●
Healthcare workers who will have contact with patients or clinical materials
Laboratory staff that will have contact with patients, clinical materials or derived isolates.
Veterinary and staff such as abattoir workers who handle animal species known to be susceptible to TB, eg, simians
Prison staff working directly with prisoners
Staff of care homes for the elderly
Staff of hostels for homeless people and facilities accommodating refugees and asylum seekers
Unvaccinated, tuberculin-negative individuals aged under 35 years in these occupations are recommended to receive BCG. There are no data on the protection afforded by BCG vaccine when it is given to adults aged 35 years or over. Not all healthcare workers are at an equal risk of TB. There are likely to be categories of healthcare workers who are at particular risk of TB, and should be part of the clinical risk assessment when the use of BCG is being considered for a healthcare worker over 35 years of age. Travellers and those going to reside abroad may also be at increased risk. BCG may be required for previously unvaccinated, tuberculin-negative individuals according to the destination and the nature of travel. The vaccine is recommended for those under 16 years who are going to live or work with local people for more than three months in a country where the annual incidence of TB is 40/100,000 or greater. People seeking vaccination for themselves or their children should be assessed for specific risk factors for TB. Those without risk factors should not be offered BCG vaccination but should be advised of the current policy and given written information. 16
Classical Scabies (Sarcoptes Scabiei ) 11.1.1
Sarcoptes Scabiei causes scabies in humans and can affect people of any socio economic class. A number of other species of Sarcoptes cause mange in pets and domestic animals but these mites do not survive on humans. The scabies mite burrows through the upper layers of the skin feeding on the dermal tissues. Clinical symptoms result from sensitisation to the mites and to their faeces. Extensive and permanent burrows are only produced by the female mite, which is capable of living for up to two months on the human host. Scabies is transmitted from person to person only by close and prolonged physical contact.
Clinical Features There may be no sign of infection for 2 - 4 weeks after exposure. When an allergy develops to the saliva and faeces of the mite and an itchy symmetrical rash appears. If the person has had scabies before the rash may appear within a few days of exposure. The rash comprises small red papules and is seen anywhere on the body. The population of mites builds up over 2 â€“ 4 months and a fully developed case of scabies will have an average population of 20 adult mites. This results in intense itching, worse at night.
Identification When an individual is first infested with the scabies mite, there is seldom any evidence of symptoms for the first month. Clinical symptoms arise only when individuals become sensitised to the mites. Once sensitised and in all subsequent infestations, symptoms may occur rapidly, 1 â€“ 4 days. Intense itching is one of the most commonly reported symptoms particularly at night and over most of the body. Scratching leads to broken skin and the formation of pustules. The majority of the burrows (if seen) are found between the fingers and toes, at the bends of the knees and elbows but the skin of the scrotum, penis, knees, buttocks and breasts may be affected. The scabies rash is a symmetrical allergic skin reaction that may appear on the body from the underarms to the calves, and around the waist. The diagnosis of scabies is based on the appearance and distribution of the rash and by the presence of burrows. Examination of the surface of the skin for burrows using a magnifying glass. Where possible the diagnosis should be confirmed by a dermatologist who sees / isolates mites, eggs or faecal pellets from a skin scraping.
Practical information Linen and laundry There is no need to deal with clothing and linen in a special way, a normal wash in a machine is adequate. If no washing machine is available, hand-wash in hot water, using household gloves. Furniture Mites do not live on or in furniture; therefore there is no risk of transmission. Persistent itching Itching may persist for one to two weeks after application of medication. This may not necessarily be due to failure of treatment and can be easily treated. 17
Standard precautions Disposable gloves should be worn for contact until after treatment has been applied. All sleeping partners of an infected individual should be treated. 11.2
Atypical Scabies In individuals with a suppressed immunity Atypical scabies may occur. The condition results in a scaly-crusted skin and is highly contagious. In children and the elderly, scabies may be atypical in that the face and scalp may be affected and burrows are seldom found. A confirmed diagnosis is essential to ensure that clients are not being treated for other skin conditions. There is a small risk of cross infection through upholstered furniture, particularly in communal areas, e.g. in nursing and residential homes and so thorough cleaning and vacuuming are recommended. It is important to seek advice from the infection prevention and control team. Outbreak management Outbreaks of scabies must be reported to The Health Protection Agency to ensure a coordinated approach for administering treatment for all clients, staff and close relatives is undertaken.
Human Lice There are three types of human lice, the head louse, the body louse and the pubic (crab) louse. All are specific to man and each specific to a particular area of the body. 11.3.1
Head Lice (Pediculus Capitis) Head lice are primarily seen in nursery and primary school children. Transmission of lice occurs during head-to-head contact. Head lice are only found on the hairs of the scalp. The head louse is a small wingless insect that lives on hair near the scalp and feeds on blood from the scalp. It needs hair to grip onto and to lay its eggs on. They are very difficult to see and well camouflaged, but needs to stay warm. They therefore, cannot survive away from the human host. Head lice are passed on by direct head to head prolonged contact, and at no other time. The lice cannot jump, swim or fly, so cannot be spread without head to head contact. It does not matter whether hair is long, short, dirty or clean â€“ lice have no preference. Early detection Head lice cannot be prevented. Regular combing and hair washing do not prevent infection, or eliminate established infections. The aim of combing is early detection. Ideally hair should be combed weekly with a fine comb after washing. This will assist in early detection. It is useful to use a white towel, or white paper to catch the specks so that they can easily be seen and identified. Live eggs at the root of the hair, may be dark and can be difficult to see. Live lice caught in a comb have moving legs and can be seen. If there is any uncertainty, advise the carer to stick their findings on to clear tape and seek advice from the nurse, doctor, health visitor or community pharmacist. Nits are the egg cases that lice leave behind after they hatch. These empty egg shells are pearly white in colour and are easier to see than lice. Treatment and control 18
Treatments may be prescribed or purchased from a community pharmacy. Lotion formulations are considered to be the most effective in killing lice and eggs. These preparations should not be used on babies under 6 months. The insecticide should not be applied to a person's hair if they have been swimming within 24 hours of the proposed application without first washing and drying the hair. Chemicals within the swimming baths can weaken the effectiveness of the solution. It is no longer recommended to treat all household members but everyone else in the household should be checked. They should only be treated if live lice are found. Care in applying the treatment is important to promote effectiveness. It is best to put a few drops every few centimetres onto the head and work the liquid outwards over the hair. It is important to work the solution behind the ears and down the nape of the neck. Care in the application of the product is more important than the type of treatment chosen. A second treatment, seven days later, is advised to catch recently hatched lice, as the eggs are relatively resistant. There is no reason to keep children away from school or nursery or to restrict their activities. Failed treatment An itchy or reddened scalp does not indicate head lice. Other family and close friends should be re-checked in case infection has been re-acquired. It cannot be re-acquired from hairbrushes, bedding or similar objects. It is important to continue combing on a weekly basis to look for lice. 11.3.2
Body Lice Body lice are found on the body surface, especially in the axilla and around the waist. People infested usually present with pruritus, excoriations and secondary infection as a result of scratching. Transmission is by close body contact. Treatment can be obtained through the Community Pharmacist or GP. When removing clothing and applying treatment, gloves and plastic aprons should be worn. Clothing and bedding should be washed in a hot cycle or dry cleaned.
Crab louse (pthirus pubis) Pubic lice are crab like in appearance. Infestation occurs on coarse body hair such as pubic hair and eyelashes. In men the chest hair, beard and moustache may also be infested. Transmission of crab lice occurs during close physical contact. All hairy parts of the body must be treated in adults. Treatment can be obtained through the Community Pharmacist or GP. Simultaneous treatment of all infested family members and sexual contacts should occur. Lice on eyelashes and eyebrows are best treated by smearing petroleum jelly on the hair for 10 days. This kills the nymphs as they hatch. Crab lice eggs are not found on the hairs of the scalp.
Fleas Fleas are true insects, when a flea feeds it injects saliva into the dermis of the skin, this causes intense itching at the bite site which lasts for several days. A flea bite is characterised by a tiny dark spot surrounded by reddish swollen skin. The fleas that have the greatest impact on humans are the human flea, the plague or rat flea and the jigger flea. There are also a number of animal and bird fleas that will feed opportunistically on man and cause a severe bite. The most important flea in humans is the cat and dog flea.
The more common cause of flea infestation is the cat flea which will bite humans in the absence of the primary feline host. Incidents in PCT properties should be reported to Health Property Management, and a call logged with the relevant facilities company. 12.
Other Infections / Infectious Diseases Appendix D provides information regarding how the disease spreads, incubation periods, whether the infection/ infectious disease is notifiable and special precautions required when caring for an individual with the infection.
Equality Impact Assessment This policy was found to be compliant with this philosophy (see Appendix C).
Training Needs Analysis NHS Kirklees is committed to the training and continuing development of all staff including independent contractors on all relevant issues surrounding the management of patients with an infection, infestation or infectious disease. Heads of Service must ensure that training needs are identified and implemented following an agreed action plan.
Monitoring compliance with this policy ●
The Trust will have key indicators for the monitoring of infection prevention and control.
Essential Steps audits to ensure standard universal precautions policy is being implemented.
Percentage of incident reports identifying a failure in compliance with this policy.
Percentage of clinical and non-clinical staff undertaking mandatory annual infection prevention and control training.
Quality indicators will be a part of normal performance monitoring against a set of local, regional and nationally standards. (Nationally the evidence for Standards for Better Health will be superseded in 2009 by the Care Quality Commission).
References ● Winning Ways: Working Together to Reduce Healthcare Associated Infection in England, Chief Medical Officer, 2003 ● Getting ahead of the Curve: A Strategy for Combating Infectious Diseases, Department of Health, 2002 ● The Health Act 2008. Code of Practice for the Prevention and Control of Health Care Associated Infections. Department of Health. ● Health protection regulations: response to the consultation. 8 July 2009 ● Shifting the Balance of Power the next steps. Securing Delivery – Human Resources Framework, Department of Health, January 2002 ● About the Healthcare Commission. Inspecting, Informing, Improving. Commission for Healthcare Audit and Inspection 2005. ● Standards for Better Health. Legislative Basis Section 46 of the Health and Social Care (Community Health and Standards) Act 2003. ● Mid Yorkshire Hospitals NHS Trust MRSA screening and decolonisation 21 July 2009. ● Department of Health 2009, Clostridium difficile infection, how to deal with the problem. Gateway reference 9833. ● HPA website. Extended spectrum beta lactamase – frequently asked questions accessed 28th Feb, 2010 ● HPA website. Glycopepticicle resistant enterococci, frequently asked questions ● NICE Guidelines (2006) Preventing and Treating Tuberculosis ● Department of Health (2007) Health Clearance for tuberculosis, hepatitis B, hepatitis C and HIV: New healthcare workers
Appendices Appendix A â€“ Definitions Infection Prevention and Control Infection prevention and control is the use of evidence based practice, training and education, policies and procedures to prevent or minimise the risk of cross infection, through a managed environment, to patients, staff and visitors. Infection An infection is the detrimental invasion and multiplication of disease producing micro-organisms in the tissues or the body. This results in the tissues reacting to the invasion causing inflammation, heat and redness. The infection may be caused by pathogenic bacteria, viruses, fungi, protozoa, parasites or prions. Infestation This is when an individual has scabies, head lice, or other types of ectoparasite lice or ticks that cause a reaction in the body. Infectious Disease A disease that can be transmitted from person to person or from other species to humans.
APPENDIX B Key stakeholders consulted/involved in the development of the policy/procedure
Stakeholders name and designation
Key Participant Yes/No
Feedback requested Yes/No
Kirklees Infection Control Committee
KCHS Senior Infection Prevention and Control Nurse
Health Protection Agency Nurse and CCDC
Feedback accepted Yes/No
APPENDIX C Equality Impact Assessment Tool Insert Name of Policy / Procedure Yes/No 1.
4. 5. 6. 7.
Does the policy/guidance affect one group less or more favourably than another on the basis of: Race
Religion or belief
Sexual orientation including lesbian, gay and bisexual people
Disability - learning disabilities, physical disability, sensory impairment and mental health problems
Is there any evidence that some groups are affected differently? If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? Is the impact of the policy/guidance likely to be negative? If so can the impact be avoided? What alternatives are there to achieving the policy/guidance without the impact? Can we reduce the impact by taking different action?
COMMUNICABLE DISEASES / INFECTIONS DISEASE
CHICKEN POX (VARICELLA-ZOSTER INFECTIONS)
Chicken pox – 11-21 days usual 15-18
Unknown – occurs when a pathogenic strain of clostridium difficile colonises the gastrointestinal tract. Unclear – 7–10 days is an average, the infectious period commences at onset of symptoms and may continue for several weeks after resolution.
FOOD POISONING: CAMPYLOBACTER
SPECIAL INSTRUCTIONS AND INFORMATION
Chicken pox - direct person to person contact by airborne spread of vesicular fluid or respiratory secretions and by contact with articles recently contaminated from vesicles and mucous membranes. Faecal / oral.
Exclude children and healthcare workers until five days from the onset of rash. No exclusion criterion needs to be applied to individuals with herpes zoster. See NHSK Clostridium Difficile Policy.
The main routes of spread are person to person via faecal / oral. Animal to person, drinking water contamination may occur from agricultural sources or human sewage contamination.
Hand washing after contact with faeces. Safe disposal of sewage. Immuno suppressed patients to boil water before consumption and avoid contact with farm animals and infected humans. Guidelines for farm visits by children. No public health response usually necessary, screening of transplant donors for active disease.
2-4 weeks The virus may remain latent for long periods.
Transmission is through body fluids, blood or transplanted organs. In the newborn infection may have been acquired transplacentally or during birth.
Most cases occur within 2 to 5 days, with an average of 3 days
Direct transmission from animals and person to person spread. Via contaminated food, milk or water.
Good hand hygiene. Avoid food handling until asymptomatic. Food handlers to remain away from work until 48hr symptom free. Adequate cooking of meat – especially poultry.
Incubation period ranges from 6 hours to 3 days. Most cases occur within 12–36 hours of ingestion.
Consumption of contaminated food. Person to person spread via the faecal-oral route.
Care with food and personal hygiene.
Incubation is between 12-96 hours but may be up to one week. The infectious period is during diarrhoeal period.
Person to person spread via the faecal-oral route.
Good personal hygiene, care with food and water.
Either directly or contamination of the food, water or environment.
Incubation period dependent on diagnosis of GI infection, eg, Norovirus – 15–50 hours.
Faecal-oral route, via contaminated foods, infected food handlers, water borne.
Incubation period – 7-10 days but extremes of 3-25 days have been reported. Incubation period is 1-4 days for acute infection.
Via faecal/oral route directly person to person or via food or water. Giardia cysts are environmentally resistant and survive well in cold water. Commonly acquired by contact with either infectious patients or carriers, particularly nasal carriers. Transmission via contaminated unpasteurised milk is recognised.
GROUP A HAEMOLYTIC STREPTOCOCCAL INFECTIONS (including Scarlet fever)
HEPATITIS A & E
HEPATITIS B C & D
HERPES SIMPLEX VIRUS (HSV TYPE 1)
By direct contact with the head of an affected person. Head lice cannot jump or fly.
15-50 days the mean is 28. The infectious period is from 2 weeks before onset of symptoms until one week after. 3-6 months
Person to person spread via the faecal-oral route.
Person to person via a number of blood borne routes. Sharing of drug injecting equipment. Sexual contact. Mother to baby. Contact with virus in saliva or lesions.
Good standards of personal and food hygiene. In-patients should be isolated as advised by the infection prevention & control team. Additional cleaning with the use of hypochlorite may be advised. Adequate control of infection and food hygiene practices, advice to travellers on safe food and water. Can result in wide ranging infections from a sore throat to necrotising fasciitis. Advice from infection prevention and control team must be sought. Single room accommodation may be necessary until bacteriologically clear or 3 days after start of appropriate antibiotic therapy. Regular grooming by combing is important. Treatment is either chemical or by wet combing with a detector comb for two weeks. Children must not be excluded from school. See section 8.2 of this policy
See section 8.2 of this policy
Cuts and abrasions on the carers' hands must be covered when having direct patient contact. Gloves should be worn by health and social care staff.
HERPES SIMPLEX VIRUS
Sexually transmitted via contact with infectious discharges or lesions.
Prompt effective treatment and refrain from sexual intercourse until treated. Sexual contact should be identified, examined and treated as appropriate.
Herpes Zoster is caused by reactivation of latent varicellazoster virus.
Carriage does not occur. Transmission is via direct person to person contact with lesions and airborne spread of vesicular fluid. Infectious only if lesions are exposed or disseminated, (will not transmit shingles, but cause chicken pox). Person to person as a result of exposure to infected blood or tissues, eg, sexual contact, sharing needles and syringes, transfusion of infected blood. The skin becomes infected after bacteria entre through a break in the skin such as a cut or an insect bite. It is easily spread person to person or by sharing towels or clothing. The infectious period lasts from one day before until
Discuss exclusion with infection prevention and control team.
(HSV TYPE 2)
HERPES ZOSTER (SHINGLES)
1–3 days occasionally up to 5 days
2-10 days average is 5.5 days
7–13 days but the range is 4–19 days. Patients continue to excrete for many months. 8–13 but usually 10 days. The period of communicability starts just before the onset of the prodrome and lasts until 4 days after the rash appears.
3–5 days after onset of symptoms in adults. Transmission is via respiratory secretions.
Legionella is not transmissible from person to person. The reservoir for the organism is environmental water. Transmission occurs by inhalation of aerosols or droplets from an infected dose of the organism. Humans acquire the infection by contact with water, soil or materials contaminated with the urine of infected animals. Spread is person to person by direct contact with nose and throat secretions, or respiratory droplets.
Public health education to reduce high risk activities that carry a risk of HIV transmission. Basic hygiene measures reduce chance of spread.
Personal hygiene to reduce transmission by coughing, sneezing or contaminated hands. Annual seasonal influenza programme for those aged 65 years or more, plus those aged 6 months or over in clinical at risk groups. Immunisation should be offered to front line health and social care workers. Maintenance and monitoring of water systems. Store hot water above 60° C. Store cold water below 20° C.
Control rodent populations.
Routine vaccination programme. Exclude from school until 5 days from the onset of rash.
Usually 3–5 days although it may be up to 10 days.
Person to person spread through respiratory droplets and direct contact with nose and throat secretions.
2-14 days according to type
Many infectious agents can cause meningitis.
2-3 weeks, average 18 days. Cases are infectious up to a week before parotid swelling until 9 days after. Paratyphoid gastroenteritis is 1 – 10 days. The incubation period varies with the site of infection but is typically 2–6 weeks.
Through droplet spread and direct contact with saliva of a case.
RSV (RESPIRATORY SYNCYTIAL VIRUS)
2-8 days with an average of 5 days.
RUBELLA (GERMAN MEASLES)
Infective embryos develop within 5 – 6 hours
1 – 3 weeks. Infectious period lasts as long as bacilli are present in the stool Dependent on which virus.
VIRAL HAEMORRHAGIC FEVER (VHF) WHOOPING COUGH
Food borne from consumption of foods contaminated by a human case. Transmission is with direct skin to skin contact with an infected person or animal or by indirect contact with fomites eg, combs and brushes. Person to person transmission is by the faecal-oral route. Transmission from respiratory secretions either directly or via contaminated hands handkerchiefs. The infectious period starts shortly before commencement of symptoms to one week after the appearance of symptoms. Direct person to person contact by respiratory droplets.
Transferred to the mouth on fingers as a result of scratching. Person to person spread or indirectly on bedding and clothing. Adult worms do not live for longer than six weeks. Ingestion of water or food contaminated by faeces from a human case.
Should be considered in any patient presenting with pyrexia of unknown origin returning from abroad. Droplet spread from an infectious case.
Infectivity is relatively low and requires prolonged close contact such as that in the household or mouth kissing. Patients are no longer infectious within 24 hours of starting antibiotic treatment. Vaccines offer prevention. Seek advice from infection prevention and control team. Routine MMR vaccination. Exclusion from school for 5 days from onset of parotid swelling.
Early recognition and prompt effective treatment. Maintain high levels of personal, environmental hygiene. Exclude until 48 hours after the diarrhoea and vomiting have settled. Personal hygiene. Immunisation is available to high risk cases.
Routine vaccination programme. Screen all women in early pregnancy and immunise following delivery if rubella susceptible. Prompt treatment of cases and their household contacts. Handwashing. Underwear, bedding changed regularly. Vaccination is recommended for travellers to endemic countries. Personal hygiene. Strict infection prevention and control precautions.
Routine immunisation programme.
HELMINTHS â€“ INTESTINAL ROUNDWORMS
Depends upon the type of worm.
Humans are the reservoir and transmission is indirect.
Good personal hygiene. Depends upon type of worm.
Sign Off Sheet regarding Dissemination of Procedural Documents
To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval.
Title of Document:
Management of Patients with an Infection, Human Infestation, Infectious Disease Policy
Dr Judith Hooper
NHS Kirklees Governance Committee
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