In general, patients with respiratory virus infections should
be isolated in single cubicles or cohorted with respiratory
precautions. The room should be under negative pressure. Gloves
and gowns (or plastic aprons) should be worn on entering the room.
The value of filter masks is highly debatable, but should be worn
when handling the patient. Hand washing must be carried out on
leaving the room. The number of staff attending the patient
should be restricted. Disinfection of surfaces may be carried out
by 1000 ppm hypochlorite. Viruses under this category include
varicella-zoster, measles, mumps, rubella, parvovirus, influenza,
parainfluenza, and RSV. Where possible, nursing of patients
should be carried out by staff known to be immune eg. for VZV,
mumps, measles, and rubella. For this reason, It would be
invaluable to have a record of staff immunity to childhood
illnesses kept either by the sister in charge or by the
occupational health department.
1. Chickenpox
Outbreaks of chickenpox is of particular concern in wards with
immunocompromized patients, particularly paediatric oncology
wards with leukaemic children, adult oncology wards, and bone
marrow transplant recipients. It is also of concern in obstetric
wards and neonatal wards. In the case of obstetric wards, the
main concern is that chickenpox is likely to be more severe in
pregnant women, and therefore, if supplies permit, susceptible
women should be given ZIG. Any baby born whose mother developed
the rash of chickenpox within 7 days of delivery should also be
given ZIG and possibly acyclovir. Acyclovir is thought to be safe
for the fetus. The following are guidelines for dealing with
potential contacts of chickenpox in susceptible wards.
Patients with uncomplicated chickenpox do not require
admission to hospital. If admission is required, then the
patient should be put in respiratory isolation. The same
applies to patients with other conditions who develop
chickenpox while in hospital. For patients with shingles,
contact isolation would be sufficient.
Other patients on the ward should be assessed for
immunity for VZV; usually, a past history of a chickenpox-like
illness diagnosed by the General Practitioner is
sufficient; however, IgG antibody screening of all
patients would be preferable, especially for those
individuals who are predisposed to severe chickenpox.
Those found to be negative should be discharged home if
their condition allows. If they must remain in hospital,
they should be cohorted together and put in respiratory
isolation during the period of infectivity (10-21 days
following contact), until the incubation period has
passed. Essentially, these patients must not have contact
with immunosuppressed patients.
ZIG should be given to seronegative patients who are
susceptible to severe VZV disease such as leukaemic
children, immunocompromised individuals, pregnant women,
and neonates. In the latter case, it may also be
reasonable to give IV acyclovir since ZIG is not
completely effective in preventing neonatal chickenpox,
although this has not been properly evaluated. These
patients who are given ZIG and isolated should be
isolated for at least 28 days since ZIG is known to
prolong the incubation period. If ZIG is not available,
oral acyclovir may be used instead for a period of 3
weeks. Live vaccine may also be given to children with
leukaemia in haematological remission.
Nursing should be carried out by immune staff only. A
register of staff immunity is important in view of the
susceptibility of 5-10% of the adult population (higher
in developing countries). Staff should be assessed for
past immunity to VZV, if negative, they should either
refrain from work for 21 days (US guidelines), or remain
in the same ward, or transferred to other wards with
immunocompetent patients doing work which requires less
patient contact.
With the availability of the vaccine, it may be advisable
to screen all staff in high risk wards and immunized if
found to be negative. The problem is whilst this is easy
for staff permanently based on the ward, there is also a
high turnover of non-permanent staff such as doctors,
domestics, porters etc. There is now active discussion on
the possibility of screening and administering the
vaccine to medical and nursing students. It may be
advisable to vaccinate all susceptible leukaemic children
who are in haematological remission before admission to
hospital.
It may be advisable not to admit non-immune children
during the period of the outbreak, up to 3 weeks after
the last diagnosed case of chickenpox.
2. Measles
Measles outbreaks are most deleterious in wards with
immunocompromised children or adults e.g. children with leukaemia
and BMT patients. Measles is definitely as dangerous as VZV in
that setting. Measles can cause severe disease in babies who are
undernourished, immunocompromised, or suffering from chronic
debilitating disease. Therefore babies with the above conditions,
or who had recently recovered from a severe illness should be
protected by HNIG.
Patients with uncomplicated measles do not require
admission to hospital, if admission is required, then
they should be put in respiratory isolation so that they
may be isolated from the immunosuppressed, babies, and
non-immune staff and patients. Patients with measles
diagnosed in hospital should be sent home where possible
if their condition allows.
Nursing should be carried out by immune staff, either in
cohorts or in individual rooms during the period of
infectivity (4 days preceding to 2 days following the
appearance of the rash)
HNIG should be given to all severely immunocompromised
children irrespective of their immunization status since
it has been reported that severe measles infection can
occur in those who had been immunized and had a
documented low-level antibody response. Two doses HNIG
should be given 48 hours apart, the actual dose depending
on the age of the patient. Therefore, the routine
screening of children for measles antibody before
admission is probably unjustified since there would be no
difference in the management. The same argument applies
to the screening of patients for immunity before the
administration of HNIG.
Immunocompetent children under 12 months in whom there is
a particular reason to avoid measles, such as a recent
severe illness, or a chronic debilitating disease can
also be given immunoglobulin. MMR vaccine should then be
given after an interval of at least 3 months, at around
the usual age.
The use of live-attenuated vaccine for postexposure
prophylaxis is contraindicated in immunocompromised
patients. The same protocol applies to immunocompromised
adults who come into contact with measles. However, work
from Japan suggests that vaccination of leukaemic
children in remission is safe and induces a protective
immune response.
The live vaccine can be used as postexposure prophylaxis
in immunocompetent children and adults who had not been
immunized since the incubation period of vaccine measles
is 7 days compared with 10 days for clinical measles. All
immunocompetent non-immune staff and children in contact
with the index case should be vaccinated immediately,
within 72 hours, unless a valid contraindication exists.
HNIG would be unnecessary in those cases.
Non-immune staff and patients for whom vaccination is too
late and who had been a contact with the index case must
be regarded as potentially infectious from the 7th day of
the first contact to the 14th day of the last contact.
During this time, they should be kept away from
susceptible patients.
It would be invaluable to have a record of staff immunity
to childhood illnesses kept either by the sister in
charge or by the occupational health department. Failing
a definite medical history, laboratory confirmation may
be useful although this service is not normally available
from most virology laboratories.
3. RSV
Prevention of the nosocomial spread of RSV infection is of
prime importance, as many hospitalized infants have underlying
conditions which make them susceptible to severe RSV infection. A
number of hospital outbreaks of RSV infection have been described
in infants, the immunosuppressed, and the elderly.
Affected patients identified clinically as having RSV
must be isolated immediately in single cubicle or
cohorted for the duration of virus shedding which
corresponds to the duration of the symptoms. This period
last up to 7 days in healthy children, but can be much
longer in the immunosuppressed, leukaemic children, and
adults.
Hand washing is the most important measure that can be
used in the prevention of infection since the virus is
mainly spread by close contact. Gowns and gloves should
be worn.
The routine use of gowns and masks has not be shown to be
of additional benefit. The use of gowns may be advisable
during periods of close contact in which the infant's
secretions are apt to contaminate the clothing. Since RSV
primarily infects via the eyes and nose, masks are of
limited value. Eye-nose goggles have been reported to be
of benefit.
Recognition and cleaning of objects contaminated with
infant secretions should be carried out as soon as
possible.
Infected infants should be isolated and cohorted,
preferably as far as possible to infants with underlying
chronic diseases who are susceptible to severe RSV
infection.
Nursing personnel should be assigned to care for either
infected infants or uninfected infants, but not both
simultaneously.
During epidemic periods, the numbers of patient contacts
and visitors should be limited.
Elective admission of infants with high-risk conditions
should be avoided during epidemic periods.
IV RSV immunoglobulin is now licensed by the FDA in the
US for the prevention of RSV infection in children <
24 months with bronchopulmonary dysplasia or premature
birth (<=35 weeks)
4. Influenza
Influenza is a particularly worrying problem in nursing homes
where individuals with chronic debilitating disease are
especially susceptible to severe life-threatening influenza
infection.
Those diagnosed or suspected as having influenza should
be cohorted together in one or two rooms, preferably with
negative ventilation. The door to the room should be
closed.
Hygienic practices among the staff, especially hand
washing should be emphasized. Gowns, gloves, and masks
are probably unnecessary unless there is prolonged
contact with the patient.
Staff taken ill should not report to work
Amantidine prophylaxis should to given to al the other
inmates and staff, together with the current vaccine
formulation.
Amantidine prophylaxis should be for a period of at least
2 weeks, in order to allow antibody to the vaccine to
develop.
Longer period of amantidine prophylaxis, up to 6 weeks or
for the duration of the outbreak, should be considered
for those who could not tolerate the vaccine due to
sensitivity to egg protein, or those who are severely
debilitated, since the vaccine is only 70% effective. It
is thought that prolonged indiscriminate amantidine usage
may lead to the emergence of amantidine-resistant viruses.
Rimantadine may be used in place of amantidine for
prophylaxis and the treatment of uncomplicated influenza
A infections, although it has fewer neurological symptoms,
it is probably not as effective as amantidine.
Zanamivir can be used instead of amantidine for the
prophylaxis and treatment of influenza. Being a
neuraminidase inhibitor, it has considerably fewer side
effects than amantidine and could thus be considered for
use in family contacts.
5. Rubella
Despite the vaccination program, a small proportion of women
of childbearing age is still susceptible to rubella. Therefore,
outbreaks of rubella occurring in hospital wards or outpatients
affecting susceptible pregnant women is still a possibility.
Affected patients should be sent home or isolated from
pregnant women during the infectious period (1 week prior
to the appearance of the rash to 10 days after its onset).
Babies with congenital rubella should be nursed in
standard isolation.
Nursing should be carried out by immune staff.
The immune status of staff and patients on the ward
should be determined following the contact. Records of
immunity may be available from occupational health or
from antenatal clinic records. Where the result was
negative or the records were not available, then immune
status testing should be carried out. Those who are
negative on initial testing should be retested at least 7
days later (or weekly up to 4 weeks) to see whether there
is seroconversion together with the appearance of IgM.
Non-immune staff and patients who may be infectious
should not have contact with pregnant women during the
infectious period (1 week before first contact to 2 weeks
after last contact)
In cases where the rubella infection is thought to have
occurred some weeks prior to testing or is thought to be
reinfection, avidity testing may be carried out.
6. Parvovirus
Infectious patients should be isolated and contact
prevented with individuals at risk of aplastic anaemia
and pregnant women.
IVIG given periodically can be used for the treatment of
aplastic anaemia
In theory, HNIG can also be used for post-exposure
prophylaxis although this has not been tested.
