Alshallali ICU Main ICU at Omdurman military teaching hospital Capacity of 17 beds: 8 medical, 4 surgical, 4 HDU and one isolation bed

4 ICU consultants 6 registrars of anesthesia 6 medical registrars 16 medical officers 60 staff nurse 18 aid nurses 12 dietitian One clinical pharmacist

14 th June > 24 th June 2012

ICU setting before 14 th April 2012

Before 14 April 2012 No: isolation room, receptionist area, clean utility rooms, visitors waiting room, on call rooms and staff offices Old ALshallali ICU Old ALshallali ICU Equipment storage Equipment storage

New extension 17 beds (3% of the total hospital beds) Missing facilities

Old ICU Old ICU New extension 17 beds ( 3% of the total hospital beds) New extension 17 beds ( 3% of the total hospital beds)

Isolation room (-ve) Medical ICU Medical ICU On call room Surgical ICU Surgical ICU HDU −−−∆−−− −−−−∆−−−− −−−−∆−−− ∆∆

Old ICU Receptionist Area Clean and Dirty Utility Rooms. Equipment Storage. Visitors Waiting Room Staff offices Plasmapheresis Old ICU Receptionist Area Clean and Dirty Utility Rooms. Equipment Storage. Visitors Waiting Room Staff offices Plasmapheresis

Medical ICU Medical ICU On call room Surgical ICU Surgical ICU HDU −−−−−−−− −−−−∆−−−− −−− ∆−−− Equipment Storage ∆ ∆∆

Two possible index cases

The first patient was 22 years immunocompetant male presented to the A&E with chickenpox complicated by chickenpox pneumonia 29 th of may Admitted to the A&E hospital for 24 hours The dept of communicable was aware of the case

Admitted to the ICU on 30/may/2012

Indication : respiratory distress with severe hypoxemia, with ? need for assisted ventilation.

Where in ICU ?

Medical ICU Medical ICU On call room Surgical ICU Surgical ICU HDU −−−−−−−− −−−−∆−−−− −−− ∆−−− Equipment Storage ∆ ∆∆

INFECTION CONTROL PRECAUTIONS Standard precautions Disposable gloves Surgical masks

Instructions : nursed by staff with H/O childhood chickenpox Exclusion of susceptible staff from attending the affected patient

Transported to radiology department without any infection control precautions

Patient improved on : Oxygen therapy I.V acycloviar I.V steroids Discharged on the 7 th of June

On the 8 th of June the second possible index patient was admitted

55 years old diabetic female presented with herpes zoster ophthalmicus complicated by secondary bacterial infection

Indication for ICU: swelling of the tongue and lips, and the risk of upper airway obstruction.

Medical ICU Medical ICU On call room Surgical ICU Surgical ICU HDU −−−−−−−− −−−−∆−−−− −−− ∆−−− Equipment Storage ∆ ∆∆

No infection control precautions !!!!!

Discharged on 11 th of June

3 days after discharging the second patient.

14 th of June The first secondary case, was staff nurse

15 th June : one medical officer 16 th June : one medical officer 17 th NO case reported 18 th June : one case staff nurse 19 th June : one case staff nurse

20 th : 4 staff + one patient

The infection prevention and control team was informed on the 20 th of June

21 June : 4 cases HCWs 22 June : 4 cases HCWs 23 June : 3 cases HCWs 24 June : 2 cases HCWs

Secondary cases continued till 24 th of June

Diagnosis of varicella was based on clinical appearance, namely an acute generalized maculo-papulo-vesicular rash, without other apparent cause.

StaffAge/ gender PH of similar illness Preg.Previous expo. to CK case Incub. period, days Direct contact with the patient 1 Direct contact with the patient 2 Aware of the patient ∆ N125 FNO 14YESNOYES N226 FNO Unknown16NOYES N325 FNO 20NO YES N424 FNO 20YES N523 FNO 21NO YES N624 FNO 24YESNOYES N723 FNO YES22YES N825 FNO 22YESNOYES N924 MNO----NO22NO YES N1024 FNO YES24YES Dr 126 FNO 15NOYES Dr 225 FNO YES21YESNOYES Dr 325 FNO 23NO YES

StaffAge/ gender PH of similar illness PregPrevious exposure to CK case Incub. period, days Direct contact with the patient 1 Direct contact with the patient 2 Aware of the patient ∆ A.N140 FNO Unkonwn21NO YES A,N228 MNO---YES19YESNOYES A.N331 MNO----NO18YES A.N425 FNO 23NO YES A.N526 FNO YES20YESNOYES A.N623 FNO 20NO YES D 127 FNO 21YES D 224 FNO YES22NO YES D 324 FNO 23NO YES Pt 124 MNO---NO20NO YES

Total NO. secondary cases : HCWs - One patient Age range : 24-40yr 19 females (non was pregnant) 4 males

All reported no prior history of chickenpox or VZV vaccination.

6 reported PH of contact with close relative with chickenpox. 2 were not sure.

11 of HCWs who developed chickenpox reported contact with the index patient NO1 7 reported contact with the index patient NO2. 5 HCWs reported contact with both index patients.

All infected staff reported awareness of the high infection rate of chickenpox Only 2 staff (physician) were aware that shingles is infectious

None has any education about the mode of transmission and the additional precautions required to prevent exposure to, and spread of VZV. No written guidelines

Only one patient infected with chickenpox, 20 th of June.

Medical ICU Medical ICU On call room Surgical ICU Surgical ICU HDU −−−−−−−− −−−−∆−−−− −−− ∆−−− Equipment Storage ∆ ∆∆

Possible Infection routes Direct contact form the patient 1 st or 2 nd ? Direct contact from infected staff ?

Air borne transmission from the first patient ?

Outbreak management The infection prevention and control team was informed on the 20 th of June

The staff were excluded from work until they became no longer infectious. They were given sick leave (range, 10–15 days) until the entire rash crusted and they became well.

Evacuate the ICU for 72hr. : disinfection. Using Formaldehyde (formalin )

No admission to ICU : for two weeks All patients were shifted to the Medical ICU HDU & SICU : disinfected with chlorine based disinfectant (intermediate level DI)

Visitors continued to be allowed with no precautions

Limited resources Varicella zoster antibody testing Varicella zoster vaccine Respirator masks : N95, P2 and P3 masks

-Ve pressure isolation room : 9/7/2012

Summary of the out break Total number of secondary cases were 22 unvaccinated ICU staff who developed chickenpox 15–24 days following exposure : - 9 staff nurses : 15% of total staff - 6 aid nurse : 30% - 4 medical officers : 25% of total staff - 3 dietician : 25%

A total of 276 person-days of work were lost.

Complications of chickenpox in secondary cases : -Staff ? -Patient ?

Why this has happened ?

What have we done since then to prevent recurrence of similar outbreak or outbreaks of other communicable disease ?

approach

References. Practical Guidelines for Infection Control in Health Care Facilities ©World Health Organization 2004

Immunization of Health-Care Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR, 2011; 60(RR-7).

Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008

Ideal approach NOTIFICATION REQUIREMENTS EDUCATION STAFFING AIRBORNE PRECAUTIONS CONTACT PRECAUTIONS TRANSPORTATION VISITORS VZV EXPOSURES STAFF WITH VZV INFECTION

Modes of transmission of VZV Communicability The incubation period

TRANSMISSION The most common modes of transmission of VZV are the following:

Person to person from infected respiratory secretions

Respiratory contact with airborne droplets

Direct contact with aerosols

Inhalation of aerosol from vesicular fluid of skin lesions of patient with acute Chicken or Herpes Zoster (Shinges)

COMMUNICABILITY Patients with Chickenpox or Herpes Zoster (Shingles) are infectious from 1-2 days before the onset of rash, through the first 4-5 days until the lesions have formed crusts.

Chickenpox is highly contagious. Secondary attack rates in household contacts are as high as 90%.

Staff who develop Chickenpox or Herpes Zoster (Shingles) are a source of infection to other non-immune or immunocompromised patients or staff.

INCUBATION PERIOD The incubation period is from day 10 to day 21 post exposure to either Chickenpox or Herpes Zoster (Shingles). Up to 85% of non-immune people exposed to Chickenpox become infected.

NOTIFICATION REQUIREMENTS - All staff MUST notify Infection Control of any suspected or confirmed cases of: Chickenpox Disseminated Zoster in an immunocompromised patient Herpes Zoster (Shingles).

Staff education Staff education should be a central focus of the infection control program.

Clearly written policies, guidelines, and procedures are needed in many instances for uniformity, efficiency, and effective coordination of activities.

STAFFING Only staff who have had Chickenpox (or a blood test confirming chickenpox), Herpes Zoster (Shingles) or 2 doses of the Varicella Zoster vaccine should care for patients with Chickenpox, Disseminated Zoster or Herpes Zoster (shingles).

An employee’s health programme must be in place to prevent and manage infections in hospital staff.

Varicella is highly contagious

Adults are at high risk of developing complications

Vaccination of hospital staff against varicella is recommended. Practical Guidelines for Infection Control in Health Care Facilities ©World Health Organization 2004

The CDC and many infectious diseases experts recommend the varicella vaccine for healthcare workers.varicella vaccine

Varicella For HCWs who have no serologic proof of immunity, prior vaccination, or history of varicella disease, (chickenpox) give 2 doses of varicella vaccine, 4 weeks apart. CDC. Immunization of Health-Care Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR, 2011; 60(RR-7).

Healthcare workers should be screened for varicella immunity at the time of employment.

Routine vaccination for all healthy persons aged >13 years is recommended for those without evidence of immunity. Advisory committee on immunization practice. Recommended adult immunization shedule: USA. Ann intern med 2007.

Airborne and Contact Precautions Are intended to reduce the risk of transmission of the infectious agent VZV to staff, patients and visitors who have no immunity to the disease or have not been vaccinated against the disease.

AIRBORNE PRECAUTIONS PATIENT PLACEMENT

CHICKENPOX AND DISSEMINATED HERPES ZOSTER MUST be cared for in a negatively ventilated room.

HERPES ZOSTER (SHINGLES) MUST be cared for in a single room in a ward with no immunosuppressed patients.

RESPIRATORY PROTECTION Masks are not required when entering the room as only staff that have had Chickenpox, Herpes Zoster (Shingles) or 2 doses of the Varicella Zoster vaccine and are not immunosuppressed are to care for the patient.

CONTACT PRECAUTIONS Wear gloves for contact with lesions on the patient or potentially infective material or surfaces in the patient’s environment. Change gloves after contact with infective material. Hand wash or disinfect hands immediately after removing gloves. Cover localised lesions to contain vesicle exudate.

Wear a gown whenever it is anticipating that clothing may have direct contact with infective or potentially infective lesions, material or surfaces.

TRANSPORTATION Limit patient movement outside the room to medically necessary/essential procedures. Wherever possible, use portable equipment to perform x-rays and other procedures in the room.

If procedures are medically necessary/essential the following must be implemented:

Before the patient is transferred, the ward/unit in which the patient is isolated MUST notify the accepting area that the patient has VZV infection and requires additional AIRBORNE AND CONTACT PRECAUTIONS.

During transport/transfer non-ventilated patients MUST wear a mask (N95 if possible or a surgical mask). During transport/transfer support staff MUST wear gloves and a gown if direct patient contact is anticipated.

VISITORS Staff MUST check if visitors have had chickenpox or Herpes Zoster (Shingles) before they enter the room.

What Personal Protective Equipment (PPE) visitors will be required to wear will depend on their immunity and degree of contact with the patient.

Notification Negative pressure room Vaccination of staff

Conclusion This outbreak highlights the importance and benefit of occupational health programs in developing countries and the need for rapid involvement of infection control experts to target and prevent the spread of emerging and reemerging infectious agents.

Infection control team should ensure all staff are aware of their immune status in relation to Varicella Zoster Virus, the mode of transmission and the additional precautions required to prevent exposure to, and spread of VZV.

Adherence to isolation precautions, education, pre-employment anti-VZV-IgG screening and vaccine coverage of staff could have prevented the occurrence of this outbreak.

Complications of chickenpox in secondary cases :

All recovered without complications

Thank You!

Responsibilities of the infection control team Advise staff on all aspects of infection control and maintain a safe environment for patients and staff Provide educational programmes on the prevention of hospital infection for all hospital personnel

Provide a basic manual of policies and procedures and ensure that local written guidelines based on these are in existence.

Establish systems of surveillance of hospital infection in order to identify at-risk patients and problem areas that need intervention. Methods for surveillance may include case finding by ward rounds and chart reviews, reviews of laboratory reports, and targeted prevalence or incidence surveys.

Advise management of patients requiring special isolation and control measures. Investigate and control outbreaks of infection in collaboration with medical and nursing staff.

Ensure that an antibiotic policy is in existence. Liaise with the hospital doctors and administration (managerial and nursing), community health doctors and nurses, and infection control staff in adjacent hospitals.

Provide relevant information on infection problems to management and the ICC. Perform other duties as required, e.g., kitchen inspections, pest control, waste disposal.