POLICY FOR THE MANAGEMENT OF CHICKENPOX/SHINGLES DOCUMENT CONTROL: Version: 4 Ratified by: Clinical Effectiveness Committee Date ratified: 9 August 2012 Name of originator/author: Infection Prevention and Control Nurse Specialist Name of responsible Infection Prevention and Control Committee committee/individual: Date issued: 17 August 2012 Review date: August 2015 Target Audience The policy applies to all staff responsible for caring for patients with chickenpox / shingles
CONTENTS SECTION PAGE NO 1. INTRODUCTION 3 2. PURPOSE 3 3. SCOPE 3 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 4 4.1 Board of Directors 4 4.2 Director of Infection Prevention and Control (DIPC) (Deputy Chief 4 Executive/Director of Nursing) 4.3 Infection Prevention and Control Committee 4 4.4 Infection Control Doctors/Consultant Microbiologists 5 4.5 Infection Prevention and Control (IPC) Nurse Specialists 5 4.6 Consultant Medical Staff 5 4.7 Modern Matrons/Service Managers 5 4.8 Staff 6 5. PROCEDURE 6 5.1 Transmission of the Virus 6 5.2 Complications and High Risk Groups (Patients & Staff) 6 5.3 Confirmation of Chickenpox or Shingles 7 5.4 Treatment 7 5.5 Post Exposure Management following Significant Exposure 7 5.6 Management of a Patient with Chickenpox in Clinical Areas 8 5.7 Management of Staff Member with Chickenpox 8 5.8 Risk Assessments and Management of at risk individuals following significant exposure to Chickenpox or Shingles 8 6. TRAINING IMPLICATIONS 10 7 MONITORING ARRANGEMENTS 10 8. EQUALITY IMPACT ASSESSMENT SCREENING 10 8.1 Privacy, Dignity and Respect 10 9. LINKS TO OTHER TRUST PROCEDURAL DOCUMENTS 11 10. REFERENCES 11 11. APPENDICES 12 Page 2 of 14
1. INTRODUCTION Chickenpox is also known as Varicella. It is an acute, highly transmissible infectious disease caused by the Varicella zoster virus (VZV). Illness usually starts with 1-2 days of fever and malaise followed by a very itchy rash that looks like small fluid filled blisters (vesicles) on the face and scalp, spreading to the trunk and the abdomen and eventually to the limbs. Vesicles can be minimal in some cases and are often missed. Complications are more common in neonates and adults than in infants and school children. Following primary infection the virus stays in the body in a latent state in the dorsal root ganglia, reactivation of the virus causes Shingles (Herpes Zoster). People with shingles are also contagious and contact with the virus from the shingles lesions can result in chicken pox infection in non-immune people e.g. people who have never had chicken pox. It is not possible to develop shingles from exposure to a person with chickenpox. The first signs of shingles are pain at the affected nerve site usually on one side of the body especially the chest followed by a rash of fluid filled blisters which last for 7 days. Reactivation of the virus is usually associated with immunosuppressant therapy, old age or HIV infection. Chickenpox is not a notifiable disease in England and Wales. Laboratory confirmation is rarely sought and the diagnosis is usually made on clinical grounds. Locally clinical teams must report all suspected and confirmed cases to the infection prevention and control team. Laboratory confirmation is rarely sought and the diagnosis is usually made on clinical grounds. 2. PURPOSE The policy content is based on sound infection prevention and control principles and national guidance. The purpose of this policy is to reduce and minimise the risk of healthcare associated infections and to ensure that patients with suspected or confirmed infection will be managed according to best practice, and that the risks of others acquiring infection are assessed and managed effectively. 3. SCOPE The policy applies to all staff providing care to all patients under the care of the Trust, whether in a direct or indirect patient care role. Adherence to this policy is the responsibility of all staff employed by the Trust, including agency, locum and bank staff contracted by the Trust. This policy should be read in conjunction with: Hand Hygiene Policy Standard Infection Prevention and Control Precautions Policy Isolation Policy Laundry Policy Decontamination Policy Page 3 of 14
Waste Management Policy for the management of sharps/inoculation injuries and other blood or body fluid exposure incidents policies This policy should be considered and included in services that are contracted and commissioned by the Trust. 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 4.1 Board of Directors The Board of Directors are responsible for having policies and procedures in place to support best practice, effective management, service delivery, management of associated risks and meet national and local legislation and/or requirements. 4.2 Director of Infection Prevention and Control (DIPC) (Deputy Chief Executive/Director of Nursing) The DIPC: Reports directly to the Chief Executive and the Board Reports identified cases of infections/alert organisms and conditions, including outbreaks of infection Reports all incidents requiring root cause analysis investigation Reports directly to the Chief Executive and assures the board of directors on the organisations performance in relation to HCAIs. Acts on legislation, national policies and guidance ensuring effective policies are in place and audited in relation to infections/alert organisms & conditions 4.3 Infection Prevention and Control Committee The main duties of the Infection Prevention and Control Committee are: To oversee compliance with national standards/targets in relation to the prevention and control of healthcare associated infections (HCAI), including the Health and Social Care Act 2008. NHS Litigation Authority (NHSLA), and the Care Quality Commission. To oversee key infection prevention & control issues in regards to Policy development and review Audit Education & training Communication with staff patients and the public Monitor infection control incidents Review root cause analysis reports, identify lessons learnt, develop and monitor action plans To ensure that robust plans for the management of outbreaks of infection are in place and to monitor their effectiveness. Page 4 of 14
To agree the annual infection prevention and control report and work programme prior to its submission to Clinical Governance Committee. To inform the Clinical Governance Committee of clinical risk issues relating to the Trust. To monitor compliance for infection prevention & control training. To oversee the Trust s compliance with Essential Standards of Quality and Safety (Outcome 8). To horizon scan for new guidance and documents relating to infection prevention & control To oversee the Trust s infection prevention & control work programme. 4.4 Infection Control Doctors/Consultant Microbiologists These staff are medical microbiologists hosted within the local provider acute Trust whose main duties are to: Be available for 24 hour access, arrangements made through local service level agreements Provide expert microbiology advice for the management and treatment of microorganisms including outbreaks of infection. Advise on antibiotic policy/prescribing and challenge inappropriate practices 4.5 Infection Prevention and Control (IPC) Nurse Specialists These staff are employed within RDaSH. Their role is: To provide expert professional advice and education on the prevention and control of infection to other professionals, multi-disciplinary groups, patients and carers. To lead in the investigation of identified cases of infection/alert organisms & conditions. To advise on control measures, delegating responsibility to Trust staff as appropriate. To give advice on complex issues relating to infection prevention and control and report findings to the DIPC. 4.6 Consultant Medical Staff The Consultant Medical staff are responsible for the supervision of any Junior Medical staff assigned to work with them, and as part of this supervision they should be satisfied that the Junior staff member: Reads and understands the Policy Adhere to the policy Are aware of and comply with antibiotic prescribing guidance 4.7 Modern Matrons/Service Managers All Service Managers and Modern Matrons are responsible for: Membership at the Infection Prevention and Control Committee. Page 5 of 14
Ongoing compliance with this policy within their clinical areas and reporting non compliance to the DIPC via the IP&CT Reporting all matters relating to infection prevention and control to the Deputy Director of Nursing. Facilitating feedback of information related to surveillance data and identified cases of infection/alert organisms & conditions Report confirmed cases of infection/alert organisms & conditions through the Trust s reporting system 4.8 Staff All healthcare workers who are involved with the care of a patient within the inpatient services and community must: Comply with this policy and guidance on all identified cases of infection/alert organisms & conditions. It is the responsibility of each individual member of staff to Adhere to the requirements set out within this policy All healthcare workers are expected to be immune to chickenpox; therefore, those who have no history or are unsure of their chickenpox status should seek advice from the Occupational Health Department. Pregnant healthcare workers who are suspected or confirmed as having been exposed to someone with chickenpox or shingles must seek advice from the Occupational Health Department. 5. 5.1 PROCEDURE Transmission of the virus Chickenpox infection is spread directly from person to person via respiratory secretions, airborne droplet infection or through direct contact with vesicles or contact with infected articles, bedding and clothing. Chickenpox is highly contagious and can infect up to 90% of the people who come into contact with the disease. All staff must observe the Trust hand hygiene and standard infection control policies at all times. The chickenpox virus is plentiful in the nasopharynx in the first few days of infection and in the vesicles until they dry up. The infectious period starts from 1-2 days before the rash appears and lasts until all of the vesicles are dry and crusted (HPA, 2006). All cases must be isolated (See Isolation Policy) and an assessment of the risks to other patient, staff and visitor contacts must be carried out. Shingles cases are infectious until all of the lesions are crusted. There is no respiratory Involvement. Isolation is recommended especially if the blisters cannot be covered. Inform infection control for all cases and if in doubt isolate until all of the risks have been eliminated. 5.2 Complications and High Risk Groups (patients and staff) Chickenpox is a serious disease in immunocompromised people and the infectious period can be prolonged in these cases. The disease is more serious in infants within the first 4 weeks of life and adults, especially pregnant women and smokers who are at Page 6 of 14
risk of Varicella pneumonia, secondary bacterial infections and encephalitis. Pregnant women are at greatest risk in the second or early in the third trimester. Chickenpox also carries great risks of congenital Varicella syndrome for the fetus. Risks to the fetus and to neonates from maternal chickenpox are related to the time of infection in the mother (Enders et al 2000). Infection in the later stages of pregnancy can cause premature delivery or neonatal chickenpox infection. This is especially serious if the mother becomes infected 7 days before the birth. Other clinical conditions that increases the risk of severe illness: Patients receiving or who have had chemotherapy or radiotherapy in the past 6 months Any person on immunosuppressive treatment or bone or organ transplant in the past 6 months Steroid therapy Symptomatic HIV infection 5.3 Confirmation of chickenpox or shingles Whenever exposure to VZV is suspected, the diagnosis of chickenpox or shingles must be confirmed by a medical practitioner or a dermatologist, if index case is within the hospital (staff or in-patient). The diagnosis of these conditions is clinical and they should be differentiated from other types of rash. 5.4 Treatment There is no specific treatment for chickenpox. It is a viral infection that will not respond to antibiotics. Treatment is usually based on reducing the symptoms such as fever and itchiness. Shingles can be treated with oral antiviral drugs such as acyclovir. People at high risk of developing serious complications can be given immunoglobulin and/ or acyclovir to prevent severe complications. If Varicella Zoster Immunoglobulin (VZIG) is required, the clinician who is responsible for the care of the patient should seek advice from the Consultant Microbiologist. The Immunoglobulin must be given within 72 hours of exposure but can be effective up to 10 days following exposure. Post exposure acyclovir started 7-9 days following exposure and continued for 2 weeks has also been shown to be effective. 5.5 Post Exposure management following significant exposure The aim of post exposure management is to protect individuals at high risk of suffering from severe illness and is normally indicated for exposures between 2 days before, to 5 days after the onset of the rash. Varicella Zoster Immunoglobulin (VZIG) prophylaxis is recommended for people who have had a significant exposure. A significant exposure means: Face to face contact with a case of chickenpox In the same ward/clinic room or living room as a case of chickenpox for 15 minutes Household contacts Contact with disseminated shingles and exposed lesions e.g. ophthalmic shingles Page 7 of 14
Contact with immunosuppressed patients with shingles on any part of the body in whom viral shedding may be greater The risks of acquiring infection from a case with non exposed shingles (e.g. on the trunk) may be remote. 5.6 Management of a patient with chickenpox in clinical areas On identification of a patient with chickenpox in a clinical area clinical staff must ensure prompt communications to the Infection Prevention and Control team and Ward Managers. Isolate the patient in a single room with the door closed Identify when the vesicles appeared as the patient will have been infectious for at least 48 hours prior to this, with potential risks to others Ensure that vaccinated staff members (including domestics) with a definite history of vaccination, or history of previous chickenpox infection or shingles are allocated to the care of the index case Ensure that visitors entering the room have had chickenpox or vaccination. Place an isolation card on the door Gloves & aprons must be worn for direct patient contact, removed, bagged in the room and hands washed prior to exit (Pratt et al 2007) Used tissues should be disposed of as clinical waste Linen should be placed in a red alginate bag in the room prior to placing in the appropriate green wheelie bin Ensure that the domestic staff are aware of contact and isolation precautions and use correct colour coded cleaning equipment Provide dedicated toilet and equipment for the duration of isolation Use single use equipment whenever possible Ensure that a terminal clean is carried out at the end of the isolation period If the patient requires admission to a general hospital for management, the receiving unit and ambulance staff must be informed in advance of the infectious condition prior to transfer Inform infection prevention and control team and make a list of all staff and patient contacts to ensure that all risks are assessed and followed up 5.7 Management of staff member with chickenpox The staff member must inform his/her manager and occupational health who will notify the infection prevention and control team. Staff must stay at home until all of the lesions have crusted Confirm when the vesicles first appeared as the person will have been infectious for at least 48 hours prior The manager should make a list of all staff in contact with the index case which will be sent to occupational health Page 8 of 14
A list of patients who have been in contact with the index case should be sent to the infection prevention and control team. Health Care Workers (HCWs) diagnosed with localised herpes zoster (shingles) on a part of the body that can be covered with a dressing or clothing should be allowed to work if they are clinically well. If they work with high risk groups including neonates or staff or patients who are immunocompromised or pregnant an individual risk assessment must be taken by the manager in conjunction with Occupational Health Department to determine appropriate action. HCWs with localised shingles that cannot be covered or who are immunocompromised, and HCWs with disseminated lesions should be excluded from the work place until there are no new lesions and all lesions have crusted over (Royal College of Physicians 2010) 5.8 Risk Assessments and Management of at risk individuals following significant exposure to Chickenpox or Shingles Patient Contacts Clarify if the patient falls into the higher risk category Establish if the patient has had a significant exposure Complete the patient contact list (Appendix 1.) Establish if the patient has a positive history of chickenpox or has had a previous antibody test. Non immune in-patients who are not immunocompromised should be isolated in a single room until immunity is confirmed following an antibody test. If antibody tests cannot be confirmed isolate from day 7-21 after the contact (in case they are incubating the virus with potential for further spread), or until discharged from hospital. On discharge they should be advised to contact their GP if they develop a rash (Hawker et al 2001). Non-immune in-patients who are immunocompromised should be isolated in a side room from day 7 following the contact to day 28 or until discharged. Advice as above should be given. Varicella Zoster Immunoglobulin (VZIG) or post exposure acyclovir should be given to non-immune pregnant contacts and immunocompromised people following significant exposure on advice of Consultant Microbiologist Staff Contacts All staff should be aware of their immune status Staff who develop a rash that they suspect to be chicken pox or shingles must refrain from work and seek advice from their manager. If non-immune staff are aware that they have had significant exposure to chickenpox outside of the Trust, they should contact occupational health prior to coming to work Staff who have been exposed to chickenpox or shingles from a patient/staff/visitor index case while on duty should notify the infection prevention and control team during working hours or the next morning and stay at home until cleared by occupational health The manager where the exposure occurred is responsible for completing the staff contact list and the immune status if known (Appendix 2) The list should be sent without delay to occupational health. Page 9 of 14
Non-immune staff that have had a significant exposure may need to be restricted from duties during the infectious phase of the incubation period (7-21 days after exposure). Non immune pregnant staff will be advised by occupational health about potential risks on an individual basis Visitor Contacts Establish if a visitor has had a significant exposure Establish if the visitor is non-immune (never had chickenpox or Immunisation) Non-immune pregnant women should contact their G.P. Visitors should be advised about the risks of visiting clinical areas and informed that they should not visit if they develop flu-like symptoms and a rash. 6. TRAINING IMPLICATIONS There are no specific training needs in relation to this policy, but all staff will need to be aware of its contents. Staff will be made aware through: Line manager Team Brief Team meetings One to one meetings/supervision Trust Policy web site 7. MONITORING ARRANGEMENTS Area for Monitoring How Who by Reported to Frequency Non compliance to policy Monitoring of IR1s Managers/ matrons. IP&C Nurse Specialists Infection prevention and control committee Bi Monthly 8. EQUALITY IMPACT ASSESSMENT SCREENING The completed Equality Impact Assessment for this Policy has been published on the Equality and Diversity webpage of the RDaSH website click here 8.1 Privacy, Dignity and Respect The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi s review of the NHS, identifies the need to organise care around the individual, not just clinically but in terms of dignity and respect. Indicate how this will be met No issues have been identified in relation to this policy. Page 10 of 14
As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided). 9. LINKS TO OTHER TRUST PROCEDURAL DOCUMENTS Hand Hygiene Policy Standard Infection Prevention and Control Precautions Policy Policy for the Management of Sharps/Inoculation Injuries and other Blood or Body fluid Exposure Incidents Policy Trust Cleaning Policy Decontamination Policy Infection Control Policy for the Prevention and Management of Infections Policy for the Management of Blood and Body Fluid Spillages. Aseptic Technique and Aseptic Non-Touch Technique 10. REFERENCES Enders, G. and Miller, E. (2000) Varicella and herpes zoster in pregnancy and the newborn. In: Arvin, A.M. & Gershon, A.A. (eds.) Varicella-Zoster Virus. Virology and Clinical Management. Cambridge: Cambridge University Press Health protection agency: www.hpa.org.uk/infections/topics_az/chickenpox/gen-info.htm Accessed 29.11.07 Heymann D.L. (2008) Control of Communicable Diseases Manual. 19 th ed. Washinton DC. APHA Press. Kumagai, T. (1999) Varicella-Zoster virus-specific cellular immunity in subjects given acyclovir after household chickenpox exposure. The Journal of Infectious Diseases 180; 834-7. Morgan-Capner, P. & Crowcroft, N. (2000) Guidance on the Management of, and exposure to, rash illness in pregnancy. Report of the PHLS Working Group National Institute for Health and Clinical Excellence (2012) Prevention and control of healthcare associated infections in primary and community care. NICE clinical guideline 139 Pratt RJ, Pellowe CM, Wilson JA, Loveday H P, Harper PJ, Jones SRLJ, McDougall C, Wilcox MH (2007). epic 2: National Evidence-based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection 2007; 65 (Supplement):S1- S31. Page 11 of 14
Royal College of Physicians (2010) Varicella Zoster Virus: Occupational aspects of management a national guideline. Salisbury, D, Ramsay M and Noakes K. (2006) Varicella in: Immunisation against infectious disease, Dept. of Health, 3rd ed. TSO (The Stationery Office) 421-42. Page 12 of 14
Appendix 1 Varicella zoster virus (VZV) Patient Contact List Clinical Area: Date: Name NHS Number Date of contact with index case Has the patient had chickenpox or vaccine against chickenpox? Yes/No/Don t know Immunocompromised Yes/No (Details) Page 13 of 14
Appendix 2 Varicella zoster virus (VZV) Staff Contact List Clinical Area: Date: Name NHS Number Date of contact with index case Has the patient had chickenpox or vaccine against chickenpox? Yes/No/Don t know Immunocompromised Yes/No (Details) Page 14 of 14