ADENOVIRUS CONJUNCTIVITIS SURVEILLANCE PROTOCOL FOR ONTARIO HOSPITALS Developed by the Ontario Hospital Association and the Ontario Medical Association Joint Communicable Diseases Surveillance Protocols Committee Approved by: The OHA and The OMA Board of Directors The Ministry of Health and Long-Term Care The Minister of Health and Long-Term Care Published and Distributed by the Ontario Hospital Association Published May 2002 Last Reviewed and Revised October 2017 OHA/OMA Communicable Disease Surveillance Protocols Page 1
Adenovirus Conjunctivitis Surveillance Protocol for Ontario Hospitals Published May 2002, Last Reviewed and Revised October 2017 This protocol was developed jointly by the Ontario Hospital Association and the Ontario Medical Association to meet the requirements of the Public Hospitals Act 1990, Revised Statutes of Ontario, Regulation 965. This regulation requires each hospital to have bylaws that establish and provide for the operation of a health surveillance program including a communicable disease surveillance program in respect of all persons carrying on activities in the hospital. The communicable disease program is to include the tests and examinations set out in any applicable communicable disease surveillance protocol. The regulation states that the communicable disease surveillance protocols that hospitals must adopt are those "published jointly by the Ontario Hospital Association (OHA) and the Ontario Medical Association (OMA) and approved by the Minister (of Health and Long-Term Care)." This Protocol has been reviewed since the previous version; changes have been highlighted in yellow for easy identification. Protocols are reviewed on a regular basis, every two years or as required. The protocol reflects clinical knowledge, current data and experience, and a desire to ensure maximum cost effectiveness of programs, while protecting health care workers and patients. It is intended as a minimum standard that is practical to apply in most Ontario hospital settings. It does not preclude hospitals from adopting additional strategies that may be indicated by local conditions. OHA/OMA Communicable Disease Surveillance Protocols Page 2
Members of the Joint OHA/OMA Communicable Disease Surveillance Protocols Committee Representing the Ontario Hospital Association Dr. Kathryn Suh (Co-chair) Medical Director, Infection Prevention and Control Program The Ottawa Hospital, Ottawa Suzanne Pelletier RN BScN CIC Clinical Manager, Infection Prevention and Control Health Sciences North, Sudbury Representing the Ontario Medical Association Dr. Maureen Cividino (Co-chair) IPAC Physician, Public Health Ontario Occupational Health Physician St. Joseph s Healthcare, Hamilton Katherine Patterson Health Promotion Specialist, Health Policy and Promotion Ontario Medical Association Representing the Ministry of Health and Long-Term Care Melissa Helferty, MIPH Manager, Infectious Disease Policy & Programs Disease Prevention Policy & Programs Branch Population and Public Health Division Kathleen Poole, MScN, COHN(C) CIC Infection Control Practitioner, Providence Care, Kingston Dr. Irene Armstrong Associate Medical Officer of Health Communicable Disease Control Toronto Public Health, Toronto Ontario Occupational Health Nurses Susan Ann McIntyre RN, COHN(C),CRSP Director, Corporate Health & Safety Services St. Michael's Hospital, Toronto Public Health Ontario Sandra Callery, RN MHSc CIC Director, Infection Prevention and Control Ontario Hospital Association Rachel Bredin Senior Consultant, Health and Safety EX-OFFICIO Dr. Nikhil Rajaram Medical Consultant Health Care Unit, Occupational Health and Safety Branch Ministry of Labour Amanda Martens Policy Advisor Henrietta Van hulle, BN, MHSM, COHN(c), CRSP, CDMP Executive Director, Health and Community Services Public Services Health and Safety Association OHA/OMA Communicable Disease Surveillance Protocols Page 3
Rationale For Adenovirus Conjunctivitis Surveillance Protocol Conjunctivitis ( pink eye ) may be caused by a variety of bacteria and viruses, but adenovirus is a primary cause of outbreaks of conjunctivitis in health care settings. Nosocomial outbreaks occur primarily in eye clinics/offices, but have also been described in other settings, including neonatal intensive care units 1, pediatric units, 2 and long-term care homes. 3,4 Both patients and health care workers (HCWs) may acquire and transmit adenovirus during these outbreaks. As this protocol is directed primarily to conjunctivitis due to adenovirus, differentiation from bacterial and other viral causes is important. Onset of adenovirus conjunctivitis is typically sudden with pain, and associated with watery discharge, photophobia, blurred vision, low-grade fever, malaise, and preauricular lymphadenopathy. Corneal infiltrates may interfere with vision for weeks to months; in severe cases, permanent scarring may result. Preauricular lymphadenopathy is absent in bacterial conjunctivitis and serves as a distinguishing feature. Bacterial conjunctivitis usually presents with mucopurulent discharge. The incubation period of adenovirus conjunctivitis is from 5 to 12 days, with viral shedding from the late incubation period to 14 days after onset. 5 Transmission is by direct contact with infectious eye secretions or indirect contact with contaminated surfaces, equipment/devices, or solutions. Adenovirus may survive on surfaces for prolonged periods. 6,7 Trauma, even minor, or eye manipulation will increase risk of infection. At present, there is no effective antiviral therapy available. Compliance with environmental cleaning and disinfection protocols is essential when dealing with adenovirus conjunctivitis. Details of environmental cleaning and disinfection can be found in the Provincial Infectious Disease Advisory Committee s (PIDAC) Best Practices for Environmental Cleaning for Prevention and Control of Infections in All Health Care Settings. 8 This protocol is only one component of an infection prevention and control program; HCWs must consistently adhere to Routine Practices. 9 OHA/OMA Communicable Disease Surveillance Protocols Page 4
Adenovirus Conjunctivitis Surveillance Protocol for Ontario Hospitals I. Purpose Developed by The Ontario Hospital Association and the Ontario Medical Association Published May 2002, Last Reviewed and Revised October 2017 The purpose of the protocol is to provide direction to hospitals to prevent transmission of adenovirus conjunctivitis between health care workers (HCWs) and patients. II. Applicability This protocol applies to all persons carrying on activities in the hospital, including but not limited to employees, physicians, nurses, contract workers, students, postgraduate medical trainees, researchers and volunteers. The term HCW is used in this protocol to describe these individuals. This protocol does not apply to patients or residents of the facility or to visitors. When training students or hiring contract workers, the hospital must inform the school/supplying agency that the school/agency is responsible for ensuring that their student/contractors are managed according to this protocol. This protocol is for the use of the Occupational Health Service (OHS) in hospitals. It is expected that OHS collaborate with Infection Prevention and Control and other departments, as appropriate. III. Pre-placement HCWs should be advised to report symptoms of conjunctivitis to OHS. IV. Continuing Surveillance There is no need for routine screening of any persons carrying on activities in the hospital. V. Exposure Adenovirus conjunctivitis is transmitted by direct or indirect contact of ocular mucous membranes with infectious eye secretions, via contaminated hands or contaminated surfaces, equipment/devices,or solutions. OHA/OMA Communicable Disease Surveillance Protocols Page 5
Work Restrictions There are no work restrictions for exposed, asymptomatic HCWs. VI. Acute Disease Infected HCWs should be instructed to: avoid touching eyes. clean hands after contact with eye secretions. not share articles that might come in contact with eyes, e.g. wash cloths, towels, makeup, eye drops, pillows, glasses. clean and disinfect potentially contaminated surfaces. Work Restrictions HCWs with adenovirus conjunctivitis should not provide patient care from the time of onset of conjunctivitis in an eye for a period of 14 days after onset. If the second eye becomes infected, HCWs should not provide patient care for a period of 14 days after onset of the conjunctivitis in the second eye. HCWs with purulent conjunctivitis caused by other microorganisms should be restricted from patient care for the duration of symptoms and instructed on proper hand hygiene. Infected HCWs may continue to provide non-patient care duties, provided they adhere to established standards for hand hygiene. 10 All HCWs must be cleared through OHS before returning to work. VII. Reporting Adenovirus conjunctivitis is not reportable to the local Medical Officer of Health for the purposes of the Health Protection and Promotion Act (HPPA). In accordance with the Occupational Health and Safety Act and its regulations, an employer must provide written notice within 4 days of being advised that a worker has an occupational illness, including an occupationally-acquired infection, and/or a Workplace Safety and Insurance Board (WSIB) claim has been filed by or on behalf of the worker with respect to an occupational illness, to the: Ministry of Labour, Joint Health and Safety Committee (or health and safety representative), and trade union, if any. OHA/OMA Communicable Disease Surveillance Protocols Page 6
Occupationally acquired infections are reportable to the WSIB. OHA/OMA Communicable Disease Surveillance Protocols Page 7
References 1. Calkavur S, Olukman O, Ozturk AT, et al. Epidemic adenoviral keratoconjunctivitis possibly related to ophthalmological procedures in a neonatal intensive care unit: lessons from an outbreak. Ophthal Epidemiol 2012;19:371-9. 2. Hoyle E, Erez J, Kirk-Granger H, et al. An adenovirus 4 outbreak amongst staff in a pediatric ward manifesting as keratoconjunctivitis a possible failure of contact and aerosol infection control. Am J Infect Control 2016; 44:602-604. 3. James L, Vernon MO, Jones RC, et al. Outbreak of human adenovirus type 3 infection in a pediatric long-term care facility Illinois, 2005. Clin Infect Dis 2007;45:416-20. 4. Dominguez-Berjon MF, Henando-Briongos P, Miguel-Arroyo PJ, et al. Adenovirus transmission in a nursing home: analysis of an epidemic outbreak of keratoconjunctivitis. Gerontology 2007;53:250-4. 5. Heymann D. Control of Communicable Diseases Manual, 20th ed., American Public Health Association, 2015, pp. 125-128. 6. Centers for Disease Control and Prevention. Adenovirus-associated epidemic keratoconjunctivitis outbreaks - four states, 2008 2010. MMWR Morb Mort Wkly Rep 2013;62:637-41. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6232al.htm 7. Kramer A, Schwebke I, Kampf G. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infect Dis 2006;6:130. doi:10.1186/1471-2334-6-130. 8. Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committee. Best Practices for Environmental Cleaning for Prevention and Control of Infections in All Health Care Settings. 2nd Revision. Toronto, ON: Queen s Printer for Ontario; 2012. https://www.publichealthontario.ca/en/browsebytopic/infectiousdiseases/pidac/ Pages/PIDAC_Documents.aspx 9. Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committee. Routine Practices and Additional Precautions in All Health Care Settings. 3rd Edition. Toronto, ON: Queen s Printer for Ontario; 2012. https://www.publichealthontario.ca/en/browsebytopic/infectiousdiseases/pidac/ Pages/PIDAC_Documents.aspx OHA/OMA Communicable Disease Surveillance Protocols Page 8
10. Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committee. Best Practices for Hand Hygiene in All Health Care Settings. 4th Edition. Toronto, ON: Queen s Printer for Ontario; 2014. https://www.publichealthontario.ca/en/browsebytopic/infectiousdiseases/pidac/ Pages/PIDAC_Documents.aspx 11. Pihos AM, Epidemic keratoconjunctivitis: a review of current concepts in management. J Optom2013:6, 60-74. 12. Public Health Ontario. Recommendations for Conjunctivitis Prevention in Ophthalmology/Optometry Clinical Office Practice. 2016. http://www.publichealthontario.ca/en/erepository/recommendations_conjunctiviti s_prevention.pdf OHA/OMA Communicable Disease Surveillance Protocols Page 9