HEALTH PROTECTION TEAM DIRECTORATE OF PUBLIC HEALTH AND PLANNING EXCLUSION POLICIES FOR INFECTIOUS DISEASES September 2010
Issued by the Health Protection Team NHS Grampian Summerfield House 2 Eday Road Aberdeen AB15 6RE 01224 558520 Fax 01224 558566 Email: [email protected] Website:
CASE MANAGEMENT REPORTING AND INVESTIGATION OF ILLNESS NHS Grampian’s Health Protection Team (HPT) is responsible for the surveillance, investigation and control of communicable disease and non-infectious environmental hazards in Grampian. An outbreak is defined either as two or more linked cases of the same illness or when the observed number of cases exceeds the number expected. All suspected outbreaks should be reported to the HPT by telephone on 01224 558520. Infectious diseases are reported to the Health Protection Team from a variety of sources including;
• Educational establishments including nursery, primary and secondary schools
• Health and social care colleagues, care homes, day care centres, prisons, community and recreational facilities
There are specific diseases/organisms that require notification to the Health Protection Team under The Public Health etc (Scotland) Act 2008 (further information available at http://www.hps.scot.nhs.uk/publichealthact/index.aspx ) Diseases notified by the diagnosing doctor are marked with (1). Organisms notified by the diagnostic laboratory are marked (2) FURTHER ADVICE AND INFORMATION including NHS Grampian’s infection control document entitled “SAFE WORKING PRACTICE INFECTION CONTROL IN THE COMMUNITY” and various leaflets are available from the team:
• By telephone on Aberdeen 01224 558520
http://www.nhsgrampian.org/nhsgrampian/gra_display_simple_index.jsp?pContentID=5690&p_applic=CCC&p_service=Content.show&
BASIC PRINCIPLES ROUTINE CONTROL MEASURES TO MINIMISE THE SPREAD OF INFECTIONS INCLUDE:
• Any individual who is unwell and has symptoms of an acute illness should NOT attend nursery, school, work etc
• Thorough hand washing with liquid soap followed by drying with paper towels
• Maintaining a clean environment including dealing with spillages of body fluids immediately
• Appropriate use of protective clothing e.g. disposable gloves and aprons
• Appropriate management of soiled linen, sharps and waste
• Covering broken skin and prompt first aid for injury or exposure to body fluids
• Appropriate vaccination and/or exclusion of ill individuals
ENTERIC INFECTIONS
Cases and contacts with enteric (diarrhoea & vomiting) symptoms should follow standard management i.e. cases and contacts can return to work or school 48 hours after first normal stool except where specific exclusions are stated for high-risk groups A, B, C and D (see page 3). Remember - if there is any doubt about hygiene, exclude as Group A. GROUPS THAT POSE AN INCREASED RISK OF SPREADING INFECTION Any person of doubtful hygiene or with unsatisfactory toilet, hand washing or hand drying facilities at home, work or school
Children who attend pre-school groups or nursery People whose work involves preparing or serving unwrapped foods not subjected to further heating/cooking Health or Social Care staff who have direct contact with highly susceptible patients or persons in whom a gastrointestinal infection would have particularly serious consequences PRECAUTIONS TO MINIMISE THE SPREAD OF GASTROINTESTINAL INFECTION (ENTERIC PRECATIONS) All the routine control measures listed above in Basic Principles - routine control measures to minimise the spread of infections include:
• Stay home until 48 hours after symptoms have settled
• Do not swim in public swimming pools, visit hospitals or care homes until 48 hours after gastrointestinal symptoms have
DEFINITIONS
Asymptomatic
No symptoms of illness displayed, with or without confirmation of infecting organism
Individual with symptoms and/or a laboratory confirmed specimen
An individual linked to a case that has been exposed to the infectious organism e.g. household member.
Symptomatic contacts are often managed as cases until proven negative
Diarrhoea is defined as three or more loose stools (stools that conform to the shape of the container) in 24
Diarrhoea
hours or, for those who normally have loose stools, an altered bowl pattern for that person.
Organisms found in infected faeces are swallowed by people. The organisms may be on/in contaminated
Faecal – oral transmission
surfaces, food or water. For example organisms can be found on toilet flush handles or in inadequately
treated private water supplies. The infected faeces may be human or animal.
Foodborne disease
Any disease of an infectious or toxic nature caused by or thought to be caused by the consumption of food
or water. Food comprises all foodstuffs and drinks.
Incubation period
The interval between exposure to an infection and the appearance of the first symptoms
Standard management
Exclude from work, school, nursery etc until 48 hours after first normal stool.
Symptomatic
Symptoms of illness displayed, with or without confirmation of infecting organism
Vomiting
Sudden onset of vomiting where there is no alternative non-infective cause
CLINICAL INCUBATION COMMON SOURCES & MEANS MANAGEMENT EXCLUSION FEATURES OF SPREAD AEROMONAS Cases – Enteric precautions Cases – 48 hours after first Contacts - None Contacts - None Discuss with HPT Discuss with HPT
2 days to 1 year, Faecal oral spread via water, raw or
DYSENTERY Cases– Enteric precautions Cases – Exclude groups C&D (Entamoeba Contacts - Screen contacts histolytica)
Contacts – Discuss with HPT BACILLUS CEREUS Two clinical Cases – Enteric precautions Cases - 48 hours after first Contacts - None Contacts - None CAMPYLOBACTER Cases – Enteric precautions Cases – 48 hours after first Contacts - None Contacts - None CLINICAL INCUBATION COMMON SOURCES & MEANS MANAGEMENT EXCLUSION FEATURES OF SPREAD Discuss with HPT Discuss with HPT Cases –Normally hospitalised Cases – Groups ABCD - 2 Contacts – Clinical surveillance
for those not in Groups ABCD. Contacts – Discuss with HPT OTHER CHOLERA Discuss with HPT Discuss with HPT ORGANISMS (non O1 or O139) Cases– Enteric precautions Cases- 48 hours after first Contacts - None
Contacts - None Urgently discuss with HPT CLOSTRIDIUM BOTULINUM Cases - None Cases-hospitalised Contacts - None Contacts - None CLINICAL INCUBATION COMMON SOURCES & MEANS MANAGEMENT EXCLUSION FEATURES OF SPREAD CLOSTRIDIUM Cases Cases -48 hours after first DIFFICILE Contacts - None Contacts - None
which may result in symptoms. Symptoms include diarrhoea, abdominal pain, fever
CLOSTRIDIUM Cases - enteric precautions Cases - 48 hours after first PERFRINGENS Contacts - None Contacts - None CRYPTOSPORIDIUM Cases - enteric precautions Cases- 48 hours after first Contacts - None
after first normal stool Contacts - None CLINICAL INCUBATION COMMON SOURCES & MEANS MANAGEMENT EXCLUSION FEATURES OF SPREAD Exclusion based on risk DYSENTERY Cases –enteric precautions assessment - discuss all cases/contacts with HPT Shigella sonnei Symptomatic contacts - As Cases– Groups AB - 2
48 hours after first normal stool for those not in Groups AB. Symptomatic contacts – As cases AsymptomaticContacts– None Exclusion based on risk DYSENTERY Cases -enteric precautions assessment so discuss all cases and contacts with HPT Sh.boydii Symptomatic Contacts – as Sh.dysenteriae cases Cases- Groups ABCD - 2 Sh. flexneri
Symptomatic contacts - As cases. Asymptomatic contacts– screenand exclude groups ABCD until 2 consecutive negative faecal samples at least 24 hours apart CLINICAL INCUBATION COMMON SOURCES & MEANS MANAGEMENT EXCLUSION FEATURES OF SPREAD ESCHERICHIA Cases - enteric precautions Cases - 48 hours after first COLI ENTERITIS Contacts – None (Including Contacts – None Enterotoxigenic and Enteropathogenic)
CLINICAL INCUBATION COMMON SOURCES & MEANS MANAGEMENT EXCLUSION FEATURES OF SPREAD Exclusion based on risk assessment so discuss all E COLI O157 VTEC Management is based on risk cases and contacts with HPT assessment by Health Board appointed Competent Person Cases therefore discuss all cases and contacts with HPT Cases– Enteric precautions Symptomatic contacts - Test all close contacts i.e. those 48 hours after first normal stool Symptomatic Contacts - Asymptomatic Contacts - Note: If case is in group A or B groups A or B will not start until Cases in Group A&B should not swim in public swimming pools until exclusion lifted. All other cases 48 hours symptom free.CLINICAL INCUBATION COMMON SOURCES & MEANS MANAGEMENT EXCLUSION FEATURES OF SPREAD GIARDIASIS Cases - Enteric precautions Cases - 48 hours after first Contacts - None Contacts - None Management and exclusion HEPATITIS A Cases – enteric precautions. based on risk assessment so discuss all cases and contacts with HPT Cases - exclude until 7 days Or 7 days after onset of Contacts - HPT will advise on Contacts - none BUT it Asymptomatic contacts that Symptomatic Contacts - Asymptomatic - None Through sexual intercourse CLINICAL INCUBATION COMMON SOURCES & MEANS MANAGEMENT EXCLUSION FEATURES OF SPREAD HEPATITIS E Cases- enteric precautions Exclusion based on risk assessment so discuss all Notifiable (2) Contacts – none cases and contacts with HPT Cases- risk assess Contacts - none Note: NE&N central London HPU 2006 Exclusion for all cases and those ABCD up to 14 days after first symptoms. Advise to avoid contact with pregnant women. NOROVIRUS Cases - enteric precautions Cases - 48 hours after first Contacts - None Contacts - none
• Eating food contaminated by others • Swallowing suspended viral particles dispersed after vomiting
Consumption of shellfish harvested from contaminated water
CLINICAL INCUBATION COMMON SOURCES & MEANS MANAGEMENT EXCLUSION FEATURES OF SPREAD SALMONELLA Cases- enteric precautions Cases-48 hours after first INFECTION Cases in A&B require Contacts- None Symptomaticcontacts- 48
hours after first normal stool Asymptomaticcontacts – None Discuss with HPT Discuss with HPT SALMONELLA TYPHI & Cases - Enteric precautions. Cases - Groups ABCD until PARATYPHI Contacts- Test all household
Each sample obtained 1 week apart, commencing 3 weeks after completion of treatment Contacts - Exclude Groups ABCD until 2 negative stools at 48 hour apart. Start sampling after case has commenced treatment. CLINICAL INCUBATION COMMON SOURCES & MEANS MANAGEMENT EXCLUSION FEATURES OF SPREAD STAPHYLOCOC- Cases - enteric precautions Cases 48 hours after first CUS AUREUS Contacts - None Contacts - Group C exclude
food handlers with septic lesions on exposed skin until successfully treated.
YERSINIA Cases- enteric precautions Cases - 48 hours after first Contacts - None Contacts - None CLINICAL FEATURES INCUBATION COMMON SOURCES MANAGEMENT EXCLUSION & MEANS OF SPREAD CHICKENPOX Discuss with HPT Community Settings Cases Cases Contacts Contacts - None Healthcare settings Healthcare Settings CLINICAL FEATURES INCUBATION COMMON SOURCES MANAGEMENT EXCLUSION & MEANS OF SPREAD SHINGLES Cases Cases
clusters of clear vesicles (the virus that
Contacts Contacts None.
prior to rash and it may Infectious Disease
Healthcare Settings
disease: antibody negative pregnant women, neonates and immunocompromised until lesions have crusted over. Note: Susceptible contacts (including staff) are potentially infectious 8 -21 days after contact (8 –28 days if VZIG has been given) and should be excluded from contact with those at increased risk during this period.
CLINICAL FEATURES INCUBATION COMMON SOURCES MANAGEMENT EXCLUSION & MEANS OF SPREAD COLD SORES Cases Cases Contacts - None Contacts - None CONJUNCTIVITIS Cases Cases Contacts - Basic principles Contacts - None
clothing and other items. Spread, high during acute stage of infection
DIPHTHERIA Discuss cases and contacts Discuss cases and contacts Cases Contacts CLINICAL FEATURES INCUBATION COMMON SOURCES MANAGEMENT EXCLUSION & MEANS OF SPREAD FIFTH DISEASE Discuss with HPT Cases - None Cases Contacts Contacts - None GLANDULAR Cases - Basic principles Cases - None
etc can cause infection Contacts - None Contacts - None BLOOD BORNE Cases - None VIRUS (HIV, HEPATITIS B & C Contacts - None
Blood to blood i.e. from a sharp injury.
CLINICAL FEATURES INCUBATION COMMON SOURCES MANAGEMENT EXCLUSION & MEANS OF SPREAD HAND, FOOT AND Cases - Basic principles Cases - None. MOUTH DISEASE Contacts - None Contacts - None
Not to be confused with Foot & Mouth Disease.
HEAD LICE
PLEASE REFER TO NHS GRAMPIAN’S HEAD LICE POLICY (2007)
IMPETIGO Cases - Basic principles Cases Contacts - Basic principles Contacts - None
Spread. As long as lesions are discharging or a carrier state persists.
INFLUENZA Cases - Basic principles Cases - None Notifiable (2)
closed environments. Contacts - Basic principles Contacts - None
Cases are infectious from 1 day before the onset of symptoms until 3 - 5days after onset in Adults (Hawker et al 2005)
CLINICAL FEATURES INCUBATION COMMON SOURCES MANAGEMENT EXCLUSION & MEANS OF SPREAD Discuss with HPT Discuss with HPT Cases Cases Contacts Contacts - None
HNIG may be indicated following Healthcare workers need to
MENINGOCOCCAL Fever, severe Discuss cases and contacts Discuss with HPT INFECTION Cases - None Contacts - None CLINICAL FEATURES INCUBATION COMMON SOURCES MANAGEMENT EXCLUSION & MEANS OF SPREAD MOLLUSCUM Cases - Basic principles Cases CONTAGIOSUM Contacts - None Contacts - None Cases Cases Contacts - None Contacts - None POLIOMYELITIS Discuss cases and contacts Discuss cases and contacts
symptoms. Can be transmitted as long as virus present in stools and nasopharynx.
CLINICAL FEATURES INCUBATION COMMON SOURCES MANAGEMENT EXCLUSION & MEANS OF SPREAD RINGWORM Cases Cases Contacts - None Contacts - None Cases Discuss with HPT Cases
respiratory secretions. Salivary testing kit to HPA
Contacts Contacts - None
infants with CRS. From 1 week before to 6 days after onset of rash.
Cases Cases Contacts Contacts - None CLINICAL FEATURES INCUBATION COMMON SOURCES MANAGEMENT EXCLUSION & MEANS OF SPREAD immunity are
Bedding and clothing are not considered a major risk of transmission.
Cases Cases STREPTOCOCCAL including: INFECTION Contacts - None Contacts - None CLINICAL FEATURES INCUBATION COMMON SOURCES MANAGEMENT EXCLUSION & MEANS OF SPREAD INVASIVE GROUP Cases Cases STREPTOCOCCUS Bacteraemia Contacts Contacts - None Discuss contacts with HPT
Spread, 7 days before onset of iGAS until 24 hours after start of antibiotics (NHS Grampian May 2010) Increased risk of sporadic iGas - aged 65+ ,recent Varicella infection, HIV +ve, diabetes heart disease, cancer high dose steroids, IV drugs. (HPA, 2004)
Cases Cases - None STREPTOCOCCUS meningitis pneumonia Contacts - None Contacts - None
commonly 3 – Intra partum antibiotic 4 weeks
CLINICAL FEATURES INCUBATION COMMON SOURCES MANAGEMENT EXCLUSION & MEANS OF SPREAD colonised with GBS appears to reduce neonatal infection. THREADWORMS
Eggs are transferred to Cases Cases - None
itching then transferred repeated 2 weeks later.
Contacts - None Contacts TUBERCULOSIS Discuss with HPT Cases Cases Contacts Contacts - None TUBERCULOSIS Discuss with HPT Cases - None (Non-Respiratory) Cases Contacts Contacts - None CLINICAL FEATURES INCUBATION COMMON SOURCES MANAGEMENT EXCLUSION & MEANS OF SPREAD TUBERCULOSIS Cases Cases - None Environmental (atypical) Contacts - None Contacts - None Cases Cases - None Contacts - None Contacts - None
Some types can be transmitted sexually. Increased risk of spread in immunosuppressed individuals.
WHOOPING Discuss with HPT Discuss with HPT (Pertussis) Cases Cases Contacts – None Contacts
decreases to negligible Dodhia et al (2002)
References General NHS Grampian. Safe Working Practice Infection Control in the Community 2007 HPS Infection prevention and control in childcare settings (DRAFT) May 2010 HPA. Guidance on infection control in schools and other childcare settings. April 2010. (www.hpa.org.uk) Immunisation Against Infectious Diseases 2006 “The Green Book” Updated chapters found at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_079917 Please ensure that you check online for most recent version Gastrointestinal Infections
Guidance on the Investigation and Control of Outbreak of Foodborne disease in Scotland SEHD/FAS 2002 – under revision PHLS Preventing person-to-person spread following gastrointestinal infections: guidelines for public health physicians and environmental health officers. (www.hpa.org.uk) Commun Dis Public Health 2004; 7 (4): 362-384 http://www.hpa.org.uk/cdph/issues/CDPHvol7/No4/guidelines2_4_04.pdf Clostridium difficile Guidance on Prevention and Control of Clostridium difficile Infection (CDI) in Healthcare Settings in Scotland HPN September 2009 http://www.hps.scot.nhs.uk/pubs/Publication_Search/Publication_Detail.aspx E coli Guidance for the Public Health Management of Infection with Verotoxigenic Escherichia coli (VTEC) HPN October 2008 http://www.documents.hps.scot.nhs.uk/about-hps/hpn/vtec.pdf Hepatitis A Guidance for the prevention and Control of Hepatitis A infection HPA 2009 http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1259152095231 Diphtheria Bonnet J.M and Begg. N.T Control of diphtheria: guidance for consultants in communicable disease control. Communicable Disease And Public Health 1999; 2:243-9 Measles Guidelines for the Control of Measles Incidents and Outbreaks in Scotland. Health Protection Network Scottish Guidance. May 2010 http://www.documents.hps.scot.nhs.uk/about-hps/hpn/measles-guidelines.pdf Parvovirus Natasha S. Crowcroft, C.E. Roth, Bernard J. Cohen & Elizabeth Miller. Guidance for control of Parvovirus B19 infection in healthcare settings and the community. J Pub Health Med 1999; 21 (4): 439-446 Rash in pregnancy PHLS Guidelines on the management of, and exposure to, rash illness in pregnancy (including consideration of relevant antibody screening programmes in pregnancy). (www.hpa.org.uk) Commun Dis Public Health 2002; 5 (1): 59–71 Streptococcus – Group A HPA Interim guidelines for the management of close community contacts of invasive group A streptococcal disease. Community Disease Public Health 2004; 7 (4); 354-61. http://www.hpa.org.uk/cdph/issues/CDPHVol7/no4/guidelines1_4_04.pdf
NHS Grampian Interim Guidance for the Public Health Management of Invasive Group A Streptococcal infection (iGAS) May 2010 Tuberculosis Guidelines for the Control of Tuberculosis Incidents and Outbreaks in Scotland. Health Protection Network Scottish Guidance. March 2009 http://www.documents.hps.scot.nhs.uk/about-hps/hpn/tuberculosis-guidelines.pdf Varicella SEHD Varicella Immunisation for Healthcare Workers. SEHD/CMO (2004) 2 Whooping cough (Pertussis) H.Dodhia, N.S.Crowcroft, J.C.Bramley & E.Millar. UK guidelines for use of erythromycin chemoprophylaxis in persons exposed to pertussis. J Pub Health Med 2002; 24 (3): 200-206
Epilepsy in Rett syndrome – notes for talk at ORSA meeting, September 2010 This talk was part of a three-person panel discussion and had two principal 1) to describe why and how epileptic seizures develop in the human brain 2) to review the main features of epilepsy in Rett syndrome (RTT) – what kinds of seizures occur and at what age; who is more likely to develop epileptic seizures; wh
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