Chickenpox and Shingles Policy

Chickenpox and Shingles Policy
Reference Number:
602
Author & Title:
Julia Bloomfield – Infection Control Nurse
Responsible Directorate:
Corporate
Review Date:
April 2014
Ratified by (committee):
Clinical Governance Committee
Date Ratified:
April 2011
Version:
3
Related Procedural Documents
Index:
1.
Introduction ___________________________________________________ 3
2.
Purpose of this policy ___________________________________________ 3
3.
Duties / Responsibilities _________________________________________ 3
4.
Transmission __________________________________________________ 4
5.
Symptoms of Chickenpox _______________________________________ 4
6.
Symptoms of Shingles __________________________________________ 5
7.
Infection Control Precautions ____________________________________ 5
8.
Contacts ______________________________________________________ 6
9.
Management of Contacts ________________________________________ 7
10.
Monitoring Compliance ________________________________________ 8
11.
References __________________________________________________ 8
Appendix 1:
Consultation Schedule _________________________________ 9
Appendix 2:
Chickenpox Patient/Staff Contact Tracing Form ___________ 10
Appendix 3:
Acquisition of Varicella Zoster Immunoglobulin ___________ 11
Equality Impact Assessment Tool ___________________________________ 12
Ratification Check List_____________________________________________ 13
Document name: Chickenpox and Shingles Policy
Issue date: April 2011
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Status: Final
1.
Introduction
Chickenpox (varicella) and Shingles (zoster) is an acute, highly infectious disease
caused by the varicella zoster virus (VZV). It is a common disease of childhood and
90% of adults raised in the UK are immune (DOH, 2006). When immunity wanes, as
occurs in old age and states of immuno-suppression, reactivation of the virus may be
triggered locally in the nerves and skin resulting in an attack of shingles.
2.
Purpose of this policy
The purpose of this policy is to establish infection control procedures for suspected
and confirmed cases of chicken pox or shingles.
To ensure healthcare workers are aware of the actions and precautions required to
minimise the risk of transmission between patients, staff and visitors.
3.
Duties / Responsibilities
All staff have a responsibility for ensuring that the principles outlined within this
document are universally applied. This policy applies to all members of staff who are
involved in any aspect of the development and use of procedure development.
Key organisational duties are identified as follows:
3.1
Chief Executive
The Chief Executive has ultimate responsibility to ensure that the control of hospital
infection is addressed according to department of health directives. This
responsibility is delegated to the Director of Infection Prevention and Control.
3.2
The Director of Infection Prevention and Control
The Director of Infection Prevention and Control is responsible for the organisational
adoption of the policy for the control and management of chicken pox and shingles
infection.
3.3
Infection Control Team and Occupational Health Team
The Infection Control Team is responsible for giving expert advice and training
related to all infection control practice concerning chickenpox/ shingles management.
The Infection Control Team will commence contact tracing in the event of a
chickenpox / shingles outbreak for patients and the Occupational Health Team will
commence contact tracing for staff management issues.
3.4
Ward Managers and Head of Departments
Ward Managers and Heads of Department are responsible for ensuring that all staff
are familiar with the policy and that the management of patients or members of staff
Document name: Chickenpox and Shingles Policy
Issue date: April 2011
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diagnosed with chickenpox/ shingles is carried out in their areas in accordance with
this trust policy.
3.5
Individual Responsibility
All staff both clinical and non clinical must ensure they have read and understood the
policy and incorporate the guidance on the care and management of patients with
chickenpox /shingles into their clinical practice. They must be aware of their role in
the prevention of healthcare associated infection in the working environment,
including reporting unusual rash and pruritic conditions.
Staff will inform Occupational Health if they suspect or develop symptoms of chicken
pox or shingles.
4.
Transmission
Chickenpox is highly contagious, infecting up to 90% of people who are exposed to
the disease. It is transmitted by the following routes:•
•
•
•
Direct Contact with lesions
Droplet or airborne spread of vesicle fluid
Secretions of the respiratory tract of chickenpox cases
Vesicle fluid of patients with herpes zoster
The most infectious period is 1-2 days before the rash appears, but infectivity continues
until all the lesions have crusted over (commonly 5-6 days after onset of illness).
Shingles is less contagious as there is no infectious incubation period and the virus is
confined to the rash, which may be easily covered in most instances.
Non-immune individuals may develop chickenpox from a person with shingles.
Antibody testing can be performed to assess immunity to VZV.
5.
Symptoms of Chickenpox
Chickenpox may initially begin with cold-like symptoms, as the virus is shed from the
naso-pharynx for up to 5 days before the rash appears. This is followed by a high
temperature and an intensely itchy, vesicular (fluid-filled blister-like) rash. Crops of
vesicular spots appear, mostly over the trunk and to a lesser extent the limbs. The
severity of infection varies and it is possible to be infected but show no symptoms.
Infectivity may be prolonged in patients with altered immunity.
•
Children who have become infected with VZV may be asymptomatic or develop
a chickenpox rash. Nearly all children recover completely and have detectable
antibodies for many years. Re-infection with VZV is rare. The virus can become
latent in sensory nerves and present in later life as herpes zoster (shingles)
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•
6.
Adults with chickenpox may develop more severe disease and complications
including pneumonia. Pregnant women are at particular risk of complications
affecting the foetus/neonate which arise as a result of the mother contracting the
infection.
Symptoms of Shingles
Following chickenpox infection, the virus lays dormant in the nervous tissue for life.
Reactivation of the virus is generally associated with conditions that depress the
immune system. Virus from the vesicles can be transmitted to susceptible individuals
who have not had chickenpox and they may subsequently develop chickenpox.
The first sign of shingles is typically pain in the area of the affected nerve. A rash of
fluid filled blisters appears in the affected area. This rash is usually persistent for about
7 days but the pain may continue for longer. The affected area may become intensely
painful.
The virus is shed from the skin lesion until it dries and forms scabs, airborne
transmission may occur.
7.
Infection Control Precautions
All staff caring for a patient with suspected chickenpox/shingles should have a
previous history of chickenpox or be known to be immune. The Occupational Health
Department hold vaccination and immunity details on all staff.
7.1 Isolation Precautions
•
Isolate all patients with a possible/confirmed diagnosis of chickenpox or
shingles on admission and continue until discharge because of the risk of
varicella in susceptible immuno-compromised patients.
•
Inform the Infection Control Team that you have a patient with a
possible/confirmed diagnosis of chickenpox/shingles
•
Clinical waste bags and red linen bags should be secured within the isolation
room
Visiting should be restricted to close family members/designated guardians known to
have had chickenpox in the past. In the event of non-immune visitors, staff must
seek advice from the Infection Control
•
Visiting should be restricted to close family members/designated guardians
known to have had chickenpox in the past. In the event of non-immune
visitors, staff must seek advice from the Infection Control Team or the on call
Microbiologist regarding the appropriate precautions, as these may vary
depending on the ward, patient and visitor
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7.2 Protective Clothing
•
During the isolation period, it is not necessary to wear face protection/masks
for general healthcare duties
•
See Universal Precautions Policy for guidance as standard universal
precautions apply for dealing with all other body fluids
7.3 Decontamination Advice
•
Standard precautions apply for the cleaning of isolation rooms. Deep or
special cleans are not required.
•
Toys/games – use only toys which can be wiped or washed with detergent
and water, dry thoroughly.
7.4 Post Mortem Contact
•
8.
Body bag is required only if the active lesions or rash are still wet (see
Universal Precautions Policy)
Contacts
8.1 Patient Contacts
A Chickenpox ‘Contact’ is defined as any patient or staff member who is nonimmune to the varicella-zoster virus and who has had contact with a case of
chickenpox at anytime from 48 hours before the onset of the rash until all the lesions
are crusted and there is no further cropping
This will include:
•
Being in the same room as the index case for more than 15 minutes
•
Direct face to face contact for three minutes or same room contact with an
infectious person or within 10 metres on an open ward
•
Contact with clothing and bedding soiled by discharge from the blisters
A Shingles ‘Contact’ can be defined as any patient or staff member who is nonimmune to the varicella-zoster virus and who has had contact with a case of
disseminated, exposed shingles from the day of the rash until crusting of the
exposed rash
This will include:
•
Contact with the wet shingles rash
•
Contact with clothing and bedding soiled by discharge from the blisters
8.2 Staff Contacts
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Staff contacts that are not chicken pox immune must be identified because they
could transmit the disease to vulnerable patients while incubating the disease
themselves. Non-immune staff may be offered vaccination to protect themselves and
patients. This immunity status needs to be assessed by Occupational Health
Department.
9.
Management of Contacts
Potentially High Risk Patients include:•
•
•
•
•
•
•
•
•
Those who have received oral or parenteral steroids in the past 3 months
Patients with leukaemia, lymphoma or bone marrow transplant recipients
Patients who have had solid organ transplants
Patients who have had radiotherapy in the last 3 months
AIDS patients
Critically ill patients i.e. long stay ITU
Pregnant women
Infants under 1 month old
Adult Smokers are at a higher risk of contracting VZV.
9.1 Management of high risk patient contacts
If a patient is immuno-compromised and contracts VZV then the decision regarding
where the patient should be nursed will be made in consultation with the clinician
responsible for their care and with the Infection Control Team.
The medical team should discuss the case with a Medical Microbiologist or Consultant
Paediatrician as appropriate. If Human Varicella-Zoster Immunoglobulin (VZIG) is
indicated, the optimum time for administration of medication is within 96 hours of
contact or as early as possible, within 10 days of contact.
9.2 Non-immune staff exposed to developing chickenpox/shingles
These staff must report immediately to Occupational Health (see Infection Control
and Fitness to Work Policy)
Susceptible individuals are considered infectious for 10-21 days after contact and
MUST remain off work during this time or until vesicles have scabbed over after active
infection. If contacts have received VZIG for any reason, this is extended to 28 days
after contact.
Occupational Health will report any cases of chickenpox in staff to the Infection Control
Team in order to establish if there are any possible patient contacts.
The Occupational Health Department will establish if there are any possible staff
contacts. (See APPENDIX A)
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9.3 Chickenpox in pregnancy
Mothers who have previously had chickenpox are considered immune, however nonimmune pregnant women must seek advice from their medical team as a matter of
urgency as maternal chickenpox may cause complications to the foetus or neonate.If
immune status is unclear, laboratory staff may be able to check for immunity on stored
bloods.
10. Monitoring Compliance
Evidence of non-compliance with this policy will be assessed by the Infection Control
Team, in order to identify immediate actions required to improve patient and staff
safety.
Themes and trends related to the suboptimal management of Chickenpox patients
will be reviewed by the Saving Lives Implementation Committee, in order to identify
actions required to address identified areas of risk.
11. References
Department of Health
Chickenpox (varicella) immunisation for healthcare workers
30/12/2003, 34156 Crown
Department of Health (2006) Immunisation against infectious diseases (The Green
Book)
P Rice, K Simmons, R Carr, and J Banatvala
Lesson of the Week: Near fatal chickenpox during prednisolone treatment
BMJ, Oct 1994; 309: 1069 - 1070
Control of Communicable Diseases Manual, Heymann DL (ed) (18th Edition)
American Public Health Association 2004
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Appendix 1:
Consultation Schedule
Name and Title of Individual
Wendy Lloyd - Pharmacist
Sarah Meisner- Infection Control Doctor
Christopher Knechtli – Consultant
Haematologist
Infection Control Team
Date Consulted
Nov 2009
Oct 2009
Oct 2009
Name of Committee
Saving Lives Implementation Committee
Date of Committee
2009
Document name: Chickenpox and Shingles Policy
Issue date: April 2011
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October 2009
Ref.: 602
Status: Final
Appendix 2:
Form
Chickenpox Patient/Staff Contact Tracing
Name of index case….………………………Hospital Number………….……
On-set of rash/blisters……………………………………….….
Period of infectivity/contact…………………/…………….…...
Ward…………………………………………………………….…..
Please add patient/staff names in box below who have had contact with the index
case. E.g., Face to face contact or in the same room (see Chickenpox policy).
Return this form to the Infection Control Department for patients or Occupational
Health for staff.
Name
Date of Birth/
Hosp No.
How to get hold of varicella zoster
immunoglobulin (VZIG)
Who to contact
Information needed
Blood test
result
Comments
When Microbiology approval has been
obtained to release a VZIG dose in
pharmacy working hours
Contact Pharmacy Dispensary on ext. 4640
• Name of approving Microbiologist
•
Patient’s name, unit number and age or
date of birth
•
Number of vials issued
•
Expiry dates of vials
•
Name of the requesting clinician
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Issue date: April 2011
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Status: Final
Appendix 3: Acquisition of Varicella Zoster
Immunoglobulin
Please note:
•
The VZIG is held in the pharmacy department fridge, as there are no storage
facilities in Microbiology
•
Pharmacy cannot release any doses without Microbiology approval
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Equality Impact Assessment Tool
To be completed and attached to any procedural document when submitted to the
appropriate committee for consideration and approval
Initial Screening
Policy, service,
function:
strategy,
procedure
or Policy
Lead (e.g. Director, Manager, Clinician):
Francesca Thompson
Person responsible for the assessment:
Name:
Julia Bloomfield
Job Title:
Infection Control Nurse
Is this a new or existing policy, service strategy, procedure or function?
Existing
Who is the policy/service strategy, procedure or function aimed at?
•
Carers
•
Staff
Are any of the following groups adversely affected by the policy?
If yes is this high, medium or low impact (see attached notes):
Group
Disabled people:
Race, ethnicity &
nationality
Male/Female/transgender
:
Age, young or older
people:
Sexual orientation:
Religion, belief and faith:
Affected?
No
No
Impact
No
No
No
No
If the answer is yes to any of these proceed to full assessment.
This applies whether the impact assessment is high, medium or low.
If the answer is no to all categories, the assessment is now complete
1. Does the policy, service strategy, procedure or
function
include measures which promote equality?
2. If yes, what are these measures?
Document name: Chickenpox and Shingles Policy
Issue date: April 2011
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No
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Status: Final
Ratification Check List
Author; attach this to each copy of the policy being sent to a Committee for final ratification.
Dear Chairman
Please would you review this document at your next meeting and agree final approval and
organisational ratification.
Title of meeting:
Date of meeting:
Title and Reference of document: Chickenpox and Shingles 602
Name of author:
Julia Bloomfield
Are there any elements of this policy which present
operational issues that require further discussion? If yes,
please provide a contact name for the author.
Yes
No
N/A
Does the document include a training plan?
Yes
No
N/A
Is the policy referenced?
Yes
No
N/A
Are up to date National Guidelines included?
Yes
No
N/A
If you are the appropriate forum, have the necessary
resources been agreed to implement this document?
Yes
No
N/A
Is there a plan for policy implementation?
Yes
No
N/A
Does your meeting recommend further consultation with
groups or staff other than listed at the front of the policy?
Yes
No
N/A
What are the cost implications of implementing this policy?
Equipment
£
Yes
No
N/A
Staffing (additional)
£
Yes
No
N/A
Training
£
Yes
No
N/A
Other
£
Yes
No
N/A
Document endorsed without further comment?
Yes
No
Further amendments to document suggested?
Yes
No
Name of Chair:
Signature: ____________________________ Date: ________________________
Document name: Chickenpox and Shingles Policy
Issue date: April 2011
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Status: Final