Protecting Ourselves Against

High Risk Infections

Dr Ashley Price

Consultant Infectious Diseases

Newcastle upon Tyne Hospitals Foundation Trust

• Do you know what PPE to wear if asked to

assess a patient with possible MersCoV

– Yes

– No

• Have you been fit tested for FFP3 mask?

– Yes

– No

10yrs after

SARS in Toronto:

Index Case

A 78 year old woman arrives back in Toronto from trip to

Hong Kong

• February 25 – Develops febrile illness with anorexia,

myalgias, sore throat, cough

• February 28 – Sees MD, given antibiotics

• March 2 – Develops shortness of breath

• March 5 – Dies at home (thought to be heart attack)

SARS in Toronto:

Spread within Household

• Feb 27 - 43 year old son of index case

develops febrile illness (case #2)

• Admitted to Scarborough Grace March 7th, died March

13th

• March 3 to 12 – all of index case’s other

household contacts develop illness

• 24 year old daughter in law, 5 month old grandson, 34

year old son, 79 year old husband

SARS in Toronto:

First spread outside household

• March 5th – Daughter of index case, who had visited her mother while ill, develops SARS

• March 9th – Family MD who saw 3 ill family members on March 6th develops SARS

• March 10th, 13th – Two patients (cases #8 and #9) who spent time in ER observation area with (Case #2) on March 7/8th develop SARS

SARS in Toronto: Spread at Scarborough Grace - I

• From case #2 and ill family to 5 ICU nurses

• From case #8 to two paramedics, one firefighter, four

ER staff, one anaesthetist (precautions initiated in ER;

no further transmission except to anaesthetist

performing intubation)

• From case #8’s ill wife to 7 ER visitors, one housekeeper

• From case #9 (admitted before outbreak recognized) to 20 hospital staff and students in CCU and on medical unit (nurses, MDs, support staff, radiology, pharmacy, etc.)

Spread within Hospital

SARS in Toronto:Spread to Other Hospitals

• Mount Sinai Hospital

– Case #10 transferred to ICU

– 7 staff infected

• York County Hospital

– Case #9 transferred to ICU

– Wife of case #9, also admitted with #hip (but had

SARS as well)

– 14 staff and one patient infected

SARS in Toronto:

Other Spread

• Household contacts of cases

– Estimated risk of unprotected exposure 24%

• Doctors offices when SARS patients were present

• Persons visiting SARS patients at home

• Funerals of SARS patient at which family members

were ill

• Religious retreats

• Workplace

Probable and Suspect Cases of SARS in Ontario by Date of Onset

(April 22, 2003 as of 9:00 a.m.)

0

5

10

15

20

25

Fe

b-2

3

Fe

b-2

5

Fe

b-2

7

Ma

r-01

Ma

r-03

Ma

r-05

Ma

r-07

Ma

r-09

Ma

r-11

Ma

r-13

Ma

r-15

Ma

r-17

Ma

r-19

Ma

r-21

Ma

r-23

Ma

r-25

Ma

r-27

Ma

r-29

Ma

r-31

Ap

r-02

Ap

r-04

Ap

r-06

Ap

r-08

Ap

r-10

Ap

r-12

Ap

r-14

Ap

r-16

Date of Onset

Number of Cases

Suspect

Probable

Notes:

1) Total Probable Cases = 136 (1 case with unknown onset date); Total Suspect Cases = 125(2 cases with unknown onset date)

2) Cases in epi curve includes individuals with known onset dates from all health units with reported cases

Source: Ontario Ministry of Health and Long Term Care, April 22, 2003 as of 9:00am

Severe Acute Respiratory Syndrome (SARS)

Toronto (21/04/03)

Exposure No. (%)

Healthcare worker 95 (36)

Nosocomial patient or visitor 49 (19)

Household contact 77 (29)

Travel 12 (5)

Under investigation 28 (11)

SARS in Toronto:What have we learned?

• Cases of SARS that are not suspected pose the

greatest danger to staff

– High index of suspicion and SARS isolation for

febrile patients best protection

• Ill visitors can spread the disease in the

hospital to staff and patients

– Visitor restrictions essential until outbreak is over

SARS in Toronto:What have we learned?

• Early detection of infection vital so that

precautions can be used to prevent spread

– Fever surveillance in patients and staff critical to

ensuring that transmission is stopped

• Infection control precautions are effective, but

require very careful attention to detail to be

most effective

SARS in Toronto:What have we learned?

• Intubation, and potentially other cough-inducing procedures in the ICU/ward, poses special risks from some, but not all patients

• Some patients much more infectious than others

– No means to identify these patients currently

Kenema Hospital, Sierra Leone, July 2014

Screening area

Waste disposal

Slide courtesy of Dr Catherine

Houlihan

Treatment areas

Monrovia case

management camp.

Liberia

Moyamba case

management camp,

Sierra Leone

Hysteria of Ebola

• Lawyer for nurse Kaci Hickox not allowed to train in Gym

• North Korea puts all foreigners under 21 day quarantine

• Patient ringing up ward 19, RVI to say they are frightened of attending our clinic

• “Suspect” case closes Eldon Gardens

MERS CoV

Infectious Disease Hazard Groups

1) Identify the patient

Key Pathogens in Circulation

• MERsCoV- risk is mainly in travellers from Middle

East (outbreak contained in South Korea)

• Influenza every year- H7N9 occurring in China,

mostly contact with poultry, some clusters

occurring, H5N8 in poultry few cases in humans

• Ebola/VHF- Ebola last case was June 2016

• Measles, Mumps, Chickenpox, Influenza, RSV,

coronaviruses, tuberculosis, Group A strep,

norovirus e.t.c

Risk Assessment

• All patients with fever should have a basic risk assessment:

– Travel, where and when (incubation period MERsCoV is 14 days, influenza 10 days, VHF 21 days).

– What did they do? Any contact? Poultry for avian influenza, human contact, eating bush animals, tick bites.

– Symptoms, generally a history of fever and URTI for MERS/INF, fever for VHF.

– Has the patient got signs of LRTI/pnuemonia, is there another clear cause for symptoms.

– PHE guidance should be consulted.

http://www.promedmail.org/

http://www.who.int/csr/don/en/

2) Isolate and wear appropriate PPE

High level isolation environment on ID unit

PPE

Microorganism

PPE required

Gloves Apron Visor/goggles Surgical maskLong sleeved

apron

FFP3

mask

Pulmonary TB (smear positive) � � as required - � +/-

Multi-drug resistant TB � � as required - � �

Influenza � � as required � AGP AGP

Bordetella pertussis

(whooping cough)� � as required � AGP AGP

Haemophilus influenza

(Epiglottitis only)� � as required � AGP AGP

Adenovirus � � as required � AGP AGP

Parainfluenza � � as required � AGP AGP

Respiratory syncytial virus

(RSV)� � as required � AGP AGP

Coronavirus � � As required � AGP AGP

Fit Testing FFP3 mask

Contact ID SpR on call (09.00-22.00) and after 22.00 ID Consultant on call

Contact Paediatric ID Consultant

ID to check against relevant definition for clinical assessment. If x-ray required (acute only) should be portable with appropriate IPC precautions taken

If MERS / SARS / Asian flu is still suspected ID to contact Virologist (21104 or via switchboard) and

Health Protection Team (0300 303 8596) and staff to wear PPE described below

Virologist to contact:

• Reference lab to arrange testing

• Biomedical Scientist to arrange specimen

transport via courier

• IPC

• If WIC give advice on patient transport

On directions of the Virologist staff to send the following VIRAL specimens (not in WICs):

• Sputum or NPS

• Nose and throat

• Serum sample

MUST USE viral swabs (green top swab)

Isolate in Room 2, ED / WIC single room

AdultPaediatric

Suspected MERS / SARS / Avian / Pandemic Flu

PPE

Staff entering the room must wear:

• Disposable long sleeved fluid repellent gown with cuffs

• Gloves

• FFP3 mask (must be fit tested)

• Visor

(Waste disposed as normal Clinical Waste)

PPE removal

Must be removed as follows:

• Away from the patient - gown, then gloves,

clean hands with hand sanitizer (gel) then

remove visor via back strap (WIC only - also FFP3 mask)

• Wash hands

• Remove FFP3 mask via back strap in ante-room then wash hands again

Equipment for highly pathogenic

infections • Involvement of supplies dept. is essential to

obtain and monitor stock levels

• Enhanced PPE – Fluid repellent gowns; X large long, large long

and medium long)

– Long thick green plastic aprons Theatre hoods Disposable visors

– FFP3 masks

– Long cuffed non-sterile nitrile gloves (sml, med, lge, X lge)

– Non-latex surgeons gloves; selection of sizes

– Non-sterile nitrile gloves; size small, medium, large and extra large

– Duct tape for securing long gloves

– Wellington boots

• High level PPE – from national source so difficult to obtain

Doffing

• Stand beside waste bin and drop all removed PPE into bin as follows ensuring that no part of your body / clothing comes into contact with the outside of the PPE:

• Gown and gloves as one;

• untie the gown from the side

• cross arms and grab the shoulder area of the gown and pull the gown away from the body

• turn the inside of the gown over the outside rolling into a small bundle, away from the body

• place bottom of gown in the waste bin and then continue to remove the sleeves and gloves together, ensure at all times that the outside of the gown does not touch your clothing or body

• Gel hands

• Visor – with eyes closed take hold of strap at back of head and lift forward and upward. Drop into bin.

• Gel hands

• Mask and theatre hood - with eyes closed and head up remove theatre hood and mask altogether as follows: – Grab theatre hood at the bottom front

– Tear open and move front pieces to the back

– With hands grabbing the underside of the hood, lift all head PPE forward and off ensuring no contamination of the face occurs.

– Drop into the bin.

• Gel hands

• Stand next to the green zone, remove sock, place in waste bin and stand directly into crock in green zone, repeat for other foot.

• Gel hands

• Wash hands with antiseptic solution (e.g. Hibiscrub) in the green zone ante-room

Other considerations

• X-ray

• Appropriate investigations

– Liaison with virology/microbiology and PHE

• Notification to PHE

• Waste management

• Cleaning and decontamination

• Will you get fit tested for FFP3 mask and ask

about enhanced PPE in your trust?

– Yes

– No

Key Points

• Ensure early identification of patients with potentially infectious diseases

• Ensure patients are isolated early in an appropriate area

• Ensure staff are protected as soon as it becomes clear that there is a risk with the right protection and they have been trained

• Ensure that contacts are identified

• Ensure the environment is cleaned and waste dealt with appropriately

• Ensure where vaccine available you are vaccinated