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Guideline Title: VARICELLA ZOSTER (CHICKENPOX), HERPES ZOSTER (SHINGLES): ADDITIONAL AIRBORNE AND CONTACT PRECAUTIONS
Campus: Category: Responsibility for Review: Date Approved: Bayside Health Infection Control Chief Medical Officer December 2007 Control No.: Related Policy No.: Rev.: Review Date: BH0206 BH0305 002 December 2010

GUIDELINES
These guidelines should be read in conjunction with the Bayside Health Infection Control Requirements Policy and other guidelines in the Infection Control Manual available in every ward and clinical department and on the Bayside Health Intranet.

PURPOSE
To ensure all staff are aware of their immune status in relation to Varicella Zoster Virus (VZV) (Chickenpox/Shingles), the mode of transmission and the additional precautions required to prevent exposure to, and spread of VZV. BACKGROUND VARICELLA ZOSTER VIRUS VZV is a member of the herpes virus group. Like other herpes viruses, VZV can persist in the body after the primary (first) infection, as a hidden infection. Primary infection with VZV results in Chickenpox. Herpes Zoster (Shingles) is the result of a recurrent infection. Exposure to shingles can result in chickenpox, you cannot get shingles from shingles. The mechanism that controls reactivation is not well understood however factors associated with recurrent disease include aging and immunosuppression. In immunocompromised persons, Herpes Zoster (Shingles) may disseminate (up 36% in one report) causing generalised lesions (Disseminated Zoster) and central nervous system, pulmonary and hepatic involvement. Varicella zoster is a more serious illness in adults and is potentially fatal in immunocompromised patients. Secondary bacterial infections of lesions with staphylococcus or streptococcus are a common cause of hospitalisation and outpatient visits. The virus is believed to have a short survival time outside of the infectious host. Airborne and Contact Precautions are intended to reduce the risk of transmission of the infectious agent Varicella Zoster Virus (VZV) to staff, patients and visitors who have no immunity to the disease or have not been vaccinated against the disease.

Varicella Zoster (Chickenpox), Herpes Zoster (Shingles): Additional Airborne and Contact Precautions Approved by Bayside Health Clinical Governance Committee on 20 December 2007

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TRANSMISSION The most common modes of transmission of VZV are the following:

Person to person from infected respiratory secretions Respiratory contact with airborne droplets Direct contact with aerosols Inhalation of aerosols from vesicular fluid of skin lesions of patients with acute Chickenpox or Herpes Zoster (Shingles)

COMMUNICABILITY

Patients with Chickenpox or Herpes Zoster (Shingles) are infectious from 1-2 days before the onset of rash, through the first 4-5 days until the lesions have formed crusts. Immunocompromised patients are probably contagious during the entire period new lesions are appearing. Chickenpox is highly contagious. Secondary attack rates in household contacts are as high as 90%. Staff who develop Chickenpox or Herpes Zoster (Shingles) are a source of infection to other non-immune or immunocompromised patients or staff.

INCUBATION PERIOD The incubation period is from day 10 to day 21 post exposure to either Chickenpox or Herpes Zoster (Shingles). Up to 85% of non-immune people exposed to Chickenpox become infected. PROCEDURES These guidelines MUST be used in addition to STANDARD PRECAUTIONS. All staff MUST adhere to the following: A. NOTIFICATION REQUIREMENTS

All staff MUST notify Infection Control of any suspected or confirmed cases of Chickenpox, Disseminated Zoster in an immunocompromised patient or Herpes Zoster (Shingles).

B.

STAFFING

Only staff who have had Chickenpox (or a blood test confirming chickenpox), Herpes Zoster (Shingles) or 2 doses of the Varicella Zoster vaccine should care for patients with Chickenpox, Disseminated Zoster or Herpes Zoster (shingles). Immunosuppressed staff MUST NOT care for patients with VZV infection.

Varicella Zoster (Chickenpox), Herpes Zoster (Shingles): Additional Airborne and Contact Precautions Approved by Bayside Health Clinical Governance Committee on 20 December 2007

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C.

AIRBORNE PRECAUTIONS PATIENT PLACEMENT OUTPATIENTS

If a patient with Chickenpox, Disseminated Zoster or Herpes Zoster (Shingles) is identified in an outpatient area, they should be placed in a private room/area where the door can be closed and wear an N95 mask (if possible) or a surgical mask. Time spent in waiting areas with other people must be limited.

EMERGENCY AND TRAUMA CENTRE PATIENTS AND INPATIENTS

A single room is required for all patients with VZV infections.

HERPES ZOSTER (SHINGLES)

Patient with Herpes Zoster (Shingles) MUST be cared for in a single room in a ward with no immunosuppressed patients. Patients in a Wards/Units/Department with immunosuppressed patients MUST be transferred to a negatively ventilated room.

CHICKENPOX AND DISSEMINATED HERPES ZOSTER Patients with Chickenpox or Disseminated Herpes Zoster MUST be cared for in a negatively ventilated room NEGATIVELY VENTILATED SINGLE ROOMS (ONLY AVAILABLE AT ALFRED HOSPITAL) Negatively ventilated rooms are available in the following areas:

Emergency Department Ward 7 West Intensive Care areas

Staff in Wards/Units/Departments with negatively ventilated rooms should notify the Engineering Controller of the requirement for negative ventilation and request the ventilation be checked. This should be done in: ICU areas - before the patient is placed in the room; and Emergency Department and Ward 7 West before placing the patient in the room (preferable) or soon after.

The door to the room MUST be closed at all times except for entering and exiting. A STOP sign MUST be placed on the door.

Varicella Zoster (Chickenpox), Herpes Zoster (Shingles): Additional Airborne and Contact Precautions Approved by Bayside Health Clinical Governance Committee on 20 December 2007

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RESPIRATORY PROTECTION

Masks are not required when entering the room as only staff that have had Chickenpox, Herpes Zoster (Shingles) or 2 doses of the Varicella Zoster vaccine and are not immunosuppressed are to care for the patient.

D.

CONTACT PRECAUTIONS

Cover localised lesions to contain vesicle exudate. Wear gloves for contact with lesions on the patient or potentially infective material or surfaces in the patients environment. Change gloves after contact with infective material. Hand wash or disinfect hands immediately after removing gloves. Wear a gown whenever it is anticipating that clothing may have direct contact with infective or potentially infective lesions, material or surfaces.

E.

VISITORS

Staff MUST check if visitors have had chickenpox or Herpes Zoster (Shingles) before they enter the room. What Personal Protective Equipment (PPE) visitors will be required to wear will depend on their immunity and degree of contact with the patient. Staff MUST instruct and supervise all visitors on the use of Personal Protective Equipment (PPE) and hand washing or disinfecting.

F.

VENTILATED/ANAESTHETISED PATIENTS (The Alfred & SDMH)

A suitable bacterial/viral filter MUST be placed on the ventilator/anaesthetic circuit expiratory line. Aerosols may be generated during the following procedures or conditions:
o o o o o

Endotracheal suctioning procedures Changing of ventilator circuit Insertion of a nebuliser into a ventilator circuit Intubation procedures Any procedure where coughing may be stimulated or disconnection of the ventilator circuit (either intentionally or accidentally)

Varicella Zoster (Chickenpox), Herpes Zoster (Shingles): Additional Airborne and Contact Precautions Approved by Bayside Health Clinical Governance Committee on 20 December 2007

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G.

ISOLATION CLEANING

Daily and terminal cleaning of the room by the Isolation Cleaning Team (at the Alfred), at SDMH and CGMC this will be performed by appropriately trained cleaning staff. In addition to thorough surface cleaning, adequate disinfection of bedside equipment and environmental surfaces is required including:
o o o o o o

Bedrails Bedside table Trolleys Commodes Doorknobs Tap handles

Patient care equipment such as IV pumps and ventilators MUST be cleaned at least daily or more often when visible soiling/contamination occurs. Consider a checklist to promote accountability for cleaning responsibilities.

H.

PATIENT CARE EQUIPMENT

Patient equipment MUST be wiped over with a disinfectant before removing from the patients room. Follow current practices for cleaning and disinfection or sterilisation of patient care equipment. Portable equipment used for performing x-rays or other procedures in the patients room MUST have the external surfaces wiped over with a disinfectant.

I.

WASTE DISPOSAL

Waste MUST be disposed of in accordance with Waste Management Policy available on the Intranet.

J.

NEGATIVE VENTILATION (The Alfred)

All routine maintenance and monitoring of negative ventilation system/s will be performed by the Engineering Department.

K.

TRANSPORTATION

Limit patient movement outside the room to medically necessary/essential procedures. Wherever possible, use portable equipment to perform x-rays and other procedures in the room.
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Varicella Zoster (Chickenpox), Herpes Zoster (Shingles): Additional Airborne and Contact Precautions Approved by Bayside Health Clinical Governance Committee on 20 December 2007

If procedures are medically necessary/essential the following must be implemented:

Before the patient is transferred, the ward/unit in which the patient is isolated MUST notify the accepting area that the patient has VZV infection and requires additional AIRBORNE AND CONTACT PRECAUTIONS. During transport/transfer non-ventilated patients MUST wear a mask (N95 if possible or a surgical mask). During transport/transfer support staff MUST wear gloves and a gown if direct patient contact is anticipated.

L.

PROCEDURAL/DIAGNOSTIC AREAS

Where possible these procedures should be scheduled last on the list or at the end of the day. Before the patient is transferred, the ward/unit in which the patient is isolated MUST notify the accepting area that the patient has VZV infection and requires additional AIRBORNE AND CONTACT PRECAUTIONS. If procedures are medically necessary/essential, the accepting area MUST implement appropriate additional precautions including:
o o o o

The procedure should be performed in a room where the door can be closed. A STOP sign MUST be placed on the door. Traffic in and out of this room MUST be controlled. Implementation of additional precautions as outlined above.

M.

PROCEDURAL/DIAGNOSTIC AREAS CLEANING

On completion of the procedure the department/diagnostic area must be cleaned:

o o

The Isolation Cleaning Team-The Alfred Appropriately trained cleaning staff at SDMH and CGMC

N.

OPERATIVE PROCEDURES (The Alfred & SDMH)

When booking the patient for an operative procedure the Medical Officer MUST notify the Operating Suite Floor Coordinator or that the patient has VZV infection requires additional AIRBORNE AND CONTACT PRECAUTIONS. Where possible these procedures should be scheduled last on the list or at the end of the day. Before the patient is transferred the ward/unit in which the patient is isolated MUST notify the Operating Suite Floor Coordinator that the patient has VZV infection and requires additional AIRBORNE AND CONTACT PRECAUTIONS.

Varicella Zoster (Chickenpox), Herpes Zoster (Shingles): Additional Airborne and Contact Precautions Approved by Bayside Health Clinical Governance Committee on 20 December 2007

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The operative procedure should be undertaken in accordance with Policies and Guidelines outlined in the Operating Suite Policy Manual. Patients are not to be recovered with other patients in the Post Anaesthesia Care Unit but are to be recovered in the Operating Room.

O.

OPERATING THEATRE CLEANING

On completion of the procedure the operating theatre MUST be cleaned. o o At the Alfred this will be undertaken by the Isolation Cleaning Team. At SDMH this will be undertaken by appropriately trained cleaning staff.

P.

DISCONTINUATION OF AIRBORNE AND CONTACT PRECAUTIONS

Airborne and Contact Precautions can cease when all the lesions are dry and crusted. The decision to terminate precautions MUST be made on a case-by-case basis after discussion with Infection Control.

Q.

VZV EXPOSURES STAFF

Any breaches in precautions MUST be reported to Infection Control. Infection Control at the Alfred will notify the Staff Health Services. Staff Health Services (located at the Alfred) and Infection Control at SDMH and CGMC will determine the need for employee evaluation and follow up. If after assessment the staff member is found to be VZV antibody negative and exposure is confirmed the staff member MUST have wellness checks in either Staff Health Services at the Alfred, Infection Control at SDMH and CGMC, or the Emergency Department from Day 10 to Day 21 post exposure before commencing work each day. If the staff member is suspected or confirmed as having chicken pox then they to be excluded from work until all lesions are dry and crusted.

PATIENTS

Infection Control and Infectious Diseases Unit staff will investigate and advise relevant Heads of Units of any patient exposures.

R.

DOCUMENTATION

Staff Health Service (the Alfred) and Infection Control (SDMH and CGMC) will maintain a database of all staff undergoing VZV assessment. Staff will be provided with a medical vaccination card.

Varicella Zoster (Chickenpox), Herpes Zoster (Shingles): Additional Airborne and Contact Precautions Approved by Bayside Health Clinical Governance Committee on 20 December 2007

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S.

STAFF HEALTH SERVICE (The Alfred) and SDMH, CGMC IMMUNISATION CLINICS PRE EMPLOYMENT

Pre-employment screening and vaccination are offered to all non-immune staff. If staff are unsure of their immune status they can check with a family member for a history of Chickenpox or present to the immunisation service at each site for a blood test. Staff with negative blood test should be considered for varicella zoster virus vaccine. The VZV immune status of staff working with high risk patients such as those with cancers or organ transplants, should be determined before commencing work in these areas

STAFF WITH VZV INFECTION

If a staff member develops Chickenpox, Disseminated Herpes Zoster or Herpes Zoster (Shingles) they MUST be excluded from work until all lesions are dry and crusted.

T.

CAULFIELD GENERAL MEDICAL CENTRE AND SANDRINGHAM DISTRCT MEMORIAL HOSPITAL (NO NEGATIVELY VENTILATED ROOMS) CHICKENPOX AND DISSEMINATED ZOSTER

Any patient suspected or confirmed of having chickenpox or disseminated herpes zoster (shingles) are to be: o o Placed in a single room or area where the door can be closed. Should be only be cared for by staff who have had Chickenpox (or a blood test confirming chickenpox), Herpes Zoster (Shingles) or 2 doses of the Varicella Zoster vaccine. The patient should be transferred to a health care facility with a negative ventilation facilities as soon as possible to limit ongoing exposure.

HERPES ZOSTER (SHINGLES)

All patients with herpes zoster (shingles) must be cared for in a single room with the door closed until all lesions are dry and crusted. Only staff who have had Chickenpox (or a blood test confirming chickenpox), Herpes Zoster (Shingles) or 2 doses of the Varicella Zoster vaccine should care for patients.

CLEANING

Routine cleaning of patient rooms should occur daily and on discharge.

PATIENT AND STAFF EXPOSURES

Refer to heading Q in this document

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Varicella Zoster (Chickenpox), Herpes Zoster (Shingles): Additional Airborne and Contact Precautions Approved by Bayside Health Clinical Governance Committee on 20 December 2007

INTER CAMPUS OR INTERHOSPITAL TRANSFERS

Ward staff should notify site specific infection control staff of any transfers of patients with shingles or chickenpox between sites. Ward staff must ensure that ambulance or transport personnel are notified of any additional infection control precautions required during transfer.

RELATED DOCUMENTATION
Infection Control Requirements Policy Waste Management Policy Intranet Intranet

REFERENCES
1. 2. 3. 4. Infection Control Guidelines for the Prevention of Transmission of Infectious Diseases in the Healthcare Setting. 2004. Australian Government, Department of Health and Ageing. Epidemiology and Prevention of Vaccine Preventable Diseases, 8th Edition. 2005. CDC National Immunisation Program. www.cdc.gov/nip/publications Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Draft 2004, Centres of Disease Control and Prevention (CDC) Weber. D, Rutala. W. Prevention and Control of Varicella in Hospitals. UptoDate Online.

Contact person: Email:

Glenys Harrington i.control@alfred.org.au

Position: Phone:

Infection Control Program Coordinator 9076 3139

Varicella Zoster (Chickenpox), Herpes Zoster (Shingles): Additional Airborne and Contact Precautions Approved by Bayside Health Clinical Governance Committee on 20 December 2007

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