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---------------------------------------------------------------------------REPORT OF THE MONTH, Volume X, Number 1 - 2006
- - - - from the North Carolina Statewide Program for Infection Control and Epidemiology
----------------------------------------------------------------------------CONTENTS:
NEWS FEATURES
Alcohol-Based Hand Rub Placement
NC Pandemic Influenza Plan Updated
REGULATORY/LEGISLATIVE
Guidelines for Preventing the Transmission of Mycobacterium tuberculosis
in Health-Care Settings, 2005
NEWS AND ANNOUNCEMENTS
CA-MRSA Information on SPICE Web Page
New Guidelines for Pacemaker Insertion in the Catheterization Lab
Immunization Strategy to Eliminate Transmission of Hepatitis B Virus
Ralstonia, Respiratory Device Recall
Supplemental Testing for Confirmation of Reactive Oral Fluid Rapid HIV
Antibody Tests
Recall of Immunodiagnositc HBsAg Confirmatory Kit
Recommended Childhood and Adolescent Immunization Schedule 2006
Legionella in Ornamental Fountains
$100 Million to Accelerate State and Local Pandemic Influenza Preparedness
Efforts
Pandemic Influenza Planning: A Guide for Individuals and Families
New laboratory Test to Detect Human Infections with Avian Influenza
COURSES FOR THE INFECTION CONTROL PROFESSIONAL
______________________________________________________________________
NEWS FEATURES
Alcohol based hand rub (ABHR) placement 2006
In the January 2006 edition of Environment of Care (EC) News, the Joint Commission
on Accreditation of Healthcare Organizations (JCAHO) provides their official stand on
the use of alcohol-based hand rubs (ABHR). The EC News article is intended to
provide clarification on JCAHO's interpretation and enforcement of the amendment to
the 2000 and 2003 editions of the Life Safety Code that specifically defines the
requirements for safe use of ABHR in healthcare facilities. The EC News article
explicitly discusses dispenser placement and permissible volume separately for gel
ABHR and for foam ABHR. Since the article was released, questions have been raised
by the Association for Professionals in Infection Control and Epidemiology (APIC) and
the American Society for Healthcare Engineering (ASHE) members on two key items
within the article: the definition of adjacent and the prohibition of installing dispensers of
foam ABHR in egress corridors. Because JCAHO's stance has just been issued and
may be further refined or modified based on the outcome of current industry efforts to
perform fire modeling of foam products (similar to ASHE's fire modeling study of gel
products), it is unreasonable for JCAHO surveyors to expect immediate compliance with
these expectations or to apply these expectations retrospectively. Therefore, ASHE and
APIC suggest the following plan of action:
*
Hospitals should comply with these new expectations for new installations of
dispensers only.
*
If a hospital cannot meet these expectations for new installations because of
space constraints, then they should perform a product-specific risk assessment to
determine if manufacturer labeling indicates any product-specific hazards to be
addressed in the usage or dispensing of the product. ASHE believes that JCAHO's
concerns about foam products center on the use of an aerosol propellant (the liquefied
or compressed gas that expels the contents from the aerosol container). If the foam
product does not use a flammable propellant, the foam product may be dispensed in the
same manner as gel products (i.e., no restriction from placement in egress corridors).
*
This risk assessment, and usage according to manufacturer labeling, should be
the basis for justifying any deviations from the JCAHO guidance for new installations
and document the action taken.
*
Hospitals should work with their local fire officials to determine compliance with
local regulations.
Through observance and adherence to the requirements identified in the National Fire
Protection Association (NFPA) amendment, ABHR use can be effectively managed to
allow ready access by healthcare workers and family members and minimize the
potential risk of fire.
Judene Bartley MS MPH CIC (ASHE-APIC liaison, APIC Public Policy Committee
Member)
Denise Graham (Senior Director of Public Policy, Association for Professionals in
Infection Control and Epidemiology)
NC Pandemic Influenza Plan Updated
The North Carolina Pandemic Influenza Plan was first released in October 2004. This
plan was revised and the updated version was released on January 26, 2006. The
entire plan may be viewed and downloaded from
http://www.epi.state.nc.us/epi/gcdc/pandemic.html.
Of particular interest to those in Infection Control is Section F, Preparedness in
Healthcare Facilities. The primary changes in this revision are:
1) Alteration of pandemic phases to coincide with federal guidelines;
2) Expansion of precaution measures and patient cohorting (Background and
Pandemic Phase 6);
3) Enhanced guidance for limiting hospital admissions, transfers, and discharges
(Pandemic Phase 6);
4) Inclusion of “Communication and Reporting” guidelines (Pandemic Phase 6); and
5) Expanded guidance for monitoring and managing the health status of healthcare
workers (Pandemic Phase 6).
In addition to the above revisions, it is necessary for healthcare facilities to assess and
obtain adequate supplies of vaccines, antiviral agents, and both durable and
consumable medical equipment. It is also recommended that you collaborate with your
local public health and emergency management personnel to identify Alternative Care
Facilities (ACFs). In the event of a pandemic, it will be necessary to reserve the
hospitals for those patients who are extremely ill, and thus perform triage and medical
care for those who are less ill at alternate sites.
REGULATORY/LEGISLATIVE
Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in
Health-Care Settings, 2005
In 1994, CDC published the Guidelines for Preventing the Transmission of
Mycobacterium tuberculosis in Health-Care Facilities, 1994. Given the changes in
epidemiology and a request by the Advisory Council for the Elimination of Tuberculosis
(ACET) for review and update of the 1994 tuberculosis (TB) infection control document,
CDC has reassessed the TB infection control guidelines for health-care settings. This
report updates TB control recommendations reflecting shifts in the epidemiology of TB,
advances in scientific understanding, and changes in health-care practice that have
occurred in the United States during the preceding decade. In the context of diminished
risk for health-care-associated transmission of M. tuberculosis, this document places
emphasis on actions to maintain momentum and expertise needed to avert another TB
resurgence and to eliminate the lingering threat to healthcare workers (HCWs), which is
mainly from patients or others with unsuspected and undiagnosed infectious TB
disease. CDC prepared the current guidelines in consultation with experts in TB,
infection control, environmental control, respiratory protection, and occupational health.
The new guidelines have been expanded to address a broader concept; health-careassociated settings go beyond the previously defined facilities. The term "health-care
setting" includes many types, such as inpatient settings, outpatient settings, TB clinics,
settings in correctional facilities in which health care is delivered, settings in which
home-based health-care and emergency medical services are provided, and
laboratories handling clinical specimens that might contain M. tuberculosis. The term
"setting" has been chosen over the term "facility," used in the previous guidelines, to
broaden the potential places for which these guidelines apply. (From Summary in
MMWR 2005;54(RR-17).
Listed below are key recommendations in the 2005 guidelines.
1.
Guideline and healthcare facility TB plan should include all employees, students,
and volunteers.
2.
Tuberculin skin test (TST) should be obtained on all new employees (even in
facilities at consider low risk). Two-stage test should be obtained on employees
who have not had a TST within previous 12 months.
3. An extensive 8 page TB risk assessment form (Appendix B) has been added and
should be completed once and then updated periodically (annually if possible) at
each facility.
4. Annual TST for facilities classified at medium risk. No mention is made of making
TST mandatory for employees.
5. Ensure patient adherence to airborne precautions.
6. Consider developing an operating room (OR) with reversible flow (hallway to OR)
or positive-pressure room with a negative pressure anteroom.
7. Based on the risk assessment, consideration should be given to using a higher
level of respiratory protection (e.g., PAPR) in the following circumstances:
obtaining induced sputum or performing bronchoscopy on a patient with known or
suspected tuberculosis.
8.
For patients with known or suspected tuberculosis, the ambulance ventilation
system should be operated in the nonrecirculated mode, and the maximum amount
of outdoor air should be provided to facilitate dilution.
9. TST conversion of a healthcare worker should be reported to the health
department. An investigation of a test conversion should be performed in
collaboration with the local or state health departments. Laboratory and infectioncontrol records should be reviewed to identify all patients (and any HCWs) who
have suspected or confirmed infectious TB disease and may have transmitted M.
tuberculosis to the healthcare worker (HCW).
10. Visitors to airborne infection isolation rooms and other areas with patients who
have suspected or confirmed infectious TB disease may be offered respirators and
should be instructed by a HCW on the use of the respirator before entering an
airborne infection isolation room.
11. “Visitors of all hospitalized pediatric TB patients should be screened for TB disease
as soon as possible to ensure that they do not become sources of healthcareassociated transmission of M. tuberculosis.”
12. Patients (including children) who have suspected or confirmed TB disease and
who are not on anti-TB treatment should be considered infectious if characteristics
include:
Presence of cough
Cavitation on chest radiograph
Positive AFB sputum smear results
Respiratory tract disease with involvement of lungs or airways, including larynx
Failure to cover mouth and nose when coughing
Undergoing cough-inducing or aerosol generating procedures
13. Patients with TB disease may be discharged if ALL of the following are met:
A specific plan exists for follow-up care with the local TB-control program
The patient has been started on a standard multidrug anti-TB regimen, and directly
observed therapy has been arranged
No infants or children, aged <4 years or persons with immunocompromising conditions
are present in the household
All immunocompetent household members have been previously exposed to the patient
The patient is willing to not travel outside of the home except for healthcare-associated
visits until the patient has negative sputum smear results
14. “Patients and HCWs should not be allowed to read their own TST results.”
15. Additional TST training for healthcare workers who place or read TST includes a 3hour lecture, supervised 9 hours of observation of practical work, and
administration of 10 total TST successfully placed using saline, as demonstrated
by wheals of 6-10 mm. This replaces the previous training recommendation of
only watching a video.
16. Anergy testing is not useful in screening for diagnosis of atent tuberculosis
infection or asymptomatic TB disease.
17. Pregnant HCWs should be included in serial skin testing as part of an infection
control program or a contact investigation because no contraindication for TST
exists.
18. Consider use of in vitro cytokine-based immunoassay test, the Quantiferon-TB
Gold (QFT-G), for all circumstances where the traditional TST has been used (i.e.,
routine screenings and contact investigations). A separate guideline published in
the December 16, 2005 MMRW (No RR15 1-49-55) cited advantages to the QFTG test in detecting latent and non-symptomatic TB infected-cases and eliminating
false positives due to BCG or battey antigen response to other mycobacterium.
This ELISA one-step blood test eliminates the need for repeat visits for TST
readings.
19. Periodic fit testing for respirators used in environments where a risk for M.
tuberculosis transmission exists can serve as an effective training tool in
conjunction with the content included in employee training and retraining. The
frequency of periodic testing should be supplemented by the occurrence of the
following:
A risk for transmission of M. tuberculosis
A change in facial features of the wearer
A medical condition that would affect respiratory function
Physical characteristics of the respirator (despite the same model number), or
A change in the model or size of the assigned respirator
Note: Annual fit testing for the N95 is not recommended.
Guidelines: Read at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm
Print at http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf
Quantiferon-TB Gold - Read at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5415a4.htm
Print: http://www.cdc.gov/mmwr/PDF/rr/rr5415.pdf
NEWS AND ANNOUNCEMENTS
CA-MRSA Information on SPICE Web Page
The North Carolina Consensus Guideline for Management of Suspected CommunityAcquired Staphylococcus aureus (CA-MRSA) Skin and Soft Tissue Infections (STIs) is
available on the internet for downloading and printing. This consensus guideline was
developed by the NC Statewide Program for Infection Control and Epidemiology
(SPICE) in conjunction with the Public Health and Institutional Task (PHIT) Force for
Best Practices, North Carolina, December 2005. In addition, it is supported by the North
Carolina Public Health Department, the Association for Professionals in Infection
Control and Epidemiology - North Carolina Chapter, and the North Carolina Infectious
Disease Society.
http://www.unc.edu/depts/spice/CA-MRSA.html
New Guidelines for Pacemaker Insertion in the Catheterization Lab
December 5, 2005. The Society for Cardiovascular Angiography and Interventions
released an updated set of guidelines for infection control in cardiovascular
catheterization laboratories. Release of these revised guidelines was prompted in part
by the recognition that interventional cardiology procedures have become increasingly
complex in recent years. The guidelines, published in the January 2006 issue of
Catheterization and Cardiovascular Interventions: Journal of the Society for
Cardiovascular Angiography and Interventions, update a document published in 1992.
Guidelines at http:// www.scai.org/PDF/ID%20guidelines.pdf
Press release is at http://www.scai.org/pr.aspx?PAGE_ID=4319
Immunization Strategy to Eliminate Transmission of Hepatitis B Virus
December 23, 2005. A Comprehensive Immunization Strategy to Eliminate
Transmission of Hepatitis B Virus Infection in the United States. Recommendations of
the Advisory Committee on Immunization Practices (ACIP) Part 1: Immunization of
Infants, Children, and Adolescents was published in the MMWR. Approximately 90% of
babies who contract hepatitis B virus (HBV) infection will become chronic carriers and,
of those, 25% will die of liver cancer or cirrhosis. Administration of the birth dose of
hepatitis B vaccine will help prevent the serious consequences of HBV infection during
perinatal and early childhood periods. This report is the first of a two-part statement
from the Advisory Committee on Immunization Practices (ACIP) that updates the
immunization strategy to eliminate HBV transmission in the United States. This
document includes the following updated recommendations:
1. Implementation of universal vaccination of newborns before hospital discharge
2. Vaccination of children and adolescents who were not previously vaccinated
Read The MMWR 12/23/05, 54(RR16);1-23
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5416a1.htm?s_cid=rr5416a1_eM
Print at: http://www.cdc.gov/mmwr/PDF/rr/rr5416.pdf
Ralstonia, Respiratory Device Recall
Vapotherm, Inc., Stevensville, Maryland, initiated a nationwide recall of all Vapotherm
2000i Respiratory Gas Humidification devices. Some of these devices have been found
to contain the Ralstonia species of bacteria. Ralstonia, as with any Gram-negative
organism, may cause infection, sepsis and in most severe cases be life-threatening.
Health care practitioners should seek alternative respiratory gas humidification devices.
Any health care facilities that have the Vapotherm 2000i device must return all devices
to Vapotherm, Inc. For instructions for return, see listing in the recall information
website at http://www.vtherm.com/recall or call Vapotherm, Inc. at 1-866-827-6843. The
"Vapotherm 2000i" label is located on the front of the device on the lower right-hand
corner. If there is a question in identification of the product please contact Vapotherm
for assistance.
This device is used in both the home and in health care institutions for warming and
humidifying breathing gases, such as oxygen, delivered by nasal cannula.
The finding of Ralstonia in Vapotherm units was first reported by the Centers for
Disease Control and Prevention (CDC) in the October 21, 2005 issue of the Morbidity
and Mortality Weekly Report.
http://www.cdc.gov/mmwr/PDF/wk/mm5441.pdf
Source: FDA Recall E-mail List (edited)
Additional information is available online
http://www.fda.gov/CDRH/recalls/recall-101305.html
Supplemental Testing for Confirmation of Reactive Oral Fluid Rapid HIV Antibody
Tests
December 16, 2005. The CDC reported receiving reports of false positive results from
multiple HIV testing programs using oral fluid specimens in the OraQuick® Advance
Rapid HIV-1/2 Antibody Test. Some false positives are to be expected within the range
of specificity for the test. CDC is actively working to investigate these reports, assess
the test's current performance, and consider whether changes in testing protocols
should be recommended. In the meantime, current protocols for confirmation of
reactive rapid HIV test results should be followed.
See MMWR Dispatch online at
www.cdc.gov/mmwr/preview/mmwrhtml/d15416a1.htm?s_cid=mm54d1216a1_e
Print at: http://www.cdc.gov/mmwr/PDF/rr/rr5415.pdf
Recall of Immunodiagnositc HBsAg Confirmatory Kit
December 15, 2005. The HBsAg Confirmatory Kit is used to confirm the presence of
Hepatitis B surface antigen in human blood and plasma that has initially been found to
be reactive using the VITROS Immunodiagnostic Products HBsAg Reagent Pack.
(Ortho-Clinical Diagnostics). An unknown component in the diluting solution used to
test blood and serum samples may produce 'Not Confirmed' results for samples found
to be positive with the initial test, which can cause some results to be classified as false
negatives
http://www.fda.gov/cdrh/recalls/recall-121505.html
Recommended Childhood and Adolescent Immunization Schedule 2006
January 6, 2006. The Advisory Committee on Immunization Practices (ACIP)
periodically reviews the recommended childhood and adolescent immunization
schedule to ensure that the schedule is current with changes in vaccine formulations
and reflects revised recommendations for the use of licensed vaccines, including those
newly licensed. The recommendations and format of the childhood and adolescent
immunization schedule and catch-up schedule for January-December 2006 were
approved by ACIP, the American Academy of Pediatrics (AAP), and the American
Academy of Family Physicians (AAFP).
Read at: www.cdc.gov/mmwr/preview/mmwrhtml/mm5451-Immunizationa1.htm
Print at: www.cdc.gov/mmwr/PDF/wk/mm5451.pdf
Legionella in Ornamental Fountains
The South Dakota Health Department commissioned guidelines for control of legionella
in ornamental fountains. The guidelines discuss in detail fountains in healthcare
facilities. The guidelines are available online
http://www.state.sd.us/doh/Pu bs/legion.htm (South Dakota Link) or
http://www.legione llarm.com/guidelines/guidelines.htm (Direct Link)
$100 Million to Accelerate State and Local Pandemic Influenza Preparedness
Efforts
January 12, 2006. U. S. Health and Human Services announced $100 million in funding
for state and local preparedness. This funding is part of $350 million included in the
recent emergency appropriation for combating pandemic influenza passed by Congress
in December. States and municipalities will use these funds to accelerate and intensify
current planning efforts for pandemic influenza and to exercise their plans. The focus is
on practical, community-based procedures that could prevent or delay the spread of
pandemic influenza, and help to reduce the burden of illness communities would
contend with during an outbreak.
www.hhs.gov/news/press/2006pres/20060112.html#skip#skip
More information on pandemic preparedness efforts is available at
http://www.pandemicflu.gov
Pandemic Influenza Planning: A Guide for Individuals and Families
Pandemic Influenza Planning: A Guide for Individuals and Families is a new tool to help
Americans understand the threat of pandemic influenza and specific actions they can
take to protect themselves and their families. The handbook includes a "Pandemic Flu
Planning Checklist for Individuals and Families" as well as "Family Emergency Health
Information Sheet" to help people gather information and resources. The checklist
breaks activities into three categories: "To plan for a pandemic;" "To limit the spread of
germs and prevent infection;" and "Items to have on hand for an extended stay at
home." A copy of the Pandemic Influenza Planning: A Guide for Individuals and
Families, other checklists and pandemic planning information are available online at
http://www.pandemicflu.gov/plan/pdf/guide.pdf
New Laboratory Test to Detect Human Infections with Avian Influenza
February 3, 2006. The Food and Drug Administration (FDA) announced the approval of
a new laboratory test to diagnose H5 strains of influenza in patients suspected to be
infected with the virus. The test was developed by the Centers for Disease Control and
Prevention (CDC). The product approved is called the Influenza A/H5 (Asian lineage)
Virus Real-time RT-PCR Primer and Probe Set. The test provides preliminary results on
suspected H5 influenza samples within four hours once a sample arrives at the lab and
testing begins. Previous testing technology would require at least two to three days to
render results. If the presence of the H5 strain is identified, then further testing is
conducted to identify the specific H5 subtype (e.g., H5N1).
Press release: http://www.hhs.gov/news/press/2006pres/20060203.html
Read MMWR: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm55e203a1.htm
Print MMWR: http://www.cdc.gov/mmwr/pdf/wk/mm55e203.pdf
COURSES FOR THE INFECTION CONTROL PROFESSIONAL
"Infection Control in Long-Term Care Facilities” will be held March 6-8, 2006 in Chapel
Hill. Information and registration are available online at
http://fridaycenter.unc.edu/pdep/iclong/
“Infection Control Part I: Clinical Surveillance of Healthcare-Associated Infections” will
be held in Chapel Hill May 8-12, 2006. Information and registration are online at
http://fridaycenter.unc.edu/pdep/ici/
“Infection Control Part II: The ICP as an Environmentalist” will be held in Chapel Hill
September 18-22, 2006.
-----------------------------------------------------------------------------------Contributors to Report of the Month: Karen K. Hoffmann, RN, MS, CIC; William A.
Rutala, PhD, MPH; David J. Weber, MD, MPH; Jennifer MacFarquhar, RN, BSN, CIC;
Eva P. Clontz, MEd.
-----------------------------------------------------------------------------------To subscribe to the Report of the Month, send email to
[email protected]
Report of the Month is also available on the home page of the Statewide Program for
Infection Control and Epidemiology at http://www.unc.edu/depts/spice/
The Statewide Program for Infection Control and Epidemiology (SPICE) is funded by
the General Assembly of North Carolina to serve the State. SPICE is not a regulatory
agency but provides education and consultation to North Carolina healthcare facilities.
Sent February 2006
Copyright 2006 Statewide Program for Infection Control and Epidemiology