CONTENTS:
NEWS FEATURES
NEWS FEATURES
Effective Way to Eliminate Clostridium difficile in the Environment
In July 2005, the Centers for Disease Control and Prevention (CDC) provided updated information on preventing C. difficile - associated disease in hospitals and other healthcare settings that includes implementing an environmental cleaning and disinfection strategy.
(1) Ensure adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently. (2) Use an Environmental Protection Agency (EPA)-registered hypochlorite-based disinfectant for environmental surface disinfection after cleaning in accordance with label instructions; generic sources of hypochlorite (e.g., household chlorine bleach) also may be appropriately diluted and used. (Note: alcohol-based disinfectants are not effective against C. difficile and should not be used to disinfect environmental surfaces.) (3) Follow the manufacturer's instructions for disinfection of endoscopes and other devices.
Infection control practices in long term care and home health settings are similar to those practices taken in traditional health-care settings.
Surfaces should be kept clean, and body substance spills should be managed promptly as outlined in CDC's “Guidelines for Environmental Infection Control in Health-Care Facilities.” Hospital cleaning products can be used for routine cleaning. Hypochlorite-based disinfectants have been used with some success for environmental surface disinfection in those patient-care areas where surveillance and epidemiology indicate ongoing transmission of C. difficile . Consult the aforementioned guidelines for use conditions for generic sources of hypochlorite-based products (e.g., household chlorine bleach) for disinfection of environmental surfaces.
Note: EPA-registered hospital disinfectants are recommended for general use whenever possible in patient-care areas. At present there are no EPA-registered products with specific claims for inactivating C. difficile spores, but there are a number of registered products that contain hypochlorite. If an EPA-registered proprietary hypochlorite product is used, consult the label instructions for proper and safe use conditions. For more information see this CDC web site. (From the CDC)
http://www.cdc.gov/ncidod/dhqp/id_Cdiff.html
Since that CDC publication in July, a recent study demonstrated the activity of regular bleach (1:10 dilution or 5000 ppm free chlorine) could inactivate C. difficile spores greater than or equal to 6 log 10 reduction on hard environmental surfaces in approximately 5-10 minutes under ambient conditions (Am J Infect Control 2005;33:320-5). Sodium hypochlorite (bleach), and all disinfectants, should be handled with care for protection of staff. In units with high endemic Clostridium difficile infection rates or in an outbreak setting, use dilute solutions of 5.25-6.15% sodium hypochlorite (e.g., 1:10 dilution of bleach) for routine environmental disinfection.
In addition to environmental cleaning to control transmission of C. difficile , hand hygiene is also important. C. difficile spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item. Healthcare workers should perform hand hygiene using either alcohol-based hand rubs or soap and water. If a cluster is identified, consider using only soap and water for hand hygiene when caring for patients with C. difficile -associated disease. Healthcare facilities may choose to use soap and water hand hygiene followed by alcohol-based waterless agents as routine practice when caring for patients with C. difficile or diarrhea of unknown origin. Patients with C. difficile disease should be placed on Contact Precautions for the duration of the illness until diarrhea resolves. Facilities experiencing a cluster of unusually severe disease outcome (e.g., megalacolon, death) should consider having the toxin identified. There has been a new toxin strain identified in the Northeast that may produce 15 to 20 times the virulence of Toxin A or B seen to date. This increased virulence is thought to be related to a loss of the regulator gene that prevents overproduction of toxin. This new toxin strain has been isolated in a North Carolina hospital.
NC Discouraging Personal Stockpiles of Antivirals
The North Carolina Department of Health and Human Services has issued a memorandum to health-care providers discouraging them from issuing prescriptions for personal stockpiles of influenza virus neuraminidase inhibitor antiviral medications. In recent days there has been much media attention given to the avian influenza (bird flu) crisis in Asia and the likelihood of a human influenza pandemic. Given the reports that the circulating avian influenza virus H5N1 is resistant to the antivirals amantadine and rimantadine, there are concerns that persons are asking their health-care providers for prescriptions for the antiviral medications Tamiflu or Relenza for their personal stockpiles in the event of a pandemic.
The North Carolina Division of Public Health strongly discourages personal oseltamivir (Tamiflu) or zanamivir (Relenza) stockpiling because:
From Jeffrey Engel, MD, NC State Epidemiologist, Public Health
QUESTION OF THE MONTH
Routine Culturing in Pharmacy
Note: This question is reprinted from the APIC listserv along with the response from Dr. Arjun Srinivasan of the CDC.
Q. In accordance with USP 797 guidelines, we are performing monthly settle plate cultures in our low and medium-risk sterile compounding areas of our Home Infusion Pharmacy. Pharmacy is asking that routine surface cultures and glove fingertip cultures also be performed to validate cleaning processes and to monitor personnel. Pharmacy agrees that this routine culturing is not required by 797, but they have citations from home infusion expert presentations, home infusion journal articles, and even a module from a home infusion certificate program that recommend performing surface cultures routinely. How should infection control respond?
A. The Division of Healthcare Quality Promotion (DHQP) at the Centers for Disease Control and Prevention agrees that the recommendations for routine environmental sampling of compounding pharmacy environments in USP standard 797 pose some problems and should be reconsidered. We have pointed out that the recommendations are in conflict with current CDC guidelines for environmental infection control. DHQP has provided comments to USP, as they are in the process of revising standard 797, encouraging them to re-visit the recommendations for these routine environmental cultures and instead recommend environmental sampling in the same circumstances they are recommended in all other healthcare settings as described in the environmental infection control guidelines.
Arjun Srinivasan, MD
LCDR USPHS
Medical Epidemiologist
Division of Healthcare Quality Promotion
Centers for Disease Control and Prevention
REGULATORY/LEGISLATIVE
International Code Council Revises Safety Codes to Conform to CMS
November 3, 2005 . A three year collaborative effort between Association for Professionals in Infection Control and Epidemiology (APIC), Society for Healthcare Epidemiology of America (SHEA), the American Society for Healthcare Engineers (ASHE), American Hospital Association, National Fire Protection Association and other healthcare organizations has come to fruition as the International Code Council (ICC) has revised its safety codes to conform to the Centers for Medicare and Medicaid (CMS) regulation permitting alcohol-based hand-rub dispensers in hospital corridors. The ICC is the fire safety standard-setting organization for most states and localities. Alcohol-based hand sanitizers have been shown to have a positive impact on healthcare professionals' hand hygiene and to reduce the spread of healthcare-associated infections. ICC revisions will have to be adopted on a state-by-state basis and primarily affects new construction. Additional information is available on the internet.
From APIC Public Policy statement
http://www.ashe.org/ashe/codes/handrub/index.html
NEWS AND ANNOUNCEMENTS
CDC's Advisory Committee on Immunization Practices Expands Hepatitis A Vaccination for Children
October 28, 2005 . An advisory committee to the Centers for Disease Control and Prevention (CDC) has recommended that all children in the United States receive hepatitis A vaccine. The previous recommendation of the Advisory Committee on Immunization Practices (ACIP) in 1999, called for vaccinations in states with the highest rates of hepatitis A. About two-thirds of cases are now reported from states in which hepatitis A vaccination of children was not recommended. The ACIP recommendation is for children to receive the first dose of a two-dose series of hepatitis A vaccine between 1 and 2 years of age and that the vaccine be integrated into the routine childhood vaccination schedule.
Advisory Committee on Immunization Practice Recommends Adult Vaccination with New Tetanus, Diphtheria and Pertussis Vaccine
The Centers for Disease Control and Prevention's (CDC) Advisory Committee on Immunization Practices (ACIP) at its recent meeting (October 26 and 27) in Atlanta, voted to recommend that adults from 19 to 64 years of age be vaccinated with a newly licensed adult booster tetanus, diphtheria and pertussis (whooping cough) vaccine (Tdap).
Under the ACIP recommendation, the Tdap vaccine would replace the currently recommended tetanus-diphtheria vaccine that is used as the adult booster vaccine. The new vaccine helps protect adults from pertussis, an illness with severe and prolonged cough. It also reduces the risk of transmitting pertussis to infants.
In June, the ACIP recommended that adolescents 11 and 12 years of age be given Tdap in place of the tetanus-diphtheria (Td) booster typically given to adolescents. The committee also recommended that Tdap be given to adolescents 13 through 18 who missed the 11 to 12 year dose of Td. Adolescents 11 to 18 who have already been vaccinated with Td are encouraged to receive a dose of Tdap at intervals shorter than 10 years, to add protection against pertussis.
Recommended Antimicrobial Agents for the Treatment and Postexposure Prophylaxis of Pertussis - 2005 CDC Guidelines December 9, 2005 . Recommended Antimicrobial Agents for the Treatment and Postexposure Prophylaxis of Pertussis - 2005 CDC Guidelines. The recommendations in this report were developed to broaden the spectrum of antimicrobial agents that are available for treatment and postexposure prophylaxis of pertussis. They include updated information on macrolide agents other than erythromycin (azithromycin and clarithromycin) and their dosing schedule by age group.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5414a1.htm
Guidelines for the Investigation of Contacts of Persons with Infectious Tuberculosis
December 16, 2006 . Guidelines for the Investigation of Contacts of Persons with Infectious Tuberculosis, Recommendations from the National Tuberculosis Controllers Association and CDC. This statement, the first issued jointly by the National Tuberculosis Controllers Association and CDC, was drafted by a working group consisting of members from both organizations on the basis of a review of relevant epidemiologic and other scientific studies and established practices in conducting contact investigations. This statement provides expanded guidelines concerning investigation of TB exposure and transmission and prevention of future cases of TB through contact investigations. In addition to the topics discussed previously, these expanded guidelines also discuss multiple related topics (e.g., data management, confidentiality and consent, and human resources). These guidelines are intended for use by public health officials but also are relevant to others who contribute to TB control efforts.http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5415a1.htm
Health and Human Services Pandemic Influenza Plan
November 2, 2005 . The US Department of Health and Human Services (HHS) Pandemic Influenza Plan is a detailed guide for how the nation's health care system can prepare and respond to an influenza pandemic. The HHS plan specifies four major components of preparedness and response to pandemic influenza: (1) Intensifying surveillance and collaborating on containment measures-both international and domestic; (2) Stockpiling of antivirals and vaccines and working with industry to expand capacity for production of these medical countermeasures; (3) Creating a seamless network of federal, state and local preparedness, including increasing health care surge capacity; and (4) Developing the public education and communications efforts so critical to keeping the public informed. (from HHS press release)
The plan can be found online at
http://www.pandemicflu.gov
SPICE Influenza Web Page
“Influenza” is a new web page on the SPICE web site. Links are provided to North Carolina , US government, and World Health Organization information about influenza. In addition, Dr. David Weber has provided a set of downloadable slides, Preparedness for an Influenza Pandemic: Focus on Vaccine Development and Hospital Preparedness.
http://www.unc.edu/depts/spice/flu.html
European Team Develops Human Vaccine for H7N1 Bird Flu Strain
October 27, 2005 . European influenza experts have developed the first human vaccine for the H7N1 strain of avian influenza, which can jump from poultry to humans. H7N1 caused lethal flu outbreaks in Italian poultry in 1999. But the risk of it emerging as a pandemic strain is lower than H5N1, which has killed more than 60 people in Asia . A six-partner consortium from Britain , France and Italy - including academic and scientific institutions as well as the vaccines unit of Franco-German drug maker Sanofi-Aventis - has developed the new vaccine, called RD-3. Clinical trials will begin in spring 2006.
FDA Approves First Test to Screen for West Nile Virus in Donors of Blood, Organs, Cells and Tissues
December 1, 2005 . The Food and Drug Administration (FDA) announced the approval of the first West Nile Virus (WNV) blood test to screen donors of blood, organs, cells and tissues. The Procleix WNV Assay, developed by Gen-Probe Inc., and marketed by Chiron Corporation, detects viral genetic material (ribonucleic acid or RNA). This new test will help protect patients who receive blood and other such products against West Nile infection. To date, there have been 30 documented cases of people who most likely acquired WNV from a blood transfusion, including nine who died.
http://www.fda.gov/bbs/topics/NEWS/2005/NEW01266.html
Personal Protective Equipment (PPE) and Patient Care Web Page
This website has information about personal protective equipment (PPE) that is regulated by FDA for use in patient care, including surgical masks and surgical N-95 respirators, medical gloves, and surgical gowns. Use this website to learn about PPE used to protect healthcare workers and patients during patient care activities.
http://www.fda.gov/cdrh/ppe/index.html
COURSES FOR THE INFECTION CONTROL PROFESSIONAL
"Infection Control in Long-Term Care Facilities” will be held March 6-8, 2006 in Chapel Hill .
“Infection Control Part I: Clinical Surveillance of Healthcare-Associated Infections” will be held in Chapel Hill May 8-12, 2006.
“Infection Control Part II: The ICP as an Environmentalist” will be held in Chapel Hill September 18-22, 2006.