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

• 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

NEWS FEATURES

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.

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

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-care-associated 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 infection-control 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 healthcare-associated 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 3-hour 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 latent 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 QFT-G 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

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: 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 Community-Acquired 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.

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 www.scai.org/PDF/ID%20guidelines.pdf
Press release is at 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 at
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5416a1.htm?s_cid=rr5416a1_eM
Print at http://www.cdc.gov/mmwr/PDF/rr/rr5416.pdf

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. www.cdc.gov/mmwr/PDF/wk/mm5441.pdf
Source: FDA Recall E-mail List (edited)

Additional information is available online
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: 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

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).

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

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

www.pandemicflu.gov/plan/pdf/guide.pdf

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: www.hhs.gov/news/press/2006pres/20060203.html
Read MMWR: www.cdc.gov/mmwr/preview/mmwrhtml/mm55e203a1.htm
Print MMWR: 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. Registration and information are online at 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. Registration and information are online at fridaycenter.unc.edu/pdep/ici/

"Infection Control Part II: The ICP as an Environmentalist" will be held in Chapel September 18-22, 2006.

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. The SPICE is not a regulatory agency but provides education and consultation to North Carolina healthcare facilities.

Sent February 2006

Copyright 2006 Statewide Infection Control Program