Joy Cleghorn and Juno Thomas
In June 2013, a 66-year-old female presented to hospital with sudden onset of:
The patient had been discharged from hospital two weeks prior, following hematopoietic stem cell transplant and was admitted immediately back into the oncology ward.
She waited at the duty station for 15 minutes whilst a bed was made up for her in a two-bedded cubicle with a spatial distance between beds of well over one meter.
Approximately one hour after the patient had settled and was becoming acquainted with her fellow patient, the Infection Prevent and Control Specialist/Practitioner became aware of the patient’s admission and immediately arranged for transfer to an isolation ward outside of the oncology department. Droplet and Contact precautions were implemented and immunised staff that were not pregnant were allocated to nurse the patient.
Question 1: What is the differential diagnosis
Answer to Q1
Influenza A (H3N2) was confirmed by laboratory testing
Question 2: What group of high risk patients should receive annual influenza vaccination?
Answer to Q2
During most influenza seasons mortality rates are highest amongst the following patients and they should be vaccinated:
In addition, vaccination should also be considered for people in contact with patients at high risk of developing severe/complicated influenza disease, in order to reduce the risk of transmitting infection to high risk patients. This would include domestic workers, children, care workers etc.
Question 3: What infection prevention and control concerns should be addressed with regards to vaccination and/or chemoprophylaxis, and what treatment should be given to the patient?
Answer to Q3
Influenza can be transmitted in three ways:
The control of influenza virus transmission in health care settings includes measures that minimize spread by aerosol and fomites (environmental). For this reason, transmission-based precautions that need to be implemented are droplet and contact precautions.
The infected patient is highly allergic to eggs and had therefore always declined to have the influenza vaccine. The trivalent inactivated influenza vaccine (TIV) that is supplied in both public- and private-sector markets may contain trace amounts of egg protein, but true anaphylaxis following TIV is extremely rare.
Respiratory virus PCR testing can be performed on a variety of clinical specimens (throat ± nasal swabs, nasopharyngeal swabs/aspirates, sputum, bronchoalveolar lavage, lung tissue etc.).
The patient should not have been re-admitted into a high-risk oncology ward and she was also placed in a common area in the unit whilst waiting for a bed without being asked to don a surgical mask.
Infection could easily have spread from the index patient to her room-mate through contamination of high touch areas e.g. bathroom door handles etc. despite adequate spatial distance between beds.
The index patient’s room-mate in the oncology ward was transferred to another room and the area was terminally disinfected using soap and water, followed by a hypochlorite detergent. Adenosine triphosphate (ATP) swabbing was done to ensure that adequate cleaning had taken place and the room was sealed for micro mist fogging with hydrogen peroxide.
When x-rays were required, it was preferable to use a mobile x-ray unit, which was terminally disinfected (together with the x-ray plates).
Routine annual influenza vaccination is recommended for all high-risk persons aged ≥ 6 months old, healthcare workers, and also for persons in contact with high-risk persons (e.g. family members or care-givers of high-risk persons).
The World Health Organization has recommended that trivalent vaccines for use in the 2014 southern hemisphere influenza season contain strains for influenza A(H1N1)pdm09, influenza A(H3N2) and influenza B. The influenza season in South Africa generally starts between April and June each year, and the influenza vaccine is usually available by February-March each year. Being vaccinated before the onset of the influenza season offers the best protection against influenza disease, since it takes about two weeks to develop protective antibodies following vaccination. The importance of hand hygiene cannot be over emphasised: The ‘My 5 Moments for Hand Hygiene’ approach taken from the World Health Organization defines the key moments when healthcare workers should perform hand hygiene.
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