Answer to Q1

Infectious causes:

• Bacteria:
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Gram-negative bacteria (e.g. Klebsiella pneumoniae, Pseudomonas aeruginosa)
  • Atypical infections – Legionella spp, Mycoplasma pneumoniae; Chlamydophila pneumoniae
  • staphylococci
• Viruses:
  • Human herpes viruses (importantly CMV)
  • Respiratory viruses (Influenza A and B, Respiratory syncytial virus [RSV]), adenovirus, rhinoviruses, coronaviruses)
• Fungi:
  • Aspergillus spp,
  • Pneumocystis jirovecii (PCP)

Non-infectious causes:

• Radiation-induced or drug-induced lung disease

Influenza A (H3N2) was confirmed by laboratory testing

Question 2: What group of high risk patients should receive annual influenza vaccination?

Answer to Q3

• Ensure that all oncology department staff have had, or receive current season influenza vaccination.
• Vaccinate all oncology ward patients who may not already have received vaccination. Urge household members of the infected patient and other oncology patients’ household contacts, including care-givers, domestic staff and children, to be vaccinated.
• Once influenza is suspected, empiric treatment with oseltamivir (or zanamavir) must be prescribed and commenced immediately. Do not wait for laboratory test results since influenza infection can progress rapidly and is associated with higher rates of complications and death in high-risk patients.

Influenza can be transmitted in three ways:

• Direct contact with an infected person
• Contact with fomites (contaminated equipment or high touch areas e.g. door handles, light switches etc.)
• Inhalation of virus-laden aerosols.

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.

Outcomes and Lessons Learned

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.

• Before touching a patient
• Before a clean/aseptic procedure
• After body fluid exposure risk
• After touching a patient
• After touching a patient’s surroundings