Case of the Month

November 2013

Joy Cleghorn and Juno Thomas

In June 2013, a 66-year-old female presented to hospital with sudden onset of:

  • myalgia
  • fever of 38.1°C
  • malaise
  • headache
  • sore throat
  • non-productive cough
  • rhinitis

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

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 Q2

During most influenza seasons mortality rates are highest amongst the following patients and they should be vaccinated:

  • Age ≥ 65 years of age
  • Children < 2 years of age
  • Diabetes mellitus
  • Pulmonary, chronic cardiac, hepatic, renal or neurological disease
  • Immunosuppression
    • Malignancy
    • Severe primary immunodeficiency
    • High dose corticosteroids/other types of immunosuppressive therapy
    • HIV-infected patients
  • Morbidly obese (BMI ≥ 40)
  • ≤ 18 years on long-term aspirin therapy
  • Residents of nursing homes and other long-term care facilities
  • Pregnancy or post-partum (within 2 weeks of delivery)

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

  • 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

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