- Email: [email protected]
Low measles, mumps and rubella (MMR) vaccine uptake in hospital healthcare worker contacts following suspected mumps infection
Letters to the Editor / Journal of Hospital Infection 76 (2010) 84–95
Acknowledgements The authors would like to acknowledge the contributions of Ms C. Cooper (vaccine uptake data) and Mr P. O’Kelly (statistician) of Beaumont Hospital in the preparation of this manuscript. Conflict of interest statement None declared. Funding sources None. References 1. Ballestas T, McEvoy SP, Doyle J. Co-ordinated approach to healthcare worker influenza vaccination in an area health service. J Hosp Infect 2009;73:203–209. 2. National Foundation for Infectious Diseases. Call to action: influenza immunization among health care personnel. Bethesda, MD: NFID; 2008. 3. Sartor C, Tissot-Dupont H, Zandotti C, Martin F, Roques P, Drancourt M. Use of a mobile cart influenza program for vaccination of hospital employees. Infect Control Hosp Epidemiol 2004;25:918–922. 4. Palmore T, Vendersluis J, Morris J, et al. A successful mandatory influenza vaccination campaign using an innovative electronic tracking system. Infect Control Hosp Epidemiol 2009;30:1137–1142. 5. Quigley R, Hayes B. Determinants of influenza vaccination uptake among healthcare workers at a tertiary referral hospital. Ir Med J 2006;99:200–203. 6. Goldstein AO, Kincade JE, Gamble G, Bearman RS. Policies and practices for improving influenza immunization rates among healthcare workers. Infect Control Hosp Epidemiol 2004;25:908–911.
H.S.S. Muhammad B. Hayes* Beaumont Hospital, Dublin, Ireland * Corresponding author. Address: Occupational Health Department, Beaumont Hospital, PO Box 1297, Dublin 9, Ireland. Fax: 00353 1 809 2315. E-mail address: [email protected] (B. Hayes) Available online 8 July 2010 Ó 2010 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jhin.2010.05.008
Low measles, mumps and rubella (MMR) vaccine uptake in hospital healthcare worker contacts following suspected mumps infection Madam, Mumps transmission can occur in hospital settings, and, as reactive measures are not always successful in preventing further cases, vaccination of healthcare workers is the key preventive measure.1 UK guidance advises that healthcare workers (HCWs) should be ‘immune to measles, mumps and rubella for the protection of their patients’, demonstrated by two documented MMR doses or serological evidence of immunity.2 In 2008 the Department of Health wrote to clinicians highlighting the importance of HCW immunity to measles following a hospital-acquired measles death. Despite this, many HCWs have not had their immunity assessed and documented, with around one-third of Trusts not
91
having information on MMR uptake by their staff.3 Where cases occur in hospital, it is difficult to determine or to predict the likelihood of mumps immunity in contacts, although UK resident adults born before 1970 are likely to have had natural mumps infection.2 Following a mumps case in hospital, current Health Protection Agency (HPA) guidance is that all susceptible contacts (including all staff born after 1980 without documentation of two doses of MMR) should be vaccinated to avoid tertiary cases. Staff with clinical mumps infection should be excluded from work for 5 days from the onset of illness, but contacts can continue to work in ‘most instances’. Guidance in the USA is more stringent and recommends exclusion of the case for 9 or 10 days, and exclusion of contacts from work from 12 days post first exposure to 25 days following the last exposure unless immunised or immune.4 In two separate incidents in 2008, suspected mumps cases in staff members at a local Acute Trust were reported to the Norfolk, Suffolk and Cambridgeshire Health Protection Unit. The incident control team, after consulting the immunisation department at the HPA Centre for Infections, adopted a policy whereby all close staff contacts identified were assessed and excluded from work where immunity to mumps (defined as above) could not be demonstrated. A close contact was defined as someone working in the same clinical team or area of the hospital, who had been at work while the case was both potentially infectious (7 days before onset) and working in the hospital. Household contacts of the case who were also hospital staff were included. Demographic information and history of mumps infection and MMR immunisation were recorded for all contacts. Serum samples were requested from all contacts without documented two-dose immunisation and tested for immunoglobulin G (IgG) to mumps virus using complement fixation testing. Staff were excluded from 12 days from first exposure to 25 days post last exposure unless they could demonstrate immunity to mumps. Contacts not excluded but lacking documentation of two MMR doses were advised to seek occupational health advice if they developed a respiratory or febrile illness in the two weeks following the latest exposure date. In the event, both cases were found not to be mumps infections early on, but a cohort of 42 contacts from two separate hospital departments had already been assessed. Only 3/42 (7%) had documented evidence of two doses of MMR vaccine: one (2%) had had one dose and the remaining 38 (90%) had no evidence of vaccination. Forty-eight percent had a history of mumps infection, 38% said they had no history of mumps infection and 14% were unsure. Thirty-six out of 39 were tested serologically, of whom 32 (89%) had detectable IgG against mumps virus. The percentage with mumps IgG was 94% (30/35) in those born before 1970 compared to 71% in those born after 1970, but this difference was not statistically significant (Fisher exact P ¼ 0.141), and most staff (83%) were born before 1970. Four contacts were given a course of MMR vaccine: three with negative serology, and one with mumps IgG but who was found not to have immunity to measles. The low level of documented MMR uptake we found (7%) is of concern, despite the level of mumps immunity. We have recommended to the Trust that they assess staff immunity and document it in an easily accessible form. Since the incidents the Trust has been working to improve MMR uptake in staff and has delivered more than 400 doses to staff. Mumps continues to be a problem in the UK, with several outbreaks reported in higher education institutions, some of which train HCWs and could potentially introduce mumps into an Acute
92
Letters to the Editor / Journal of Hospital Infection 76 (2010) 84–95
Trust. Assessment of all staff, not just new employees, together with immunisation where required, is therefore very important. Failure to act can result in situations like the one described here, with the attendant acute increase in workload for occupational health, infection control and microbiology services.
Conflict of interest statement None declared. Funding sources None. References 1. Fischer PR, Brunetti C, Welch V, Christenson JC. Nosocomial mumps: report of an outbreak and its control. Am J Infect Control 1996;24:13–18. 2. Salisbury D, Ramsay M, Noakes K, editors. Immunisation against infectious disease (‘The Green Book’). London: Stationery Office; 2006. 3. Pezzoli L, Noakes K, Gates P, Begum F, Pebody R. Can we know the immunization status of healthcare workers? Results of a feasibility study in hospital trusts, England, 2008. Epidemiol Infect 2009;4:1–8. 4. Bolyard EA, Tablan OC, Williams WW, Pearson ML, Shapiro CN, Deitchmann SD. Guideline for infection control in health care personnel: Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1998;19: 407–463.
C.J. Williamsa,* L.D. Liebowitzb J. Leveneb P. Naira a Norfolk, Suffolk and Cambridgeshire Health Protection Unit, UK b Queen Elizabeth Hospital, King’s Lynn, UK Corresponding author. Address: Norfolk, Suffolk and Cambridgeshire Health Protection Unit, Croxton Road, Thetford, Norfolk IP24 1JD, UK. E-mail address: [email protected] (C.J. Williams)
*
Available online 9 June 2010 Ó 2010 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jhin.2010.03.011
Dissemination of Bacillus cereus in the burn unit due to contaminated non-sterile gloves Madam, The hands of healthcare workers can be highly contaminated, especially during routine care procedures when they are exposed to body fluids. In addition to hand hygiene, nonsterile gloves are an important tool in minimising cross-transmission of micro-organisms from one patient to another. However, healthcare workers must be aware that non-sterile disposable gloves could be contaminated with a wide range of bacteria, including spore-forming agents.1 Here we describe an outbreak of Bacillus cereus in our burn unit due to the use of disposable gloves. Over a two-week period in July 2009, B. cereus was isolated from wound specimen samples from three patients in the burn
unit. One of the patients was a 22-year-old male who suffered 22% total body surface area burns due to a car accident. As he was exposed to potentially contaminated water used by the fire brigade to extinguish the flames, this patient was believed to be the index patient. Subsequently, environmental samples (surfaces, water and air) were taken in the rooms of the patients and all three patients were placed in contact isolation. Furthermore, as B. cereus from contaminated 70% ethyl alcohol has been shown to have caused a pseudo-epidemic, all liquids (disinfectants, soap, shampoo) were sampled and removed from the patients’ rooms.2 High touch surfaces were disinfected twice daily using 0.5% chloramine in water, and all healthcare workers were asked to wash their hands carefully instead of using alcoholic hand rubs. Despite all these measures three new cases occurred. Environmental samples remained strongly contaminated with B. cereus. Subsequently, it was decided to disinfect the whole burn unit using a chlorine solution of 3000 ppm. However, new environmental samples still revealed a massive presence of B. cereus on different surfaces (e.g. telephones, computer keyboards, infusion pumps, blood gas devices). In addition, B. cereus was isolated from opened boxes of newly introduced disposable nitrile gloves. Accordingly, a study was conducted to investigate bacterial contamination of non-sterile disposable gloves. Twenty-four boxes of nitrile gloves and 24 boxes of vinyl gloves were tested. For each box, the inner cardboard surface and the gloves were tested. Of the nitrile boxes, 20/24 (83%) were contaminated with B. cereus, whereas only 3/24 (12.5%) of the vinyl boxes were contaminated. New environmental surface cultures taken after switching to vinyl gloves showed a significantly decreased contamination level with B. cereus. We here describe dissemination of B. cereus in our burn unit due to contaminated disposable nitrile gloves. B. cereus is a spore-forming, aerobic Gram-positive, motile rod that can be isolated from many different sites.3 When found in laboratory cultures, they are usually interpreted as contaminants.4 Apart from being a common food-poisoning organism, B. cereus has also been reported to be the cause of local and systemic infections.3 As B. cereus is widely distributed in the environment including soil, dust, and fresh and marine waters, it is known to cause soft tissue infections associated with post-surgical wounds, scalds, burns, and traumatic injuries.5 As one of our patients suffered from burns which were exposed to potentially contaminated water used by the fire brigade, we suspected this patient to be the index patient. However, thoroughly implemented infection control measures did not resolve the dissemination of B. cereus at our burn unit. Recently, several outbreaks of B. cereus have been described.6,7 Although our patients had no clinical infectious signs, contaminations of wounds and spread of B. cereus to other immunocompromised patients could potentially lead to life-threatening infections. Thorough investigation showed that contaminated disposable gloves were the cause of the presence of B. cereus in the burn unit. It has already been shown that disposable gloves can be contaminated and that gloves made of nitrile are significantly more contaminated with bacteria than those made of latex or polyvinyl.1 As the European manufacturing standards for non-sterile gloves only require physical testing, guidelines and quality norms on bacterial contamination of disposable gloves are needed.
Conflict of interest statement None declared. Funding sources None.
Acknowledgements The authors would like to acknowledge the contributions of Ms C. Cooper (vaccine uptake data) and Mr P. O’Kelly (statistician) of Beaumont Hospital in the preparation of this manuscript. Conflict of interest statement None declared. Funding sources None. References 1. Ballestas T, McEvoy SP, Doyle J. Co-ordinated approach to healthcare worker influenza vaccination in an area health service. J Hosp Infect 2009;73:203–209. 2. National Foundation for Infectious Diseases. Call to action: influenza immunization among health care personnel. Bethesda, MD: NFID; 2008. 3. Sartor C, Tissot-Dupont H, Zandotti C, Martin F, Roques P, Drancourt M. Use of a mobile cart influenza program for vaccination of hospital employees. Infect Control Hosp Epidemiol 2004;25:918–922. 4. Palmore T, Vendersluis J, Morris J, et al. A successful mandatory influenza vaccination campaign using an innovative electronic tracking system. Infect Control Hosp Epidemiol 2009;30:1137–1142. 5. Quigley R, Hayes B. Determinants of influenza vaccination uptake among healthcare workers at a tertiary referral hospital. Ir Med J 2006;99:200–203. 6. Goldstein AO, Kincade JE, Gamble G, Bearman RS. Policies and practices for improving influenza immunization rates among healthcare workers. Infect Control Hosp Epidemiol 2004;25:908–911.
H.S.S. Muhammad B. Hayes* Beaumont Hospital, Dublin, Ireland * Corresponding author. Address: Occupational Health Department, Beaumont Hospital, PO Box 1297, Dublin 9, Ireland. Fax: 00353 1 809 2315. E-mail address: [email protected] (B. Hayes) Available online 8 July 2010 Ó 2010 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jhin.2010.05.008
Low measles, mumps and rubella (MMR) vaccine uptake in hospital healthcare worker contacts following suspected mumps infection Madam, Mumps transmission can occur in hospital settings, and, as reactive measures are not always successful in preventing further cases, vaccination of healthcare workers is the key preventive measure.1 UK guidance advises that healthcare workers (HCWs) should be ‘immune to measles, mumps and rubella for the protection of their patients’, demonstrated by two documented MMR doses or serological evidence of immunity.2 In 2008 the Department of Health wrote to clinicians highlighting the importance of HCW immunity to measles following a hospital-acquired measles death. Despite this, many HCWs have not had their immunity assessed and documented, with around one-third of Trusts not
91
having information on MMR uptake by their staff.3 Where cases occur in hospital, it is difficult to determine or to predict the likelihood of mumps immunity in contacts, although UK resident adults born before 1970 are likely to have had natural mumps infection.2 Following a mumps case in hospital, current Health Protection Agency (HPA) guidance is that all susceptible contacts (including all staff born after 1980 without documentation of two doses of MMR) should be vaccinated to avoid tertiary cases. Staff with clinical mumps infection should be excluded from work for 5 days from the onset of illness, but contacts can continue to work in ‘most instances’. Guidance in the USA is more stringent and recommends exclusion of the case for 9 or 10 days, and exclusion of contacts from work from 12 days post first exposure to 25 days following the last exposure unless immunised or immune.4 In two separate incidents in 2008, suspected mumps cases in staff members at a local Acute Trust were reported to the Norfolk, Suffolk and Cambridgeshire Health Protection Unit. The incident control team, after consulting the immunisation department at the HPA Centre for Infections, adopted a policy whereby all close staff contacts identified were assessed and excluded from work where immunity to mumps (defined as above) could not be demonstrated. A close contact was defined as someone working in the same clinical team or area of the hospital, who had been at work while the case was both potentially infectious (7 days before onset) and working in the hospital. Household contacts of the case who were also hospital staff were included. Demographic information and history of mumps infection and MMR immunisation were recorded for all contacts. Serum samples were requested from all contacts without documented two-dose immunisation and tested for immunoglobulin G (IgG) to mumps virus using complement fixation testing. Staff were excluded from 12 days from first exposure to 25 days post last exposure unless they could demonstrate immunity to mumps. Contacts not excluded but lacking documentation of two MMR doses were advised to seek occupational health advice if they developed a respiratory or febrile illness in the two weeks following the latest exposure date. In the event, both cases were found not to be mumps infections early on, but a cohort of 42 contacts from two separate hospital departments had already been assessed. Only 3/42 (7%) had documented evidence of two doses of MMR vaccine: one (2%) had had one dose and the remaining 38 (90%) had no evidence of vaccination. Forty-eight percent had a history of mumps infection, 38% said they had no history of mumps infection and 14% were unsure. Thirty-six out of 39 were tested serologically, of whom 32 (89%) had detectable IgG against mumps virus. The percentage with mumps IgG was 94% (30/35) in those born before 1970 compared to 71% in those born after 1970, but this difference was not statistically significant (Fisher exact P ¼ 0.141), and most staff (83%) were born before 1970. Four contacts were given a course of MMR vaccine: three with negative serology, and one with mumps IgG but who was found not to have immunity to measles. The low level of documented MMR uptake we found (7%) is of concern, despite the level of mumps immunity. We have recommended to the Trust that they assess staff immunity and document it in an easily accessible form. Since the incidents the Trust has been working to improve MMR uptake in staff and has delivered more than 400 doses to staff. Mumps continues to be a problem in the UK, with several outbreaks reported in higher education institutions, some of which train HCWs and could potentially introduce mumps into an Acute
92
Letters to the Editor / Journal of Hospital Infection 76 (2010) 84–95
Trust. Assessment of all staff, not just new employees, together with immunisation where required, is therefore very important. Failure to act can result in situations like the one described here, with the attendant acute increase in workload for occupational health, infection control and microbiology services.
Conflict of interest statement None declared. Funding sources None. References 1. Fischer PR, Brunetti C, Welch V, Christenson JC. Nosocomial mumps: report of an outbreak and its control. Am J Infect Control 1996;24:13–18. 2. Salisbury D, Ramsay M, Noakes K, editors. Immunisation against infectious disease (‘The Green Book’). London: Stationery Office; 2006. 3. Pezzoli L, Noakes K, Gates P, Begum F, Pebody R. Can we know the immunization status of healthcare workers? Results of a feasibility study in hospital trusts, England, 2008. Epidemiol Infect 2009;4:1–8. 4. Bolyard EA, Tablan OC, Williams WW, Pearson ML, Shapiro CN, Deitchmann SD. Guideline for infection control in health care personnel: Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1998;19: 407–463.
C.J. Williamsa,* L.D. Liebowitzb J. Leveneb P. Naira a Norfolk, Suffolk and Cambridgeshire Health Protection Unit, UK b Queen Elizabeth Hospital, King’s Lynn, UK Corresponding author. Address: Norfolk, Suffolk and Cambridgeshire Health Protection Unit, Croxton Road, Thetford, Norfolk IP24 1JD, UK. E-mail address: [email protected] (C.J. Williams)
*
Available online 9 June 2010 Ó 2010 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jhin.2010.03.011
Dissemination of Bacillus cereus in the burn unit due to contaminated non-sterile gloves Madam, The hands of healthcare workers can be highly contaminated, especially during routine care procedures when they are exposed to body fluids. In addition to hand hygiene, nonsterile gloves are an important tool in minimising cross-transmission of micro-organisms from one patient to another. However, healthcare workers must be aware that non-sterile disposable gloves could be contaminated with a wide range of bacteria, including spore-forming agents.1 Here we describe an outbreak of Bacillus cereus in our burn unit due to the use of disposable gloves. Over a two-week period in July 2009, B. cereus was isolated from wound specimen samples from three patients in the burn
unit. One of the patients was a 22-year-old male who suffered 22% total body surface area burns due to a car accident. As he was exposed to potentially contaminated water used by the fire brigade to extinguish the flames, this patient was believed to be the index patient. Subsequently, environmental samples (surfaces, water and air) were taken in the rooms of the patients and all three patients were placed in contact isolation. Furthermore, as B. cereus from contaminated 70% ethyl alcohol has been shown to have caused a pseudo-epidemic, all liquids (disinfectants, soap, shampoo) were sampled and removed from the patients’ rooms.2 High touch surfaces were disinfected twice daily using 0.5% chloramine in water, and all healthcare workers were asked to wash their hands carefully instead of using alcoholic hand rubs. Despite all these measures three new cases occurred. Environmental samples remained strongly contaminated with B. cereus. Subsequently, it was decided to disinfect the whole burn unit using a chlorine solution of 3000 ppm. However, new environmental samples still revealed a massive presence of B. cereus on different surfaces (e.g. telephones, computer keyboards, infusion pumps, blood gas devices). In addition, B. cereus was isolated from opened boxes of newly introduced disposable nitrile gloves. Accordingly, a study was conducted to investigate bacterial contamination of non-sterile disposable gloves. Twenty-four boxes of nitrile gloves and 24 boxes of vinyl gloves were tested. For each box, the inner cardboard surface and the gloves were tested. Of the nitrile boxes, 20/24 (83%) were contaminated with B. cereus, whereas only 3/24 (12.5%) of the vinyl boxes were contaminated. New environmental surface cultures taken after switching to vinyl gloves showed a significantly decreased contamination level with B. cereus. We here describe dissemination of B. cereus in our burn unit due to contaminated disposable nitrile gloves. B. cereus is a spore-forming, aerobic Gram-positive, motile rod that can be isolated from many different sites.3 When found in laboratory cultures, they are usually interpreted as contaminants.4 Apart from being a common food-poisoning organism, B. cereus has also been reported to be the cause of local and systemic infections.3 As B. cereus is widely distributed in the environment including soil, dust, and fresh and marine waters, it is known to cause soft tissue infections associated with post-surgical wounds, scalds, burns, and traumatic injuries.5 As one of our patients suffered from burns which were exposed to potentially contaminated water used by the fire brigade, we suspected this patient to be the index patient. However, thoroughly implemented infection control measures did not resolve the dissemination of B. cereus at our burn unit. Recently, several outbreaks of B. cereus have been described.6,7 Although our patients had no clinical infectious signs, contaminations of wounds and spread of B. cereus to other immunocompromised patients could potentially lead to life-threatening infections. Thorough investigation showed that contaminated disposable gloves were the cause of the presence of B. cereus in the burn unit. It has already been shown that disposable gloves can be contaminated and that gloves made of nitrile are significantly more contaminated with bacteria than those made of latex or polyvinyl.1 As the European manufacturing standards for non-sterile gloves only require physical testing, guidelines and quality norms on bacterial contamination of disposable gloves are needed.
Conflict of interest statement None declared. Funding sources None.