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Evidence Review:
Communicable Disease (Public Health Measures)
Population and Public Health
BC Ministry of Healthy Living and Sport
This paper is a review of the scientific evidence for this core program. Core program evidence
reviews may draw from a number of sources, including scientific studies circulated in the
academic literature, and observational or anecdotal reports recorded in community-based
publications. By bringing together multiple forms of evidence, these reviews aim to provide a
proven context through which public health workers can focus their local and provincial
objectives. This document should be seen as a guide to understanding the scientific and
community-based research, rather than as a formula for achieving success. The evidence
presented for a core program will inform the health authorities in developing their priorities, but
these priorities will be tailored by local context.
This Evidence Review should be read in conjunction with the accompanying Model Core
Program Paper.
Evidence Review prepared by:
Lilian Yuan, Shaun Peck and Bonnie Henry
Evidence Review accepted by:
Population and Public Health, Ministry of Healthy Living and Sport (July 2008)
Core Functions Steering Committee (January 2009)
© BC Ministry of Healthy Living and Sport, 2010
Core Public Health Functions for BC: Evidence Review
Communicable Disease (Public Health Measures)
Population and Public Health, Ministry of Healthy Living and Sport
TABLE OF CONTENTS
1.0 Overview/Setting the Context ............................................................................................. 1 1.1 An Introduction to This Paper.................................................................................... 1
2.0 Methodology ....................................................................................................................... 3
3.0 Isolation and Quarantine ..................................................................................................... 4 3.1 Effectiveness of Quarantine and Isolation ................................................................. 5 3.2 Disease Parameters that Affect Quarantine and Isolation .......................................... 6 3.3 Compliance with Quarantine and Isolation ................................................................ 7 3.4 The Ethics of Isolation and Quarantine ..................................................................... 8
3.5 Updated Quarantine Act ............................................................................................ 9
4.0 Community-based Infection Control Measures ................................................................ 10 4.1 Child Care Facilities in British Columbia ................................................................ 10
4.2 Exclusion of Sick Children from Child Care Facilities and Schools ....................... 11 4.3 Day Care and School Closure .................................................................................. 13 4.4 Exclusion of Infected Workers ................................................................................ 13
4.4.1 Blood-borne Infections ........................................................................................ 13 4.4.2 Enteric Diseases ................................................................................................... 14
4.5 Restrictions on Public Gatherings ............................................................................ 15 4.6 Simultaneous Use of Multiple Community-Based Interventions ............................ 15
5.0 Facility-based Measures.................................................................................................... 17 5.1 Disease Transmission in Facilities ........................................................................... 17 5.2 Personal Protective Equipment ................................................................................ 18
5.3 Gloves ...................................................................................................................... 19
5.4 Gowns ...................................................................................................................... 20 5.5 Masks, Respiratory Protection and Eye Protection.................................................. 20 5.6 Patient and Staff Cohorting ...................................................................................... 21
5.7 Screening of Patients and Staff ................................................................................ 22 5.7.1 Patients ................................................................................................................. 22 5.7.2 Staff ...................................................................................................................... 23 5.7.3 Visitors ................................................................................................................. 24
5.8 Restriction of Admissions and Transfers ................................................................. 24
5.9 Facility Closure ........................................................................................................ 25
6.0 Infection Control in Relation to Diseases ......................................................................... 26 6.1 Antibiotic-Resistant Organisms ............................................................................... 26 6.2 Respiratory Diseases ................................................................................................ 27
6.3 Enteric Diseases ....................................................................................................... 28 6.4 Emerging Communicable and Zoonotic Diseases ................................................... 28 6.5 Vector-borne Diseases ............................................................................................. 29 6.6 Blood-borne Diseases (e.g., HIV, Hepatitis B and Hepatitis C) .............................. 29 6.7 Reproductive and Sexual Health .............................................................................. 29 6.8 Tuberculosis ............................................................................................................. 30 6.9 Vaccine-Preventable Diseases ................................................................................. 30
7.0 Conclusion ........................................................................................................................ 31
References ................................................................................................................................. 32
Core Public Health Functions for BC: Evidence Review
Communicable Disease (Public Health Measures)
Population and Public Health, Ministry of Healthy Living and Sport
List of Tables
Table 1: Evidence of the Efficacy of an Intervention – Did it Work? ..................................... 3
Table 2: Results of Mathematical Models that Examined Public Health Interventions to
Control SARS ............................................................................................................ 6
Table 3: Epic2 Recommendations for Glove Use (2007) ...................................................... 19
Table 4: Epic2 Recommendations for Gown Use (2007) ...................................................... 20
Table 5: Epic Recommendations for Use of Face Masks, Eye and Respiratory Protective
Equipment (2007) .................................................................................................... 21
Table 6: Control Measures for MDROs Employed in Studies Performed in Health Care
Settings, 1982-2005 (Siegel 2006)........................................................................... 26
Core Public Health Functions for BC: Evidence Review
Communicable Disease (Public Health Measures)
Population and Public Health, Ministry of Healthy Living and Sport 1
1.0 OVERVIEW/SETTING THE CONTEXT
In 2005, the British Columbia Ministry of Health released a policy framework to support the
delivery of effective public health services. The Framework for Core Functions in Public Health
identifies communicable disease as one of the 21 core programs that a health authority provides
in a renewed and comprehensive public health system.
The process for developing performance improvement plans for each core program involves
completion of an evidence review used to inform the development of a model core program
paper. These resources are then utilized by the health authority in their performance
improvement planning processes.
This evidence review was developed to identify the current state of the evidence-based on the
research literature and accepted standards that have proven to be effective, especially at the
health authority level. In addition, the evidence review identifies best practices and benchmarks
where this information is available.
1.1 An Introduction to This Paper
The focus of this paper is public health measures which are used to prevent and control outbreaks
in the community and within facilities. These include quarantine and isolation, restriction on
public gathering, school and facility closures, patient and health care worker (HCW) screening,
and cohorting of patients and HCW. Some of these measures are controversial and highly
unpopular. As seen in the severe acute respiratory syndrome (SARS) outbreak, quarantine of
large numbers of people was instituted quickly because of incomplete information about disease
transmission (National Advisory Committee on SARS 2003).
This paper does not review infection control, which is defined by the Centers for Disease Control
and Prevention (CDC) as “measures practiced by health care personnel in health care facilities to
decrease transmission and acquisition of infectious agents.” Important aspects of outbreak
prevention and control such as hand washing and immunization are also not covered since they
have been reviewed in other core program papers. For an assessment of disinfection and
environmental cleaning, readers are referred to Health Canada’s Infection Control Guidelines:
Handwashing, Cleansing, Disinfection and Sterilization in Health Care, available at:
http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/98pdf/cdr24s8e.pdf.
An effective public health response requires adequate public health infrastructure. The National
Advisory Committee on SARS and Public Health (2003) states that this includes organizational
capacity, an adequate public health workforce, optimal business processes and
information/knowledge systems. Coordinated efforts are also required by all levels of
governments and partner agencies involved in managing the outbreak.
In British Columbia, the legal authority for public health action rests mostly with the Medical
Health Officer and the Provincial Health Officer whose powers are described under the Health
Act and Regulations. The Medical Officer of Health also has the authority to control
Core Public Health Functions for BC: Evidence Review
Communicable Disease (Public Health Measures)
Population and Public Health, Ministry of Healthy Living and Sport 2
communicable diseases under the Venereal Diseases Act and Regulations, as well as the School
Act.
Legal authority to protect public health also exists within municipalities, regional districts and
many other organizations such as BC Ambulance Service, Ministry of Agriculture, Ministry of
Attorney General (police services). The Hospital Act and Regulations give regional health
authorities legislated responsibilities for infection control in health care institutions. In addition,
federal acts (e.g., the Quarantine Act) enable the federal government to take action or require
action to be taken by provinces or territories.
This paper is divided into four sections. The first reviews the evidence for isolation and
quarantine; the second examines community-based infection control measures; the third
discusses facility-based control measures, and the fourth reviews infection control measures in
relation to specific groups of diseases.
Core Public Health Functions for BC: Evidence Review
Communicable Disease (Public Health Measures)
Population and Public Health, Ministry of Healthy Living and Sport 3
2.0 METHODOLOGY
This paper reviews the evidence for public health measures to prevent and control outbreaks in
the community and within facilities. The literature search included the following databases:
MEDLINE, OLDMEDLINE, EMBASE, and CINAHL. Searches were limited to English-
language publications using the following search terms:
Quarantine, isolation, 1918 influenza outbreak, SARS outbreak, school closure,
interfacility transfer, cohorting, infections in day care, screening in hospital
(diseases were specified e.g., MRSA), facility closure, mass gathering and
disease, personal protective equipment, and infection control guidelines (in
general and for specific diseases).
Titles and abstracts of citations were reviewed and potentially relevant articles were retrieved.
Reference lists in retrieved articles were scanned and additional citations were obtained.
The Cochrane Collaboration database and NHS Health Technology Assessment database were
also searched for systematic reviews about relevant topics. Websites of Canadian, UK and US
government agencies as well as the Canadian Pediatric Society and the American Academy of
Pediatrics were searched for infection control guidelines. National and provincial pandemic
influenza plans as well as the Campbell Commission’s SARS reports were reviewed for pertinent
information.
The National Health Service (NHS) evidence grading system was used to grade the material:
Table 1: Evidence of the Efficacy of an Intervention – Did it Work?
Level of
Evidence
Type of Evidence
1++ High quality meta-analyses, systematic reviews of RCTs (Including cluster RCTs), or RCTs with
a very low risk of bias.
1+ Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias.
1-* Meta-analyses, systematic reviews of RCTS, or RCTS with a high risk of bias.
2++ High quality systematic reviews of, or individual high quality non-randomised intervention
studies (controlled non-randomised trial, controlled before-and-after, interrupted time series),
comparative cohort and correlation studies with a very low risk of confounding, bias or chance.
2+ Well conducted, non-randomised intervention studies (controlled non-randomised trial,
controlled before-and-after, interrupted time series). Comparative cohort and correlation studies
with a high risk of confounding, bias or chance.
2-* Non-randomised intervention studies (controlled non-randomised trial, controlled before-and-
after, interrupted time series), comparative cohort and correlation studies with a high risk of
confounding, bias or chance.
3 Non-analytical studies (e.g., case reports, case series).
4 Expert opinion, formal consensus.
* Studies with a level of evidence (-) should not be used as basis for making recommendations.
Source: NHS Health Development Agency. (2005). Grading Evidence and Recommendations for Public Health
Interventions: Developing and Piloting a Framework. Adapted from SIGN (2001).
Core Public Health Functions for BC: Evidence Review
Communicable Disease (Public Health Measures)
Population and Public Health, Ministry of Healthy Living and Sport 4
3.0 ISOLATION AND QUARANTINE
Isolation refers to the separation of known infected or symptomatic people from others, for the
period of communicability, to prevent the transmission of infection (Gostin 2003, Day 2006).
This person can be isolated at home, a designated facility or if clinically indicated, admitted to a
hospital.
Quarantine, on the other hand, is the restriction of activities of asymptomatic persons who have
been exposed to a case of communicable disease during its period of communicability (i.e.,
contacts) to prevent disease transmission during the incubation period if infection should occur.
The two main types of quarantine are (Heymann 2004):
Absolute or complete quarantine: The limitation of freedom of movement of those
exposed to a communicable disease for a period of time not longer than the longest usual
incubation period of that disease, in such manner as to prevent effective contact with
those not so exposed.
Modified quarantine: A selective, partial limitation of freedom of movement of contacts,
commonly on the basis of known or presumed differences in susceptibility and related to
the assessed risk of disease transmission. For example, BCCDC recommends that during
an influenza outbreak, all non-immunized staff from an outbreak facility must be
excluded from working in non-outbreak facilities for 3 days after their last shift in the
outbreak facility (BCCDC 2005).
o Modified quarantine includes: personal surveillance, the practice of close medical
or other supervision of contacts to permit prompt recognition of infection or
illness but without restricting their movements; and segregation, the separation of
some part of a group of persons from the others for special consideration, control
or observation.
Quarantine can operate at the individual (e.g., exposed contact) or population level (e.g.,
attendees of a public gathering). Geographic quarantine can involve restrictions on travel to and
from designated areas or places (Gostin 2003, Upshur 2003, Inglesby 2006). Closure of
community borders around a geographic area is known as a cordon sanitaire.
The word “quarantine” is derived from the Italian words, quarantins and quarnta gironi, which
refer to the 40-day period during which ships and their crews were isolated in the Port of Venice
(Sattenspiel 2003). Descriptions of quarantine can be found in the Old Testament as well as in
Hippocratic teaching in the 5th
century B.C. (Gensini 2004). More recent records of quarantine
can be found in the 14th
century when regulations prevented ships coming from places infected
with plague from docking. Readers who are interested in the history of quarantine can refer to
articles by Gensini (2004), Jones (2005) and Sattenspiel (2003).
Isolation and quarantine are optimally performed on a voluntary basis, in accordance with the
instructions of health officials. However, medical health officers have the legal authority to
compel mandatory isolation and quarantine of individuals and groups when necessary to protect
the public’s health. Persons who are quarantined should be monitored regularly by a health
Core Public Health Functions for BC: Evidence Review
Communicable Disease (Public Health Measures)
Population and Public Health, Ministry of Healthy Living and Sport 5
department official to assess symptoms and address any needs (Ontario Ministry of Health 2006,
US Department of Health and Human Service 2005).
Quarantine is a contentious issue and people have argued for and against it for well over a
century. During the 19th
century, quarantine was at the centre of debate at International Sanitary
Conferences (Jones 2005). In the 21st century, some have argued that quarantine played little or
no role in controlling SARS (Schabas 2004), while others believed that quarantine helped to
quell the outbreak (Diamond 2003).
3.1 Effectiveness of Quarantine and Isolation
Most assessments of the effectiveness of community-wide isolation and quarantine stem from
evaluations of the 1918-19 influenza pandemic and the 2003 SARS outbreak. Historical records
show that in Edmonton during the 1918 influenza pandemic, community-based interventions
such as quarantine and isolation, school closure and banning of public gatherings had little
impact on the epidemic (McGinnis 1977). Even in cities such as Lomé, British-occupied Togo,
where vigorous efforts were used (e.g., isolation of known cases and their contacts, confinement
of troops to barracks, closure of schools and churches, ban on public meetings and stoppage of
road and rail traffic), influenza continued to spread (Patterson 1983). As early as 1919, Whitelaw
tried to evaluate the impact of public health measures in controlling the spread of influenza in
Canada but was unable to carry out his evaluation because the measures were poorly
implemented (Whitelaw 1919).
Sattenspiel and Herring (2003) created a mathematical model to examine the effects of
quarantine in three small Manitoba communities in 1918-19. Estimates of the likely mobility
rates during the flu epidemic were derived from daily counts of arrivals and departures recorded
in the Hudson Bay Company Post Journals. Results of the simulation showed that at best,
quarantine reduced the number of influenza cases by 25% and delayed the epidemic peak.
Paucity of historical data renders such assessments difficult; societal differences between the past
and the present also limit the usefulness of the conclusions drawn.
In 2003, cases of severe acute respiratory syndrome (SARS) occurred in approximately 30
countries. In five countries, significant outbreaks were reported – Canada, China (including
Hong Kong), Taiwan, Vietnam and Singapore. Because the pathogen was initially unknown and
modes of transmission were unclear, quarantine and isolation were widely used to control disease
spread (Wang 2007). Ou et al (2003) reported that the number of persons quarantined in China
could have been reduced by 66% if efforts were focused only on persons who had contact with a
SARS patient. These findings were corroborated by Wang et al (2007) who found the efficiency
of SARS quarantine in Taiwan could have been improved by targeting persons with exposure to
SARS cases instead of including quarantine for travelers from SARS infected areas.
Researchers have also used different types of mathematical models to assess the effectiveness of
quarantine and isolation during the SARS outbreak. Lipsitch (2003) and Riley (2003) measured
reproductive rates1 before and after the introduction of quarantine and early detection of new
1 Reproduction rate (R0) is the average number of secondary cases generated by a primary case. If R0 is <1, an
epidemic cannot be sustained; if R0 is >1, an epidemic occurs.
Core Public Health Functions for BC: Evidence Review
Communicable Disease (Public Health Measures)
Population and Public Health, Ministry of Healthy Living and Sport 6
cases. A compartmental model was used by Zhang (2005), while Hsieh used a discrete time
model (2007). Results of mathematical modeling suggest that quarantine was an effective
intervention measure during the SARS outbreak in 2003. Findings from these studies are
summarized below:
Table 2: Results of Mathematical Models that Examined Public Health Interventions to
Control SARS
Author Findings
Hsieh 2007 Quarantine of potentially exposed contacts of suspected SARS patients prevented
approximately 461 additional SARS cases (81%) and 62 additional deaths (63%)
in Taiwan. Quarantine of travelers arriving at borders from SARS affected areas
had relatively minor effect, reducing only about 5% of cases and deaths. The
combined impact of both types of quarantine had reduced the case numbers and
deaths by almost 50%.
Zhang 2005 Simulation showed that quarantine delay would have resulted in an increased
number of SARS cases in China. Simulation also showed that premature lifting of
preventive and control measures would have resulted in a larger number of SARS
cases and a second epidemic peak.
Riley 2003 Transmission rate2(β) fell by 67-94% and R0
1 dropped from 2.7 to < 1 when
control measures were introduced in Hong Kong. The effects of individual control
measures were not examined.
Lipsitch 2003 Reproduction rate (R0)1 dropped dramatically after institution of control measures.
The decline in secondary cases coincided with quarantine of asymptomatic
contacts and isolation of SARS cases.
Chau 2003 Quarantine of close contacts of confirmed SARS cases was insufficient to control
SARS in Hong Kong. Quarantine of close contacts of both confirmed and
suspected cases was necessary to prevent disease spread in the community.
Level of Evidence: 2-
(i.e., Non-randomized intervention studies using mathematical modeling)
3.2 Disease Parameters that Affect Quarantine and Isolation
Fraser et al (2004) used mathematical models of different infectious disease outbreaks to find out
which parameters are associated with the successful use of isolation and quarantine. In their
model, community mixing is assumed to be homogeneous i.e., all susceptible individuals are
equally likely to become infected. They found the amount of transmission which occurs before
the onset of symptoms and from asymptomatic individuals (θ) is an important predictor of how
well isolation and quarantine would work in reducing disease spread. Models show that for high
values of θ, neither isolation nor quarantine would be effective. When θ < 1/R01, isolation can be
used alone to be effective. When θ > 1/R01, both isolation and quarantine would need to be used.
Comparing R0 and θ estimates for SARS, smallpox, pandemic influenza, Fraser et al found
SARS to be the easiest infection to control because of low R0 and θ values. Their analysis found
that effective isolation of symptomatic patients would be sufficient to control an outbreak. The
2 T(β): Transmission rate is the number of persons infected per infectious person per day.
Core Public Health Functions for BC: Evidence Review
Communicable Disease (Public Health Measures)
Population and Public Health, Ministry of Healthy Living and Sport 7
second most readily controlled infection is smallpox. In this situation, both isolation and
quarantine would be required. Influenza, on the other hand, was found to be very difficult to
control because of high levels of pre-symptomatic transmission as well as short incubation
periods (approximately 2 days).
The effectiveness of quarantine can be compromised by an inability to trace all infected contacts
before they become infectious or by noncompliance with quarantine or by the possibility that
some individuals remain infectious after quarantine is lifted. Similarly, the effectiveness of
isolation can be limited by the delays with which a sick person is segregated or by failures of
infection control while these patients are in isolation (Lipsitch 2003). Despite the difficulties in
implementing quarantine and isolation measures to perfection, one needs to bear in mind that as
long as the reproductive rate is reduced below 1, the epidemic will be controlled.
3.3 Compliance with Quarantine and Isolation
Results of a study of quarantine in Toronto found that civic duty, not fear of legal consequences
was the main motivator for those who complied with quarantine during the SARS outbreak
(DiGiovanni 2004). In the final report of the SARS Commission, Justice Campbell concluded
that “laws are only the last resort…while it is important to strengthen the legal machinery
available to public health officials, it is even more important to strengthen the things that
encourage public cooperation.” (Campbell 2006).
During the SARS outbreak, 23,103 contacts required quarantine. Of those, only 27 (0.1%) were
issued a legally enforceable quarantine order due to noncompliance (Svoboda 2004). Even
though Ontario enjoyed high levels of quarantine compliance, DiGiovanni identified the
following impediments to observance:
Fear of loss of income;
Poor logistical support;
Psychological stress;
Spotty monitoring of compliance;
Inconsistencies in the application of quarantine measures between various jurisdictions;
and
Problems with public communications.
Similar findings were reported by Hawryluck (2004) from his survey of 129 quarantined
individuals.
Core Public Health Functions for BC: Evidence Review
Communicable Disease (Public Health Measures)
Population and Public Health, Ministry of Healthy Living and Sport 8
The studies and stories of quarantine during SARS show that the legal power to quarantine
comes with a responsibility to ensure that those in quarantine are given adequate support to
enable them to comply. Necessary supports include (Campbell 2006):
Delivery of groceries;
Refill and delivery of medication;
Ensuring that children are safely transported to and from day care or school;
Taking care of children, people with special needs and the elderly whose primary
caregivers have been quarantined;
Special quarantine contingencies for vulnerable populations, such as the homeless;
Ensuring that those under quarantine have an adequate supply of personal protective
equipment.
The Campbell Commission report recommended that “every government emergency plan should
provide a basic blueprint for the most predictable types of compensation packages and that they
be ready for use, with appropriate tailoring, immediately following any declaration of
emergency.”
Level of Evidence: 3 (i.e., case reports)
3.4 The Ethics of Isolation and Quarantine
Isolation and quarantine pose difficult questions about the acceptability of restrictive measures to
achieve public health goals (Bensimon 2007). Upshur (2003) and Gostin (2003) have used the
public health ethics framework to address this issue. The four principles of the framework are:
the harm principle, proportionality, reciprocity, and least restrictive measures.
First, there should be clear and measurable harm to others should disease go unchecked.
Second, public health authorities should use least restrictive measures proportional to the
goal of achieving disease control. This means that quarantine is voluntary before more
restrictive means such as mandatory orders and sanctions are imposed.
Third, reciprocity requires that society assist individuals who have curtailed their liberty
for the good of others. This means providing individuals with adequate food and shelter
and psychological support, accommodating their absence from the workplaces and not
discriminating against them.
Finally, there is the transparency principle which requires public health authorities to
communicate clearly their justification for their actions. A process of appeal ought to be
in place.
Core Public Health Functions for BC: Evidence Review
Communicable Disease (Public Health Measures)
Population and Public Health, Ministry of Healthy Living and Sport 9
3.5 Updated Quarantine Act
The Quarantine Act came into force on December 12, 2006 and replaced a law that had remained
largely unchanged since its adoption in 1872 (Tiederman 2007). The intent of this federal public
health legislation is to prevent the introduction and spread of a communicable disease arriving in
or departing from Canada.
The updated Act enhances the federal government’s authority to deal with suspected cases of
communicable diseases at international entry points like airports. Federal officials can deny entry
or compel passengers to debark for transfer to quarantine centers. It allows the federal
government to close Canadian border points to carriers arriving from a region affected by an
outbreak of a serious communicable disease.
It requires the airline and shipping industries to report an illness or death before arrival or
departure. Quarantine officers can detain people who refuse medical examination and prevent
Canadians from traveling abroad while infectious. Officials can divert a plane or vessel to
another location; they can also order the decontamination, or even destruction of conveyances
such as airplanes and cargo ships.
The Act does not apply to domestic travel and it does not address issues of interprovincial
movement. Provincial surveillance, reporting requirements, information exchange and
interprovincial travel limitations are not covered by the Act (Kondro 2007, PHAC 2004).
Further information about the updated Quarantine Act can be found at: http://www.phac-
aspc.gc.ca/media/nr-rp/2004/2004_54_e.html.
Core Public Health Functions for BC: Evidence Review
Communicable Disease (Public Health Measures)
Population and Public Health, Ministry of Healthy Living and Sport 10
4.0 COMMUNITY-BASED INFECTION CONTROL MEASURES
When outbreaks occur in the community, public health authorities can turn to community-based
containment measures. These interventions are based on the principle of social distancing which
refers to measures that serve to reduce contact between people (Inglesby 2006). They can be
divided between measures for children and those for adults (CDC 2007):
a. Children and Teenagers
i. Exclusion of infectious children from school and/or child care programs
ii. Cancelling of school-based activities
iii. Cancellation of community-based children’s activities
iv. Closure of school and/or child care programs
b. Adults
i. Exclusion of infectious workers
ii. Modify work place schedules and practices to reduce social contact
iii. (e.g., staggered shifts, teleconference instead of face-to-face meetings, work from
home)
iv. Cancel or postpone public gatherings (e.g., stadium events, theatre performances,
church services, transit system)
v. Closure of public buildings (e.g., community recreational centres, shopping mall)
Community-based interventions need to be combined with good infection control practices (e.g.,
good hand hygiene, cough etiquette) and adequate immunization to reduce infections in group
settings.
1. Hand washing: www.cdc.gov/cleanhands/
2. Cough etiquette: www.cdc.gov/flu/protect/covercough.htm
3. Immunization: http://www.phac-aspc.gc.ca/publicat/cig-gci/index.html
4.1 Child Care Facilities in British Columbia
In British Columbia, there are two basic types of child care: licensed and license-not-required.
Any caregiver looking after more than two children not related to them must have a license to
operate. The Community Care Facilities Branch which is part of the Health Protection Division
of the Ministry of Health is responsible for the development and implementation of legislation,
policy and guidelines to protect the health and safety of people being cared for in licensed
facilities.
Licensed child care programs must meet the requirements of the Community Care and Assisted
Living Act and the Child Care Licensing Regulation. The Community Care and Assisted Living
Act can be found at: http://www.qp.gov.bc.ca/statreg/stat/C/02075_01.htm. The Child Care
Licensing Regulation can be found at:
http://www.qp.gov.bc.ca/statreg/reg/C/CommuCareAssisted/319_89.htm.
Community care licensing programs are administered locally by Medical Health Officers and
licensing officers who inspect and monitor for the purpose of promoting health and safety.
Core Public Health Functions for BC: Evidence Review
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Population and Public Health, Ministry of Healthy Living and Sport 11
4.2 Exclusion of Sick Children from Child Care Facilities and Schools
Child care facilities and schools are well known sites of infectious disease transmission (Haskins
1986, Lu 2004). The risk of transmitting infections in a group increases with its size. In a study
of 1,100 children between 37 and 54 months, rates of upper respiratory tract illness,
gastrointestinal tract illness, and ear infections were higher in children enrolled in child care
facilities with more than 6 children (Bradley 2003).
Exclusion is sending home or refusing admission to a child with an illness or health problem.
This is intended to prevent transmission of infection among children in group settings. However,
few studies have shown its effectiveness. The Canadian Pediatric Society (CPS) (1999) found no
data to show that a 5-day exclusion policy that starts once chickenpox is diagnosed slows down
the spread of chickenpox within a school or day care centre. Transmission was greatest in the
prodrome period before onset of rash. In addition, no transmission was documented after
children returned to school less than 5 days from onset of rash. Based on these data, the CPS now
recommends a more permissive policy where a child is allowed to return to school or day care as
soon as he or she is well enough to participate normally in all activities, regardless of the state of
the rash.
A prospective study was conducted in Minneapolis to evaluate the risk of acquiring subsequent
infections as a result of attendance at a short term day care facility for mildly ill children. No
significant difference was found between rates of infection for respiratory illness, gastrointestinal
illness and chickenpox among children who attended the day care facility compared with rates of
subsequent infections for children participating in a home-based sick child care program. The
authors were not able to demonstrate that children who attended the sick child day care center
were at significantly increased risk of developing subsequent infections when compared with a
matched group of children who did not attend the center (MacDonald 1990). A review of
scientific evidence shows that the evidence of effectiveness for exclusion is weak.
Despite the weak evidence, standards for exclusion of ill children have been published by the
American Academy of Pediatrics, American Public Health Association and the National
Resource Center for Health and Safety in Child Care (2002). The document acknowledges that
short term exclusion of children with many mild infectious diseases is likely to have only a
minor impact on the incidence of infection among other children in the group:
http://nrc.uchsc.edu/SPINOFF/IE/IncExc.pdf.
The document states that temporary exclusion of a child is indicated if:
The illness prevents the child from participating comfortably in activities;
The illness results in a greater need for care than the child care staff can provide without
compromising the health and safety of the other children;
Core Public Health Functions for BC: Evidence Review
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Population and Public Health, Ministry of Healthy Living and Sport 12
The child has any of the following conditions:
o Fever
o Signs and symptoms of severe illness e.g., lethargy, uncontrolled coughing,
persistent crying, difficulty breathing, wheezing
o Diarrhea
o Blood in the stools (unexplained)
o Vomiting (> 2 times in 24 hours0
o Abdominal pain > 2 hours
o Mouth sores with drooling
o Rash with fever or behaviour change
o Purulent conjunctivitis
o Pediculosis (head lice) from end of the day until after the first treatment
o Scabies until after treatment has been completed
The child has any of the following diseases:
o Tuberculosis
o Impetigo until 24 hours after treatment
o Strep throat until 24 hours after initial treatment
o Chickenpox until all sores have dried and crusted (this differs from CPS statement
discussed above)
o Pertussis
o Mumps
o Hepatitis A
o Measles
o Rubella
o Shingles
o Herpes simplex
Level of Evidence: 4
(Expert Opinion)
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4.3 Day Care and School Closure
Influenza epidemics have been found to be amplified in primary school settings (Neuzil 2002). A
temporal relationship was noted between school holidays and a decrease in the incidence of
influenza diagnoses in France from 1984 to 2000 (Valleron 2004). However, school closures do
not always result in a reduction in influenza infections. In 1918, more influenza cases developed
among pupils in a Chicago school after a holiday than when schools were in session. It was
postulated that school closure might be less effective in some areas because children can more
easily meet elsewhere (Jordan 1919). Some have expressed concern that during a pandemic
influenza outbreak, closure of schools and day cares could result in children gathering in other
settings thus limiting the effect of closures (Ontario Ministry of Health 2006).
A simulation model developed by Ferguson et al (2006) of pandemic influenza transmission in
the US and Great Britain showed that school closure can reduce peak attack rates by 40%.
However, results by Vynnyky (2007) were less optimistic. Using UK data from the 1957
influenza pandemic to estimate the impact of school/nursery closures in a future pandemic, it
was found that closure of schools/nurseries could reduce the epidemic size only by a very small
amount (< 10%) if reproductive rate (R0) is high (e.g., 2.5 to 3.5) and modest amounts (e.g.,
22%) if R01 is low (e.g., 1.8).
The World Health Organization concluded that data on the effectiveness of school closures are
limited (WHO 2006). During a two-week teachers’ strike in Israel which occurred in the midst of
an influenza outbreak in 2000, significant decreases were seen in the rates of respiratory
infection diagnosed among children 6 to 12 years of age (relative risk 0.58, 95% CI 0.57 – 0.59).
When schools reopened, rates of respiratory infections rose again (Heymann 2004).
Day care closures have been used to control shigellosis outbreaks in some settings (Weismann
1975), but not in others (Grenobile 2004). The simultaneous occurrence of shigella clusters in
two Seattle day-care centres provided an opportunity to study the effectiveness of two different
intervention strategies. One day care closed for 24 working days during which time alternate care
arrangements were made for attendees. The second day-care centre remained open and allowed
children and staff who were on antimicrobial treatment to return. They were separated from
others in the centre and used their own room, bathroom and playground until they had two
consecutive negative cultures following treatment. Similar attack rates were found among
children, staff and family members at both centres (CDC 1984).
Level of Evidence: 2-
((i.e., Correlation studies)
4.4 Exclusion of Infected Workers
4.4.1 Blood-borne Infections
There have been two confirmed instances of HIV transmission from health care workers to
patients (CDC 1990, Blanchard 1998); at least 46 reports of HCWs transmitting HBV to patients
during invasive procedures; and at least three reports of HCV transmission from infected health
care providers to patients (Beltami 2000).
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Currently available data provide no basis for recommendations to restrict the practice of health
care workers (HCWs) infected with HIV, hepatitis B (HBV), or hepatitis C (HCV) who perform
procedures not identified as exposure-prone; however, HCWs should not perform exposure-
prone procedures unless they have sought counsel from an expert review panel (Beltami 2000).
In British Columbia, the College of Physicians and Surgeons’ Advisory Committee on Blood-
Borne Communicable Diseases reviews information pertinent to an affected physician and
advises him/her of specific guidelines relevant to his/her practice and, any restrictions on practice
that should be implemented to minimize the potential of transmission to patients. Practice
guidelines which have been developed by the Advisory Committee are available at:
https://www.cpsbc.ca/cps/college_programs/bbcd_panel.
4.4.2 Enteric Diseases
The risk of transmission from infected food handlers has been documented in an international
literature review (Guzewich 1999). The authors identified 81 outbreaks involving over 14,700
people between 1975 and 1998. Studies have also documented person-to-person transmission of
enteric infections in health care (Carter 1987, McCall 2000) and child care settings (O’Donnell
2002, Galanis 2003, Gouveia 1998).
Under the Health Act Communicable Disease Regulation BC Reg 4/83, the Medical Officer of
Health can inform the employer or child care facility that their employee or attendee is infected
with a communicable disease that can spread to others and should be excluded from work or
attendance until they have met the appropriate criteria.
BCCDC has published guidelines for the exclusion of cases and contacts who work or attend
high-risk settings (BCCDC 2007). It is available at:
http://www.bccdc.org/content.php?item=192.
Based on severity of illness and evidence that continued presence or work in a high-risk setting
leads to transmission of infection, cases and in some instances, contacts of cases with
verotoxigenic E. coli, hepatitis A, Salmonella typhi/paratyphi and Shigella infections are
excluded from high-risk settings. Microbiological clearance is required before they return. A
high-risk setting is defined as one where the case or contact’s activities increases the chance of
transmission of enteric infections e.g., food premises, child care facilities, residential and acute
health care facilities or other clinical settings.
Level of Evidence: 2-
(i.e., Non-randomized intervention studies)
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4.5 Restrictions on Public Gatherings
Restricting public gatherings is one method of social distancing, the goal of which is to reduce
the risk of coming in contact with an infected person. This can be a useful control measure for
diseases that are transmitted by people who are asymptomatic or mildly ill (Ontario Ministry of
Health 2006). However, these measures will have significant impact on the community and
workplace. The Ontario Pandemic Influenza Plan suggests that public health authorities use the
following criteria to determine whether to restrict public gatherings:
Will cancellation of the gathering or activity cause significant public disruption?
Are alternative services in place?
Will canceling the gathering or activity cause significant public panic?
Are cancellations feasible?
Is implementation sustainable?
To date, there are no data about the effectiveness of a ban on public gathering. This intervention
has only been studied along with other community-based measures.
Level of Evidence: 4
(Expert Opinion)
4.6 Simultaneous Use of Multiple Community-Based Interventions
Hatchett et al (2007) examined the timing of different types of community-based interventions in
17 US cities during the 1918 influenza pandemic. Cities in which multiple interventions (e.g.,
school closures, bans on public gatherings) were implemented at an early phase of the epidemic
had half the peak death rates of cities which did not, and had 20% lower cumulative mortality.
Bootsma and Ferguson (2007) studied the effect of public health measures on the 1918 influenza
pandemic. They acquired data on the timing of interventions such as school closures, banning of
mass gatherings, mandating mask wearing, case isolation and disinfection measures for 16 US
cities3. For another 7 cities
4, they only had data on the start dates of interventions. They used the
susceptible-exposed-infected-recovered (SEIR) epidemic model in the analysis. The study
showed that variation in control measures explained some of the total excess mortality observed
among cities. If controls could have been maintained at the maximum level of effectiveness for
each city, mortality could have been reduced by at least 40%.
The study also showed that timing of public health interventions had a profound influence on the
pattern of the influenza pandemic. Cities which introduced measures early in their epidemics
achieved moderate but significant reductions in overall mortality. In cities that saw a double-
3 Atlanta, Baltimore, Chicago, Fall River, Indianapolis, Kansas City, Milwaukee, Minneapolis, New York, Newark,
Philadelphia, Pittsburgh, San Francisco, Spokane, St Louis and Washington. 4 Boston, Buffalo, Detroit, Rochester, St Paul, Seattle, Toledo.
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peaked epidemic, control measures may have been “too effective” stopping transmission so
effectively that substantial numbers of susceptible individuals remained in the population when
controls were lifted, leading to another epidemic peak. In cities where transmission had been
continuing for longer before interventions were introduced, no second epidemic peak was seen,
because insufficient susceptible remained to restart transmission once interventions were lifted.
The cities which achieved maximum reduction in mortality were those that implemented both
early and effective interventions throughout the first peak, and then were able to reintroduce
these when transmission increased again. Bootsma and Ferguson stated that “causality will never
be proven, because, unsurprisingly, control measures were nearly always introduced as case
incidence was increasing and removed after it had peaked. Thus, the broad correlation observed
between the incidence and the timing of control measures was predefined…more work is needed
to attempt to disentangle the impact of different control measures”.
Lo et al (2005) reported that influenza and other respiratory infections declined in Hong Kong
during the 2003 SARS epidemic, following institution of social distancing interventions such as
banning of public gatherings, school closure, case isolation etc. The findings suggest that these
measures may have reduced the spread of other respiratory infections other than SARS.
Level of Evidence: 2-
(i.e., Correlation studies)
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5.0 FACILITY-BASED MEASURES
Transmission of infection within a facility requires three elements: a source of infecting
microorganisms, a susceptible host and a means of transmission (Garner 1996). Human sources
of the infecting microorganisms may be patients, staff or on occasion, visitors. Other sources of
infecting microorganisms can be the patient’s own flora and inanimate environmental objects
such as equipment that have become contaminated.
Host factors such as age, underlying disease, certain treatments, immunosuppressive agents,
breaks in the first line of defense mechanisms caused by surgical operations, indwelling catheters
etc. may render patients more susceptible to infection.
5.1 Disease Transmission in Facilities
Microorganisms are transmitted in facilities by several routes, and the same organism can be
transmitted by more than one route. There are five main routes of transmission – contact, droplet,
airborne, common vehicle and vector-borne (Brachman 1998).
Contact transmission includes direct, indirect and droplet transmission. Direct
transmission occurs from direct physical contact between an infected (or colonized)
individual and a susceptible host. Indirect transmission involves transfer of
microorganism via an intermediate object such as contaminated instruments.
Droplet transmission is a type of contact transmission, but it is considered separately
because it requires different precautions. Droplet transmission refers to large droplets
>5µm in diameter, generated during coughing or sneezing or during procedures such as
bronchoscopy or suctioning. These droplets are propelled < 1m, through the air and
deposited on the conjunctiva, nasal or oral mucosa of the susceptible host.
Airborne transmission refers to dissemination of microorganisms by aerolization. Such
microorganisms are widely dispersed by air currents and inhaled by susceptible hosts
who may be some distance from the source.
Common vehicle transmission refers to a single contaminated source such as food,
medication, equipment etc. which serves to transmit infection to multiple hosts.
Vector-borne transmission refers to transmission by insect vectors. Such transmission has
not been reported in Canadian hospitals (Health Canada 1999).
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Figure 1: How Microorganisms Are Acquired
A variety of infection control measures are used to decrease the risk of transmission of
microorganisms in health care facilities. National infection control guideline are published which
reviews routine practices and additional precautions to prevent the transmission of
microorganisms in a variety of settings (Health Canada 1999): http://www.phac-
aspc.gc.ca/publicat/ccdr-rmtc/99pdf/cdr25s4e.pdf.
Routine practices refer to the type of care that should be provided to all patients regardless of
their diagnosis or presumed infection status. Additional precautions are necessary for certain
pathogens because of their high transmissibility or epidemiological importance. (This document
is currently under revision).
National guidelines about handwashing, cleaning, disinfection and sterilization in health care can
be found at: http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/98pdf/cdr24s8e.pdf.
5.2 Personal Protective Equipment
National evidence-based guidelines for preventing health care-associated infections were
commissioned by the Department of Health (England). Known as the “epic initiative”,
researchers conducted systematic reviews of the literature to formulate their recommendations.
The original guidelines were published in 2001 (Pratt 2001) but these were updated in 2007
(Pratt 2007); they are now known as epic2 infection prevention guidelines.
The complete series of evidence tables are posted on the epic website at:
http://www.epic.tvu.ac.uk.
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The evidence for use of personal protective equipment (PPE) by health care workers in general
care settings is presented here. Expert opinion suggests that the primary uses of PPE are to
protect staff and reduce opportunities for transmission of microorganisms. The decision to use
PPE must be based on an assessment of the level of risk associated with a specific patient care
activity or intervention and take account of current health and safety legislation.
5.3 Gloves
Studies have shown that gloves can reduce nosocomial infection rates (Hartstein 1997, Klein
1989). Expert opinion agrees that there are two main indications for the use of gloves:
To protect hands from contamination with organic matter and microorganisms; and
To reduce the risk of transmission of microorganisms to both patients and staff.
Gloves must be discarded after each care activity for which they were worn in order to prevent
the transmission of microorganisms to other sites in that individual or to other patients.
Systematic reviews have shown that gloves used for clinical practice may leak when apparently
undamaged (Pratt 2001). Expert opinion supports the view that the integrity of gloves cannot be
taken for granted and hands can become contaminated during the removal of gloves. A study of
vancomycin resistant enterococcus (VRE) showed that the organism remained on the hands of
health care workers after the removal of gloves (Tenorio 2001).
Table 3: Epic2 Recommendations for Glove Use (2007)
Recommendations Level of Evidence
Gloves must be worn for invasive procedures, contact with sterile sties, and
non-intact skin or mucous membranes, and all activities that have been assessed
as carrying a risk of exposure to blood, body fluids, secretions and excretions;
and when handling sharp or contaminated instruments.
Class D5
Gloves must be worn as single use items. They are put on immediately before
an episode of patient contact or treatment and removed as soon as the activity is
completed. Gloves are changed between caring for different patients, or
between different patients, or between different care/treatment activities for the
same patient.
Class D5
Gloves must be disposed of as clinical waste and hands decontaminated, ideally
by washing with liquid soap and water after the gloves has been removed.
Class D5
Neither powdered nor polythene gloves should be used in health care activities. Class C6
Level of Evidence: 4
(Expert Opinion)
5 Class D: Evidence level 3 (e.g., case series, case reports) or 4 (expert opinion), or extrapolated evidence from studies rated as 2+ (e.g., case
control or cohort studies) or formal consensus 6 Class C: Evidence level 2+ (e.g., case control or cohort studies) or extrapolated evidence from studies rated as 2++(High quality case control or
cohort studies or high quality systematic review of case control or cohort studies)
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5.4 Gowns
Epic researchers identified four small observational studies that investigated the potential for
uniforms to become contaminated during clinical care but none of the studies established an
association between contaminated uniforms and health care-associated infections. A Cochrane
systematic review of 8 studies which assessed the effects of gowning in newborn nurseries found
no evidence to suggest that gowns were effective in reducing mortality, clinical infection or
bacterial colonization in infants admitted to newborn nurseries (Webster 2003). One quasi-
experimental study suggested the use of gowns and gloves as opposed to gloves alone could
reduce the acquisition of VRE in the intensive care unit setting (Puzniak 2002).
International guidelines currently recommend that protective clothing should be worn by all
health care workers when close contact with the patient, materials or equipment may lead to
contamination of clothing with microorganisms, or when there is a risk of contamination with
blood, body fluids, secretions or excretions. (Garner 1996, Health Canada 1999, Clark 2002).
Table 4: Epic2 Recommendations for Gown Use (2007)
Recommendations Level of Evidence
Disposable plastic aprons must be worn when close contact with the patient,
materials or equipment are anticipated and when there is a risk that clothing
may become contaminated with pathogenic microorganisms or blood, body
fluids, secretions or excretions, with the exception of perspiration.
Class D5
Plastic aprons/gowns should be worn as single-use items, for one procedure,
or episode of patient care, and then discarded and disposed of as clinical
wasted. Non-disposable protective clothing should be sent for laundering.
Class D5
Full-body fluid-repellant gowns must be worn where there is a risk of
extensive splashing of blood, body fluids, secretions or excretions, with the
exception of perspiration, onto the skin or clothing of health care personnel.
Class D5
Level of Evidence: 4
(Expert Opinion)
Systematic reviews have found no evidence that gowns are effective in reducing health care
related infections.
5.5 Masks, Respiratory Protection and Eye Protection
Expert opinion recommends that face and eye protection reduce the risk of occupational
exposure of health care workers to splashes of blood, body fluids, secretions or excretions.
Surgical facemasks are used to protect against contact with respiratory droplets and inhalation of
airborne respiratory particles (Garner 1996). Facemasks are used in conjunction with eye
protection to protect the mucous membranes of the wearer from exposure to blood and/or body
fluids. Systematic review shows that different eyewear offered protection against physical
splashing of infected substances into the eyes but compliance was poor (Pratt 2001).
Respiratory protective equipment is recommended for the care of patients with certain
respiratory diseases such as tuberculosis or SARS (Seto 2003). The filtration efficiency of these
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masks protects the wearer from inhaling small respiratory particles but to be effective, they must
fit closely to the face to minimize leakage around the mask.
Table 5: Epic Recommendations for Use of Face Masks, Eye and Respiratory Protective
Equipment (2007)
Recommendations Level of Evidence
Face masks and eye protection must be worn where there is a risk of
blood, body fluids, secretions or excretions splashing into the face and
eyes.
Class D5
Respiratory protective equipment i.e., particulate filter mask, must be
correctly fitted and used when recommended for the care of patients
with respiratory infections transmitted by airborne particles.
Class D5
Level of Evidence: 4
(Expert Opinion)
5.6 Patient and Staff Cohorting
Cohorting of patients is the assignment of patients known to be infected with the same organism
to the same room, or grouping of infected and non-infected patients in separate wards. Lior et al
(1996) reported successful control of a vancomycin resistant enterococci (VRE) outbreak on a
renal ward in Toronto where cohorting of colonized patients was used. Cohorting of staff is the
assigning of staff to work in either affected or unaffected areas of a facility but not both. It has
been successfully employed to control hospital outbreaks such as Respiratory syncytial virus
(Snydman 1988). BCCDC recommends the cohorting of health care workers for control of
influenza-like illness outbreaks (2005).
Patient and staff cohorting has been used to interrupt transmission of VRE at a community
hospital. Infected or colonized patients were cohorted on a single ward with dedicated nursing
staff and patient-care equipment. Following the establishment of the cohort ward, VRE
prevalence among all hospitalized patients decreased from 8.1% to 4.7% (p=0.14) and VRE
prevalence among patients whose VRE status was unknown before cultures were obtained
decreased from 5.9% to 0.8% (p=0.002) (Jochimsen 1999). The BCCDC has recommended
nurse cohorting for the control of VRE outbreaks when there is evidence of nosocomial spread
(BCCDC 2001).
More recently, both patient and staff cohorting have been used to control methicillin-resistant
Staphlococcus aureus (MRSA). A systematic review of isolation policies in the hospital
management of MRSA has examined the effect of nurse cohorting (Cooper 2003). Of nine
studies which met the inclusion criteria, one study provided positive effect of nurse cohorting.
Coello et al (1994) described 1050 cases of MRSA over 3.5 years. A significant drop in MRSA
incidence followed institution of nurse cohorting of MRSA patients isolated in single rooms or in
cohorts. The remaining studies were found to provide weak evidence for reduction in MRSA
infection with nurse cohorting (Cooper 2003).
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A second systematic review also examined the effect of nurse cohorting as one of many
strategies used to prevent and control MRSA (Loveday 2006). The authors concluded that there
was a lack of good quality evidence for the effectiveness of strategies to control MRSA. In a
study investigating the effect of a dedicated orthopaedic cohort unit on the control of MRSA,
mathematical modelling was used to estimate the effect of the unit (Talon 2003). Modelling
demonstrated that in the absence of the cohort unit, the risk of acquiring MRSA would have
increased by 160%. The authors concluded that the dedicated cohort facilities helped to control
the transmission of MRSA.
Both systematic reviews found the tendency to report the simultaneous implementation of
multiple interventions increased the difficulty in drawing clear conclusions abut the effect of
individual interventions. However, both reviews identified a small number of studies which
suggest that nurse cohorting contributes to reductions in MRSA incidence.
Level of Evidence: 2-
(Non-randomized intervention studies with a high risk of confounding, bias or chance)
5.7 Screening of Patients and Staff
5.7.1 Patients
Evidence for screening of infectious diseases can be found in the Chapter “Evidence Base for
Secondary Prevention of Communicable Diseases.” However, screening for multidrug-resistant
organisms is not covered in that chapter so it is discussed below.
One aspect of controlling the spread of multi-drug resistant organisms (MDRO) such as MRSA,
VRE, Acinetobacter baumannii, has been the screening of colonised or infected patients (Muto
2003, Ostrowsky 2001, Simor 2003, Jernigan 1996). Screening involves taking swabs from one
or more body sites (e.g., nose, wounds) where carriage is most likely, and carrying out laboratory
tests on these samples. Those found to be culture positive are managed in a way to prevent
transmission of infection to others.
An assessment of screening policies and infection control practices in 32 health care facilities in
Iowa, Nebraska and South Dakota, showed a decline in point prevalence of VRE in facilities
where surveillance cultures and isolation of infected patients were instituted (Ostrowsky 2001).
Perencivich et al (2004) used mathematical modelling to evaluate interventions to decrease VRE
transmission and found the use of active surveillance cultures (ASC) (versus no cultures)
decreased transmission by 39% and that with pre-emptive isolation plus ASC, transmission could
be decreased by 65%. Estimated costs of ASC and isolation measures to control a MRSA
outbreak were compared with the estimated excess costs of not promptly controlling
transmission. Weekly active surveillance cultures and isolation of patients with MRSA halted an
outbreak at this hospital, and cost 19- to 27-fold less than the attributable costs of MRSA
bacteraemias in another outbreak that was not promptly controlled (Karchmer 2002). Recent UK
guidelines for MRSA control which were based on systematic review of the evidence
recommends targeted screening of high-risk patients based on medical indications or admission
to high-risk units (Coia 2006).
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Despite success reported by some studies, others did not reach the same conclusion. At a Geneva
hospital, nasal and perianal swabs were taken from patients admitted to medical intensive care
unit (ICU) and surgical ICU and tested for MRSA. Even though it resulted in a reduction in
medical ICU acquired MRSA infections (relative risk 0.3, 95% confidence interval 0.1–0.7), it
had no effect in the surgical ICU (relative risk 1.0, 95% confidence interval 0.6–1.7) (Harbath
2006). In another study, all patients in an ICU had nasal and rectal swabs on admission and
weekly thereafter; decolonization with antibiotics was provided to MRSA carriers. During the 6-
year follow-up period, MRSA remained poorly controlled throughout the hospital even though
rate of extended spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) acquisition
fell (Troche 2005). The effectiveness of multidrug-resistant enterobacteriaceae (MDRE)
screening in the non-outbreak setting was questioned by researchers in Toronto. Patients
admitted for new organ transplantation were screened for
MDRE colonization. Of
the 287
patients, 69 (24%) were colonized, and
6 (9%) of the
69 developed clinical infections.
Most
colonizing isolates (66/69) were unique and no clinical
infections resulted from patient-to-patient
transmission. The annual cost of a surveillance program
was calculated at Canadian
$1,130,184.44. Thus, the routine use of
MDRE surveillance and isolation
was deemed not
warranted in the absence of
an outbreak in
this population (Gardam 2002).
Level of Evidence: 2-
(Non-randomized intervention studies with a high risk of confounding, bias or chance)
5.7.2 Staff
a. MRSA: A systematic review of staff screening for MRSA concluded that the evidence
for staff screening was poor and it was unclear what role colonized staff played in the
transmission of MRSA (Nicholson 1997). Another systematic review published in 2006
came to similar conclusions (Ritchie et al).
Level of Evidence: 2-
(Non-randomized intervention studies with a high risk of
confounding, bias or chance)
b. Tuberculosis: Guidelines in Canada and the US recommend that all health care workers
(pre-placement and employed) be screened for tuberculosis, ideally at initiation of
employment (PHAC 1996, Francis J. Curry 1999).
The purpose is to:
Identify HCW with inactive TB and when appropriate, to offer them preventive
therapy to decrease their risk of developing active TV;
Identify HCW with active TB and ensure that they are appropriately treated;
Document conversion rates;
Establish HCW’s baseline TB infection status, as a reference for future TB exposure.
Level of Evidence: 4
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c. Influenza: The Centers for Disease Control has the following recommendation for health
care worker screening in acute care facilities during influenza season (2007):
If there is no or only sporadic influenza activity occurring in the surrounding community:
Monitor health-care personnel for influenza-like symptoms and consider removing them
from duties that involve direct patient contact, especially those who work in specific
patient care areas (e.g., intensive care units (ICUs), nurseries, organ-transplant units). If
excluded from duty, they should not provide patient care for 5 days after the onset of
symptoms.
If widespread influenza activity is in the surrounding community: Evaluate health-care
personnel, especially those in high-risk areas (e.g., ICUs, nurseries, and organ transplant
units) for symptoms of respiratory infection; perform rapid influenza tests to confirm that
the causative agent is influenza and to determine whether they should be removed from
duties that involve direct patient contact. If excluded, they should not provide patient care
for 5 days following the onset of symptoms.
Level of Evidence: 4
5.7.3 Visitors
Influenza: The CDC has the following recommendation for visitors to acute care facilities during
influenza season (2007). Through the posting of notices, visitors are asked to self-screen for
respiratory symptoms and to take the recommended action.
If there is no or only sporadic influenza activity occurring in the surrounding community:
Discourage persons with symptoms of a respiratory infection from visiting patients. Post notices
to inform the public about visitation restrictions.
If widespread influenza activity is in the surrounding community: Notify visitors (e.g., via posted
notices) that adults with respiratory symptoms should not visit the facility for 5 days and children
with symptoms should not visit for 10 days following the onset of illness.
Level of Evidence: 4
5.8 Restriction of Admissions and Transfers
Temporary restriction of admissions during an outbreak is a means of protecting susceptible
patients from exposure to infection. The CDC (2007) has recommended curtailment or
elimination of elective medical and surgical admissions and restriction of cardiovascular and
pulmonary surgery to emergency cases during influenza outbreaks (especially those with high
attack rates and severe illness) in the community or acute-care facility.
During the SARS outbreak in Toronto, it was determined that disease spread between hospitals
was due in part to interfacility patient transfers (Svoboda 2004, Dwosh 2003, Varia 2003). In
order to prevent SARS transmission, a command, control, and tracking system known as the
Provincial Transfer Authorization Centre (PTAC) was developed; it used a medical decision
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algorithm to determine whether a patient transfer could take place. A subsequent study found the
PTAC medical decision algorithm highly sensitive and specific in properly authorizing
interfacility patient transfers (MacDonald 2006).
This study examined a decision algorithm used to restrict transfer of potentially infectious
patients but it did not study the effectiveness of transfer restriction in curbing disease spread in
hospitals. No studies were found which have evaluated transfer restriction as an infection
prevention and control measure.
Level of Evidence: 4
5.9 Facility Closure
Nosocomial outbreaks of Pseudomonas aeruginosa (Moolenaar 2000, Foca 2000) and MRSA
(CBC news, March 9, 2007) have led to the closure of neonatal intensive care units (NICU).
During the SARS outbreak in Toronto, entire hospitals were closed when nosocomial
transmission was documented within the facility (Svoboda 2004). Hospital closures also
occurred in other cities such as Beijing, Hong Kong, and Singapore (Gopalakrishna 2004).
Facility closure was one of several interventions which were implemented during the outbreak.
While SARS cases dropped sharply following enhanced infection-control measures, it is difficult
to know what role facility closure played in curbing disease transmission because multiple
interventions were used simultaneously (Svoboda 2004).
Level of Evidence: 3
(Case series)
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6.0 INFECTION CONTROL IN RELATION TO DISEASES
6.1 Antibiotic-Resistant Organisms
Multidrug-resistant organisms (MDRO) are microorganisms that are resistant to one or more
classes of antimicrobial agents. They include such organisms as MRSA, VRE and certain gram-
negative bacilli (MDR-GNB) like Escherichia coli and Klebsiella pneumonia. In most instances,
MDRO infections have clinical manifestations that are similar to infections caused by susceptible
pathogens but the options for treating these patients are very limited. Increased lengths of stay,
costs and mortality have been associated with MDROs. Once MDROs are introduced into a
health care facility, transmission and persistence is determined by the availability of vulnerable
patients, selective pressure exerted by antimicrobial use, increased potential for transmission, and
the impact of prevention efforts (Siegel 2006).
Most studies reporting successful MDRO control have employed 7 to 8 different interventions
concurrently or sequentially. They are summarized in Table 6 and were reviewed in a 2006 CDC
document, which is available at (Siegel 2006):
http://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf.
Table 6: Control Measures for MDROs Employed in Studies Performed in Health Care Settings,
1982-2005 (Siegel 2006)
Focus of MDRO
(No. of Studies)
MDR-GNB
(n=30)
MRSA
(n=35)
VRE
(n=39)
No. (%) of Studies Using Control Measure
Education of staff, patients or visitors 19 (63) 11 (31) 20 (53)
Emphasis on handwashing 16 (53) 21 (60) 9 (23)
Use of antiseptics for handwashing 8 (30) 12 (36) 16 (41)
Contact Precautions or glove useα 20 (67) 27 (77) 34 (87)
Private Rooms 4 (15) 10 (28) 10 (27)
Segregation of cases 4 (15) 3 (9) 5 (14)
Cohorting of Patients 11 (37) 12 (34) 14 (36)
Cohorting of Staff 2 (7) 6 (17) 9 (23)
Change in Antimicrobial Use 12 (41) 1 (30 17 (440
Surveillance cultures of patients 19 (63) 34 (97) 36 (92)
Surveillance cultures of staff 9 (31) 8 (23) 7 (19)
Environmental cultures 15 (50) 14 (42) 15 (38)
Extra cleaning & disinfection 11 (37) 7 (21) 20 (51)
Dedicated Equipment 5 (17) 0 12 (32)
Decolonization 3 (10) 25 (71) 4 (11)
Ward closure to new admission or to all patients 6 (21) 4 (12) 5 (14)
Other miscellaneous measures 6 (22)β
9 (27)γ
17 (44)δ
α Contact Precautions mentioned specifically, use of gloves with gowns or aprons mentioned, barrier
precautions, strict isolation, all included under this heading. β
includes signage, record flagging, unannounced inspections, selective decontamination, and peer compliance
monitoring (1 to 4 studies employing any of these measures). γ includes requirements for masks, signage, record tracking, alerts, early discharge, and preventive isolation of
new admissions pending results of screening cultures (1 to 4 studies employing any of these measures). δ includes computer flags, signage, requirement for mask, one-to-one nursing, changing type of thermometer
used, and change in rounding sequence (1 to 7 studies employing any of these measures).
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Two systematic reviews of the evidence for interventions in preventing and controlling MRSA
concluded that the quality of study in this field was generally weak (Loveday 2006, Cooper
2003). However, the following interventions can be considered in the prevention and control of
the disease in acute care hospitals and long-term-care settings (Loveday 2006):
Use of active surveillance cultures to identify and subsequently manage high-risk patients
with MRSA colonization/infection may have a role in reducing transmission.
The isolation or cohorting of patients with MRSA colonization/infection may have a role
in reducing transmission.
The long term effectiveness of topical decolonization strategies in eradicating MRSA is
unproven, but short-term use in specific patient groups may be of benefit.
The effectiveness of environmental cleaning is an important factor in strategies to prevent
the nosocomial transmission of MRSA.
Treated combinations of the above measures in high-risk environments may have a role
in controlling the nosocomial transmission of MRSA.
Staff compliance with infection control procedures needs to be improved.
BCCDC’s guidelines for prevention and control of antibiotic-resistant organisms can be found at:
http://www.bccdc.org/content.php?item=194.
Ontario Provincial Infectious Disease Advisory Committee (PIDAC)’s “Best Practices for
Infection Prevention and Control of Resistant Staphlyococcus aureus and Enterococci in All
Health Settings.” Is available at:
http://www.health.gov.on.ca/english/providers/program/infectious/diseases/best_prac/bp_staff.pd
f.
Guidelines for Prevention and Management of Community-Associated Methicillin-resistant
Staphlococus aureus: A Perspective for Canadian Healthcare Practitioners is available at:
http://www.pulsus.com/infdis/17_SC/Pdf/mrsa_ed.pdf.
6.2 Respiratory Diseases
Droplet and contact transmission precautions should be taken for all definite or possible
respiratory tract infections such as bronchiolitis, colds, croup, pneumonia, pharyngitis etc
(Health Canada 1999). Specific recommendations can be found in Health Canada’s
Routine Practices and Additional Precautions for Preventing Transmission of Infections
in Health Care (1999) which is available at: http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/99vol25/25s4/index.html.
BCCDC guidelines for the control of Influenza-like-illness (ILI) outbreaks can be found
at: http://www.bccdc.org/content.php?item=194.
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6.3 Enteric Diseases
Patients with diarrhea should be managed with contact transmission precautions until an
infectious cause is ruled out. Details can be found in Health Canada’s Routine Practices
and Additional Precautions for Preventing Transmission of Infections in Health Care
(1999) which is available at: http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/99vol25/25s4/index.html.
Best practices for management of Clostridium difficile infection in health care settings
was published by the Provincial Infectious Diseases Advisory Committee (Ontario
Ministry of Health 2006). It is available at:
http://www.health.gov.on.ca/english/providers/program/infectious/diseases/best_prac/bp_
cdiff_050106.pdf.
BCCDC’s infection control guidelines for the control of gastroenteritis outbreaks in long
term care facilities is available at:
http://www.bccdc.org/downloads/pdf/lab/reports/CDManual_GEGuidelines_sep2003_no
v05-03.pdf.
BCCDC guidelines for Exclusion of Enteric Cases and their Contacts can be found at:
http://www.bccdc.org/content.php?item=192.
BCCDC’s guidelines about prevention of enteric diseases at petting zoos and open farms
can be found at: http://www.bccdc.org/content.php?item=192.
6.4 Emerging Communicable and Zoonotic Diseases
Emerging diseases include previously unknown diseases or diseases that have reappeared after a
significant decline in incidence. Changes in human demographics, behaviour, land use etc. are
contributing to new disease emergence by changing transmission dynamics to bring people into
closer and more frequent contact with pathogens.
Concerns about an impending influenza pandemic have generated worldwide interest in
human cases of avian influenza infection. Interim WHO infection control guidelines for
managing avian influenza in health care settings can be found at:
http://www.who.int/csr/disease/avian_influenza/guidelines/EPR_AM_final1.pdf.
National and provincial pandemic influenza guidelines are available at:
o Canada: http://www.phac-aspc.gc.ca/cpip-pclcpi/.
o British Columbia: http://www.bccdc.org/content.php?item=150.
BCCDC’s guidelines about prevention of zoonotic diseases at petting zoos and open
farms can be found at: http://www.bccdc.org/content.php?item=192.
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6.5 Vector-borne Diseases
Vector-borne transmission occurs when vectors such as mosquitoes, flies, rats, and other vermin
transmit microorganisms; this route of transmission is of less significance in causing outbreaks in
North America than in other regions of the world (Garner 1996). Such transmission has not been
reported in Canadian hospitals (Health Canada 1999).
6.6 Blood-borne Diseases (e.g., HIV, Hepatitis B and Hepatitis C)
Infection control measures such as education, safety devices, sharps management,
personal protective equipment etc. to prevent blood-borne diseases have been reviewed
by the Public Health Agency of Canada (PHAC) in its report: Prevention and Control of
Occupational Infections in Health Care (2002), Appendix II: http://www.phac-
aspc.gc.ca/publicat/ccdr-rmtc/02pdf/28s1e.pdf.
Laboratory testing of source blood following a blood and body fluid exposure is
recommended by PHAC. This is voluntary and requires informed consent. In Ontario,
legislation is in place to allow certain persons to apply to a medical officer of health for
an order requiring a blood sample for testing of hepatitis B, hepatitis C and HIV. The
results are then made available to the physician of the exposed individual to assist in his/
her management of the patient (Ontario Ministry of Health website).
Hepatitis B prevention should also include universal immunization of children, pre-
exposure immunization of high-risk groups (e.g., those at risk of occupational exposure
to blood and body fluids) and post-exposure intervention for those exposed to hepatitis B
virus. Further information about hepatitis B vaccination can be found in the Canadian
Immunization Guide 2006: http://www.phac-aspc.gc.ca/publicat/cig-gci/index.html.
BCCDC guidelines for blood and body fluid exposure management can be found at:
http://www.bccdc.org/content.php?item=192.
Evidence for partner notification and post-exposure prophylaxis following exposure to
blood borne infections is reviewed in the chapter “Evidence Base for Secondary
Prevention of Communicable Diseases.”
6.7 Reproductive and Sexual Health
See Section 6.6 (Blood-borne Diseases).
Evidence for screening and partner notification of sexually transmitted infections is is reviewed
in the chapter “Evidence Base for Secondary Prevention of Communicable Diseases.”
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6.8 Tuberculosis
Public Health Agency of Canada’s infection control guidelines (1996) to prevent
tuberculosis transmission is available at: http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/96vol22/22s1/index.html.
Evidence for screening, contact notification and prophylaxis for tuberculosis is reviewed
in the chapter “Evidence Base for Secondary Prevention of Communicable Diseases.”
Canadian Tuberculosis Guidelines, 6th
edition is expected in Summer 2007.
6.9 Vaccine-Preventable Diseases
Infection control measures to prevent transmission of vaccine-preventable diseases such
as measles, mumps, rubella, N. 30eningitides, H. influenza, pertussis etc. can be found in
Health Canada’s Routine Practices and Additional Precautions for Preventing
Transmission of Infections in Health Care (1999) which is available at: http://www.phac-
aspc.gc.ca/publicat/ccdr-rmtc/99vol25/25s4/index.html.
Information about immunization recommendations can be found in the Canadian
Immunization Guide 2006: http://www.phac-aspc.gc.ca/publicat/cig-gci/index.html.
BCCDC guidelines for management of H. influenza type b, Hepatitis A, meningococcal
disease, pertussis, rabies and varicella zoster are available at:
http://www.bccdc.org/content.php?item=192.
A review of post-exposure prophylaxis following exposure to infections can be found in
the chapter “Evidence Base for Secondary Prevention of Communicable Diseases.”
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7.0 CONCLUSION
Public Health Measure Level of
Evidence
Quarantine and Isolation:
Moderate evidence of effectiveness demonstrated during SARS outbreak
Weak evidence of effectiveness during 1918 influenza pandemic
2-
Compliance with quarantine:
Good evidence of voluntary compliance during SARS outbreak
3
Exclusion of Sick Children from Child Care Facilities and Schools:
Recommendation is based on expert opinion
4
Day care and School Closures
Weak evidence of effectiveness
2-
Exclusion of Infected Workers:
Good evidence of effectiveness
2-
Restrictions on Public Gatherings:
Weak evidence of effectiveness
Recommendation is based on expert opinion
4
Simultaneous Use of Multiple Community-based Interventions
Moderate evidence of effectiveness
2-
Personal Protective Equipment
Good evidence of effectiveness of gloves
Weak evidence of effectiveness of gowns
Good evidence of effectiveness of eye protection but compliance is poor
4
Patient and Staff Cohorting
Moderate evidence of effectiveness
2-
Patient screening for multidrug resistant organisms
Equivocal evidence – some studies show effectiveness while others do not
2-
Staff screening for MRSA
Weak evidence of effectiveness
2-
Staff screening for TB and influenza
Recommendation is based on expert opinion
4
Visitor screening for influenza
Recommendation is based on expert opinion
4
Restriction of admissions or transfers
Recommendation is based on expert opinion
4
Facility Closure
Has only been studied as part of multiple intervention strategies during SARS
outbreak
3
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