Primary Health Care Preparedness

Infection Control:

Real-life recent scenario from a GP surgery in Auckland:
Mr T rings for a GP appointment and is given a routine morning appointment. He arrives at the surgery and, after reporting to the reception desk, takes a seat in the waiting room with other patients. He looks flushed and is coughing. After waiting about 15 minutes for his appointment he is taken into the consulting room. His history includes the fact that he has returned the previous evening from Jakarta, where he was attending a family wedding on a 5-day trip.

He had not had any contact with poultry or birds, or visited any markets. The wedding was held in a private home. He became unwell 48 hours ago with a fever, cough, and headache, but no SOB. However, he is obviously feeling quite unwell.

Examination findings include a fever of 40.1, obviously flushed and miserable appearance, and presence of cough. Scattered signs are present in the right lung field.

A viral throat swab is taken for influenza virus. This process elicits a cough reflex from the patient, who apologises. He is referred to a local private radiology facility, where he has a CXR. No specific infection control procedures are followed at the radiology clinic. The CXR shows fluid in the horizontal fissure in the right lung, but no consolidation.

The patient is prescribed paracetamol and augmentin and goes home with his wife. He slowly improves over the following week and is reviewed twice, once after 3 days after the development of a rash on his lower back.

The virologist rings the surgery when the specimen is received, seeking further information. PCR testing on the swab is positive for influenza A, but negative for H5N1.

Issues:

• How could reception staff have better identified the nature of the problem either when he phoned for an appointment or when he presented in an unwell condition to the surgery?
• What steps could have been taken to reduce risk of cross-infection while waiting for his appointment?
• How could the doctor have reduced the risk of infection to himself during the consultation and the taking of the throat swab?
• Should a pernasal nasopharyngeal swab have been taken?
• How could the radiology clinic staff have been better prepared to deal with the risk of infection?
• If Tamiflu had been available, should this have been offered to the patient?
• Was the prescription of an antibiotic appropriate?
• How could the doctor have ensured that the hospital laboratory was prepared for the processing of the TS specimen?
• What management would have been appropriate for the patient's wife and direct contact family members?
• Should the doctor have discussed the problem with the medical officer of health?

Key Principles to consider:

Influenza is transmitted from person to person in two ways: More...

• Droplet transmission: Via virus-laden large droplets (particles > 5 micrometres in diameters are defined as droplets). These are generated when an infected person coughs or sneezes and the droplets are directly deposited onto the mucosal surfaces of the upper respiratory tract of people who are near the infected person, (ie within a metre)
  Image sourced from: www.dhs.ca.gov
• Contact transmission: Through direct contact with infectious (wet) respiratory secretions, such as by touching door handles, clothing, taps, stairwell railings, keyboards, desk surfaces etc that have a deposit of the infected secretion on their surfaces and then passed through hand-to-face contact.
  

Airborne transmission may also be possible in certain settings, especially medical procedures (eg, nebulization, intubation) that lead to aerosolisation of droplets.

General recommended infection prevention and control measures:

• Organisational respiratory disease policy:
  All organisations should have policies and processes in place to ensure people with fever and respiratory symptoms do not place others at risk of infection. This should include workplace policies around sending ill people home, enabling staff to work in more isolated settings, such as from home during influenza outbreaks. As individuals may be infectious, early in the course of the illness, including the prodromal period, it is important for individuals to be aware of, and respond to, the early symptoms.
• Ventilation of internal spaces:
  All environments should be well ventilated, preferably with fresh air with opening windows or with properly designed and maintained air-conditioning systems.
  For specific Ministry of Health advice on air conditioning and influenza refer www.moh.govt.nz/moh.nsf......
• Cough hygiene/etiquette:
  All people with respiratory symptoms should practise cough etiquette whenever they are in the presence of another person
  • Avoid close contact (within a metre) with other people
  • Cover nose and mouth when coughing or sneezing
  • Use disposable tissues to contain secretions
  • Immediately dispose of used tissues in the nearest lined rubbish bin, either pedal operated or unlidded
  • · Immediately wash and dry hands after coughing and using tissues
• Hand hygiene:
  Activities that involve hand-to-face contact present significant risk because of the potential for transmitting influenza, eg eating, grooming, smoking. It is essential that hands are washed and dried or hand antisepsis is used before any activity that involves hand-to-face contact.
• Physical Distancing:
  A distance of at least one metre should be maintained between people wherever possible, and people who are unwell should seek to minimise their contact with others wherever practicable. During a pandemic crowded places and large gatherings of people should be avoided.
• Protective barriers:
  Barriers, eg glass, perspex may be useful in some environments, eg counter staff, supermarket operators, public transport to reduce face-to-face contact with members of the public where keeping a distance from others is not practicable. Note that avoiding physical exposure will also be important such as hand-to-hand, face-to-face contact.

For further information:
Refer to "Interim Guidelines for Personal Protection and Using Personal Protective Equipment During an Influenza Pandemic" Ministry of Health 16 Sept 2005