What We Need is a Red Book for College Health: Infection Control for the College Campus

Evelyn Wiener, MDUniversity of Pennsylvania

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United States Environmental Protection AgencyPublic Health Image Library

SESSION OBJECTIVES• List communicable diseases for which

infection control measures are indicated

• Identify modes of transmission for communicable diseases

• Identify appropriate infection control measures for common and/or serious contagious diseases

• Know the campus and community resources involved with implementing infection control measures 3

LA2/23/12•History:– Sore throat & cough x 1 day– PMH pneumonia one year ago

•Physical exam– BP 138/85 HR 115 T 98.5– Pharynx red, TM normal– Lungs clear

•Symptomatic treatment advised

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LA, continuedReturns 2/28/12•CXR (obtained 2/23) was negative•Symptoms have continued, cough worse•Physical exam– BP 147/91 HR 113 T 99.0– Pharynx red, cervical adenopathy– Lungs clear, but frequent dry coughing fits,

speaking in full sentences

•Symptomatic measures continued

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LA, continued2/29/12•Goes to ER - cough incessant, uncontrolled by codeine

•What is the differential diagnosis?

•What else do you need to know?

•What do you need to do?

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What are the infection control issues?

Which issues are unique to college setting?

Who needs to be involved/informed?

Where do you find the answers?

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WHAT NOW?

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STUDENT

PARTNERS

PARTNERS

FRIENDSFRIENDS

ROOMMATES

ROOMMATES

CLASSMATE

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CLASSMATE

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FamilyFamily

STUDENT AFFAIRS

STUDENT AFFAIRS

FACULTYFACULTYRES LIFE

STAFF

RES LIFE

STAFF

FACILITIESFACILITIES

HEALTH SERVICEHEALTH SERVICE

FAMILY

HUMAN RESOURCES

HUMAN RESOURCES

Risk Management

Risk Management

ADMINISTRATIONADMINISTRATION

Environmental Health

Environmental Health

WHAT DO STUDENTS NEED TO KNOW?**Also parents, staff, media

• Who is at risk for exposure?

• What should students do if they were exposed?

• What should students do if they have symptoms?

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WHAT DO ADMINISTRATORS NEED TO KNOW?

• Same as students

PLUS• Extent of outbreak• Measures needed to control outbreak• Need to provide support to affected students• Need for resources• Talking points

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WHAT DO CLINICAL STAFF NEED TO KNOW?

• Same as students and administrators

PLUS• On-site infection control measures• Clinical presentation• Diagnostic tests• Management• Reporting

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CAMPUS INFECTION CONTROL ISSUES

• How do basic infection control principles apply in a campus environment?– Populations– Facilities– Significant functions

• What resources are needed?

• What resources are available?

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STUDENT POPULATIONS

Residential studentsCommutersPart-time studentsGreek systemAthletesHealth care studentsInternational studentsVisiting/exchange students

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OTHER POPULATIONS

FacultyStaffVisitorsSpecial program participantsContractors

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FACILITIESStudent housing

Residence hallsFraternities and sororitiesOff-campus housing

Dining hallsClassroomsResearch laboratoriesLibrariesAthletic facilitiesOther buildings

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SIGNIFICANT FUNCTIONSStudents Faculty Administration

Classes Classes HR/personnel

Research Research Finance/payroll

Housing Advising Facilities

Dining Information systems

Activities Business services

Work Public safety16

TYPES OF INFECTIOUS DISEASES

ViralBacterialFungalParasiticNematodes and helminthsCritters

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TRANSMISSION BASICS

• Airborne• Droplet• Contact• Ingestion• Blood and body fluid

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AIRBORNE TRANSMISSION

• Airborne droplet nuclei – Small particles <5 μm of evaporated droplet

• Widely dispersed• Remain suspended in air for long periods• Indication for N95 respirator

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20CDCCDC

TB Online

DROPLET TRANSMISSION

• Droplets generated primarily by coughing, sneezing, talking

• Droplets relatively large– Propelled short distance (< 3 feet)– Deposited on conjunctiva, nasal mucosa, mouth– Do not remain suspended in air

• Indication for surgical masking

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CDC CDC

scarletfeverpictures.comCDC

CONTACT TRANSMISSION

• Direct contact with infected area• Fomites• Most common route of health care-associated

infections

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CDC/Dr. Thomas SellersWikipdedia/Robert Morley

CDCMiteBitespictures.com

INGESTION

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Chicago Star Tribune

BLOOD AND BODY FLUID

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CDC CDC

CONTROL AND PREVENTION• Pre-exposure immunization

(for vaccine-preventable diseases)• Screening • Hand hygiene• Food and water safety• Universal precautions• Isolation and quarantine• Post-exposure immunization • Post-exposure chemoprophylaxis 27

RECOGNIZING AND MANAGING OUTBREAKS

• Disease surveillance• Contact identification and tracing• Pre- and post-exposure prophylaxis• Notification• Public health emergencies

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INFECTION CONTROL ISSUES

• Transmission characteristics• Diagnosis• Treatment• Evaluation of the exposed individual• Control measures• Isolation/exclusion – who, what, how long• Post-exposure measures• Environmental measures

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PERTUSSIS

ManifestationsCatarrhal stageCoughParoxysmal stage

Transmission Droplet

Incubation period Typically 7 – 10 days (range 6 -21 days)

Diagnostic testsCulturePCRDFA

Treatment Macrolide antibiotic (azithromycin)

Infectivity From onset of symptoms* to 2 weeks after onset of paroxysms

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{Total duration 6 – 10 weeks}

PERTUSSIS, continued

Control measures

Isolate student until first five days antibiotics completed or until 21 days after onset of symptomsIsolate symptomatic contacts

Candidates for post-exposure measures

Prophylaxis indicated for household and other close contactsMonitor for 21 days after last contact

Post-exposure measures

Macrolide antibiotic (azithromycin)Update Tdap when indicated, but not effective as post-exposure measure

Cleaning and disinfecting Routine cleaning only

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MEASLES

Manifestations

Fever, followed by cough, coryza, conjunctivitis and Koplik spotsErythematous maculopapular rash, starts on head and spreads downward

Transmission Airborne spread, as well as direct contact with infectious droplets

Incubation period 8 to 12 days

Diagnostic tests Culture, serology, RT-PCR

Treatment No specific antiviral therapy

InfectivityHighly infectiousContagious from four days before onset of rash to four days after rash appears

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MEASLES, continued

Control measures

Isolate for 4 days after onset of rash (airborne precautions)Isolate symptomatic contactsConsider excluding asymptomatic contacts who cannot demonstrate immunity

Candidates for post-exposure measures

Anyone who cannot demonstrate immunity

Post-exposure measures

Post-exposure immunization may be effective if given within 72 hours of exposure

Cleaning and disinfecting Routine cleaning only

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MRSA

Manifestations Pustule or boil, commonly at site of visible skin trauma

Transmission Contact

Diagnostic tests Culture and sensitivity

Treatment

Incision and drainage Empiric antibiotics may be warrantedWhen possible, obtain specimens for C&S to guide continued antibiotic choice

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MRSA, continued

Control measures

Cover infectionsExclude athletes if wounds cannot be properly coveredHand hygieneClean shared equipmentDo not share personal items

Post-exposure measures No specific measures

Cleaning and disinfecting

Usually routine cleaning sufficientFocus on surfaces that might come in contact with uncovered infectionsClean shared equipmentRoutine laundry procedures

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NOROVIRUS

Manifestations Diarrhea and vomitingSymptoms last 1 – 14 days

TransmissionIngestion Person-to-person (fecal-oral)Contaminated food or water

Incubation period 12 to 72 hours

Diagnostic tests PCR assays not commercially available

Treatment Symptomatic – antiemetics, rehydration

Infectivity Most contagious during symptoms and first 3 days of recovery

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NOROVIRUS, continued

Control measures

Standard measures for control of diarrheaScrupulous hand hygieneExclude infected individuals from food preparation, health care, child careConsider isolation for 48 hours

Candidates for post-exposure measures

Reinforce hand hygiene to anyone with potential exposure

Post-exposure measures No specific measures available

Cleaning and disinfecting

Disinfect contaminated surfaces with bleach solution or other disinfectantWash contaminated clothes and linens

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AIRBORNE DROPLET CONTACT INGESTION BLOOD/FLUID

Measles Pertussis MRSA Norovirus HIV

Chickenpox Mumps Impetigo Hep A Hep B

Zoster Meningococcus Scabies Campylobacter Hep C

Tuberculosis Influenza HSV Salmonella

SARS Strep pyogenes C. diff Shigella

Smallpox Rubella Fungi E. coli

Monkeypox Adenovirus Adenovirus

Mycoplasma Zoster

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OTHER ISSUES

• Global health concerns• Global patterns of disease• Issues for students traveling abroad• Issues for international students

• Health care students• Animal-borne diseases• Faculty and staff

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ENVIRONMENTAL CLEANING

Standards for cleaningCleaning in response to disease outbreakSpecial circumstances/settingProtective equipment

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CAMPUS RESOURCES

• SHS• Dean of students• Environmental Health• Public safety• Facilities• Human Resources• Risk Management

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COMMUNICATIONS

• Communication with administration• Communications to students (and parents)• Communications to faculty• Media releases• Notification to public health officials

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ACKNOWLEDGEMENTS

Sharon McMullen RN BSN BA University of Pennsylvania

Esther Chernak, MD, MPH, FACPDrexel University School of Public Health

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