Evidence Review: Communicable Disease - Ministry of Health...Core Public Health Functions for BC:...

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


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



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



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

http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/98pdf/cdr24s8e.pdf




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.




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).




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




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.




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.




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.




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.




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.

http://www.phac-aspc.gc.ca/media/nr-rp/2004/2004_54_e.html

http://www.phac-aspc.gc.ca/media/nr-rp/2004/2004_54_e.html




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.

http://www.cdc.gov/cleanhands/

http://www.cdc.gov/flu/protect/covercough.htm

http://www.phac-aspc.gc.ca/publicat/cig-gci/index.html

http://www.qp.gov.bc.ca/statreg/stat/C/02075_01.htm



http://www.qp.gov.bc.ca/statreg/reg/C/CommuCareAssisted/319_89.htm




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;

http://nrc.uchsc.edu/SPINOFF/IE/IncExc.pdf




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)




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).


((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).




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.


(i.e., Non-randomized intervention studies)

https://www.cpsbc.ca/cps/college_programs/bbcd_panel

http://www.bccdc.org/content.php?item=192




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.


(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.




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.


(i.e., Correlation studies)




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).




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.




http://www.epic.tvu.ac.uk/




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


(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)




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)


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


(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




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)


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


(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).




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.


(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).




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).


(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).


(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.





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.


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.


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

http://www.cdc.gov/flu/professionals/labdiagnosis.htm




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.


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).


(Case series)




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).

http://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf




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:


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.


http://www.health.gov.on.ca/english/providers/program/infectious/diseases/best_prac/bp_staff.pdf

http://www.health.gov.on.ca/english/providers/program/infectious/diseases/best_prac/bp_staff.pdf

http://www.pulsus.com/infdis/17_SC/Pdf/mrsa_ed.pdf

http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/99vol25/25s4/index.html






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-


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:


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.



http://www.health.gov.on.ca/english/providers/program/infectious/diseases/best_prac/bp_cdiff_050106.pdf

http://www.health.gov.on.ca/english/providers/program/infectious/diseases/best_prac/bp_cdiff_050106.pdf

http://www.bccdc.org/downloads/pdf/lab/reports/CDManual_GEGuidelines_sep2003_nov05-03.pdf

http://www.bccdc.org/downloads/pdf/lab/reports/CDManual_GEGuidelines_sep2003_nov05-03.pdf



http://www.who.int/csr/disease/avian_influenza/guidelines/EPR_AM_final1.pdf

http://www.phac-aspc.gc.ca/cpip-pclcpi/






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:


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.”

http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/02pdf/28s1e.pdf

http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/02pdf/28s1e.pdf






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-


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:


A review of post-exposure prophylaxis following exposure to infections can be found in

the chapter “Evidence Base for Secondary Prevention of Communicable Diseases.”










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:



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


2-

Staff screening for TB and influenza


4

Visitor screening for influenza


4

Restriction of admissions or transfers


4

Facility Closure

Has only been studied as part of multiple intervention strategies during SARS

outbreak

3




REFERENCES

Agah, R., Cherry, J.D., Garakian, A.J., et al. (1987). Respiratory Syncytial Virus (RSV) infection

rate in personnel caring for children with RSV infections. Routine isolation precautions

vs. routine procedure supplemented by use of masks and goggles. American Journal of

Diseases of Children, 141, 695–697.

American Academy of Pediatrics, American Public Health Association and the National

Resource Center for Health and Safety in Child Care. (2002). Exclusion and inclusion of

ill children in child care facilities and care of ill children in child care standards. Caring

for our children: National health and safety performance standards for out-of-home child

care programs (2nd

ed.). Elk Grove, IL: American Academy of Pediatrics.

Armstrong-Evans, M., McArthur, M.A., et al. (1999). Control of transmission of vancomycin-

resistant enterococcus faecium in a long-term-care facility. Infection Control and

Hospital Epidemiology, 20(5), 312–317.

Arnow, P., Allyn, P.A., Nichols, E.M., et al. (1982). Control of methicillin-resistant staphlyoccus

aureus in a burn unit: Role of nurse staffing. Journal of Trauma, 22, 954–959.

Aronson, S.S., & Shope, T.R. (2005). Managing infectious diseases in child care and schools.

American Academy of Pediatrics.

Austin, D.J., Weinstein, R.A., et al. (1999). Vancomycin-resistant enterococci in intensive-care

hospital settings: Transmission dynamics, persistence and the impact of infection control

programs. Proceedings of the National Academy of Sciences of the United States of

America, 96(12), 6908–6913.

Ayliffe, G.A.J., Buckles, A., Casewell, M.W., et al. (1998). Revised guidelines for the control of

methicillin-resistant staphylococcus aureus infection in hospitals. Journal of Hospital

Infection, 39, 253–290.

Barton, M., Hawkes, M., Moore, D. (2006). Guidelines for prevention and management of

community-associated methicillin-resistant staphlococus aureus: A perspective for

canadian healthcare practitioners. Canadian Journal of Infectious Diseases & Medical

Microbiology, 17(Suppl. C), 4–24.

Bell, D.M., WHO Working Group on International and Community Transmission of SARS.

(2004). Public health interventions and SARS spread, 2003. Emerging Infectious

Diseases, 10(11), 1900–1906.

Beltrami, E.M., Williams, I.T., Shapiro, C.N., & Chamberland, M.E. (2000). Risk and

management of blood-borne infections in health care workers. Clinical Microbiology

Reviews, 13(3), 385–407.

Bensimon, C.M. (2007). Evidence and effectiveness in decisionmaking for quarantine. American

Journal of Public Health, 97(S1), S44–S48.




Blanchard, A.S., Ferris, S., Chamaret, S., Guétard, D., & Montagnier, L. (1998). Molecular

evidence for nosocomial transmission of human immunodeficiency virus from a surgeon

to one of his patients. J. Virol 72,4537–4540

Blumberg, L.H., & Klugman, K.P. (1994). Control of methicillin-resistant staphylococcus aureau

bacteraemia in high-risk areas. European Journal of Clinical Microbiology & Infectious

Diseases, 13, 82–85.

Boccia, D., Samuelsson, S., et al. (2006). Effectiveness of different policies in preventing

meningococcal disease clusters following a single case in day-care and pre-school

settings in Europe. Epidemiology & Infection, 134, 872–877.

Bootsma, M.C.J., & Ferguson, A. (2007). The effect of public health measures on the 1918

influenza pandemic in US cities. Proceedings of the National Academy of Sciences of the

United States of America, 104(18), 7588–7593. Retrieved from:

http://www.pnas.org/cgi/doi/10.1073/pnas.0611071104.

Boyce, J.M., Opal, S.M., Chow, J.W., et al. (1994). Outbreak of multidrug-resistant enterococcus

faecium with transferable vanb class vancomycin resistance. Journal of Clinical

Microbiology, 32, 1148–1153.

Boyce, J.M., & Pittet, D. (2002). Guideline for hand hygiene in health-care settings. Morbidity

and Mortality Weekly Report, 51(RR16);1–44.

Brachman, P.S. (1998). Epidemiology of nosocomial infections. In: J.V. Bennett, P.S. Brachman

(eds.). Hospital infections (4th

ed.) (pp. 3–16). Philadelphia: Lippincott-Raven Publishers.

Bradley, R.H. (2003). Child care and common communicable illnesses in children aged 37 to 54

months. Archives of Pediatrics & Adolescent Medicine, 157, 196–200.

British Columbia Centre for Disease Control. (2001). British Columbia guidelines for control of

antibiotic resistance organisms (AROs) [MRSA and VRE]. Vancouver: Author.

British Columbia Centre for Disease Control. (2003). Managing outbreaks of gastroenteritis.

Vancouver: Author.

British Columbia Centre for Disease Control. (2005). Guidelines for control of ILI outbreaks.

Vancouver: Author.

British Columbia Centre for Disease Control. (2007). Exclusion of enteric cases and their

contacts from high risk settings. Vancouver: Author.

Bryant, M., Brothers, K., et al. (2006). Measures to control an outbreak of pertussis in a neonatal

intermediate care nursery after exposure to a healthcare worker. Infection Control and


Buffington, J., Sotbierski, M.G., et al. (1993). Epidemic keratoconjunctivitis in a chronic care

facility: Risk factors and measure for control. Journal of the American Geriatrics Society,

41(11), 1177–1181.

http://www.pnas.org/cgi/doi/10.1073/pnas.0611071104




Canadian Pediatric Society. (1999). School and daycare exclusion policies for chickenpox: A

rational approach. Pediatrics and Child Health, 4(4), 287–288.

Carrat, F., Lao, H., et al. (2006). A small-world-like model for comparing interventions aimed at

preventing and controlling influenza pandemics. BMC Medicine, 23(4), 26.

Carter, A.O., Borczyk, A., Carlson, J.A.K., et al. (1987). A severe outbreak of escherichia coli

O157:H7 – Associated hemorrhagic colitis in a nursing home. New England Journal of

Medicine, 317(24), 1496–1500.

Centers for Disease Control. (1984). Epidemiologic notes and reports shigellosis in day-care

centers – Washington, 1983. Morbidity and Mortality Weekly Report, 33(18), 250–251.

Centers for Disease Control. (1990). Possible transmission of human immunodeficiency virus to

a patient during an invasive dental procedure. Morbidity and Mortality Weekly Report,

39,489–493

Centers for Disease Control. (2007). Interim pre-pandemic planning guidance. Community

strategy for pandemic influenza mitigation in the USA. Atlanta, GA: Author.

Centers for Disease Control. (2007). Infection control guidance for the prevention and control of

influenza in acute-care facilities. Atlanta, GA: Author. Retrieved from:

http://www.cdc.gov/flu/professionals/infectioncontrol/healthcarefacilities.htm.

Chau, P.H. (2003). Monitoring the severe acute respiratory syndrome: Epidemic and assessing

the effectiveness of interventions in Hong Kong Special Administrative Region. Journal

of Epidemiology and Community Health, 57, 766–769.

Chowell, G., Castillo-Garsow, M.A., et al. (2003). SARS outbreaks in Ontario, Hong Kong and

Singapore: the role of diagnosis and isolation as a control mechanism. Journal of

Theoretical Biology, 224, 1–8.

Chowell, G., Fenimore, P.W., et al. (2004). Model parameters and outbreak control for SARS.

Emerging Infectious Diseases, 10, 1258–1263.

Clark, L., Smith, W., & Young, L. (2002). Protective clothing: Principles and guidance.

London: Infection Control Nurses Association.

Christie, C.D., Willke, M.J., et al. (1995). Containment of pertussis in the regional pediatric

hospital during the greater Cincinnati epidemic of 1993. Infection Control and Hospital

Epidemiology, 16(10), 556–563.

Coia, J.E., Duckworth, G.J., Edwards, D., et al. (2006) Guidelines for the control and prevention

of meticillin-resistant staphylococcus aureus (MRSA) in healthcare facilities. Journal of

Hospital Infection, 63, 1–44.

Coello, R., Jimenez, J., Garcia, M., et al. (1994). Prospective study of infection, colonization and

carriage of methicillin-resistant staphlococcus aureus in an outbreak affecting 990

patients. European Journal of Clinical Microbiology & Infectious Diseases, 13,74–81.

http://www.cdc.gov/flu/professionals/infectioncontrol/healthcarefacilities.htm




Cooper, B.S., Kibbler, C.C., et al. (2003). Systematic review of isolation policies in the hospital

management of MRSA: a review of the literature with epidemiological and economic

modelling. Health Technology Assessment, 7(39), 1–240.

Copeland, K.A., Harris, E.N., Wang, N.Y., & Cheng, T.L. (2006). Compliance with American

Academy of Pediatrics and American Public Health Association illness exclusion

guidelines for child care centers in Maryland: Who follows them and when? Pediatrics,

118(5), e1369–e1380.

Copeland, K.A., Duggan, A.K., & Shope, T.R. (2005). Knowledge and beliefs about guidelines

for exclusion of ill children from child care. Ambulatory Pediatrics, 5(6), 365–371.

Day, T. (2004). Predicting quarantine failure rates. Emerging Infectious Diseases, 10, 487–488.

Day, T., Madras, N., et al. (2006). When is quarantine a useful control strategy for emerging

infectious diseases ? American Journal of Epidemiology, 163(5), 479–485.

Department of Health. (2005). The UK Health Departments' pandemic influenza contingency

plan. London: Author.

Diamond, B. (2003). SARS spreads new outlook on quarantine models. Nature Medicine, 9,

1441.

DiGiovanni, C., Chiu, D., & Zaborski, J. (2004). Factors influencing compliance with quarantine

in Toronto during the 2003 SARS outbreak. Biosecurity and Bioterrorism: BSPS, 2(4),

265–272.

Dwosh, H.A., Hong, H.H.L., Austgarden, D., et al. (2003). Identification and containment of an

outbreak of SARS in a community hospital. Canadian Medical Association Journal,

168(11), 1415–1420.

Farr, B.M., & Bellingan, A. (2004). Pro/con clinical debate: Isolation precautions for all

intensive care unit patients with methicillin-resistant staphylococcus aureus colonization

are essential. Critical Care, 8, 153–156.

Ferguson, N.M., Fraser, C., et al. (2006). Strategies for mitigating an influenza pandemic.

Nature, 442, 448–452.

Foca, M., Jakob, K., Whittier, S., et al. (2000). Endemic pseudomonas aeroginosa infection in a

neonatal intensive care unit. New England Journal of Medicine, 343, 695–700.

Francis J. Curry National Tuberculosis Center, Institutional Consultation Services. (1999). Policy

and procedures for tuberculosis screening of health-care workers. San Francisco, CA:

Author.

Fraser, C., Anderson, R.M., & Ferguson, N.M. (2004). Factors that make an infectious disease

outbreak controllable. Proceedings of the National Academy of Sciences of the United

States of America, 101, 6146–6151.




Gala, C.L., Hall, C.B., Schnabel, K.C., et al. (1986). The use eye-nose goggles to control

nosocomial respiratory syncytial virus infection. Journal of the American Medical

Association, 256, 2706–2708.

Galanis, E., Longmore, K., Hasselback, P. et al. (2003). Investigation of an E. Coli O157:H7

outbreak in Brooks, Alberta, June-July 2002: The role of occult cases in the spread of

infection within a day care setting. Canada Communicable Disease Report, 29(3), 1–5.

Gardam, M., Burrows, L.L., Kus, J.V., et al. (2002). Is surveillance for multidrug resistant

Enterobacteriaceae an effective infection control strategy in the absence of an outbreak?

Journal of Infectious Diseases, 186(12), 1754–1760.

Garner J, Hospital Infection Control Practices Advisory Committee and Centers for Disease

Control. (1996). Guideline for isolation precautions in hospitals. American Journal of

Infection Control, 24, 24–52.

Genobile, D., Gaston, J., Tallis, G.F., et al. (2004). An outbreak of shigellosis in a child care

centre. Communicable Diseases Intelligence, 28(2), 225–229.

Gensini, G.F., & Conti, A.A. (2004). The concept of quarantine in history: From plague to

SARS. Journal of Infection, 49, 257–261.

Germann, T.C., Longini, I.M., & Macken, C.A. (2006). Mitigation strategies for pandemic

influenza in the United States. Proceedings of the National Academy of Sciences of the

United States of America, 103(15), 5935–5940.

Glass, R.J., Glass, L.M., Beyseler, W.E., & Min, H.J. (2006). Targeted social distancing design

for pandemic influenza. Emerging Infectious Diseases, 12(11), 1671–1681.

Glass, K., & Becker, N.G. (2006). Evaluation of measures to reduce international spread of

SARS. Epidemiology & Infection, 134(5), 1092–1101.

Gopalakrishna, G., Choo, P., Leo, Y.S., et al. (2004). SARS transmission and hospital

containment. Emerging Infectious Diseases, 10(3), 395–400.

Gostin, L.O., Bayer, R., & Fairchild, A.L. (2003). Ethical and legal challenges posed by severe

acute respiratory syndrome. Journal of the American Medical Association, 290(24),

3229–3237.

Gouveia, S., Proctor, M.E., Lee, M.S., et al. (1998). Genomic comparisons and shiga toxin

production among escherichia coli O157:H7 isolates from a day care center outbreak and

sporadic cases in southeastern Wisconsin. Journal of Clinical Microbiology, 36(3), 727–

733.

Gumel, A.G., Day, T., et al. (2004). Modelling strategies for controlling SARS outbreaks.

Proceedings of the Royal Society of London, 271, 2223–2232.




Guzewich, J., & Ross, M.P. (1999). Evaluation of risks related to microbiological contamination

of read-to-eat food by food preparation workers and the effectiveness of interventions to

minimize those risks. White paper, section 1: A literature review pertaining to foodborne

disease outbreaks caused by food workers, 1975-1998. Silver Spring, MD: Food and

Drug Administration, Center for Food Safety and Applied Nutrition.

Harbath, S., Masuet-Aumatell, C., Schrenzel, J., et al. (2006). Evaluation of rapid screening and

pre-emptive contact isolation for detecting and controlling methicillin-resistant

Staphylococcus aureus in critical care: An interventional cohort study. Critical Care,

10(1), R25.

Hartstein, A.I., Lemonte, A.M., & Iwamoto, P.K.L. (1997). DNA typing and control of

methicillin-resistant staphlococcus aureus at two affiliated hospitals. Infection Control

and Hospital Epidemiology, 18, 42–48.

Haskins, R., & Kotch, J. (1986). Day care and illness: Evidence, cost and public policy.

Pediatrics, 77(6 Pt 2), 951–982.

Hatchett, R.J., & Lipsitch, M. (2007). Public health interventions and epidemic intensity during

the 1918 influenza pandemic. Proceedings of the National Academy of Sciences of the

United States of America, Apr 6: [Epub ahead of print].

Hawryluck, L., Robinson, S. et al. (2004). SARS control and psychological effects of quarantine,

Toronto, Canada. Emerging Infectious Diseases, 10(7), 1206–1212.

Health Canada. (1998). Infection control guidelines: Handwashing, cleansing, disinfection and

sterilization in health care. Canada Communicable Disease Report, 24(Suppl. 8), 1–54.

Health Canada. (1999). Infection control: Guidelines and routine practices and additional

precautions for preventing the transmission of infections in health care. Canada

Communicable Disease Report, 25(Suppl. 4), 1–142.

Health Canada. (1999). Hepatitis C – Prevention and control: a public health consensus. Canada

Communicable Disease Report, 25 (Suppl. 2), 1–23.

Heymann, A., Reichman, B. et al. (2004). Influence of school closure on the incidence of viral

respiratory diseases among children and on health care utilization. Pediatric Infectious

Disease Journal, 23(7), 675–678.

Heymann, D.L. (2004). Control of communicable diseases manual [18th

ed.]. American Public

Health Association.

Honorable Mr. Justice Archie Campbell. (2006). Spring of fear: Final report of the SARS

Commission. Toronto, ON: The SARS Commission.

Hsieh, Y.H. (2005). Quarantine for SARS, Taiwan. Emerging Infectious Diseases, 11, 278–282.

Hsieh, Y.H., Chen, C.W.S., et al. (2007). Impact of quarantine on the 2003 SARS outbreak: A

retrospective modeling study. Journal of Theoretical Biology, 244, 729–736.




Hughes, C.M., & Tunney, M.M. (2007). Infection control strategies for preventing the

transmission of mrsa in nursing homes and associated older residents (protocol).

Cochrane Database of Systematic Reviews, 1(CD006354).

Inglesby, T.V., Nuzzo, J.B., O’Toole, T., & Henderson, D.A. (2006). Disease mitigation

measures in the control of pandemic influenza. Biosecurity and Bioterrorism: BSPS, 4(4),

366–375.

Jernigan, J.A., Titus, M.G., Groschel, D.H.M., et al. (1996). Effectiveness of contact isolation

during a hospital outbreak of methicillin-resistant Staphylococcus aureus. American

Journal of Epidemiology, 143,496–504.

Jochimsen, E.M., Manning, K., et al. (1999). Control of vancomycin-resistant enterococci at a

community hospital: Efficacy of patient and staff cohorting. Infection Control and


Jones, E.W. (2005). Co-operation in all human endeavor: Quarantine and immigrant disease

vectors in the 1918-1919 influenza pandemic in Winnipeg. Canadian Bulletin of Medical

History, 22(1), 57–82.

Jordan, E.O. (1919). Influenza in three Chicago groups. Journal of Infectious Diseases, 25, 74–

95.

Kahan, E., Gross, S., Horev, Z., et al. (2006). Pediatrician attitudes to exclusion of ill children

from child-care centers in Israel: Pressure on ambulatory practices. Patient Education

and Counseling, 60(2), 164–170.

Kahan, E., Gross, S., Cohen, H.A. (2005). Exclusion of ill children from child-care centers in

Israel. Patient Education and Counseling, 56(1), 93–97.

Kahn, L.H. (2007). Pandemic influenza school closure policies [letter]. Emerging Infectious

Diseases, 13(2). Retrieved May 14, 2007, from:

http://www.cdc.gov/EID/content/13/2/344.htm

Karchmer, T.B., Cage, E.G., Durbin, L.J., et al. (2002). Cost effectiveness of active surveillance

cultures for controlling methicillin-resistant S. aureus (MRSA). Journal of Hospital

Infection, 51,126–132.

Kilwein, J.H. (1995). Some historical comments on quarantine: Part 1. Journal of Clinical

Pharmacy and Therapeutics, 20, 185–187.

Kim, M.M., Mindorff, C., Patrick, M.L., et al. (1987). Isolation usage in a pediatric hospital.

Infection Control, 8, 195–199.

Klein, B.S., Perloff, W.H., & Maki, D.G. (1989). Reduction of nosocomial infection during

pediatric intensive care by protective isolation. New England Journal of Medicine, 320,

1714–1721.

Kondro, W. (2007). Revised quarantine act has serious limitations. Canadian Medical

Association Journal, 176(5), 613–4.

http://www.cdc.gov/EID/content/13/2/344.htm




Korniewicz, D.M., El-Masri, M., & Broyles, J.M. (2002). To determine the effects of gloves

stress, type of material (vinyl, nitrile, copolymer, latex) and manufacturer on the barrier

effectiveness of medical examination gloves. American Journal of Infection Control, 30,

133–138.

Landis, S.E., Earp, J.A., & Sharp, M. (1988). Day-care center exclusion of sick children:

Comparison of opinion of day-care staff, working mothers and pediatricians. Pediatrics,

81(5),662–667.

Lior, L., Litt, M., Hockin, J., et al. (1996). Vancomycin-resistant entrococci on a renal ward in an

Ontario hospital. Canada Communicable Disease Report, 22, 125–128.

Lipsitch, M., Cooper, B., et al. (2003). Transmission dynamics and control of severe acute

respiratory syndrome. Science, 300, 1966–1970.

Lloyd-Smith, J.O., & Getz, W.M. (2003). Curtailing transmission of severe acute respiratory

syndrome within a community and its hospital. Proceedings. Biological Sciences, 270,

1979–1989.

Lo, J.Y.C., Leung, Y.H., et al. (2005). Repsiratory infections during SARS outbreak, Hong Kong

2003. Emerging Infectious Diseases, 11, 1738–1741.

Loda, F.A., Glezen, W.P., & Clyde, W.A. (1972). Respiratory disease in group day care.

Pediatrics, 49(3), 428–437.

Loveday, H.P., Jones, S.R.L.J., & Pratt, R.J. (2006). A systematic review of the evidence for

interventions for the prevention and control of MRSA (1996-2004): Report of the Joint

MRSA Working Party (Subgroup A). Journal of Hospital Infection, 635, S45–S70.

Lus, N., Samuels, M.E., Shi, L., et al. (2004). Child day care risks of common infectious diseases

revisited. Child: Care, Health and Development, 30(4), 361–368.

MacDonald, R.D., & Stuart, R. (2006). Performance analysis of a medical decision algorithm to

mitigate spread of SARS due to interfacility patient transfers. Prehospital Emergency

Care, 10(3), 383–389.

MacDonald, K.L., White, K.A., Heiser, J., et al. (1990). Evaluation of a sick child day care

program: Lack of detected increased risk of subsequent infections. Pediatric Infectious

Disease Journal, 9 (1), 15–20.

McCall, B., Stafford, R., Cherian, S., et al. (2000). An outbreak of multi-resistant shigella sonnei

in a long-stay geriatric nursing centre. Communicable Diseases Intelligence, 24,272–275.

McGinnis, J.P. (1977). The impact of epidemic influenza, Canada, 1918-1919. Historical

Papers/the Canadian Historical Association, 19, 120–141.

McQueen, H. (1975). Spanish flu 1919: Political, medical and social aspects. Medical Journal of

Australia, 1, 565–570.




Meyers, L.A., Newman, M.E.J., et al. (2005). Network Theory and SARS: Predicting outbreak

diversity. Journal of Theoretical Biology, 232, 71–81.

Millar, M.R., Keyworth, N., Lincoln, C., et al. (1987). Methicillin-resistant staphlococcus aureus

in a regional neonatology unit. Journal of Hospital Infection, 10, 187–197.

Mohan, P., & Weisman, L.E. (2006). Effect of patient isolation measures for infants with

candida colonization or infection on the transmission of candida. Cochrane Database of

Systematic Reviews, 3, CD 006068.

Mohle-Boetani, J.C., Stapleton, M., Finger, R., et al. (1995). Communitywide shigellosis:

Control of an outbreak and risk factors in child day-care centers. American Journal of

Public Health, 85(6),763–764.

Monnet, D.L., Edwards, J.R., et al. (1997). Evidence of interhospital transmission of extended-

spectrum beta-lactam-resistant klebsiella pneumoniae in the United States, 1986 to 1993,

The National Nosocomial Infections Surveillance System. Infection Control and Hospital


Moolenaar, R.L., Crutcher, M., San Joaquin, V.H., et al. (2000). A Prolonged Outbreak of

Pseudomonas aeruginosa in a Neonatal Intensive Care Unit: Did staff fingernails play a

role in a disease transmission. Infection Control and Hospital Epidemiology, 21, 80–85.

Mulin, B., Rouget, C., Clement, C., et al. (1997). Association of private isolation rooms with

ventilator-associated acinetobacter baumanii pneumonia in a surgical intensive-care unit.

Infection Control and Hospital Epidemiology, 18, 499–503.

Muto, C.A., Jernigan, J.A., Ostrowsky, B.E., et al. (2003). SHEA guideline for preventing

nosocomial transmission of multidrug-resistant strains of staphylococcus aureus and

enterococcus. Infection Control and Hospital Epidemiology, 24, 362–386.

National Advisory Committee on SARS and Public Health. (2003). Learning from SARS:

Renewal of public health in Canada. Ottawa, ON: Author.

National Institute for Clinical Excellence. (2003). Infection control: Prevention of healthcare-

associated infection in primary and community care. London: Author.

Neuzil, K.M., & Zhu, Y. (2002). Illness among schoolchildren during influenza season: Effect on

school absenteeism, parental absenteeism from work, and secondary illness in families.

Archives of Pediatrics & Adolescent Medicine, 156, 986–991.

Nicholson, T., Rualridh, M., & Stein, K. (1997). Screening staff for methicillin resistant

staphylococcus aureus (MRSA). Southampton: Wessex Institute for Health Research and

Development.

Nishiura, H., Sriprom, M., et al. (2004). Modelling potential responses to severe acute

respiratory syndrome in Japan: The role of initial attack size, precaution, and quarantine.

Journal of Epidemiology and Community Health, 58, 186–191.




O’Donnell, J.M., Thornton, L., McNamara, E.B., et al. (2002). Outbreak of verocytotoxin-

producing eschericheria coli O157:H7 in a child care facility. Canada Communicable

Disease Report, 5(1), 54–58.

Ontario Ministry of Health. (2006). Ontario health plan for an influenza pandemic. Toronto,

ON: Author.

Ontario Ministry of Health. Health Protection and Promotion Act, Bill 105. Retrieved April 10,

2007, from :

http://www.health.gov.on.ca/english/providers/legislation/bill_105/105_hosp.html.

Oshitani, H. (2006). Potential benefits and limitations of various strategies to mitigate the impact

of an influenza pandemic. Journal of Infection and Chemotherapy, 12(4), 167–171.

Ostrowsky, B.E., Sohn, A.H., et al. (2001). Control of vancomycin-resistant enterococcus in

health care facilities in a region. New England Journal of Medicine, 344(19), 1427–1433.

Ou, J., & Zeng, G. (2003). Efficiency of quarantine during an epidemic of SARS - Beijing,

China, 2003. Morbidity and Mortality Weekly Report, 52(43), 1037–1040.

Pang, X., Xu, F., et al. (2003). Evaluation of control measures implemented in the SARS

outbreak in Beijing, 2003. Journal of the American Medical Association, 290(24), 3215–

3221.

Pascual, F.B., McMurtray, A., et al. (2006). Outbreak of pertussis among healthcare workers in a

hospital surgical unit. Infection Control Br J Infect Control and Hospital Epidemiology,

27(6), 546–552.

Patterson, K.D. (1983). The influenza pandemic of 1918 in the Gold Coast. Journal of African

History, 24, 485–502.

Pellowe, C.M., Pratt, R.J., Loveday, H.P., et al. (2004). Updating the evidence-base for national

evidence-based guidelines for preventing healthcare associated infections in NHS

hospitals in England: a report with recommendations. Journal of Infection Prevention,

5,10–16.

Pellowe, C.M., Pratt, R.J., Harper, P., et al. (2003). Prevention of healthcare-associated

infections in primary and community care. British Journal of Infection Control,

(Suppl),1–120.

Perencevich, E.N., Fisman, D.N., Lipsitch, M., et al. (2004). Projected benefits of active

surveillance for vancomycin-resistant enterococci in intensive care units. Clinical

Infectious Diseases, 38(8),1108–1115

Pourbohloul, B., Skowronski, D.M., et al. (2005). Modeling control strategies of respiratory

pathogens. Emerging Infectious Diseases, 11, 1249–1256.

Pratt, R.J., Pellowe, C.M., Wilson, T.A., et al. (2007). Epi2: National evidence-based guidelines

for preventing healthcare-associated infections in NHS hospitals in England. Journal of

Hospital Infection, 65S, S1–S64.

http://www.health.gov.on.ca/english/providers/legislation/bill_105/105_hosp.html




Pratt, R.J., Pellowe, C.M., & Loveday, H.P. (2001). The Epic Project: Developing national

evidence-based guidelines for preventing healthcare-associated infections. Phase I:

Guidelines for preventing hospital-acquired infections. Journal of Hospital Infection,

47S, S1–S82.

Pritchard, V. (1999). Joint commission standards for long-term care infection control: Putting

together the process element. American Journal of Infection Control, 27(1), 27–34.

Provincial Infectious Diseases Advisory Committee. (2006). Best practices document for the

management of clostridium difficile in all health care settings. Toronto: Ministry of

Health and Long Term Care.

Puzniak, L.A., Leet, T., Mayfield, J., et al. (2002). The effect on acquisition of vancomycin-

resistant enterococci. Clinical Infectious Diseases, 35, 18–25.

Public Health Agency of Canada. (2004). Questions and answers - Updated quarantine act.

Ottawa, ON: Author.

Public Health Agency of Canada. (2006). The Canadian pandemic influenza plan for the health

sector. Ottawa, ON: Author.

Public Health Agency of Canada. (1996). Guidelines for preventing the transmission of

tuberculosis in Canadian health care facilities and other institutional settings. Canada

Communicable Disease Report, 22(S1), 1–25.

Riley, S., Donnelly, C.A., et al. (2003). Transmission dynamics of the etiological agent of SARS

in Hong Kong: Impact of public health interventions. Science, 300, 1961–1966.

Ritchie, K., Eastgate, J.. et al. (2006). Clinical and cost effectiveness of screening for MRSA:

Report on health technology. Glasgow: NHS Quality Improvement Scotland.

Robinson, J. (2001). Infectious diseases in schools and child care facilities. Pediatrics in Review,

22(2), 39–46.

Sattenspiel, L. (2003). Simulating the effect of quarantine on the spread of the 1918-19 flu in

central Canada. Bulletin of Mathematical Biology, 65, 1–26.

Schabas, R. (2004). Severe acute respiratory syndrome: Did quarantine help ? Canadian Journal

of Infectious Diseases & Medical Microbiology, 15(4), 1–3.

Schoch-Spana, M. (2000). Implications of pandemic influenza for bioterrorism response.

Clinical Infectious Diseases, 31, 1409–1413.

Schutze, G.E., Jin, S., et al. (2004). Use of DNA fingerprinting in decision making for

considering closure of neonatal intensive care units because of pseudomonas aeruginaos

bloodstream infections. Pediatric Infectious Disease Journal, 23(2), 110–114.

Seto, W.H., Tsang, D., Yung, R.W.H., et al. (2003). Effectiveness of precautions against droplets

and contact in prevention of nosocomial transmission of severe acute respiratory

syndrome (SARS). Lancet, 361, 1519–1520.




Siegel, J.D., Jackson, M., et al. (2006). Management of multi-drug resistant organisms in

healthcare settings, 2006, CDC, 1–74.

Silverblatt, F.J., Mikolich, D., et al. (2000). Preventing the spread of vancomycin-resistant

enterococci in a long-term care facility. Journal of the American Geriatrics Society,

48(10), 1211–1215.

Simor, A.E., Lee, M., Vearncombe, M., et al. (2003). An outbreak due to multiresistant

acinetobacter baumannii in a burn unit: Risk factors for acquisition and management.

Infection Control and Hospital Epidemiology, 23(5), 261–267.

Smith, P.W. (1997). Infection prevention and control in the long-term-care facility, SHEA Long-

Term0Care Committee and APIC Guideline Committee. American Journal of Infection

Control, 25(6), 488–512.

Smith, P.W. (1998). Nursing home infection control: A status report. Infection Control and


Snydman, D.R., Greer, C., Meissner, C., et al. (1988). Prevention of transmission of respiratory

syncytial virus in a newborn nursery. Infection Control and Hospital Epidemiology, 9,

105–108.

St. John, R., King, A., de Jong, D., et al. (2005). Border screening for SARS. Emerging

Infectious Diseases, 11 (1),6–10.

Strangert, K. (1976). Respiratory illness in preschool children with different forms of day care.

Pediatrics, 57(2), 191–196.

Svoboda, T., Shulman, L., et al. (2004). Public health measures to control the spread of the

severe acute respiratory syndrome during the outbreak in Toronto. New England Journal

of Medicine, 350(23), 2352–2361.

Talon, D., Vichard, P., Muller, A., et al. (2003). Modelling the usefulness of a dedicated cohort

facility to prevent the dissemination of MRSA. Journal of Hospital Infection, 54, 57–62.

Tan, C.C. (2006). SARS in Singapore - Key lessons from an epidemic. Annals of the Academy of

Medicine, Singapore, 35(5), 345–349.

Tenorio, A.R., Badri, S.M., Sahgal, N.B., et al. (2001). Effectiveness of gloves in the prevention

of hand carriage of vancomycin-resistant enterococcus species by health care workers

after patient care. Clinical Infectious Diseases, 32, 826–829.

Tham, K.Y. (2004). An Emergency Department Response to SARS: A prototype response to

bioterrorism. Annals of Emergency Medicine, 43(1), 6–14.

Thrupp, L., Smith, P., et al. (2004). Tuberculosis prevention and control in long-term-care

facilities for older adults. Infection Control and Hospital Epidemiology, 25(12), 1097–

1108.




Tiederman, M. (2007). Bill C-42: An act to amend the quarantine act. Ottawa: Law and

Government Division.

Toner, E. (2006). Do public health and infection control measures prevent the spread of flu?

Biosecurity and Bioterrorism, 4(1), 84–86.

Troche, G., Joly, L.M., Guibert, M., & Zazzo, J.F. (2005). Detection and treatment of antibiotic-

resistant bacterial carriage in a surgical intensive care unit: a 6-year prospective survey.

Infection Control and Hospital Epidemiology, 26,161–165.

Upshur, R. (2003). The ethics of quarantine. Ethics Journal of the American Medical

Association, 5(11), 1-3.

U.S. Department of Health and Human Services. (2005). HHS Pandemic Influenza Plan.

Washington, DC: Author.

Valleron, A.J. (2004). Do school holidays have an impact on influenza epidemics, then on

mortality ? Proceedings of the International Conference on Options for the Control of

Influenza: Okinawa, Japan. Amsterdam: Elsevier.

Varia, M., Wilson, S., Sarwal, S., et al. (2003). Investigation of a nosocomial outbreak of severe

acute respiratory syndrome (SARS) in Toronto, Canada. Canadian Medical Association

Journal, 169,285–92.

Vorou, R., & Maltezou, H.C. (2007). Nosocomial scabies. Journal of Hospital Infection, 65(1),

9–14.

Vynnycky, E., & Edmunds, W.J. (2007). Analyses of the 1957 (Asian) influenza pandemic in the

United Kingdom and the impact of school closures. Epidemiology & Infection, April 20:

1–14 [Epub ahead of print].

Wallinga, J. (2004). Different epidemic curves for severe acute respiratory syndrome reveal

similar impacts of control measures. American Journal of Epidemiology, 160, 509–516.

Wang, T.H., Hsiung, C.A., et al. (2007). Optimizing SARS response strategies: Lessons learned

from quarantine. American Journal of Public Health, 97(S1), S98–S100.

Webb, G., Zhu, H., et al. (2004). Critical role of nosocomial transmission in the Toronto SARS

outbreak. Mathematical Biosciences and Engineering, 1(1), 1–13.

Webster, J., & Pritchard, M.A. (2003). Gowning by attendants and visitors in newborn nurseries

for prevention of neonatal morbidity and mortality (Review). The Cochrane Database of

Systematic Reviews, 2, 1–23.

Weissman, J.B., Gangorosa, E.J., Schmerler, A., et al. (1975). Shigellosis in day-care centres.

Lancet, 1(7898), 88–90.

Whitelaw, T.H. (1919). The practical aspects of quarantine for influenza. Canadian Medical

Association Journal, 9, 1070–1074.




Whimbey, E., & Bodey, G.P. (1992). Viral pneumonia in the immunocompromised adult with

neoplastic disease: The role of common community respiratory viruses. Seminars in

Respiratory Infections, 7, 122–131.

World Health Organization. (1959). Expert Committee on Respiratory Virus Disease: First

report. World Health Organization Technical Report Series, 58, 1–59.

World Health Organization. (2006). Infection control recommendations for avian influenza in

healthcare facilities. Geneva: Author. Retrieved from:

http://www.who.int/csr/disease/avian_influenza/guidelines/EPR_AM_final1.pdf.

Wu, J.T., Fraser, C., & Leung, G.M. (2006). Reducing the impact of the next influenza pandemic

using household-based public health interventions. PLoS Medicine, 3(9), 1532–1540.

Wynia, M.K. (2007). Ethics and public health emergencies: Encouraging responsibility.

American Journal of Bioethics, 7(4), 1–4.

Yip, P.S., Xu, Y., et al. (2007). Assessment of intervention measures for the 2003 SARS

epidemic in Taiwan by use of a back-projection method. Infection Control and Hospital


Yoonchang, S.W., Kim, O.S., et al. (2007). Efficacy of infection control strategies to reduce

transmission of vancomycin-resistant enterococci in a tertiary care hospital in Korea: a 4-

year follow up study. Infection Control and Hospital Epidemiology, 28(4), 493–495.

Zhang, J., Ma, Z., & Wu, J. (2005). A compartmental model for the analysis of SARS

transmission patterns and outbreak control measures in China. Applied Mathematics and

Computation, 162, 909–924.

Zhou, Y.C., & Brauer, F. (2004). A discrete epidemic model for SARS transmission and control

in China. Mathematical and Computer Modelling, 40, 1491–1506.

http://www.who.int/csr/disease/avian_influenza/guidelines/EPR_AM_final1.pdf

Date post:	28-Feb-2021
Category:	Documents
Upload:	others
View:	1 times
Download:	0 times

Evidence Review: Communicable Disease - Ministry of Health...Core Public Health Functions for BC:...

Documents