IPC

Question 1

UK Donor blood tests

Answer 1

1. Syphilis
2. Hep B - SAg, cAb, and DNA
3. HIV - 4th gen screen
4. Hepatitis C- IgG, antigen/RNA
5. HEPE - PCR
6. HTLV - serology

Additional

1. Malaria
2. T cruzi
3. WNV - PCR
4. CMV - serology for BMT and neonate recipients

Question 2

Category B

Answer 2

UN3373

Infectious substance that does not meet criteria for Cat A

Packaging should have 3 components: primary receptacle, secondary packaging, and outer packaging (MUST BE RIGID).
Absorbent material in the secondary packaging.

Question 3

Category A

Answer 3

UN2814 or UN2900(Animals)
Pathogens when exposure occurs, capable of causing permanent disability, life-threatening or fatal disease to humans or animals.

Packaging should have 3 components: leak-proof primary receptacle, leak-proof secondary packaging, and outer packaging (MUST BE RIGID).
Absorbent material in the secondary packaging.
Itemised list of contents between 2nd and outer packaging.

Question 4

HCID PPE

Answer 4

filtering face piece 3 (FFP3) respirator
hood
longer-length visor
long rear-fastening fluid-resistant surgical gown tied to the side
medium thickness apron
inner gloves
middle gloves taped to the gown with microporous tape
outer gloves
wellington boots

Question 5

HAIRS

Answer 5

Human Animal Infections and Risk Surveillance (HAIRS) group

Monthly meeting for risk assessment

HAIRS is chaired by the Department for the Environment, Food and Rural Affairs (Defra), with secretariat functions provided by UKHSA’s Emerging Infections and Zoonoses team.

The group includes representatives from:

UKHSA
Defra
the Department of Health and Social Care (DHSC)
the Animal and Plant Health Agency (APHA)
the Food Standards Agency
Public Health Wales
Welsh Government
Public Health Scotland
Scottish Government
Public Health Agency of Northern Ireland
the Department of Agriculture, Environment and Rural Affairs for Northern Ireland
the Department of Agriculture, Food and the Marine
Health and Safety Executive
Republic of Ireland, Infrastructure, Housing and Environment
Government of Jersey
Isle of Man Government
the States Veterinary Officer, Bailiwick of Guernsey

Multi-step process for risk assessments

1. hazard identification
2. hazard review (information assimilation, preliminary review, determination of action)
3. risk assessment (evidence gathering, assessment of the zoonotic risk or probability of infection in the UK population, assessment of the UK human health impact)
4. risk management options
5. risk communication

Question 6

VHF scenario AtoZ

Answer 6

The Control of Substances Hazardous to Health (CoSHH) Regulations requires employers to assess risk to their employees in the workplace.

1. Risk assessment based on algorithm - unlikely/low possibility/high possibility/confirmed

LOW POSSIBILITY

2. Standard precautions, FFP3 if AGP
3. Testing of specimens for patient management should be performed using containment level 2 (CL2) laboratory procedures.

HIGH POSSIBILITY OF VHF

4. Side room with enhanced IPC measures. Contact RIPL.
5. PPE - full HCID PPE.
6. Investigations required will include URGENT malaria tests as well as full blood count, U&Es, LFTs, clotting screen, CRP, glucose and blood cultures. These tests should be performed using CL2 laboratory procedures

CONFIRMED VHF

7. Formation of an incident control team (ICT). Notify HPT, RIPL notifies ECDC, Media handling strategies. HCID unit notified.
8. Antivirals, specifically ribavirin, have been shown to be effective in the treatment of early-stage arenavirus infections, particularly Lassa fever. There is however evidence to suggest that ribavirin may prolong the incubation period for Lassa fever. Antivirals are not generally recommended for contacts due to the absence of evidence of their proven effectiveness for prophylaxis. However, antivirals may be considered for those direct contacts at highest risk, subject to individual risk assessment.
9. VHF HCID units: RFH & Newcastle. HCID network activation with regular meetings. Patient transfer to designated HCID centre by ambulance.

Question 7

SABTO/JPAC/NHSBT screening & contra-indications

Answer 7

1. Influenza: Lungs and bowel should not be used from donors with confirmed influenza infection.

Bone marrow & Cord blood - MUST NOT donate if taking Oseltamavir/Zanamavir or had symptoms suggestive of flu in the preceding 7 days.

Other organs may be offered, and the final decision lies with the transplanting surgeon weighing the balance of risks for therecipient.

2. DENV: Known Dengue virus infection is a contraindication to donation of solid organs for transplantation is a contraindication to tissue donation - advice has been given as a position statement by JPAC
   Donation may be considered 6 months after recovery from infection with Dengue virus.
   For asymptomatic organ donors returning from affected areas, an individual risk assessment is required before donation.
3. CHIKV: Known Chikungunya virus infection is a contraindication to donation of solid organs for transplantation is a contraindication to tissue donation - advice has been given as a position statement by JPAC.

Donation may be considered 6 months after recovery from infection with Chikungunya virus.

For asymptomatic organ donors returning from affected areas, an individual risk assessment is required before donation.

4. ZIKV: Due to the possibility of sexual transmission by semen, consideration should be given to the possibility of Zika virus infection (asymptomatic or otherwise) in potential donors whose sexual partner has been in an area affected by Zika virus.

Known Zika virus infection: is a contraindication to donation of solid organs for transplantation except in exceptional circumstances is a contraindication to tissue donation

Donation may be considered 6 months after recovery from infection with Zika virus.
For asymptomatic organ donors returning from affected areas, an individual risk assessment is required before donation.

5. WNV: Known West Nile virus infection:
   is a contraindication to donation of solid organs for transplantation is a contraindication to tissue donation

For asymptomatic donors returning from affected areas, an individual risk assessment is required before donation.

Donor transmission may occur from an asymptomatic individual or from a donor who died of unrecognised and therefore undiagnosed West Nile neuroinvasive disease

IF ALREADY TRANSPLANTED:

In cases where NAT testing is positive for WNV and the organs have been used, the details of the positive test should be communicated immediately to NHSBT Organ Donation and Transplantation (ODT) Duty Office (0117 975 7580) who will inform all centres that received organs and/or tissue from the donor. ODT will liaise with appropriate health authorities and all concerned transplant centres. 

Removal of the transplanted organ (even if possible) will not prevent transmission. 

Temporary reduction of immunosupppression has been suggested as it may allow the recipient to mount an immune response to WNV. However, there is no direct evidence to support this as an effective intervention. 

ODT will seek advice from an NHSBT Consultant Virologist on screening and management of donors/recipients prior to disseminating the advice to relevant stakeholders.

5. JCV: Previous JC virus infection is not a contraindication to donation of tissues or organs.

A confirmed diagnosis of progressive multifocal leukoencephalopathy is an absolute contraindication to donation of tissues or organs

6. MMR: Acute disease is a relative contraindication to donation of solid organs for transplantation.

Careful consideration of benefits from transplant is required.
Acute disease is an absolute contraindication to donation of tissues unless life preserving.

7. MERS-CoV & SARA-CoV: is an absolute contraindication to donation of solid organs for transplantation
   is an absolute contraindication to donation of tissues
8. Mpox: Acute illness, if confirmed, is an absolute contraindication to donation of tissues and solid organs for transplantation.
   Donation can be accepted following exposure to Mpox more than 21 days before, with no signs or symptoms of Mpox.
   Donation can be accepted after complete recovery from Mpox at least 14 days previously.
9. Rabies:
   * is an absolute contraindication to donation of solid organs for transplantation
   * is an absolute contraindication to donation of tissues
10. Yellow fever

• is an absolute contraindication to donation of solid organs for transplantation
• is an absolute contraindication to donation of tissues

11. Viral haemorrhagic fevers (VHF)

• acute disease is an absolute contraindication to donation of solid organs for transplantation
• acute disease is an absolute contraindication to donation of tissues

12. COVID-19:

Symptomatic gamete donor
The donor should be deferred if, at the time of donation or in the preceding 7 days, the donor has a new continuous cough or a temperature greater than 37.8°C. The donor can donate after 28 days from full recovery.

Asymptomatic gamete donor
If the donor is asymptomatic, government advice about those who should self-isolate should be considered including the implications this may have on the donation process.

Confirmed C-19: No using lungs. If died of covid, no using ANY ORGANS.

Blood & BM: Must not donate if less than 14dayssince resolution of symptoms.

13. HCV - all organs but NOT TISSUE

Question 8

Outbreak investigation

Answer 8

1. Confirm outbreak and diagnosis

More cases than expected? Problem properly diagnosed?
Multiple countries affected?
Coordinated investigation needed?
Decide on coordinator of investigation (Member State, ECDC, EC, WHO etc.);
Form outbreak control team;
Alert other networks and entities.

2. Define a case

Agree on case definitions - confirmed, probable, possible.
3. Identify cases and obtain information

Conduct case finding by means appropriate to the outbreak;
Obtain information on disease and exposures.
4. Describe data collected

Characterize the outbreak by time (epidemic curve), place and person.

5. Develop hypothesis

Interpret the descriptive findings;
Use information from trawling interviews or other relevant national studies;
Review available evidence on previous outbreaks;
Assess surveillance data and existing knowledge on reservoirs and presence in foods (EFSA, TESSy, EPIS and Zoonoses reports).
6. Test hypothesis: analytical studies

7. Microbiological investigation and additional studies

Collect food, water and/or environmental samples;
Determine what happened with the implicated source or vehicle;
Collect information on food distribution/traceback investigations (origin of foods).

8. Implement control measure (by national and EU authorities)
9. Communicate results, including outbreak report
10. Evaluate and update procedures and toolbox

Question 9

Outbreak meeting - who should attend?

Answer 9

1. Clinical team
2. IPC team - nurses and doctor
3. DipC - chair
4. Site representative
5. Estates & cleaning
6. Comms team
7. Executive team - director of nursing
8. UKHSA rep
9. OH rep

Question 10

IDPS screening

Answer 10

3 infections - HIV, HBV, syphilis

LAB REQUIREMENTS:

The IDPS screening laboratories must:

be accredited by the UK Accreditation Service (UKAS) to ISO 15189:2012 medical laboratories – requirements for quality and competence
meet the IDPS laboratory QA evidence requirements mapped to ISO 15189:2012
participate in external quality assurance (EQA) schemes accredited to ISO 17043:2010 conformity assessment – general requirements for proficiency testing
use reference laboratories accredited to ISO 15189:2012 for confirmation of screen positive results when this is not available in-house

DOCTOR REQUIREMENTS:

have a named, discipline-specific clinical lead from a virology, microbiology or infectious diseases background, who has passed the FRCPath Part 2 by examination (or has a recognised examination if overseas-qualified), who has day-to-day responsibility for the IDPS service.

SAMPLE BOOKING:

Samples should be ‘logged’ as antenatal samples, assigned a laboratory accession number and booked for the appropriate tests according to the request within 24 hours of receipt in the laboratory.

REPORTING POS/EQUIVOCAL:

Positive or equivocal screening results must not be reported verbally (with the exception of urgent results as discussed below), in written or electronic form to the maternity service (for example screening team, specialist midwife or clinical nurse specialist) until confirmatory tests are completed on the screening sample.

Positive or equivocal screening results must only be reported on the screening sample for HIV, hepatitis B and syphilis following confirmation of the result using appropriate analytical methods.

TAT: 8 WORKING DAYS

EXPEDITED: The test turnaround time of by or before 8 working days does not apply for women without screening results who are:

in labour or who have just delivered
admitted to maternity services and have a high risk of premature labour

VERTICAL AUDIT

Antenatal screening audit
The laboratory must include in its laboratory audit schedule an annual vertical audit of an antenatal screening sample.

The audit should randomly select a confirmed screen positive sample. A different infection should be selected each year so that over a 3-year cycle confirmed screen positive samples for HIV, hepatitis B and syphilis samples are audited.

The audit should include arrival and receipt of the antenatal screening sample at the laboratory, and communication of a confirmed screen positive result by clinical services.

SAMPLE STORAGE:

When the screening tests are complete an aliquot (a suggested minimum volume of 300 microliters) from the screening sample must be stored frozen at a maximum temperature of -20 degrees Celsius for at least 2 years.

REPORTING NEG:

The phrase ‘negative now’ is being used to emphasise to women and those involved in her care that although she has tested negative in her antenatal screening sample, infection can be acquired at any time during pregnancy, after screening. Retesting may be appropriate at any stage if the woman was at risk of exposure and/or has a relevant clinical presentation. When screening is negative for all 3 infections laboratories are asked to add the following comment to reports in order to reinforce this message:

‘Negative at time the screening sample was taken. Please offer testing at any time in pregnancy if the woman has a new exposure risk or develops relevant symptoms’.

SECOND SAMPLE NEEDED TO CONFIRM

Question 11

Requirements for CL3 lab - 7 things

Answer 11

1. Negative pressure
2. HEPA filtration of input & extract air
3. Separated from other activities in the building
4. Observation window/ camera
5. Lab to have dedicated equipment
6. Sealable to permit fumigation
7. Surface including bench and floor impervious to water for ease of disinfection

Question 12

HEPA

Answer 12

High-efficiency particulate air (HEPA)

Has to filter 99.97% of all particles with a diameter up to 0.3 micro metre in size.

European Standard EN 1822-1:2009.

Question 13

EPP restrictions

Answer 13

1. HIV:
   <50 copies/mL - no restrictions
   50-200 - case by case. Repeat in 10 days.
   200 -1000 - repeat in 10 days and restrict EPP if still in same range.
   >1000 - restrict EPP.
2. HCV: restrict EPP if RNA detected.
   Repeat RNA 3 months after treatment (SVR12) - no restrictions if negative. Repeat RNA 3 months later (SVR24).
3. HBV:
   <200 copies on Treatment - no restrictions
   >200 copies - EPP restricted