IPC 3.8 Viral Respiratory Tract Infections

1.0 Introduction
2.0 Mode of transmission
2.1 Risk factors
2.2 Signs and symptoms - clinical indications
2.3 Screening
3.0 Antimicrobial treatment guidance
4.0 Infection prevention and control principles
4.1 Isolation
4.2 Hand hygiene
4.3 Respiratory / Cough hygiene
4.4 Personal protective equipment
4.5 Equipment
4.6 Environmental cleaning
4.7 Linen
4.8 Body fluids
4.9 Waste standard
4.10 Occupational exposure
4.11 Care of deceased
5.0 Outbreaks
6.0 References/Source documents
Appendix 1
Appendix 2

1.0 Introduction

Organism

The major respiratory viruses seen in healthcare are COVID-19, influenza and parainfluenza, human metapneumovirus (hMPV), respiratory syncytial virus (RSV), rhinovirus, coronavirus and adenovirus.

Respiratory viruses and infections are common, with symptoms ranging from mild nasal discharge and sore throat to more severe coryzal symptoms including fever, cough and shortness of breath. Most respiratory infections are self-limiting and confined to the upper respiratory tract. These can however progress and cause more severe infections.

Incubation period

Influenza - one to four days, average is two days .

COVID-19 - two to fourteen days.

RSV - three to five days.

Period of communicability

Influenza - for 7 days after onset of symptoms or until symptoms have settled.

COVID-19 - for 5 days after onset of symptoms or until symptoms have settled.

RSV - for 7 days after onset of symptoms or until symptoms have settled.

Some patients with respiratory viruses will no longer be infectious once asymptomatic, however this is not always the case - particularly with immunocompromised patients. Wards should discuss discontinuation of respiratory precautions with the IPC Team.

Individuals at risk

All members of the community are susceptible.

Those with compromised immune, cardiac, or pulmonary systems and other chronic conditions is at increased risk of serious complications of infection.

Neurological, hepatic, renal, pulmonary and chronic cardiac disease.
Diabetes mellitus.
Severe Immunosuppression.
Age over 65 years.
Pregnancy (including up to two weeks postpartum)
Children under 6 months of age
Obesity (BMI >=35).

Notifiable disease

COVID-19 - Yes

All others - No

Informing IPC team

Yes, immediately if symptoms suggest or, an influenza-like illness or viral respiratory tract infection is suspected, and doctors are requesting further swabs are taken.

2.0 Mode of transmission

Influenza and RSV - Droplet transmission.

COVID-19 - Droplet/Airborne

Respiratory viruses are spread by droplets expelled from the respiratory tract. The virus may also be acquired on the hands either directly from respiratory secretions or indirectly via contaminated surfaces or equipment (Coia et al, 2013). Transmission occurs when hands become contaminated and spread the virus to the respiratory tract via the eyes, nose and mouth.

2.1 Risk factors

All members of the community are susceptible.

Those with compromised immune, cardiac, or pulmonary systems and other chronic conditions is at increased risk of serious complications of infection.

2.2 Signs and symptoms - clinical indications

A respiratory virus may be diagnosed from a clinical specimen sent to the Microbiology laboratory. It is usually diagnosed by a nasopharyngeal aspirate (NPA) or viral throat swab.

Presenting symptoms of respiratory viruses are varied. They may include cold like symptoms such as: rhinitis (runny nose, sneezing or nasal congestion), cough and sometimes fever.

Influenza or 'flu' symptoms include rapid onset of headache, fever, cough, sore throat, aching muscles, and joints and pyrexia. There is a wide spectrum of severity of illness ranging from minor symptoms through to pneumonia and death.

2.3 Screening

VIRAL nose and throat swabs (PCR) should be taken where the patient meets the case definition - usually swab the 5 most recently unwell, or Lateral Flow Device for COVID-19 (patients eligible for Neutralising Monoclonal Antibodies (nMABs) only).

If a respiratory virus is suspected, isolation and infection control precautions should be commenced whilst awaiting results.

Some areas have point of care testing (POCT). Only appropriately trained and authorised staff can undertake POCT. Any results should be clearly documented in the patients’ medical notes and the relevant clinical team informed.

IPC 4.1 Obtaining a clinical sample

3.0 Antimicrobial treatment guidance

Influenza

Antiviral medicines (e.g. Oseltamivir) may be prescribed at any time on an inpatient ward for at risk patients with suspected seasonal influenza infection.
Do not wait for laboratory confirmation.
Start treatment as soon as possible, and within 48 hours of onset. (Or later at clinical discretion - there is limited evidence that treatment may reduce the risk of mortality up to five days after onset. Commencement of treatment more than 48 hours after onset is an unlicensed use of Oseltamivir and clinical judgement should be exercised).
For the most up to date influenza antiviral prescribing guidelines please access: Antimicrobial stewardship guidelines (The page is available from the 'Antimicrobial Stewardship and Guidelines' page on the Connect site)
Additional information can be accessed via: Guidance on use of antiviral agents for the treatment and prophylaxis of seasonal influenza (publishing.service.gov.uk)
Please see Appendix 2 - Summary Algorithm for prescribing antiviral treatment for influenza, extracted from the above document.

Antiviral post exposure prophylaxis

NICE has provided guidance stating that oseltamivir and zanamivir may be used for prophylaxis of persons in at risk groups following exposure to a person in the same household or residential/inpatient setting with influenza-like illness when influenza is circulating in the community (NICE, 2008)
As per NICE guidance, prophylaxis should be issued if the contact is not adequately protected by vaccination, namely if:

• the vaccination is not well matched to the circulating strain, or

• there has been less than 14 days between vaccination and date of contact with influenza

In addition, the guidance also states that, if the individual has been exposed as part of a localised outbreak (such as in an inpatient ward, care home), antiviral prophylaxis may be given regardless of vaccination status.

COVID-19

Covid-19 caring for our patients (The document is available from the Caring for our patients' page on the Connect site)

4.0 Infection prevention and control principles

(link to NICM state any variation)

4.1 Isolation

If a patient presents with any symptoms of a respiratory virus, such as COVID-19 or an influenza-like illness, the patient should be isolated as a matter of urgency.

Patient placement/assessment of infection risk

For HMP settings - where there are 2 or more people in a cell and one is suspected or confirmed as having influenza, this can pose a risk to the individual as well as to other wing or cell mates. This is because they could be asymptomatic or show no signs of being infected.

Managing flu, COVID-19 and other acute respiratory infections (ARI) in prisons and other prescribed places of detention (PPDs)

Custodial staff should isolate all cellmates from the general population for 48 hours starting from their last contact with a suspected or confirmed case of influenza.

4.2 Hand hygiene

Patient placement/assessment of infection risk

Posters:

4.3 Respiratory / Cough hygiene

Respiratory and cough hygiene (NHS England)

4.4 Personal protective equipment

For some respiratory viruses staff will be required to wear a mask (depending on procedure, and virus, could be a Type IIR surgical face mask or FFPs respirator mask)

Personal protective equipment (PPE)

Aide memoire for optimal patient placement and respiratory protective equipment (RPE) for infectious agents in hospital inpatients (based on evidence from WHO, CDC and UKHSA)

Posters:

4.10 Occupational exposure

Staff testing and/or contact tracing, where required, will be advised by the IPC Team / Occupational Health.

4.11 Care of deceased

Infection prevention and control when caring for the deceased

5.0 Outbreaks

If an outbreak is declared, the ward will be closed to admissions for minimum of 5 days from the onset of symptoms in the most recently unwell patient, as advised by IPCT in the outbreak meeting.

Link to Outbreak Guidance - still to be written.

HMP Outbreak guidance

Multi-agency contingency plan for disease outbreaks in prisons

6.0 References/Source documents

Coia, J.E. et al. (2013) ‘Guidance on the use of respiratory and facial protection equipment’, The Journal of Hospital Infection, 85(3), pp. 170-182.

DBTH (2021) Management of respiratory type viruses . (Accessed: 11 April 2024).

Department of Health and Social Care (2020) UK pandemic preparedness . (Accessed: 11 April 2024).

Egilmezer, E. et al. (2018) ‘Systematic review of the impact of point‐of‐care testing for influenza on the outcomes of patients with acute respiratory tract infection’, Reviews in Medical Virology, 28(5), p. e1995.

Klompas, M. et al. (2021) ‘Current insights into respiratory virus transmission and potential implications for infection control programs’, Annals of Internal Medicine, 174(12), pp. 1710-1718.

Lafond, K.E. et al. (2021) ‘Global burden of influenza-associated lower respiratory tract infections and hospitalizations among adults: A systematic review and meta-analysis’, PLoS Medicine, 18(3), p. e1003550.

NICE (2009) Amantadine, oseltamivir and zanamivir for the treatment of influenza TA168 . (Accessed: 11 April 2024).

NICE (2008) Oseltamivir, amantadine (review) and zanamivir for the prophylaxis of influenza TA158 . (Accessed: 11 April 2024).

NUH (2023) Respiratory viruses policy. (Accessed: 11 April 2024).

Public Health England (2016) Infection control precautions to minimise transmission of acute respiratory tract infections in healthcare settings . (Accessed: 11 April 2024).

Public Health England (2013) Multi-agency contingency plan for disease outbreaks in prisons. (Accessed: 11 April 2024).

Public Health England (2014) Pandemic influenza strategic framework . (Accessed: 11 April 2024).

Public Health England (2021) Emergency response: detailed information. (Accessed: 11 April 2024).

Public Health England (2015) Risk assessment of Enterovirus D68 (EV-D68) . (Accessed: 22 December 2022).

SFHT (2021) Respiratory tract infection (suspected or confirmed) policy . (Accessed: 11 April 2024).

Shaterian, Negin et al. (2021) ‘Facemask and respirator in reducing the spread of respiratory viruses; a systematic review’, Archives of Academic Emergency Medicine, 9(1), p. e56.

Spicer, W J. (2007) Clinical microbiology and infectious diseases. 2^nd ed. London: Churchill Livingstone.

UK Health Security Agency (2022) Flu and acute respiratory illness (ARI) in prisons and other prescribed places of detention (PPDs) . (Accessed: 22 December 2022).

UK Health Security Agency (2024) Managing flu, COVID-19 and other acute respiratory infections (ARI) in prisons and other prescribed places of detention (PPDs). (Accessed: 11 April 2024).

UK Health Security Agency (2024) MERS-CoV: public health investigation and management of possible cases. (Accessed: 11 April 2024).


Version	Date	Expert writer	Status (New, Edited)	Comments and details of changes being made
1.0	October 2022	Kim Shaw	New
2.0	March 2024	Kim Shaw	Edited	Edited and references checked to fit into new IPC manual format, and linked to National Infection Prevention and Control Manual.

Appendix 1

Requirements for Isolation and Masks for Respiratory Viruses
Infection	Main route of transmission	Isolation in side room	Surgical face mask	FFP3 masks required for all contact	FFP3 masks for aerosol generating procedures (AGP)	Duration of respiratory precautions
Enterovirus D68 (EV-D68)	Droplet and enteric		(for general care)			Generally 21 days from onset of symptoms. Precautions should only be discontinued following discussion with the IPCT
Human Metapneumovirus (hMPV)	Droplet	Only on wards with immunosupressed patients i.e. Clinical Heamatology
Influenza	Droplet, aerosol if having aerosol generating procedures (AGP)	Healthcare workers should be vaccinated.	(for general care)			7 days after onset of symptoms or until symptoms have settled For patients that are immunosupressed this may be longer so should be discussed with the IPCT
Measles	Droplet, aerosol if having aerosol generating procedures (AGP)	Only staff that are immune to measles either by past infection or immunisation may enter the room or care for the patient		FFP 3 mask recommended. If not available or no fit tested staff an FFP2 mask can be used. In emergencies, the minimal requirement is a surgical face mask		The patient is to remain in isolation until 4 days after the rash started, or longer if immunocompromised
MERs - CoV	Droplet/ aerosol					Discuss with the IPCT
Mumps	Droplet					5 days following onset of symptoms
Parainfluenza	Droplet, aerosol if having AGP		(for general care)			7 days after onset of symptoms or until symptoms have settled For patients that are immunosupressed this may be longer so should be discussed with the IPCT
Pertussis/ Whooping Cough	Droplet					5 days following commencement of treatment
Rhino virus	Droplet	Only on wards with immunosupressed patients i.e. Clinical Heamatology
Respiratory Syncytial Virus (RSV)	Droplet	Ideally in single room, but during winter periods cohort bays may be required				7 days after onset of symptoms
SARS Coronavirus	Droplet/ Aerosol					Discuss with the IPCT
Varicella (Chicken Pox)	Droplet or contact with vesicle fluid		Staff with no demonstratable immunity should avoid patient contact			Will require both respiratory and wound and skin (contact) special precautions. Precautions should continue until all lesions have crusted (usually about 5 days)

Appendix 2

Algorithm for prescribing antiviral treatment for influenza

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