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Policies,Clinical,UW Health Clinical,Infection Control

Communicable Disease Exposure Response (4.1.6)

Communicable Disease Exposure Response (4.1.6) - Policies, Clinical, UW Health Clinical, Infection Control

4.1.6


UW HEALTH CLINICAL POLICY 1
Policy Title: Communicable Disease Exposure Response
Policy Number: 4.1.6
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: January 21, 2016

I. PURPOSE

To provide direction for uniform response to communicable disease exposures w hich occur in inpatient and
outpatient UW Health settings. Note: This policy does not cover percutaneous or mucocutaneous exposures
to blood or body f luids potentially infectious for bloodborne pathogens. These exposures are covered by
Employee Health Service under UWHC policy #9.28, Management of Biohazardous Injuries.

II. POLICY ELEMENTS

A. The Infection Control Department is responsible for coordinating the response to a communicable disease
exposure w hich occurs at UW Health locations.
B. The Communicable Disease Exposure Notif ication Form is the standard means of conveying exposure
information to affected areas and is completed by the Infection Control Practitioner (ICP) coordinating the
exposure response.
C. The manager of inpatient units, clinics or ancillary w orksites on w hich exposure has occurred w ill be
responsible for identifying w hich of their employees, patients or visitors are exposed, using guidance
provided on the Communicable Disease Exposure Notif ication Form and for referring exposed employees to
Employee Health Service (EHS) for follow -up, as necessary. If the manager is unavailable, the department
director w ill be contacted to assume this responsibility.
D. When w arranted, the Medical Director of EHS or an EHS nurse practitioner w ill provide the prescription for
prophylaxis or orders for diagnostic tests for exposed employees. The attending physician w ill provide the
prescription for prophylaxis or test orders for their respective exposed inpatients. Exposed visitors w ill be
referred to their ow n physician for follow -up unless the delay w ould compromise their health.
E. The Hospital Epidemiologist or on-call Infectious Diseases physician may provide prescriptions or test
orders for employees, patients or visitors if this becomes necessary to avoid delay in follow -up of exposed
individuals.
F. Post-exposure follow -up costs associated w ith prophylaxis or diagnostic testing (e.g., tuberculin skin test)
w ill not be charged to exposed employees or patients.
G. Individual clinicians (other than those described in II.D.) shall not prescribe post-exposure prophylaxis or
order diagnostic tests for employees w ithout f irst conferring w ith EHS or the Hospital Epidemiologist.
H. Exposed University of Wisconsin students w ill be referred to University Health Service (UHS) for post
exposure follow -up. The appropriate faculty responsible for exposed students from other schools (e.g.,
Deans of students at Madison College, Edgew ood) w ill be notif ied in order to facilitate follow -up of these
individuals.
I. If a delay in follow -up of students through the channels described in II.H. is anticipated and could
compromise the health of the exposed individuals, EHS w ill provide initial follow -up, including prophylaxis,
and refer the individual to the appropriate institution or contact persons (e.g., UHS, Dean of school) for
subsequent follow -up.
J. When the communicable disease exposure may have impact on other institutions (e.g., referring hospital,
correctional facility, ambulance service) these entities w ill be notif ied by Infection Control of the exposure so
that they can facilitate appropriate follow -up for their exposed staff. Appropriate public health agencies w ill
be notif ied if the exposure involves a reportable disease, or a disease of epidemiologic signif icance to public
health.

III. PROCEDURE

A. In the event that a patient, employee or visitor is found to have a communicable disease w hich w arrants
follow -up and that other individuals have been exposed to this index case, the follow ing actions should be
taken:
i. The Infection Control Practitioner on-call w ill be notif ied of the exposure by the physician,
laboratory personnel, department manager, nursing supervisor or by other means (e.g., outside
institution, health department, etc.). Infection Control maintains 24 hour pager coverage and the on-
call Practitioner may be reached through the paging operator by dialing 262-2122 or by paging
#2570 directly.



UW HEALTH CLINICAL POLICY 2
Policy Title: Communicable Disease Exposure Response
Policy Number: 4.1.6

ii. The follow ing situations suggest or confirm the presence of a communicable disease w hich may
require isolation of the patient or further investigation, and should be reported immediately to the
Infection Control Practitioner on call:
a. Presumptive or confirmed identif ication of the follow ing organisms from any body site:
1. Bordetella pertussis
2. Mumps virus
3. Mycobacterium tuberculosis complex
4. Neisseria meningitidis
b. The follow ing f indings:
1. Presence of gram negative diplococci in blood or cerebrospinal f luid.
2. Positive Bordetella pertussis polymerase chain reaction (PCR) test.
3. Neural tissue w ith pathologic changes consistent w ith transmissible spongiform
encephalopathy (TSE) or immunohistochemical staining results supporting or
confirming the diagnosis of a TSE.
c. Clinical signs, symptoms or presentation suggestive of any of the follow ing diseases:
1. measles
2. mumps
3. meningococcal meningitis or sepsis
4. scabies
5. pertussis
6. transmissible spongiform encephalopathy
7. tuberculosis
8. varicella (chickenpox)
9. zoster (shingles) disseminated beyond a single dermatome
10. any disease in situations w here bioterrorism is suspected (e.g., smallpox,
inhalation anthrax, pneumonic plague, botulism, hemorrhagic fever viruses)
11. any other communicable disease in situations w here exposures to employees,
patients or visitors may have occurred.
iii. Infection Control personnel w ill confirm that exposure has occurred and w ill complete the
Communicable Disease Exposure Notif ication Form. If potential exposure to employees has
occurred, EHS w ill be notif ied and provided w ith the completed Communicable Disease Exposure
Notif ication form.
a. The Communicable Disease Exposure Notif ication Form identif ies the infectious individual
and the communicable disease involved, defines w hat constitutes an exposure, the time
frame of exposure and unit/clinic locations involved, specif ic medical follow -up w hich is
w arranted (e.g., recommended prophylaxis or diagnostic testing), and criteria for the
exclusion of exposed employees from duty, as w arranted.
iv. Infection Control personnel w ill distribute the completed Communicable Disease Exposure
Notif ication form and the Exposed Employee List form to managers of affected areas by email,
secure fax, or in person in a timely manner. The information w ill be review ed w ith the manager
electronically, by phone or in person and the manager given the opportunity to ask questions or
clarify any aspect of the exposure follow -up process.
v. Managers of affected areas w ill use the definition of exposure delineated on the Communicable
Disease Exposure Notif ication form to determine w hich employees w ere actually exposed.
a. The manager w ill list those employees w ho meet the definition of exposure on the
Exposed Employee List form and distribute a copy of the completed form to EHS.
1. In situations w here immediate prophylaxis is deemed necessary, the manager
may be instructed by Infection Control personnel to phone or fax the list of
exposed employees to EHS and the appropriate pharmacy (e.g., University
Hospital outpatient pharmacy , The American Center pharmacy, Clinic pharmacy,
local pharmacy) so that prescriptions can be readied immediately.
b. If prophylaxis or diagnostic testing is required for exposed employees, the EHS Medical
Director or EHS nurse practitioner w ill w rite the prescription or test order. If EHS staff are
unavailable, the Hospital Epidemiologist or on-call Infectious Disease physician w ill
prescribe prophylaxis or order testing.
1. Oral prophylaxis for employees w ill be dispensed through the appropriate
pharmacy (e.g., University Hospital outpatient pharmacy, The American Center
pharmacy, UW Health Clinic pharmacy, or local pharmacy w ith w hich UW Health



UW HEALTH CLINICAL POLICY 3
Policy Title: Communicable Disease Exposure Response
Policy Number: 4.1.6

has a contractual agreement to charge EHS at no expense to the employee.
2. Prophylaxis regimens requiring injection w ill be provided through EHS
(Emergency Department at University Hospital or The American Center w hen
EHS is closed), or other location appropriate to provide injections, at no expense
to the employee.
c. If exclusion from duty of an exposed employee is deemed necessary to avoid secondary
exposures, the department manager w ill arrange for the employee's exclusion under
administrative leave.
d. The Workers' Compensation Coordinator w ill be apprised in w riting by EHS of all exposed
personnel.
vi. Managers of affected areas w ill use the definition of exposure delineated on the Communicable
Disease Exposure Notif ication form to determine if patients w ere exposed.
a. The manager w ill identify patients w ho meet the definition of exposure and convey this list
to the Infection Control Practitioner.
1. If prophylaxis or diagnostic testing is required for inpatients the ICP, in
consultation w ith the Hospital Epidemiologist, w ill notify the medical staff caring
for these inpatients and communicate to them the recommended prophylactic
regimen or tests. Infectious Disease physicians w ill provide consultation as
needed.
2. If quarantine of exposed inpatients is w arranted, the ICP w ill notify the inpatient
unit of the appropriate type of isolation to institute and the duration of such
isolation.
b. The physicians of outpatients or recently discharged inpatients w ho meet the definition of
exposure w ill be notif ied of the exposure status of their patient.
1. The ICP, in consultation w ith the Hospital Epidemiologist, w ill communicate to
respective UW Health providers of exposed outpatients and recently discharged
inpatients the recommended prophylactic regimen or tests. Infectious Disease
physicians w ill provide consultation as needed.
2. If home quarantine of exposed outpatients or recently discharged inpatients is
w arranted, the ICP w ill convey this information to them and to their provider, and
w ill recommend that clinic visits during the quarantine period be deferred if
possible.
3. If clinic visits during the quarantine period cannot be deferred, the ICP w ill notify
the provider of the type of isolation needed for the visit and the duration of the
quarantine period.
4. The ICP, in consultation w ith the Hospital Epidemiologist or an Infectious
Disease physician, w ill add an infection indicator to the quarantined patient's
Health Link header to convey the need for isolation.
vii. In the unusual situation that visitors may have had signif icant exposure and require follow -up,
managers of affected areas w ill use the definition of exposure delineated on the Communicable
Disease Exposure Notif ication form to determine exposure status.
a. The manager, w ith assistance from the patient and nursing staff, w ill identify visitors w ho
w ere present during the infectious period, determine w hich visitors meet the definition of
exposure, and convey this list to the ICP.
1. The ICP w ill notify visitors of the exposure and recommend that they follow -up
w ith their physician.
2. Written materials providing specif ic information regarding the exposure (e.g.,
pathogen, dates of exposure, incubation period, recommended prophylaxis or
diagnostic tests) w ill be provided to exposed visitors so that this can be
accurately conveyed to their physician.
3. Public Health may be notif ied to assist w ith follow -up testing or prophylaxis for
visitors.
4. If home quarantine of exposed visitors is w arranted, the ICP w ill explain this and
the visitor w ill be excluded from hospital visitation for the duration of the
quarantine period.
IV. FORMS

Communicable Disease Exposure Notif ication Form



UW HEALTH CLINICAL POLICY 4
Policy Title: Communicable Disease Exposure Response
Policy Number: 4.1.6

Exposed Employee List Form

V. COORDINATION

Author: Infection Control Practitioner
Senior Management Sponsor: SVP, Patient Care Services and CNO
Approval committees: Infection Control Committee; UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: December 21, 2015

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VI. APPROVAL

Jeff Grossman, MD
UW Health CEO

Teresa Neely
SVP and CAAO

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VII. REFERENCES

-UWHC policy #13.04, Communicable Disease Reporting
-UWHC policy #13.07, Standard Precautions & Transmission-based Precautions (Isolation) for Inpatient
Settings
-UWHC policy #13.28, Precautions & Transmission-based Precautions (Isolation) for Ambulatory Settings
-UWHC Tuberculosis Exposure Control Plan

VIII. REVIEW DETAILS
Version: Revision
Next Revision Due: January 21, 2019
Formerly Know n as: Hospital Administrative policy #13.21