Plague

Isolation and Decontamination

Use Standard precautions for bubonic plague, and respiratory droplet precautions for suspected pneumonic plague. Y. pestis can survive in the environment for varying periods, but is susceptible to heat, disinfectants, and exposure to sunlight. Soap and water are effective if decontamination is needed. Take measures to prevent local disease cycles if vectors (fleas) and reservoirs (rodents) are present.

Isolation Precautions

Droplet Precautions plus eye protection, in addition to Standard Precautions, should be implemented for patients with pneumonic plague. Although Droplet Precautions are generally accepted as adequate for protection against pneumonic plague, some experts have questioned whether or not they are sufficient to protect healthcare workers.

Patients are considered infectious for 48 to 72 hours after initiation of appropriate antibiotic therapy with evidence of clinical improvement (see References: APIC/CDC 1999, Inglesby 2000, Weber 2001).

Standard Precautions include the following practices related to direct patient care (see References: CDC/HICPAC 2007):

  • Hand washing:
    • Wash hands after touching blood, body fluids, secretions, excretions, or contaminated items, whether or not gloves are worn.
    • Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments.
  • Gloves:
    • Wear gloves when touching blood, body fluids, secretions, excretions, or contaminated items; put on clean gloves just before touching mucous membranes and nonintact skin.
    • Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms.
    • Remove gloves promptly after use, before touching noncontaminated items or environmental surfaces, and before going to another patient, and wash hands immediately to avoid transfer of microorganisms to other patients or environments.
  • Masks, eye protection, face shields:
    • Wear a mask (ie, standard surgical mask) and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions.
  • Gowns:
    • Wear a gown to protect skin and prevent soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions.
    • Select a gown that is appropriate for the activity and amount of fluid likely to be encountered.
    • Remove a soiled gown as promptly as possible and wash hands.
  • Patient-care equipment:
    • Handle used equipment soiled with blood, body fluids, secretions, or excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other patients or environments.
    • Ensure that reusable equipment is not used for the care of another patient until it has been appropriately cleaned and reprocessed; single-use items should be appropriately discarded.

Droplet Precautions include the following (see References: CDC/HICPAC 2007):

  • Place the patient in a private room or in a room with other patients who have the same infection (ie, cohort). When a private room is not available and cohorting is not possible, a spatial separation of at least 3 ft should be maintained between the patient and other patients or visitors. (Note: Other sources suggest that contact within 2 m [6.5 ft] can spread the disease.)
  • Healthcare workers should wear a mask when working within 3 ft of the patient; a standard surgical mask is considered adequate.
  • Patient transportation should be limited to essential purposes only. If transport or movement is necessary, minimize dispersal of droplets from the patient by masking the patient using a standard surgical mask.
  • Negative-pressure rooms or other special air-handling measures are not necessary for routine care, and doors may remain open.

Contact and Droplet Precautions should be implemented when buboes are being aspirated or irrigated, owing to the propensity for aerosolization of infectious material. Contact Precautions include the following (see References: CDC/HICPAC 1996):

  • Place the patient in a private room, or, if a private room is not available, place the patient in a room with a patient who has an active infection with the same pathogen (ie, cohort). When a private room is not available and cohorting is not possible, a spatial separation of at least 3 ft should be maintained between the infected patient and other patients and visitors. (Note: Other sources suggest that contact within 2 m [6.5 ft] can spread the disease.)
  • Gloves should be worn when entering the room and removed before leaving the room; hands should be washed with an antimicrobial agent or a waterless hand washing agent immediately after removing gloves, and clean hands should not touch potentially contaminated items or environmental surfaces. Gloves should be changed during the course of patient care following contact with infective material that may contain high concentrations of microorganisms.
  • Gowns should be worn when entering the room if it is anticipated that clothing will have substantial contact with the patient, environmental surfaces, or items in the room; the gown should be removed before leaving the patient's environment.
  • Patient transport should be limited to essential purposes only; if the patient is transported out of the room, precautions should be maintained.
  • Noncritical patient-care equipment should be dedicated whenever possible. If equipment cannot be dedicated, then it should be adequately cleaned and disinfected between patients.

Decontamination

In general, environmental decontamination following an aerosol event has not been recommended, since experts have estimated that an aerosol of Y pestis organisms would be infectious for only about 1 hour (see References: Inglesby 2000).

One study demonstrated that Y pestis can survive on selected environmental surfaces for at least several days, with survival being the longest on paper (cells were still viable after 120 hours) (see References: Rose 2003), although the potential for re-aerosolization of these organisms was not addressed.

  • Commercially available bleach or 0.5% hypochlorite solution (1:10 dilution of household bleach) is considered adequate for cleaning. Experiments show that vapor-phase hydrogen peroxide may be used for decontamination in circumstances in which liquid or heat decontamination may not be suitable (eg, to meet time-sensitive schedules and activities) (see References: Rogers 2008).
  • Organisms are killed by heating at 56°C for 15 minutes or by exposure to sunlight for 4 hours. Survival is prolonged in dried blood and secretions (see References: HPA 2007).
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