---------------------------------------------------------------------------REPORT OF THE MONTH, Volume VIII, Number 2 – March-April 2004
- - - - from the North Carolina Statewide Program for Infection Control and Epidemiology
----------------------------------------------------------------------------CONTENTS:
NEWS FEATURES
Third Case of VRSA - Vancomycin Resistant Staphylococcus aureus: Change in
Laboratory Antimicrobial Susceptibility Testing Recommended
REGULATORY/LEGISLATIVE
OSHA Respiratory Protection Standard Medical Evaluation Requirement
QUESTION OF THE MONTH
Is It Legal to Mount Alcohol-Based Hand Rub Dispensers in Egress Corridors?
NEWS AND ANNOUNCEMENTS
54th Annual Tuberculosis/Respiratory Disease Institute in North Carolina
Proposed OSHA Respiratory Protection Standard
Easy Access to Requirements Page on JCAHO Website
Ricin: New Topic on OSHA Safety and Health Topics Page
Guidelines for Preventing Health-Care--Associated Pneumonia, 2003
Manufacturer's Recall of Rapid Cartridge Assay Kits
Recall of Nasal Spray Contaminated with Burkholderia cepacia Complex
FDA Approves First Oral Fluid Based Rapid HIV Test Kit
Comment Period Extended for Assigned Protection Factors Rule
Avian Flu Subject of Safety and Health Guidance
Manufacturer’s Recall of Human Rabies Vaccine
COURSES FOR THE INFECTION CONTROL PROFESSIONAL
____________________________________________________________________
NEWS FEATURES
Third Case of VRSA - Vancomycin Resistant Staphylococcus aureus: Change in
Laboratory Antimicrobial Susceptibility Testing Recommended
The third confirmed case of vancomycin-resistant Staphylococcus aureus (VRSA) was
announced at the Society for Healthcare Epidemiology of America, Inc (SHEA) meeting
in Philadelphia. More information about the case and its significance was in a brief
report in the MMWR, April 23, 2004/53. The patient resides in a long-term care facility in
New York. The Centers for Disease Control and Prevention (CDC) is continuing its
investigation to determine if cross-transmission has occurred. The CDC believes this
VRSA is not related epidemiologically to the VRSA isolates identified in Michigan and
Pennsylvania. This new VRSA has both the vanA resistance gene mediating
vancomycin resistance and the mecA gene mediating oxicillin resistance. The isolate
was found to be susceptible to chloramphenicol, linezolid, minocycline, quinupristindalfopristin, rifampin, and trimethoprim-sulfamethoxazole.
Most importantly, when the isolate was tested using the automated antimicrobial
susceptibility overnight panel Microscan (Dade Behring, Deerfield, Illinois) the
vancomycin MIC was 4 micrograms/mL. Further testing by Etest (AB Biodisk North
America, Inc., Piscataway, N.J.) indicated this isolate was resistant to vancomycin (MIC
greater than 256 micrograms/mL). The CDC confirmed the isolate was a VRSA
(vancomycin MIC=64 micrograms/mL) using the National Committee for Clinical
Laboratory Standards broth microdilution reference method. The CDC tested a second
automated antimicrobial sensitivity test and found it too did not detect the VRSA. The
CDC is concerned that additional VRSA cases may have gone undetected because of a
reliance on the automated tests for susceptibility.
The CDC is recommending potential VRSA isolates should be saved for confirmatory
testing, and clinical microbiology laboratories must ensure that they are using
susceptibility testing methods that will detect VRSA. The CDC states the most accurate
form of vancomycin susceptibility testing for staphylococci is a nonautomated MIC
method (e.g. broth microdilution, agar dilution, or agar-gradient diffusion) in which the
organisms are incubated for 24 hours before reading. Therefore, the CDC wants
laboratories using automated susceptibility testing of S. aureus strains, particularly
methicillin-resistant S. aureus, to include a vancomycin-agar screening plate containing
6 micrograms/mL of vancomycin and examine the plate for growth after 24-hour
incubation. UNC Health Care Systems laboratory has begun this practice. For more
information on preventing the spread of VRSA, go to
www.cdc.gov/ncidod/hip/vanco/vanco.htm
REGULATORY/LEGISLATIVE
OSHA Respiratory Protection Standard Medical Evaluation Requirement
Healthcare workers have asked for clarification about the OSHA Respiratory Protection
Standard requirement regarding medical evaluation. There has been a question as to
whether medical evaluation is an initial requirement or an annual requirement. SPICE
asked Dr. J. Edgar Geddie, Health Standards Officer, Education Training and Technical
Assistance Bureau, North Carolina Department of Labor/ETTA, for a response.
Dr. Geddie wrote, “What I wish to convey in my response to you is the fact that even
though medical evaluations beyond the initial medical evaluation is not an annual
requirement, fit-testing and respirator training ARE annual requirements. As noted in the
document cited below, additional medical evaluations are only required under the
circumstances listed. PLHCP is defined in the standard as ‘physician or other licensed
healthcare professional.’"
For more details, see: Major Requirements of OSHA’S Respiratory Protection Standard,
29 CFR 1910.134. March 1998
http://www.osha.gov/Training/major-req-RPS-1910_134.pdf
QUESTION OF THE MONTH
IS IT LEGAL TO MOUNT ALCOHOL-BASED HAND RUB DISPENSERS IN
EGRESS CORRIDORS?
Q: I recently saw a notice that the National Fire Protection Association (NFPA) approved
use of the alcohol-based hand rub dispensers not only in rooms but also in egress
corridors where installment was previously prohibited. Does this mean healthcare
facilities have approval by the State Fire Marshal and the North Carolina (NC) Division of
Facility Services (DFS) to put these up anywhere in the facility?
A: No, the tentative interim amendment (TIA) announced on April 28, 2004, by the
National Fire Protection Association (NFPA) amended its 2000 and 2003 Life Safety
Code (LSC) 101 to permit alcohol-based hand rubs in egress corridors but only when the
following specific conditions are met.
 corridor width of 6 feet or greater
 dispensers are separated by 4 feet or greater
 maximum individual fluid capacity is 1.2 liters in rooms, corridors, and areas open
to corridors, and 2.0 liters for dispensers in suites of rooms
 dispensers are not installed over or directly adjacent to electrical outlets and
switches
 in locations with carpeted floor coverings, dispensers installed directly over
carpeted surfaces are permitted only in sprinkler-equipped smoke compartments
 each smoke compartment may contain a maximum aggregate of 10 gallons of
alcohol-based hand rub solution and maximum of five gallons in storage.
However, the International Code Council (ICC), publisher of the International Fire Code
and companion International Building Code which are the reference documents for the
NC State Building Code, is still evaluating the information provided by the American
Society of Healthcare Engineering (ASHE). A task force of fire marshals, hospital
engineers, and industry experts is collaborating with ASHE to provide their
recommendations on safe placement of alcohol-based hand rubs. In NC local fire
marshals are the “code officials” who are permitted under Section 205 to use their
individual discretion whether to allow “alternative methods” that are “equivalent” to the
existing codes. There is no blanket statement currently under which local fire marshals
will or will not accept as equivalent NFPA’s TIA for alcohol-based hand rubs in egress
corridors. The other regulatory agency responsible for enforcement of the NC Building
Code is the Center for Medicare and Medicaid Services (CMS), Division of Facility
Services. The NC Division of Facility Services is also responsible for licensing hospitals
and long-term care facilities plus enforcing compliance with the NFPA Life Safety Code
101 that is enforced by JCAHO. Currently the CMS General Counsel is working out the
details of adopting the TIA to the 2000 and 2003 editions of the Life Safety Code. NC
DFS is advising facilities that if dispensers are already in the corridors they do not need
to take them out. Inspectors will issue a temporary waiver. Plan of Correction should
read: “Temporary waiver pending resolution of the TIA.” Facilities that have not yet put
alcohol-based hand rub dispensers in egress corridors should wait until DFS resolves its
issues with the TIA. If the TIA is adopted by the CMS and the ICC is amended, DFS and
the Office of the NC State Fire Marshal will have final guidance allowing dispensers in
corridors and effectively aligning national, state and local agencies regarding placement
of alcohol-based hand rub dispensers.
NEWS AND ANNOUNCMENTS
54th ANNUAL TUBERCULOSIS/RESPIRATORY DISEASE INSTITUTE IN NORTH
CAROLINA
The Institute will be held July 23-25, 2004 at the UMCA Blue Ridge Assembly, Black
Mountain, NC. For registration call 1-800-LUNG-USA (in NC) or 1-800-892-5650
(outside of NC). Downloadable registration form and an online registration form are at
www.lungnc.org/TBRD/
PROPOSED OSHA RESPIRATORY PROTECTION STANDARD
April 2004. Representatives from Association for Professionals in Infection Control and
Epidemiology (APIC) and the American Hospital Association (AHA) met with OSHA
Administrator John Henshaw and other OSHA officials, regarding the agency's recent
decision to include exposure to patients with potentially infectious TB under the General
Industry Respiratory Protection Standard. APIC outlined its major concerns with this
decision, citing the lack of scientific/epidemiologic justification for annual fit-testing and
the success of already existing TB control strategies. Secretary Henshaw maintained
that his number one concern is protecting workers, but also stated that he has no
intention of imposing anything that is unnecessary or that will be a waste of resources.
He is strongly considering a delay in enforcement (beyond July 1, 2004).
Excerpts from letter from Jennifer A. Wilson Director of Membership & Chapter
Relations, APIC
EASY ACCESS TO REQUIREMENTS PAGE ON JCAHO WEBSITE
JCAHO has lifted the password restriction to the JCAHO Requirements Page on the
Joint Commission Resources website. While access to the Requirements Page was
always free to accredited organizations, it is now easier to access the page, which lists
all the updates and revisions to JCAHO manuals, standards, Accreditation Participation
Requirements, policy changes and more. The page is organized by accreditation
manual, and can be accessed at
http://www.jcrinc.com/subscribers/perspectives.asp?durki=2815.
RICIN: NEW TOPIC ON OSHA SAFETY AND HEALTH TOPICS PAGE
OSHA has added an important subject on its Safety and Health Topics Page. The
discovery of ricin on a mail-opening machine closed three Senate office buildings in the
nation's capitol last month. Although no illnesses or deaths resulted, the toxin can be
used as a bioterrorist weapon in the workplace. OSHA's information on the toxin
includes hazard recognition, emergency response, and control and prevention, and also
includes links to additional resources.
http://www.osha.gov/SLTC/ricin/index.html
GUIDELINES FOR PREVENTING HEALTH-CARE--ASSOCIATED PNEUMONIA, 2003
The pneumonia guidelines were approved in 2003 and published in the MMWR March
26, 2004/Vol. 53/No. RR-3, Recommendations of CDC and the Healthcare Infection
Control Practices Advisory Committee. To stay abreast of changes in the prevention
and treatment of nosocomial pneumonia, the CDC has updated its previous guidelines
on preventing transmission of this condition. This report presents new and improved
strategies for reducing the incidence of pneumonia and other severe, acute lower
respiratory tract infections, particularly in hospitals and other health-care settings. In
addition, the report presents the latest information for preventing pertussis, infections
caused by adenovirus and human parainfluenza viruses, and severe acute respiratory
syndrome (SARS).
http://www.cdc.gov/mmwr/PDF/rr/rr5303.pdf
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm
MANUFACTURER'S RECALL OF RAPID CARTRIDGE ASSAY KITS
MMWR. March 26, 2004. Notice to Readers: Update reported on the manufacturer’s
recall of rapid cartridge assay kits on the basis of false-positive cryptosporidium antigen
tests.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5311a7.htm
RECALL OF NASAL SPRAY CONTAMINATED WITH BURKHOLDERIA CEPACIA
COMPLEX
March 26, 2004. Major Pharmaceuticals said today that it is conducting a voluntary
Class I recall of certain lots of Twice-A-Day Nasal Spray 15 ml and 30 ml bottles. The
product is contaminated with a type of bacteria called Burkholderia cepacia. Some of the
recalled lots have been found to be contaminated and could cause serious or potentially
life-threatening infections in patients with compromised immune systems, particularly
individuals with cystic fibrosis.
http://www.fda.gov/oc/po/firmrecalls/major03_04.html
FDA APPROVES FIRST ORAL FLUID BASED RAPID HIV TEST KIT
March 26, 2004. FDA approved the use of oral fluid samples with a rapid HIV diagnostic
test kit that provides screening results with over 99 percent accuracy in as little as 20
minutes. Until now, all rapid HIV tests required the use of blood in order to get such rapid
results.
From FDA News
COMMENT PERIOD EXTENDED FOR ASSIGNED PROTECTION FACTORS RULE
Interested persons wishing to comment on OSHA's Assigned Protection Factors rule
now have an additional 30 days to submit their remarks, thanks to an extension
announced by OSHA. The agency proposed revisions to the respiratory protection
standard last June to incorporate new APFs (numbers that reflect the workplace level of
respiratory protection) for respiratory protection programs. Post-hearing comments must
now be submitted not later than April 29, while post-hearing briefs must be sent by May
29. The announcement was published in the March 30, 2004, Federal Register.
From OSHA QuickTakes newsletter, April 1, 2004
AVIAN FLU SUBJECT OF SAFETY AND HEALTH GUIDANCE
While avian flu primarily impacts birds, there have been human cases confirmed in Asia.
Based on possible worker exposure, OSHA recently posted safety and health guidance
on its website to alert workers and employers about the hazards of the virus. The
guidance provides specific recommendations for farm workers and animal handlers,
laboratory workers, medical personnel, food handlers, airline flight crews and travelers.
From OSHA QuickTakes newsletter, April 1, 2004
MANUFACTURER’S RECALL OF HUMAN RABIES VACCINE
April 2, 2004/Vol. 53/MMWR. Vaccine maker Aventis Pasteur recalled four lots of
human rabies vaccine after discovering that the Imovax rabies vaccine contained live
virus. Imovax is an inactivated viral vaccine and should not contain live virus.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm53d402a1.htm
http://www.cdc.gov/mmwr/pdf/wk/mm53d402.pdf
COURSES FOR THE INFECTION CONTROL PROFESSIONAL
"Infection Control in Long-Term Care Facilities” will be held in Chapel Hill October 25-27,
2004.
“Infection Control Part I: Clinical Surveillance of Healthcare-Associated Infections” was
held in Chapel Hill May, 2004, and will be offered in the spring of 2005.
“Infection Control Part II: The ICP as an Environmentalist” will be held in Chapel Hill
November 8-12, 2004
-----------------------------------------------------------------------------------Contributors to Report of the Month: Karen K. Hoffmann, RN, MS, CIC; William A.
Rutala, PhD, MPH; David J. Weber, MD, MPH; Jennifer MacFarquhar, RN, BSN, CIC;
Eva P. Clontz, MEd.
-----------------------------------------------------------------------------------To subscribe to the Report of the Month, send email to
spice@unc.edu
Report of the Month is also available on the home page of the Statewide Program for
Infection Control and Epidemiology at http://www.unc.edu/depts/spice/
The Statewide Program for Infection Control and Epidemiology (SPICE) is funded by the
General Assembly of North Carolina to serve the State. SPICE is not a regulatory
agency but provides education and consultation to North Carolina healthcare facilities.
Copyright 2004 Statewide Program for Infection Control and Epidemiology