A nurse is preparing to teach about communicable diseases during which of the following stages

Vital signs

• Temperature
• Heart rate
• Respiratory rate
• Oxygen saturation
• Blood pressure

Inspection

• Lethargy
• Tachypnea
• Nasal Flaring
• Indrawing/retractions
• Colour
• Coryza
• Pharynx: redness, lesions
• Mucous membranes: moistness, lesions (for example, Koplik's spots)
• Skin: description of rash or petechiae (for more information, see FNIHB Pediatric and Adolescent Care Clinical Practice Guidelines – Chapter 16 – Skin)
• Joints: swelling and mobility
• Ana excoriation in diarrheal illness

Palpation

• Fontanel (in infants): size, consistency
• Neck rigidity
• Tactile characteristics of rash
• Lymphadenopathy
• Hepatosplenomegaly
• Joint movement
• Skin turgor and hydration

Auscultation (heart and lungs)

• Breath sounds
• Crackles
• Wheezing
• Stridor
• Heart sounds
• Pleural or pericardial rubs
• Murmurs

Children

• 10-21 daysFootnote 1

Infants born to mothers with active varicella around the time of delivery

• 2-16 days after birthFootnote 3

Laboratory

Testing should be carried out as per provincial/territorial policies and procedures. The tests below are for consideration.

• Varicella infection is usually a clinical diagnosis. Diagnostic testing is not necessary in a client with typical presentation. Lab investigations should be considered in the following situations:
  • Atypical rash in an immunocompromised host
  • Possible disseminated disease in an immunosuppressed host without cutaneous lesionsFootnote 8
• Source specimens may include vesicular fluids, vesicular lesions, and respiratory secretions (if pulmonary infiltrates)Footnote 9
• The test commonly ordered to confirm diagnosis of VZV is virus cultureFootnote 9
• If available, rapid diagnostic tests such as direct fluorescent antibody (DFA) or PCR may be ordered in consultation with a physician/nurse practitionerFootnote 8
• Pregnant women and immunocompromised individuals exposed to varicella should be evaluated for a history of varicella vaccination or disease
  • In the absence of a history, immunity should be assessed by serologic testing (IgG) as soon as possibleFootnote 1

For more information on post-exposure serological testing, see Table 1: Varicella Post-exposure Management for Susceptible* Individuals in Appendix A, Section A of this guideline.

Client Education

Counsel parent(s)/caregiver(s)/client on:

• How to provide comfort and prevent spread of infection
• When to follow-up at the nursing station
• The importance of trimming fingernails to prevent scratching and infectionFootnote 10
• Washing or disinfecting articles that may have been soiled by vesicle fluid or by discharge from nose or throatFootnote 2
• Keeping the child away from child centre, school or public places unless:
  • The varicella infection is mild (e.g., producing a low fever for a short time, rash with less than 30 spots)Footnote 11
  • The last lesions have scabbed overFootnote 2
  • The child feels well enough to participate in all activities
  • The child's return is approved by the child centre or school
• Ways to help control itching:
  • Use of an oatmeal bath product or add half a cup of baking soda to the bathwaterFootnote 10
  • Apply calamine lotion to the blistersFootnote 10
  • Take a prescribed antihistamine to help relieve the itchingFootnote 10
• The client should not receive any acetylsalicylic acid (ASA) or products that contain ASA. Taking ASA increases the risk of getting Reye's syndrome, which can damage the liver and brainFootnote 11.
• Counsel parent(s)/caregiver(s)/client about appropriate use of medications; dose, frequency, importance of adherence, potential side effects and interactions.

For more information on caring for a child with chickenpox, see the Canadian Paediatric Society's CaringforKids – Chickenpox.

Analgesic/antipyretic

Note: Since neonates and infants (less than 3 months of age) are less able to mount a febrile response, when they do become febrile, it is more likely to indicate a major illness.Footnote 13Footnote 14 Consult with physician/nurse practitioner - particularly for children less than 3 months of age.

Antihistamine/antipruriticFootnote 17Footnote 18Footnote 25

• Limited evidence is found to support the use of systemic antihistamines
• Benefits must be weighed against potential risksFootnote 19
• One of the antihistamines listed may be considered for the management of pruritis

Note: diphenhydrAMINE may cause sedation or paradoxical excitement in children.

Antiviral

Post-exposure management

Varicella zoster immune globulin (VarIg)Footnote 22

• VarIg may be recommended for certain susceptible groups for the prevention or reduction in severity of infection within 4 days (96 hours) of the most recent exposure to the varicella zoster virus
• The protection conferred by VarIg lasts approximately 3 weeks. Subsequent exposures occurring more than 3 weeks after a dose of VarIg will require additional doses if the criteria for administration are met
• The decision to administer VarIg should be based on fulfilling all of the following 4 criteria:
  1. The exposed person is susceptible to varicella. For more information on susceptibility and immunity, see Appendix A, Section A of this guideline Footnote 1
  2. There has been significant exposure to a person with varicella or Herpes Zoster (HZ). For the definition of 'significant exposure' to VZV, see Appendix A, Section A of this guideline
  3. The exposed person is at increased risk of severe varicella. For a description of individuals at increased risk of severe varicella, see Appendix A, Section A of this guideline
  4. Post-exposure immunization with univalent varicella vaccine is contraindicated
• Consult with a Public Health Physician if VarIg is required
• VarIg is usually provided as a single IM dose
• Arrangement to transfer the client out to receive the treatment may be necessary
• For more information on the criteria for VarIg administration, see Canadian Immunization Guide – Part 5 – Passive immunizing agents
• For the VariZIG drug monograph, see active ingredient 'Varicella' in the Health Canada Drug Product Database

Referral

• Not usually necessary unless complications are present or the client is pregnant or immunocompromised
• Arrange for medical evacuation if clinically indicated
• Coordinate referral requested as required.

Reporting

• Suspected and confirmed cases are to be reported to the provincial/territorial Public Health Physician as per provincial/territorial policy/procedure
• Varicella occurring 7 to 21 days after vaccination with varicella-containing vaccine that is moderate (50 to 500 lesions) or severe (more than 500 vesicular lesions/associated complications/hospital admission) is considered an adverse event following immunization and is reportable to the provincial/territorial MOHFootnote 1

Susceptibility and immunityFootnote 1

Significant exposures to varicella zosterFootnote 1

The following situations are considered significant exposures to VZV as result of contact with a person with varicella:

• Continuous household contact (that is living in the same dwelling) with a person with varicella
• Being indoors for more than 1 hour with a person with varicella
• Being in the same hospital room for more than 1 hour, or having more than 15 minutes of face-to-face contact with a person with varicella
• Touching the lesions or articles freshly soiled by vesicle discharge from a person with active varicella

The following situations are considered significant exposures to VZV as result of contact with a person with Herpes Zoster (HZ):

• Continuous household contact (that is living in the same dwelling) with an immunocompromised person with HZ or a person with disseminated HZ prior to or within first 24 hours of antiviral treatment
• Being indoors for more than 1 hour with an immunocompromised person with HZ or a person with disseminated HZ prior to or within first 24 hours of antiviral treatment
• Being in the same hospital room for more than 1 hour, or more than 15 minutes of face-to-face contact with an immunocompromised person with HZ or a person with disseminated HZ prior to or within first 24 hours of antiviral treatment
• Touching the lesions or articles freshly soiled by vesicle discharge from a person with active HZ

Persons at increased risk for severe varicella

The following individuals are at increased risk for severe varicella:

• Those who touch the lesions or articles of clothing freshly soiled by vesicle discharge from a person with active HZ
• Newborn infants of mothers who develop varicella from 5 days before until 48 hours after delivery
• Neonates in intensive care settings born at less than 28 weeks of gestation or weighing 1,000 g or less at birth, regardless of their mothers' evidence of immunity
• Susceptible pregnant women
• Susceptible immunocompromised persons, including HIV-infected persons with CD4 cell count <200 × 106/L or CD4 percentage <15%

Recipients of hematopoietic stem cell transplantation (HSCT) should be considered susceptible in the post-transplantation period, regardless of pre-transplant varicella immune status or post-transplant immunization history – including varicella disease, vaccination or positive serologic test results.

Referenced from Canadian Immunization Guide – Part 4 Active Vaccines – Varicella (chickenpox) Vaccine, Table 2: Varicella Post-exposure Management for Susceptible*Individuals

For more information about varicella vaccine, see the following:

• Canadian Immunization Guide – Part 4 – Active vaccines – Varicella (Chickenpox vaccine)
• Canadian Immunization Guide – Part 3 – Vaccinations in special populations
• Canadian Immunization Guide – Part 5 – Passive immunizing agents

Specific population: pregnancy

• Consult physician/nurse practitioner for further guidance when a pregnant woman has been exposed to varicella
• Pregnant women exposed to varicella should be evaluated for a history of varicella vaccination or disease. In the absence of such a history, immunity should be assessed by serologic testing (Varicella-zoster IgG).Footnote 1
• If the serum results are negative or unavailable within 96 hours from exposure, Varicella-zoster immune globulin (VarIg) should be administeredFootnote 5
• Varicella vaccine is contraindicated in pregnant womenFootnote 5
• Note: Susceptible women should receive varicella vaccination post-delivery within the appropriate time interval (at least 5 months after VarIg was given to avoid reduced vaccine efficacy from shorter intervals)Footnote 1
• Women with varicella infection during pregnancy are at risk of potential adverse maternal and fetal sequelae, including maternal pneumonitis and congenital malformations.Footnote 5 Consult physician/nurse practitioner for obstetrician/gynecologist consultation

Acyclovir recommendations for immunocompetent individuals at risk for moderate to severe varicella

• Acyclovir has been shown to inhibit viral replicationFootnote 9
• Oral acyclovir is not recommended for routine use in otherwise healthy children with varicella. However, it should be considered for individuals at increased risk of moderate to severe varicella; for example:
• Unvaccinated individuals older than 12 years of ageFootnote 3
• Individuals who have chronic cutaneous or pulmonary disordersFootnote 3
• Individuals who are receiving long-term salicylate therapyFootnote 3
• Individuals who are receiving short, intermittent, or aerosolized courses of corticosteroidsFootnote 3
• Pregnant women with significant varicella infection (if there is progression to varicella pneumonitis, hospital admission and IV acyclovir is recommended)Footnote 5
• Some experts also recommend use of oral acyclovir for secondary household cases in which the disease is usually more severe than in the primary caseFootnote 3

Note: If acyclovir suspension is not available, the acyclovir tablets can be cut to administer more accurate dosing. Tablets can be crushed for child who cannot swallow tablets.

• IV acyclovir is used for individuals with severe VZV infection or those at risk of developing serious infectionFootnote 9

Prevention

• A 2-dose primary schedule for children is recommended to improve varicella control and to decrease breakthrough cases.
• The first dose should be between 12 and 15 months of age, and
• The second dose at 18 months of age or any time thereafter but no later than school entry. Can be given as a combined vaccine with MMRFootnote 1
• Children with a clinician-diagnosed or verified history of typical chickenpox can be assumed to be immune to varicella
• Several vaccine products containing a live attenuated strain of varicella virus are licensed in Canada (e.g., Varivax IIIFootnote 23)

For more information on varicella vaccines, see the Regional Immunization Manual and the latest Canadian Immunization Guide for varicella vaccines.

Breakthrough varicella

• Subclinical varicella infection has been known to occur post-immunizationFootnote 3Footnote 4

Anterior nasal diphtheriaFootnote 27

• Onset is indistinguishable from that of the common cold and is usually characterized by a mucopurulent nasal discharge which may become blood-tinged

Pharyngeal and tonsillar diphtheriaFootnote 27

• The onset of pharyngitis is insidious; early symptoms include malaise, sore throat, anorexia, and low-grade fever

Laryngeal diphtheriaFootnote 27

• Symptoms include fever, hoarseness and a barking cough

Cutaneous diphtheriaFootnote 27

• May be manifested by rash or by ulcers

Presumptive diagnosis

• Presumptive diagnosis for diphtheria is made clinically because prompt treatment is essentialFootnote 27
• Presumptive diagnosis may include observation of a greyish-white, grey or black membrane, especially if extending to the uvula and soft palate, in association with tonsillitis, pharyngitis or cervical lymphadenopathy, or a serosanguinous nasal dischargeFootnote 30

Laboratory

Testing should be carried out as per provincial/territorial policies and procedures. The tests below are for

consideration

• Throat and/or nasopharyngeal swabs of the lesions for culture and sensitivity (C+S) to confirm diagnosisFootnote 27
• Culture of cutaneous lesionsFootnote 27

Interventions

• Monitor vital signs
• Provide oxygen and maintain client's airway PRN as per policies and procedures
• NPO as clinically indicated

IV therapy

• Start IV therapy with IV fluid such as 0.9% sodium chloride, and run at a rate sufficient to maintain hydration

For more information, see FNIHB Pediatric and Adolescent Care Clinical Practice Guidelines – Chapter 4 – Fluid Management.

Antibiotic therapy

• Antibiotics may be initiated before transfer, but only in consultation with the public health physician
• For antibiotic management of contacts and carriers, see Prevention in Appendix B, Section A of this guideline. Consult with a public health physician

Diphtheria antitoxin

If diphtheria antitoxin is required:

• Consult with a Public Health Physician
• Arrange for medical evacuation as soon as possible

Note: Currently there is no licensed product made in Canada. An anti-diphtheria serum is available from Health Canada's Special Access Program (SAP).Footnote 32 Follow provincial/territorial public health as per policies and procedures.

For additional information regarding diphtheria antitoxin, see Canadian Immunization Guide – Part 5 – Passive Immunization.

Referral

Arrange for medical evacuation if clinically indicated.

Reporting

Diphtheria is a reportable disease. Follow provincial/territorial policies and procedures for notifiable diseases.

Prevention

• Diphtheria toxoid given as diphtheria-combination vaccine according to recommended immunization schedule in your jurisdiction; for more information, see the latest Canadian Immunization Guide

For more information on ways to prevent diphtheria, see Diphtheria – Prevention.

Contact management

• Consult with local public health physician to determine management of contacts
• Contacts are defined as:
  • Household members
  • Persons who have had close face-to-face contact to a case such as intimate contact
  • Someone who shares the same room at home, school or work
  • Health care workers exposed to oropharyngeal secretions from the caseFootnote 33
• Check immunization histories of case/carrier and close contactsFootnote 30

Close contacts

• Close contacts of a diphtheria case should receive an age-appropriate dose of a diphtheria toxoid-containing vaccine unless: Footnote 28
  • The contact is known to have been fully immunized and
  • The last dose of diphtheria toxoid-containing vaccine was administered within the last 10 years
• The diphtheria toxoid-containing vaccine series should be completed for previously unimmunized or incompletely immunized contactsFootnote 28
• Close contacts also need to be cultured and treated with antimicrobial prophylaxisFootnote 34

Antibiotic treatment options for close contactsFootnote 36:

Carriers

Identified carriers in the community should also receive antibiotics. Carriers may be treated with erythromycin.

Provincial/territorial guidelines

Prodromal stage

The prodromal stage often precedes the characteristic exanthem by approximately 7 to 10 days.Footnote 37 The following may be reported by the parent(s)/caregiver(s)/client:

• FeverFootnote 37
• Coryza/rhinorrheaFootnote 40
• HeadacheFootnote 37
• MalaiseFootnote 37
• MyalgiaFootnote 37
• NauseaFootnote 40
• DiarrheaFootnote 40
• ArthralgiaFootnote 37
• Itchy rashFootnote 37

Complication of parvovirus B19 Infection in pregnancyFootnote 38Footnote 40

• Miscarriage
• Spontaneous fetal loss
• Fetal hydrops

Laboratory

Testing should be carried out as per provincial/territorial policies and procedures. The tests below are for consideration.

• If the client is otherwise healthy, the diagnosis is clinical and no lab investigations are requiredFootnote 40
• If complications are present or client is at risk of complications (e.g., client is pregnant, immunocompromised, or has an anemic disorder), lab investigations are recommended
• CBC, Reticulocyte count if client has anemia disorder, is immunocompromised or pregnantFootnote 40
• Serology for Parvovirus B19 IgM, IgG antibodiesFootnote 38

Ultrasound

• Obstetrical ultrasound may be considered. For more information on erythema infectiosum in pregnant clients, see Special Population: Pregnant Clients in Appendix C, Section A of this guideline.

Client education

• The virus spreads via nasopharyngeal droplet secretionsFootnote 43
• The condition is most infectious before the onset of symptoms but is unlikely to be contagious after the development of the rash and other symptoms
• Advise clients at risk of complications to avoid contact with those infected with this condition.
• Encourage fluids in adequate amounts to maintain hydration
• Washing hands frequently and proper disposal of used facial tissues will help prevent the spread of the infectionFootnote 37Footnote 43Footnote 44
• Avoid excessive heat and sunlight and scratching as these can make the rash worseFootnote 37Footnote 43
• Otherwise healthy children do not need to be isolated or restricted from school or daycare after the rash appearsFootnote 37
• The client should not receive any acetylsalicylic acid (ASA) or products that contain ASA. Taking ASA increases the risk of getting Reye's syndrome which can damage the liver and brainFootnote 45
• Counsel parent(s)/caregiver(s)/client about appropriate use of medications; dose, frequency, importance of adherence, potential side effects and interactions
• For more information for parent(s)/caregiver(s), see:
  • HealthLinkBC's Fifth Disease Parvovirus Infection and
  • The Canadian Paediatric Society's CaringforKids – Fifth Disease (Erythema Infectiosum)

Analgesic/antipyretic

Note: Since neonates and infants (less than 3 months of age) are less able to mount a febrile response, when they do become febrile, it is more likely to indicate a major illness. Consult physician/nurse practitioner particularly for children less than 3 months of age.

Referral

Not usually required, unless client is pregnant, immunocompromised or has an anemia disorder.

Special population: pregnant clients

• Approximately 50-75% of females of reproductive age have developed immunity to parvovirus B19Footnote 38
• About 1-3% of susceptible pregnant females will develop serologic evidence of infection in pregnancy, rising to over 10% in epidemic periodsFootnote 38
• Up to 70% of infected pregnant females will be asymptomaticFootnote 38
• If a recent parvovirus B19 infection has been diagnosed, referral to an obstetrician or a maternal-fetal medicine specialist is recommendedFootnote 38
• The client should be followed by an obstetrician or a maternal-fetal medicine specialist for counselling regarding risks of fetal transmission, fetal loss, and hydrops
• Serial ultrasounds should be performed every 1 to 2 weeks, up to 12 weeks after infection, to detect the development of anemia and hydrops (using Doppler measurement of the middle cerebral artery peak systolic velocity)Footnote 38

For more information about pregnancy and Parvovirus B19, see the Society of Obstetricians and Gynaecologists of Canada's Clinical Practice Guideline No. 316 Parvovirus B10 in Pregnancy (December 2014).

Social

• Obtain a history of exposure to determine the possible source of infectionFootnote 52
• Identify recent travel history during the incubation period (approximately 12 days)
• Identify recent contact with a confirmed or probable case of measles

Physical findings

Perform a physical examination using the IPPA approach.

• Fever of 3 degrees Celsius or higherFootnote 51
• Generalized erythematous, maculopapular rashFootnote 49
• Typically begins at the hairline, then moves to the face and neck, gradually spreading down the trunk and extremities to reach the hands and feet
• Lesions are usually discrete, but may become confluent
• Lesions blanch initially; however by days 3-4, most do not blanch with pressure
• Fine desquamation may occur over more severely affected areas
• The rash disappears in the same direction it appearedFootnote 50
• Koplik spots, i.e., bluish-white spots with an erythematous base on buccal mucosa, occurs 1 to 2 days before the rash to 1 to 2 days after the rash
• Conjunctivitis
• Generalized lymphadenopathyFootnote 50

Laboratory

In order to maximize the sensitivity of testing from a suspected case of measles in the acute phase of illness, collect serum, nasopharyngeal swab, and urine samples.Footnote 52 Testing should be carried out as per provincial/territorial policies and procedures. The tests below are for consideration.

Interventions

For case and contact management, see Appendix D, Section A of this guideline.

Client education

No specific measles treatment is available; however, severe complications can be avoided through supportive care:

• Encourage activity as tolerated
• Encourage good nutrition
• Encourage adequate fluid intake to prevent dehydration
• Provide information about disease transmission and appropriate infection control measures to minimize the possibility of transmission (including practicing good hand-washing hygiene, avoiding the sharing of drinking glasses or utensils and covering coughs and sneezes with a tissue or forearm)Footnote 52
• Counsel client to return for further assessment if there is no improvement in the signs and symptoms of the presenting condition
• Counsel parent(s)/caregiver/client about the appropriate use of medications; dose, frequency, importance of adherence, potential side effects and interactions
• The client should not receive any acetylsalicylic acid (ASA) or products that contain ASA. Taking ASA increases the risk of getting Reye's syndrome, which can damage the liver and brain

Antipyretic/analgesic

Note: Since neonates and infants (less than 3 months of age) are less able to mount a febrile response, when they do become febrile, it is more likely to indicate a major illness. Consult physician/nurse practitioner particularly for children less than 3 months of age.

Referral

• Arrange for medical evacuation if clinically indicated
• Coordinate referral request(s) as required

Reporting

• Measles is reportable. Notify the Public Health Physician of all confirmed, probable, and suspected cases of measles as soon as possibleFootnote 49
• Follow provincial/territorial policies and procedures for notifiable diseases. For more information, see Appendix D, Section B: Provincial/Territorial Guidelines for Measles (Rubeola)

Prevention and controlFootnote 52

Public health managementFootnote 52

Interpretation of lab investigations

Provincial/territorial resources

Other resources

Canadian Pharmacists Association. Compendium of Therapeutic Choices: Canada's Trusted Reference for Primary Care Therapeutics (CTC 7). Ottawa: c2014.

Public Health Agency of Canada (PHAC). Canada Communicable Diseases Report (CCDR): Guidelines for the Prevention and Control of Measles Outbreaks in Canada. [Internet] Ottawa, ON: Public Health Agency of Canada; 2013.

Health Canada. First Nations and Inuit Health Branch (FNIHB) Nursing Station Formulary and Drug Classification System. 2016 April.

Laboratory

Testing should be carried out as per provincial/territorial policies and procedures. The tests below are for consideration.

Diagnostic work-up of clinical and suspect cases may include both serology and virus detection (by PCR testing and/or isolation in cell culture).

• Buccal swab for virus detection (ideally PCR) within the first 3 to 5 days of parotitis or symptom onsetFootnote 61
• The preferred specimen is buccal swab or saliva from the buccal cavityFootnote 61

Client education

• There is no specific treatment for mumps. All confirmed and clinical cases of mumps should be offered supportive care,Footnote 59 including:
  • Activity as tolerated
  • Fluids in amounts adequate to prevent dehydration
  • Warm or cold compresses applied to the parotid area may be helpfulFootnote 62
  • Local application of cold compresses and gentle support for the scrotum (may minimize testicular pain)Footnote 62
• Advise client and/or parent(s)/caregiver(s) to limit visitors, especially unimmunized children and pregnant women, for 5 days after parotid swelling starts
• Advise client to stay home from school or post-secondary educational institutions, child care facilities, workplaces, and other group settings for 5 days from symptom onsetFootnote 63
• Encourage client to practice good hand hygiene, avoid sharing drinking glasses or utensils, and to cover coughs and sneezes with a tissue or forearmFootnote 63
• Counsel client and parent(s)/caregiver(s) about appropriate use of medications: dose, frequency, importance or adherence, potential side effects and interactions
• The client should not receive any acetylsalicylic acid (ASA) or products that contain ASA. Taking ASA increases the risk of getting Reye's syndrome, which can damage the liver and brain
• Counsel client to return for further assessment if no improvement in signs and symptoms of presenting condition

Analgesic/antipyretic

Note: Since neonates and infants (less than 3 months of age) are less able to mount a febrile response, when they do become febrile, it is more likely to indicate a major illness. Consult physician/nurse practitioner particularly for children less than 3 months of age.

Referral

• Arrange for medical evacuation if clinically indicated
• Coordinate referral request(s) as required

Reporting

Mumps is a reportable disease. Follow provincial/territorial policies and procedures for notifiable diseases.Footnote 63

Contact management

• The public health response to increased mumps activity includes:Footnote 63
  • Managing cases
  • Contact identification and management
  • Identifying social networks
  • Maintaining/enhancing surveillance for further cases and disease outcomes (e.g., hospitalizations, complications)
• Generally, a mumps outbreak is controlled using the following methods:Footnote 63
  • Defining at-risk population(s) and transmission settings
  • Preventing further transmission through case isolation and contact education/awareness
  • Protecting susceptible populations with immunization where no contraindication to measles-mumps-rubella (MMR) vaccine exists
• Contacts are defined by fulfillment of at least one of the following criteria during the infectious period (i.e., approximately 7 days before to 5 days after symptom onset):Footnote 56
  • Household members and close contacts of a case
  • Persons who share sleeping arrangements with the client, including sharing a room
  • Direct contact with the oral/nasal secretions of a case, sharing cigarettes/drinking glasses/food/cosmetics such as lip gloss, kissing on the mouth
  • Children and staff in child care and school facilities (as deemed necessary by the epidemiology of the outbreak)
  • Health care workers with unprotected face-to-face interaction within 1 metre of an infectious mumps case
• Susceptible contacts include:
  • Those born in Canada in 1970 or later who did not receive 2 doses of mumps-containing vaccine (at least 4 weeks apart) on or after their first birthday
  • Those without past history of laboratory confirmed mumps
  • Those without documented immunity to mumps

Assessment of immunization status and immunization with a mumps-containing vaccine as appropriate for age and risk factors should be conducted for susceptible contacts. Although mumps immunization after exposure to mumps may not prevent the disease, should the exposure not result in infection, the vaccine will confer protection against future exposures.Footnote 56

Note: Post-exposure prophylaxis with mumps immune globulin (Ig) is ineffective.Footnote 63

• Contacts should be advised
  • On the signs and symptoms of mumps infection (which can occur within 25 days of exposure)
  • To seek medical attention upon symptom onset if required
  • To inform the local public health unit as per provincial/territorial policies and proceduresFootnote 63
• Isolation of mumps-susceptible contacts is not required. On the basis of the epidemiology of the outbreak, susceptible groups should be targeted for immunization, especially those at greatest risk of exposureFootnote 63
• The dissemination of information to contacts should include:
  • Information on mumps disease
  • Its symptoms and prevention
  • Advice to visit one's health care provider should any symptoms develop

Prevention

In Canada, the administration of a mumps-containing vaccine is part of the routine 2-dose childhood immunization schedule. The first dose of mumps-containing vaccine is given at 12 to 15 months of age, and the second dose at 18 months of age or any time thereafter. It should be given no later than around the time of school entry.Footnote 67 The National Advisory Committee on Immunization publishes detailed recommendations pertaining to the use of vaccines in Canada.

Provincial/territorial guidelines

Other Resources

Public Health Agency of Canada. National Advisory Committee on Immunization. Statement on Measles-Mumps-Rubella-Varicella Vaccine. [Internet] Ottawa, ON: Public Health Agency of Canada; 2010 September.

Public Health Agency of Canada. Guidelines for the Prevention and Control of Mumps Outbreaks in Canada. Supplement. [Internet] Ottawa, ON: Public Health Agency of Canada; 2010 January.

Public Health Agency of Canada. National Advisory Committee on Immunization. Canada Communicable Disease Report. Statement on Mumps Vaccine. [Internet] Ottawa, ON: Public Health Agency of Canada; 2007 August 1.

Illness stages

The course of illness is typically divided into 3 stages:

Social history

• Contact history to identify possible source and to identify susceptible contacts, including contacts at high risk for severe disease
• School, daycare attendance

Laboratory

Testing should be carried out as per provincial/territorial policies and procedures and guided by client's clinical presentation.

• Nasopharyngeal swab for culture and/or PCR for B. pertussis using Calgi (calcium alginate) or Dacron swabs. Cotton swabs should not be used for culture of nasopharyngeal specimens for B. pertussis because cotton inhibits the growth of the organismFootnote 73
• A properly-obtained nasopharyngeal swab is essential for optimal results.Footnote 74 For an illustration demonstrating proper collection technique, see Appendix F, Section A of this guideline
• Instructional videos for collection of nasopharyngeal specimens are also available
• CBCFootnote 73

Client education

Provide the following education/counselling to the parent(s)/caregiver(s) and/or client:

• Activity as tolerated
• Encourage adequate fluid intake to maintain hydration
• Keep the home free from irritants that can trigger coughing, such as smoke, dust, and chemical fumesFootnote 75
• Limit new visitors to the home until 5 days after antibiotic therapy has started.
• Isolate a client with confirmed or suspected pertussis from young children and infants until the client has received at least 5 days of antibioticsFootnote 70
• Isolate a client with suspected pertussis who does not receive antibiotics for 21 days after cough onset,Footnote 76
• Counsel parent(s)/caregiver(s) and/or client on appropriate use of medications; including dose, frequency, importance of adherence, potential side effects and interactions.

For more information on caring for children with pertussis, see the Caring for Kids' Pertussis (Whooping Cough) handout.

IV therapy

IV fluid (such as 0.9% sodium chloride) may be required for client who is unable to tolerate oral feedings or who presents with signs of dehydration (e.g., due to vomiting).Footnote 77Footnote 78 For more information on pediatric fluid requirements, see.

Antipyretic/analgesic

Note: Since neonates and infants (less than 3 months of age) are less able to mount a febrile response, when they do become febrile, it is more likely to indicate a major illness. Consult physician/nurse practitioner particularly for children less than 3 months of age.

Antimicrobial therapy

• Antimicrobial treatment administered in the catarrhal phase of the illness can decrease the duration and severity of symptomsFootnote 69
• Preferred treatment for pertussis is with macrolides (i.e., azithromycin, erythromycin, clarithromycin)Footnote 83
• A shorter course (i.e., 3 days) of azithromycin for treatment or postexposure prophylaxis of B. pertussis has not been validated and is not recommendedFootnote 84
• Azithromycin is the first choice because it is given in a short and simple regimen.Footnote 74 It is the drug of choice for infants less than 1 month of ageFootnote 80

Preferred treatmentFootnote 76

Referral

• Arrange for medical evacuation if clinically indicated (e.g., infants and older children with severe disease manifestations or complications)

Reporting

Pertussis is a reportable disease. Follow provincial/territorial policies and procedures for reportable diseases.

Contact management

Contacts, especially children, must have their immunization status verified. If immunization status is incomplete and no contraindications are identified, recommended doses of vaccine should be given.

PreventionFootnote 70

• Pertussis can be prevented by immunization. Educate the public about the dangers of pertussis and the advantages of initiating immunization at 2 months of age and adhering to the immunization scheduleFootnote 81
• For adults, 1 dose of acellular pertussis-containing vaccine (Tdap) should be administered if the person has not previously received it in adulthood (18 years of age and older)
• Adults of any age, who have not received a dose of Tdap vaccine in adulthood and who are in contact or anticipate contact with infants (e.g., parents, grandparents, childcare providers), should receive pertussis vaccination
• For comprehensive information about immunization recommendations, please refer to the most recent version of the Canadian Immunization Guide

Epidemiology of pertussis in canada

For information on the epidemiology of pertussis in Canada, see the Canadian Communicable Diseases Report.

Provincial/territorial guidelines

Social history

• It is important to obtain a history of family living conditions because tape test confirmation of pinworm presence is not necessarily the determining factor in deciding to treat the client. Other factors that influence the decision would be co-sleeping, lack of washing facilities and the availability of hot water

Laboratory

Testing should be carried out as per provincial/territorial policies and procedures. The tests below are for consideration.

• Examination of stool specimens for ova and parasites is not recommended (egg shedding does not occur inside the intestinal lumen;Footnote 85 therefore, very few ova are present in stool)
• Examine the perianal and perineal area 2 to 3 hours after the client is asleepFootnote 85 (that is the time adult female pinworms are most likely to be seen in the region)
• If the adult female pinworms have not been seen, the parent(s)/caregiver(s)/client should perform the tape test at home (it may be necessary to repeat the test on three separate mornings to obtain eggs).Footnote 85 For more information on how to perform the tape test, see Appendix G, Section A of this guideline

Client education

• Instruct parent(s)/caregiver(s)/client on the importance of establishing the following behaviours among family members and close contacts:
  • Wash hands carefully after going to the toilet, changing diapers and before preparing or eating foodFootnote 90
  • Keep everyone's fingernails short and avoid nail-bitingFootnote 90
  • Avoid or prevent scratching of perianal and perineal areasFootnote 90
  • Take a bath in the morning to get rid of many of the eggsFootnote 90
  • Clean the home, change and wash bed linens and clothing frequently. This will destroy eggs and help prevent reinfection. Avoid shaking bed linens and clothing because this can scatter the eggsFootnote 90
  • Open blinds or curtains in bedrooms during the dayFootnote 90 as eggs die when exposed to sunlight
• Re-infections with pinworms can occur if the client comes into contact with pinworm eggs again
• Pinworms can stay alive in the home for up to 3 weeksFootnote 90
• Counsel parent(s)/caregiver(s)/client about appropriate use of medications; dose, frequency, importance of adherence, potential side effects and interactionsFootnote 90

For more information on caring for a child with pinworms, see the Caring for Kids' Pinworms handout.

Pyrantel pamoateFootnote 89Footnote 94

• Pyrantel pamoate dosing is weight-based at 11 mg/kg PO as a single dose (maximum dose 1,000 mg) and the treatment has to be repeated in two weeks
• The tablets are supplied as 125 mg and as such, achieving an exact weight-based dose is not likely

Note: Consult with physician/nurse practitioner for children less than 1 year of age. The risks and benefits should be considered before initiation of treatment.

Dosing recommendations for children who are 1 year of age and older:

Tape testFootnote 85

• Inform parent(s)/caregiver(s)/client that the test should be performed when the client awakens in the morning (before bathing or having a bowel movement)
• Teach parent(s)/caregiver(s)/client how to perform the tape testFootnote 85
  1. Collect the eggs by pressing transparent (not translucent) adhesive tape around the perianal area and perineal skin several times (the procedure may need to be repeated for 3 or more consecutive days before eggs are collected)
  2. Place the transparent tape in a glass jar or loosely in a plastic bag and bring it to the clinic for microscopic examination

Diagnosis

• Diagnosis is done using the tape test
• Diagnosis is positive when pinworm eggs are seen on the tape
• When this occurs, the parent(s)/caregiver(s)/client may be required to bring the sample to the clinic
• The nurse will apply the tape to a glass slide and examine it under a low-power microscopic lens, if available

Client education

• Encourage activity as tolerated
• Encourage fluid intake in adequate amounts to maintain hydration
• Reassure parent(s)/caregiver(s) of thetypically benign nature of illness
• Educate parent(s)/caregiver(s) about signs and symptoms of complications, e.g.:
  • Febrile seizure
  • Lethargy
  • Refusal to drink
  • Prolonged fever greater than 72 hours or being unable to reduce fever
• Instruct parent(s)/caregiver(s) to bring the child back to the clinic if complications arise
• Provide education regarding how to manage a febrile seizure (see additional parent/caregiver information on febrile seizures)
• Advise parent(s)/caregiver(s) that skin eruptions gradually fade and resolve without scarringFootnote 102
• Counsel parent(s)/caregivers about appropriate use of medications; dose, frequency, importance of compliance, potential side effects and interactions
• The client should not receive any acetylsalicylic acid (ASA) or products that contain ASA. Taking ASA increases the risk of getting Reye's syndrome which can damage the liver and brain

See additional information for parents/caregivers on roseola at About Kids Health or Caring for Kids.

Analgesic/ antipyretic

Note: Since neonates and infants (less than 3 months of age) are less able to mount a febrile response, when they do become febrile, it is more likely to indicate a major illness. Consult physician/nurse practitioner particularly for children less than 3 months of age.

Referral

• Not necessary, unless complications develop

Social history

• Travel history, including recent travel to an area with known rubella activityFootnote 110

Fetus

Fetal infection can occur at any stage of pregnancy. The risk of fetal damage following maternal infection is particularly high in the first trimester with progressive decline of risk thereafter.Footnote 106 Congenital rubella syndrome may result in any of the following fetal anomalies:

• Ophthalmologic (e.g., cataracts, microphthalmia, glaucoma)
• Cardiac (e.g., patent ductus arteriosus, peripheral pulmonary artery stenosis)
• Auditory (e.g.. sensorineural hearing loss)
• Neurologic (e.g., behavioural disorders, meningoencephalitis, mental retardation)
• Hepatosplenomegaly
• Jaundice

Children

• Thrombocytopenia (hemorrhagic manifestations are rare)
• Leukopenia

Adolescents

• Arthritis (about 1 week after the rash first appears; classically, the hand, knees, wrists, and ankles are affected symmetrically)Footnote 110
• Enchephalitis

LaboratoryFootnote 112

• Virus culture from clinical samples (e.g., throat swab, nasopharyngeal swab/aspirate, urine)
• Nucleic Acid Amplification Test (NAAT) (e.g., throat swab, urine) for rubella virus ribonucleic acid (RNA)
• Serum rubella Immunoglobulin M (IgM) antibody
• Serum rubella Immunoglobulin G (IgG) antibody
• If client is a female of childbearing age, determine whether she is pregnant

Client education

• Encourage activity as tolerated
• Encourage adequate fluid intake
• Exclude children with postnatal rubella from school or child care for 7 days after the onset of the rashFootnote 111
• Counsel client and parent(s)/caregivers about appropriate use of medications: dose, frequency, importance of adherence, potential side effects, interactions
• The client should not receive any acetylsalicylic acid (ASA) or products that contain ASA. Taking ASA increases the risk of getting Reye's syndrome which can damage the liver and brain
• Counsel client to return for further assessment if there is no improvement in signs and symptoms of presenting condition
• For client education of female patients of childbearing age, see Prevention in Appendix H, Section A of this guideline

Rubella exposure/infection in pregnant clientFootnote 110

• The management of the exposed pregnant client must be individualized and depends on when during gestation she was exposed and on her state of immunity
• For information on prenatal diagnosis of maternal infection and congenital rubella syndrome, see Prevention in Appendix H, Section A of this guideline

Antipyretic/analgesic

Note: Since neonates and infants (less than 3 months of age) are less able to mount a febrile response, when they do become febrile, it is more likely to indicate a major illness. Consult physician/nurse practitioner particularly for children less than 3 months of age.

Referral

• Arrange for medical evacuation if clinically indicated
• Coordinate referral request(s) as required

Reporting

Rubella is a reportable disease. Follow provincial/territorial policies and procedures for notifiable diseases.

Management of contactsFootnote 107

Prevention

• The primary objective of vaccination against rubella is to prevent infection during pregnancy
• The mainstay of prevention is the universal immunization of all Canadian childrenFootnote 110
• All females of childbearing age should be vaccinated unless they have proof of immunity either through documented evidence of prior immunization or laboratory evidence of antibodies
• Educate women of childbearing age about the importance of knowing their rubella immunization statusFootnote 112
• Screen all pregnant women to determine susceptibility to rubella and to facilitate post-partum immunization of susceptible womenFootnote 112

Provincial/territorial guidelines

Other resources

Society of Obstetricians and Gynaecologists of Canada. Clinical Practice Guidelines.

Characteristics of Scarlatina rashFootnote 123

• Diffuse erythematous eruption
• Initially appears in the groin and axilla; the rash then extends rapidly over the entire body to finally involve the extremities
• The rash is more marked along the skin folds of the inguinal, axillary, antecubital, and abdominal areas.
• Often exhibits linear petechiae in the antecubital fossae and axillary folds (Pastia's lines)
• Palms and soles are usually spared
• The numerous small papular lesions give the skin the texture of coarse sandpaper.
• Erythema blanches with pressure
• The rash begins to fade within 4 to 5 days and is followed by desquamation on the body and extremities, with peeling from the palms/fingers and soles/toesFootnote 121

Appearance of tongueFootnote 121

• During the first few days of the disease, the tongue has a white coating through which the red, edematous papillae project; this phase is referred to as 'white strawberry tongue'
• After 3 to 4 days, the tongue also desquamates, which results in a red tongue with prominent papillae, referred to as 'red strawberry tongue'

Laboratory

• Rapid Antigen Detection Test (RADT) (if available). A positive RADT is considered definitive for GASFootnote 124
• Throat swab for culture and sensitivity (C+S) if RADT is negative or unavailableFootnote 124
• Wound swab for C+S if scarlet fever is due to a GAS skin infectionFootnote 121

For more information on diagnostic tests for GAS pharyngitis see.

Interventions

• Appropriate monitoring of individuals in the community with respect to complications

Client education

• Encourage rest
• Encourage fluids in adequate amounts to maintain hydration
• To minimize the risk of transmission, advise parent(s)/caregiver(s) or client to:
  • Wash hands regularly
  • Not share eating or drinking utensils
  • Use tissues to cover the mouth and nose if coughing or sneezing
  • Dispose used tissues immediately after use to prevent contaminationFootnote 120
• Advise parent(s)/caregiver(s) or client that the client should not return to school or daycare until the first 24 hours of antibiotic therapy is completeFootnote 123
• Emphasize the importance of observing for the warning signs and symptoms of complications of GAS infections
• Advise parent(s)/caregiver(s) to promptly bring the client back to the clinic for re-assessment if child has any of the warning signs and symptoms of complications at any point during the course of the illness
• Counsel parent(s)/caregiver(s) or client about appropriate use of medications: dose, frequency, importance of adherence, potential side effects and interactions
• Advise parent(s)/caregiver(s) that the child must complete the entire course of antibiotics, even if symptoms resolve
• If a client with confirmed GAS pharyngitis remains symptomatic on appropriate antibiotic therapy after 48 hours, the client should be reassessed for such factors as acute complications of GAS pharyngitis (e.g., peritonsillar abscess, concurrent viral infections and antibiotic adherence or antibiotic failure)

Antibiotic therapy

Antibiotics are indicated in scarlet fever in order to treat the underlying GAS infection and to prevent other complications.

Analgesic/antipyretic

For all clients

• At any time if the client is getting worse
• In 2 to 3 days to monitor for medication adherence and clinical response to therapy or to check for throat C+S test result
• If client is identified as being at increased risk of any complications
• Following a course of antimicrobial therapy if there is a recurrence of symptoms compatible with GAS infection

Note: Clinical response to appropriate antimicrobial treatment is usually evident within 24-48 hours. Persistence of high fever and severe symptoms beyond this period indicates the need for reassessment and is suggestive of the development of complication(s) or another underlying disease. Antibiotic failure is also a possibility.

Follow-up for clients at high risk for acute rheumatic fever

In addition to the preceding, for clients diagnosed with scarlet fever due to GAS pharyngitis, follow-up throat cultures are recommended after a course of appropriate antibiotic treatment for clients at high risk of acute rheumatic fever.

Note: Acute rheumatic fever presents days to weeks after an acute GAS infection (most often GAS pharyngitis).

Referrals

• Arrange for medical evacuation if clinically indicated

Pediatric autoimmune neuropsychiatric disorder (PANDAS)Footnote 130Footnote 131

PANDAS has been characterized as the abrupt, dramatic onset of obsessive-compulsive disorder (including severely-restricted food intake) or tics in some children as an autoimmune response following a GAS infection. The concept of PANDAS as a distinct disease entity is controversial and research is ongoing. At present, there is insufficient evidence to support routine testing for GAS in children with neuropsychiatric symptoms, or to support long-term prophylaxis or immune-modifying therapies in children with neuropsychiatric symptoms. Any child presenting with acute-onset obsessive-compulsive disorder/eating disorders must have a thorough medical evaluation.

Asymptomatic client

Many children with TB disease are asymptomatic at presentation. They are often identified through active case finding as contacts of clients with infectious TB and are found to have abnormal chest x-rays, especially if the child is under 5 years of age.Footnote 133

Symptomatic client

Children may also present with signs or symptoms suggestive of disease. In most cases, children with symptomatic TB develop chronic, unremitting symptoms that persist for more than 2 weeks without sustained improvement or resolution following appropriate treatment for other potential diagnoses (e.g., antibiotics for pneumonia.)Footnote 139 The following may be reported by the parent(s)/caregiver(s)/client:Footnote 139

• Cough
• Fever
• Poor appetite/anorexia
• Weight loss or failure to thrive
• Fatigue, reduced playfulness, decreased activity

Past medical history

• Exposure to TBFootnote 135
• History of active TB and questionable adequacy of previous treatmentFootnote 135
• History of positive Tuberculin Skin Test (TST) and questionable prophylaxis adequacy (if the client previously received LTBI prophylaxis)Footnote 135

Laboratory

Testing should be carried out as per provincial/territorial policies and procedures. The tests below are for consideration when there are no provincial/territorial policies available.

X-ray

• X-ray may be required to confirm a diagnosisFootnote 141 or to monitor response to treatmentFootnote 142
• Frequency of films will vary and are at the discretion of the attending respirologist or TB expert

Interventions

Note: If a case of latent or active TB is confirmed, the local Public Health Physician should be notified.Footnote 132

• A diagnosis of TB infection or disease in a child should be considered a sentinel event and prompt the search of the source case, most likely an adult or adolescent in close contact with the child.Footnote 133 For more information, see Management of Contacts in Appendix J, Section A of this guideline
• Close caregivers should be evaluated to rule out TB diseaseFootnote 133
• Consideration should be given to placing all close caregivers in isolation until they have been evaluated.Footnote 133 For information on home isolation recommendations, see

Active disease

TB medications are routinely prescribed by a pediatric TB specialist. In some provinces/territories however, they may be initiated and/or prescribed by an alternate physician/nurse practitioner. All oral TB medications are provided to clients through Provincial/Territorial Public Health Programs.

Children under 5 years of age are at high risk of progressing to severe forms of TB after they have been infected with TB. If TB is suspected in children, consult with TB specialists or physician/nurse practitioner immediately in order to initiate presumptive therapy, as necessary.Footnote 133

Latent tuberculosis infection (LTBI)

Treatment regimens for LTBI may vary according to provincial/territorial treatment guidelines. TB control offices are to be consulted for further information.

The current recommended standard of treatment for LTBI is INH for 9 months daily.Footnote 133

If the source case is INH-resistant or there is epidemiologic reason to suspect that the child is infected with an INH-resistant strain, then rifampin is recommended for 4 months.Footnote 133

Note: When isoniazid (INH) is prescribed, vitamin supplementation with pyridoxine (vitamin B6) should also be prescribed because of the increased risk of symptoms related to pyridoxine deficiency, especially in children with diabetes, renal failure, malnutrition, seizure disorders, HIV infection, and/or adolescents who are pregnant and/or breastfeeding, or have substance abuse. Pyridoxine supplement is also indicated for children with meat-and milk-deficient diets, and breastfed infants.

Clients on Ethambutol (EMB)

• Clients receiving ethambutol should have a baseline visual acuity and red-green color discrimination screen monthly (frequency may vary according to the provincial/territorial treatment guidelines and/or the treating physician/nurse practitioner)Footnote 142
• Clients who take ethambutol for longer than just the initial phase of treatment should be referred to an ophthalmologist for periodic assessment of visual acuity, colour vision and visual fieldsFootnote 142

Referral

• Coordinate referral request to a pediatric infectious disease specialistFootnote 132
• Clients with suspected active TB may require medical evacuation for investigation and treatment
• If suspected or confirmed active TB, clients may need to follow additional precautions during transportation; refer to provincial/territorial policies and procedures for guidance

Reporting

TB is a reportable disease.Footnote 145 Follow provincial/territorial policies and procedures for notifiable diseases.

Management of contactsFootnote 133

• The most efficient way to prevent pediatric TB is the prompt evaluation and treatment of children exposed to an infectious adult source case. Missed opportunities to prevent cases of pediatric TB include:
  • Delayed diagnosis of infectious TB
  • Delayed reporting of a source
  • Failure to identify an exposed child during the contact investigation
  • Failure to achieve adherence of the source case
  • Failure to document sterilization of cultures
  • Failure to start preventive therapy or LTBI treatment in the child.
  • Failure to ensure that the child takes treatment
• With each pediatric active TB case, the case management team should determine which of these factors may have played a role in the child becoming infected with TB and take corrective action to prevent future cases
• All exposed children should have a symptom inquiry and TST
• Children less than 5 years of age, all close childhood contacts and all symptomatic children should also have a physical examination and chest radiography.
• Children less than 5 years of age with a new negative TST and no evidence of active TB by examination or radiologist should be given 'window' of preventive therapy to prevent the development of TB. This is because it may take up to 8 weeks after infection for the TST to convert to positive, during which time the infection may progress to active disease
• For children presumed to have been exposed to a drug-susceptible isolate, INH is recommended. The INH may be discontinued if, after a period of eight weeks after the last contact, the repeat TST is negative, and the child remains asymptomatic and is immunocompetent and more than 6 months of age
• In the exposed child, if the TST is positive and there is no clinical or radiographic evidence of disease, then a full course of treatment for LTBI is recommended
• When a child with new, active TB is the index case, reverse contact tracing must be undertaken

Tuberculin skin test and interferon gamma release assay in children

For additional information on the TST and IGRA see.

Monitoring for adverse events to antituberculosis therapy

PreventionFootnote 147

• Bacille Calmette-Guérin (BCG) is the only vaccine currently used for the prevention of miliary TB and TB meningitis, for which infants and young children are at increased risk
• Currently, the National Advisory Committee on Immunization (NACI) does not recommend BCG vaccination for all Canadians; however, it does for infants in First Nations and Inuit communities or groups of persons with an average annual rate of smear-positive pulmonary TB greater than 15 per 100,000 (all ages) population during the previous 3 years OR with an annual risk of TB infection > 0.1% if early identification and treatment of TB infection is not available

Provincial/territorial guidelines

Other Resources

Alvarez GG, Orr P, Wobeser WL, Cook V, Long R. Chapter 14: Tuberculosis Prevention and Care in First Nations, Inuit and Metis Peoples. In: Canadian Tuberculosis Standards. 7th ed. [Internet] Her Majesty the Queen in Right of Canada; 2014.

Rifampin 25mg/mL oral suspension. [Internet] Toronto, ON: SickKids Pharmacy; 2007 August (PDF Version, ## Kb, ## pages).

Pyrazinamide 100mg/mL oral suspension. [Internet] SickKids Pharmacy. Toronto, ON: SickKids Pharmacy; 2007 April (PDF Version, 54 Kb, 1 pages).

Bacteria

• Group B Streptococcus, Escherichia coli (E. coli) and other gram-negative bacilliFootnote 151
• Listeria monocytogenesFootnote 151
• Streptococcus pneumoniae (S. pneumoniae)Footnote 151
• Neisseria meningitides (N. meningitides causing meningococcal meningitis)Footnote 151
• Haemophilus influenza type BFootnote 151
• Mycobacterium tuberculosisFootnote 152

VirusesFootnote 151

• Non-polio enteroviruses (coxsackievirus A, coxsackievirus B, echoviruses)Footnote 151
• Mumps virus
• Herpes virus
• Measles virus
• Influenza virus
• Arboviruses, e.g. West Nile virus
• Lymphocytic choriomeningitis virus

Note: Human herpes simplex virus (HSV) infection in neonates can result in devastating outcomes, including significant morbidity and potential mortality.Footnote 153 Disseminated HSV infection can mimic bacterial sepsis, and clinicians need to consider possible neonatal HSV infection in unwell infants less than 6 weeks of age.

FungiFootnote 151

• Candida
• Cryptococcus
• Histoplasma
• Blastomyces
• Coccidioides

Bacterial

• Age; infants are at increased risk for bacterial meningitis compared to people in other age groupsFootnote 161
• Community settingFootnote 161
• Certain medical conditionsFootnote 161
• Cochlear implantsFootnote 162
• Penetrating head traumaFootnote 162
• Working with meningitis-causing pathogensFootnote 161
• Travel to areas where meningitis is commonFootnote 161
• Incomplete vaccinationsFootnote 163

Viral

• Neonates are at increased risk for severe systemic disease, particularly those with herpes simplex virus (HSV)Footnote 149
• Children younger than 5 years oldFootnote 148
• Individuals with weakened immune systems caused by disease, medications (such as chemotherapy) and recent organ or bone marrow transplantations are at greater risk for severe illnessFootnote 148

Infants

Infants often present with non-specific signs and symptoms:

• Fever
• Poor feeding
• Lethargy
• Vomiting
• Rash
• IrritabilityFootnote 149Footnote 162Footnote 163
• SeizuresFootnote 149Footnote 162

Older children

Older children are more likely to have more specific signs and symptoms related to meningitis:

• FeverFootnote 149Footnote 162
• HeadacheFootnote 149Footnote 163
• PhotophobiaFootnote 149Footnote 163
• NauseaFootnote 149Footnote 163
• VomitingFootnote 149Footnote 163
• ConfusionFootnote 162
• LethargyFootnote 162
• IrritabilityFootnote 162
• Neck stiffnessFootnote 149Footnote 163
• Impaired consciousnessFootnote 149Footnote 163
• SeizuresFootnote 149

Social

Known contact with someone with meningitisFootnote 150

Laboratory

Testing should be carried out as per provincial/territorial policies and procedures. The tests below are for consideration.

X-ray

Chest X-ray as clinically indicatedFootnote 163

Interventions

• Nothing by mouth (NPO), depending on child's level of consciousness
• Reassess neurological status frequently and document Glasgow Coma Scale (GCS)
• Assess fontanelles
• Maintain accurate intake and output
• Administer oxygen as required

Client educationFootnote 166

Provide the following to the child and parent(s)/caregiver(s):

• Emotional support; the sudden nature of the illness makes this extremely important
• Reassurance that the natural onset of meningitis is sudden

Additional information to provide parent(s)/caregiver(s).

Fluid management in meningitis

• Establish peripheral intravenous (IV) access
• If unable to establish a peripheral IV, an intraosseous (IO) needle should be usedFootnote 150 as per provincial/territorial policies/procedures
• Careful management of fluid and electrolyte balance is important in the treatment of meningitisFootnote 167
• For children who are not in shock or not hypovolemic, fluids should be restricted in consultation with a physician/nurse practitionerFootnote 167

Note: Development of generalized edema is a major risk factor for serious adverse outcomes in meningitis.

Antibiotic therapy

• Start antibiotic immediately if bacterial meningitis is suspected. Timely empirical antibiotic therapy is critical to treatment success because the prognosis of meningitis depends on treating infection before severe disease ensuesFootnote 163
• While the client waits to be medically evacuated, as per guidance from the accepting facility or physician/nurse practitioner, empirical antibiotics may need to be initiated
• Empirical treatments may be comprised of 2 to 3 antibiotics :
  • cefTRIAXone IV (avoid in clients who are 3 months of age or younger to avoid risk of hyperbilirubinemia) or cefoTAXime IV combined with vancomycin IV
  • Ampicillin IV may be added to cover Listeria for the immunocompromised client at riskFootnote 163

Anti-inflammatory therapy

Dexamethasone is indicated if there are no contraindications to steroid use when bacterial meningitis is suspected.

Analgesic/antipyretic

Note: Since neonates and infants (less than 3 months of age) are less able to mount a febrile response, when they do become febrile, it is more likely to indicate a major illness. Consult physician/nurse practitioner particularly for children less than 3 months of age.

Referral

• Arrange for urgent medical evacuation

Reporting

Meningitis is reportable. Follow provincial/territorial policies and procedures for notifiable diseases. For more information, see Communicable Diseases Provincial/Territorial Resources for Meningitis in Appendix K, Section B of this guideline.

Prevention and control

Vaccines are the cornerstone of prevention and control of bacterial meningitis.Footnote 171 For more information, see the latest Canadian Immunization Guide.

Chemoprophylaxis for household contacts

Provincial/territorial guidelines