Pediatric and Adolescent Care - Chapter 18 - Communicable Diseases

First Nations and Inuit Health Branch (FNIHB) Clinical Practice Guidelines for Nurses in Primary Care.

The content of this chapter was revised in February 2017.

PDF Version (1.23 MB, 103 pages)

Table of contents

Introduction

Assessment of communicable diseases

History of present illness and review of systems

When a communicable disease is suspected, a thorough history is essential. Because microorganisms can affect every system, a thorough review of every body system is indicated. Some of the more common symptoms are detailed below.

The following points should be emphasized:

  • Onset (date and time) and duration of illness
  • Fever, chills or rigors
  • Pain
  • Rash: site, colour, consistency
  • Involvement of mucous membranes or conjunctivae
  • Coryza (head cold)
  • Cough
  • Sore throat
  • Drooling
  • Vomiting
  • Diarrhea
  • Level of consciousness
  • Irritability
  • Seizures
  • Contact with a person with similar symptoms or known communicable disease
  • Travel history (specifically, recent travel to an area where a communicable disease is endemic)
  • Dietary history: raw fish; raw, undercooked or improperly preserved meat
  • Immunization history

Physical examination

Many communicable diseases affect more than one body system, so a thorough head to toe examination is indicated. The most common signs are detailed below.

Vital signs
  • Temperature
  • Heart rate
  • Respiratory rate
  • Oxygen saturation
  • Blood pressure
Inspection
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

Communicable exanthems (rash)

A communicable exanthema is a rash that "bursts forth or blooms" in association with some infections. It is characteristically widespread, symmetrically distributed on the child's body and consists of red, discrete or confluent flat spots (macules) and bumps (papules) that (at least at first) are not scaly.

Diseases that begin with an exanthem or rash may be caused by bacteria, viruses or reactions to drugs.

Some exanthems are accompanied by oral lesions, the most well known of which are the Koplik spots of measles and the oral lesions found in hand-foot-and-mouth disease.

Many viral infections of childhood are characterized by a rash occurring toward the end of the disease course. Often, the rash starts on the head and progresses down the body and out onto the extremities. About the time the rash appears, the fever associated with the infection usually disappears and the child starts to feel a lot better. Several viral illnesses are associated with rashes that are reliable for diagnosis (e.g., measles, rubella, erythema infectiosum, roseola infantum, and chickenpox), but the rashes of most viral illnesses are too variable to allow accurate diagnosis. That is why health care professionals often tell the client, "It's a virus." A thorough history and physical exam are very important to rule out more serious causes of the rash.

Chickenpox (Varicella)

Overview

Please refer to provincial/territorial guidelines for Chickenpox (Varicella) where available.

Chickenpox (Varicella) is a primary infection caused by varicella-zoster virus (VZV) and is considered to be self-limiting in otherwise healthy children.Footnote 1 Varicella varies in severity; it may be very mild with just a few spots, or severe and accompanied by fever and a widespread rash.Footnote 2 In general, risk of severe varicella infection increases with age.Footnote 1 Varicella-zoster is a vaccine preventable disease.Footnote 2

Causes

Varicella-zoster virus (VZV)Footnote 2

Transmission

  • Person-to-person: by airborne spread from respiratory tract or direct contact with fluid in the skin lesionsFootnote 2

Incubation period

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

Communicability

Very contagious; infectiousness begins 1 to 2 days before onset of rash and remains until last lesion has crustedFootnote 2

Assessment

Medication review: Review current medications, including over-the-counter, complementary and alternative medicines, as well as any chemical or substance intake that may impact management.

Allergy history: Screen for medication, latex, environmental or other allergies and determine approximately when and what type of reaction occurred.

Risk factors

Varicella-susceptible individuals are at risk for contracting varicella-zoster when exposed to an individual who:

  • Is contagious with the varicella-zoster virus
  • Has herpes zoster (shingles), which is a member of the herpesvirus family; results from reactivation of latent VZVFootnote 4

The following susceptible groups are at greater risk for complications or severe varicella disease:Footnote 1

  • Adolescents and adults
  • Immunocompromised individuals
  • Pregnant women
  • Fetuses exposed to maternal varicella disease in first 20 weeks of pregnancy are at risk for congenital varicella syndrome by transplacental infection
  • Neonates are at greater risk if the mother's varicella-zoster rash appears between 5 days before and 2 days after birthFootnote 5Footnote 6

For more information on the risks associated with varicella disease, see Table 1: Varicella Post-exposure Management for Susceptible* Individuals in Appendix A, Section A of this guideline.

History of present illness

  • Review risk factors and collect history of present illness
  • Obtain a history of exposure and immunization history (i.e., completion of 2-dose varicella-zoster vaccine immunization regimen)
  • Low-grade fever, followed by mild symptoms (e.g., headache, runny nose, general feeling of malaise)Footnote 2
  • A rash that is usually first noted on the scalp, then on extremities and trunkFootnote 4
  • A rapidly progressing, generalized and pruritic rashFootnote 4

Physical findings

Perform a physical examination using the IPPA approach

  • Low-grade fever, rhinorrheaFootnote 2
  • Vesicular rash/skin lesions that:
    • Are in various stages of developmentFootnote 4
    • Progress rapidly from macules to papules to vesicular lesions before crustingFootnote 4
    • May rupture or become purulent before they dry and crustFootnote 4
    • Appear in successive crops over several daysFootnote 4
  • Lesions:
    • Where the highest concentration is on the trunkFootnote 4
    • That appear on the mucous membranes of oropharynx, respiratory tract, vagina, conjunctiva, and corneaFootnote 4
    • That are 1 to 4 millimeters in diameterFootnote 4

Differential diagnosis

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

  • Disseminated herpes simplex virus infectionFootnote 7
  • EnterovirusFootnote 7
  • PsoriasisFootnote 7
  • Stevens-Johnson syndrome (associated with history of medication use - most commonly anticonvulsants, antibiotics, and nonsteroidal anti-inflammatory drugs)Footnote 7
  • Syphilis in neonates (can present with a blistering rash at birth)Footnote 7

Complications

Complications are more common in adolescents, adults and immunocompromised people.Footnote 1

Secondary bacterial skin and soft tissue infections

  • Severe invasive group A streptococcal infection (GAS) (varicella increases the risk of invasive GAS infection in previously healthy children by 40-60 fold. GAS includes necrotizing fasciitis and toxic shock syndrome.)
  • Bacteremia
  • Pneumonia
  • Osteomyelitis
  • Septic arthritis
  • Cerebellar ataxia
  • Stroke
  • Encephalitis

Diagnostic tests

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Diagnostic test selection is based on client history, risk factors, physical examination findings and test availability.

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.

Management

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Goals of treatment

  • Provide supportive care
  • Relieve symptoms
  • Prevent disease transmission
  • Prevent complications

Non-pharmacological interventions

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.

Prevention during pregnancy

Pregnant clients who have not had chickenpox or who are known to be seronegative for chickenpox should be advised to:

  • Avoid contact with anyone with chickenpox and shingles during pregnancy
  • Inform healthcare workers of a potential exposure without delayFootnote 12

For more information on preventing infection, see Prevention in Appendix A, Section A of this guideline.

Pharmacological interventions

In addition to consulting a physician/nurse practitioner, review the drug monograph, the FNIHB Nursing Station Formulary or provincial/territorial formulary before initiating treatment.

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.

AcetaminophenFootnote 15Footnote 16
  • Acetaminophen 10 to 15 mg/kg/dose PO q4-6h PRN
  • Maximum from all sources: acetaminophen 75 mg/kg in 24 hours or 4,000 mg in 24 hours, whichever is less
IbuprofenFootnote 24
  • Infants <6 months
    • Limited data available in infants
  • For 6 months to 12 years of age
    • Ibuprofen 5 to 10 mg/kg/dose PO q6-8h PRN
    • Maximum 400 mg/dose*
  • For greater than 12 years of age
    • Ibuprofen 200 to 400 mg PO q4-6h PRN*
  • *Maximum from all sources for all ages:
    • Ibuprofen 40 mg/kg in24 hours or 1200 mg in 24 hours, whichever is less. Under physician/nurse practitioner supervision, daily doses ≤2,400 mg may be used
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.

diphenhydrAMINE

Weight-directed dosing

  • diphenhydrAMINE (Benadryl®) 5 mg/kg/day divided into 3-4 doses
  • Maximum daily dose: 300 mg/day

Dosage by age

  • 2 years to less than 6 years of age
    • diphenhydrAMINE (Benadryl®) 6.25 mg PO q4-6h PRN
    • Maximum: 37.5 mg in 24 hours
  • 6 years to less than 12 years of age
    • diphenhydrAMINE (Benadryl®) 12.5 to 25 mg PO q4-6h PRN
    • Maximum 150 mg in 24 hours
  • 12 years of age or greater
    • diphenhydrAMINE (Benadryl®) 25 to 50 mg PO q4-6h PRN
    • Maximum 300 mg in 24 hours
Cetirizine
  • 2 years to 5 years of age
    • Cetirizine 2.5 mg PO once daily PRN
    • Maximum dose of 2.5 mg BID or 5 mg once daily
  • 6 years of age or greater
    • Cetirizine 5 to 10 mg PO once daily PRN
    • Maximum 10 mg in 24 hours
Antiviral
Healthy, immunocompetent children with varicella under the age of 12
Immunocompromised clients with severe varicella
  • An immunocompromised client with severe varicella requires IV acyclovir and medical evacuationFootnote 20Footnote 21
When to start acyclovirFootnote 26
  • Acyclovir should be started within 24 hours after the rash develops, if possible. In addition, in immunocompetent hosts, viral replication typically stops by 72 hours after the onset of rash
  • Consult physician/nurse practitioner for further guidance
Post-exposure management
Varicella vaccineFootnote 1
  • Univalent varicella vaccine - given as soon as possible and within 3 and up to 5 days after exposure - has been shown to be approximately 90% effective in preventing or reducing the severity of varicella. It is the post-exposure management of choice for susceptible, healthy, non-pregnant individuals
Healthy infants less than 12 months of age
  • Varicella vaccination is not indicated for post-exposure management of healthy infants less than 12 months of age as they are generally protected by maternal antibodies
Individuals under 50 years of age
  • If they have received only 1 dose of varicella-containing vaccine, they should be offered a second doseFootnote 1
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

Monitoring and follow-up

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Monitoring

  • Monitor vital signs as indicated by client's condition
  • If administering an agent with risk of anaphylaxis, monitor the client closely for 30 minutes

Follow-up

  • Arrange follow-up appointment for client to be assessed in 1 week
  • Advise the parent(s)/caregiver(s) to bring client back to the clinic for further assessment if there is no improvement in signs and symptoms of presenting condition or if any complications arise
  • If a close contact's immunization status is incomplete, vaccination against varicella should be arranged
  • Monitor for other cases of varicella in the community
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

Appendix A

Section A: Supplemental clinical management information

Susceptibility and immunityFootnote 1
Individuals born before 2004
  • In individuals born before 2004 (with the exception of health care workers), a self-reported history of varicella is considered a reliable history of varicella disease
Children born in 2004 or later (or health care workers)
  • A health care provider diagnosis of varicella or herpes zoster is necessary to be considered a reliable history of varicella diseaseFootnote 1
Individuals considered immune to varicella will have one or more of the following:
  • Born before 2004 (except for health care workers) A self-reported history of varicella
  • Born in 2004 or later (or health care workers) A health care provider diagnosis of varicella or herpes zoster is required
  • Documented evidence of immunization with 2 doses of a varicella-containing vaccine
  • A history of laboratory confirmed varicella infection
  • Laboratory evidence of immunity
Individuals who do not have any of the above are considered susceptible to varicella.

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

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.

Table 1 - Varicella post-exposure management for susceptible* individualsFootnote 1
Post-exposure Intervention Healthy, Non-pregnant Individual** Pregnant Individual Immunocompromised Individual****
Vaccinate with varicella vaccine Yes No No
Collect sample for VZV IgG No Yes Yes
If VZV IgG is negative, administer varicella-zoster immune globulin*** Not applicable Yes Yes

* Refer to Susceptibility and Immunity

** Refer to VarIg or information regarding newborns of mothers who develop varicella during the 5 days before to 48 hours after delivery.

*** If serology results cannot be obtained within 96 hours, administer varicella-zoster immune globulin

**** In case of hematopoietic stem cell transplant (HSCT), administer VarIg regardless of VZV IgG result

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:

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

Diphtheria

Overview

Please refer to provincial/territorial guidelines for Diphtheria where available.

Diphtheria is an acute, toxin-mediated infectious disease that affects mucous membranes (primarily those of the upper respiratory tract) and the skin. The most common sites of diphtheria infection are the pharynx and the tonsils.Footnote 27

Diphtheria is a vaccine-preventable disease. Due to routine immunization programs, diphtheria is rare in developed countries, although cases that are observed tend to be more serious. Because unfamiliarity with the disease can lead to delays in diagnosis and treatment,Footnote 28 such cases may be fatal.

Consult with physician/nurse practitioner immediately when there is suspicion of diphtheria as it may require urgent medical evacuation.

Causes

Corynebacterium diphtheriae (C. diphtheriae) bacteriaFootnote 29

Transmission

  • Occurs primarily through the spread of respiratory droplets from infected cases or carriersFootnote 29
  • Contact with articles contaminated by secretions of infected peopleFootnote 29

Incubation period

1 to 10 daysFootnote 29

Communicability

  • The infectious period in untreated individuals is usually 2 weeks or less and rarely more than 4 weeksFootnote 29
  • Bacterial shedding usually stops within 48 hours of antibioticsFootnote 29
  • Bacterial shedding from cutaneous infections continues longer than from the respiratory tractFootnote 31

Assessment

Medication review: Review current medications, including over-the-counter, complementary and alternative medicines, as well as any chemical or substance intake that may impact management.

Allergy history: Screen for medication, latex, environmental or other allergies and determine approximately when and what type of reaction occurred.

Risk factors

  • Children and adults who do not have up-to-date immunizations and who are exposed to people with diphtheria
  • Social risk factors
  • Poor skin care and hygiene
  • Unimmunized clients living in crowded, unsanitary, or impoverished conditions and who are exposed to people with diphtheria
  • Cutaneous diphtheria is often associated with overcrowding, impoverished groups and homeless personsFootnote 31

History of present illness

Review risk factors and collect history of present illness.

  • Review immunization history
  • Diphtheria infection can involve almost any mucous membrane. For clinical purposes, diphtheria may be classified according to the anatomic site of diseaseFootnote 27
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

Physical findings

Perform a physical examination using the IPPA approach.

  • Fever (usually low grade)Footnote 27
  • Client appears quite toxic/acutely illFootnote 27
  • Mucopurulent nasal discharge which may become blood-tingedFootnote 27
  • Adherent nasal and/or pharyngeal membrane. Membrane can be white, bluish-white, greyish-green or black if bleeding has occurredFootnote 27
  • The pseudomembrane is firmly adherent to the tissueFootnote 27
  • Minimal amount of mucosal erythema surrounding the membraneFootnote 27
  • Extensive pseudomembrane formation may result in respiratory obstructionFootnote 27
  • The client with severe disease may develop marked edema of the submandibular areas and the anterior neck, along with lymphadenopathy, giving a characteristic "bull neck" appearanceFootnote 27
  • Cough, hoarsenessFootnote 27
  • StridorFootnote 34
  • Respiratory distressFootnote 29
  • Cutaneous diphtheria is characterized by a scaling rash or non-healing ulcers with clearly demarcated edges and membraneFootnote 27
  • Cutaneous lesions may resemble impetigoFootnote 29
  • Late effects of absorbed toxin, appearing after 2 to 6 weeks, include myocarditis and neuropathyFootnote 30

Differential diagnosis

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

  • Bacterial and viral pharyngitisFootnote 34
  • EpiglottitisFootnote 34
  • Vincent's angina (a unique and dramatic form of gingivitis characterized by painful, inflamed gingiva with ulcerations of the interdental papillae that bleed easily)Footnote 35
  • Infectious mononucleosisFootnote 34
  • Oral syphilisFootnote 30
  • Oropharyngeal candidiasisFootnote 34

Complications

  • Myocarditis (may present as abnormal cardiac rhythms and can occur early in the course of the illness or weeks later, and can lead to heart failure. If myocarditis occurs early, it is often fatal)Footnote 27
  • Neuritis (most often affects motor nerves and usually resolves completely)
  • Paralysis of the soft palate (most frequent during the third week of illness)
  • Paralysis of the muscles, limbs and diaphragm (can occur after the 5th week)Footnote 27
  • Secondary pneumonia and respiratory failure may result from diaphragmatic paralysisFootnote 27
  • Otitis media and respiratory insufficiency due to airway obstruction, especially in infantsFootnote 27
  • ComaFootnote 27
  • DeathFootnote 27

Diagnostic tests

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Diagnostic test selection is based on client history, risk factors, physical examination findings and test availability.

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
Sample collection
  • For pharyngeal samples, ensure that any discoloured areas, ulcerations and tonsillar crypts are swabbedFootnote 27
  • For cutaneous samples:
    • Material should be taken from the affected area of the skin, either by aspirate or swab
    • Membranous material may also be cultured
    • Remove any crusted material and swab the base of the lesion(s)
  • Diphtheria is primarily a respiratory infection; however specimens should be collected from suspect skin lesion(s) during the acute phase of illnessFootnote 33

Management

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Goals of treatment

  • Prevent complications
  • Prevent disease transmission to others

Non-pharmacological interventions

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

Pharmacological interventions

In addition to consulting a physician/ nurse practitioner, review the drug monograph, the FNIHB Nursing Station Formulary or provincial/territorial formulary before initiating treatment.

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.

Monitoring and follow-up

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Monitoring

  • Monitor vital signs as clinically indicated
  • Monitor respiratory status
  • Monitor neurological status
  • Monitor intake and output
  • If administering an agent with risk of anaphylaxis, monitor the client closely for 30 minutes

Follow-up

Referral

Arrange for medical evacuation if clinically indicated.

Reporting

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

Appendix B

Section A: Supplemental clinical management information

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:
Benzathine penicillin G
  • Children <6 years of age
    • Benzathine penicillin G 600,000 units intramuscularly (IM)
  • Children >6 years of age
    • Benzathine penicillin G 1.2 million units IM

Benzathine penicillin G may be obtained through the Non-Insured Health Benefits Program, if not available through provincial/territorial formulary. It is not listed in the FNIHB Nursing Station Formulary.

or

Erythromycin
  • Erythromycin 500 mg 4 times daily for 7 to 10 days

Note: For adherence reasons, if surveillance of contacts cannot be maintained, they should receive benzathine penicillin G.

Diphtheria antitoxin
  • Diphtheria antitoxin is not recommended for post-exposure prophylaxis in asymptomatic contacts.
  • Contacts should be closely monitored and antitoxin given at the first sign(s) of illness.
  • All identified contacts should be alerted to signs and symptoms of diphtheria and advised to seek medical attention immediately should they develop any clinical manifestations of diphtheria.Footnote 33
Home isolation

Home isolation for the following contacts is indicated until treatment is complete and cultures from the nose and throat or lesions are negative.Footnote 33

  • Contacts who attend school
  • Contacts whose occupations involve:
  • Food handling
  • Close contact with children under 7 years of age
  • Known unimmunized persons
  • Care of the sick
Carriers

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

Section B: Supplemental resources

Provincial/territorial guidelines
Alberta

Alberta Health and Wellness Public Health Notifiable Disease Management Guidelines: Diphtheria.

British Columbia

BC Centre for Disease Control Diseases & Conditions: Diphtheria.

Manitoba

Public Health and Primary Health Care. Communicable Disease Management Protocols: Diphtheria.

Newfoundland and Labrador

Department of Health and Community Services. Newfoundland and Labrador Disease Control Manual: Disease Control Manual: Section 4, Diseases Preventable by Routine Vaccination – Diphtheria (PDF Version, 190 Kb, 78 pages).

Northwest Territories

Northwest Territories Health and Social Services. Communicable Disease Manual: Diphtheria. Available by selecting HSS Professionals (staff only) and entering authorized username and password.

Nova Scotia

Health and Wellness. Communicable Disease Manual: Diphtheria.

Ontario

Ontario Ministry of Health and Long-Term Care. Diseases and Conditions: Diphtheria.

Erythema infectiosum (Fifth disease)

Overview

Please refer to provincial/territorial guidelines for Erythema Infectiosum (Fifth Disease) where available.

Erythema Infectiosum (Fifth Disease) is a primarily benign childhood illness characterized by erythema of the cheeks (slapped-cheek appearance). It is highly contagious.Footnote 37

Causes

Human parvovirus B19Footnote 37

Transmission

Incubation period

4 to 21 daysFootnote 37

Communicability

Most communicable before the onset of the rashFootnote 37

Assessment

Medication review: Review current medications, including over-the-counter, complementary and alternative medicines, as well as any chemical or substance intake that may impact management.

Allergy history: Screen for medication, latex, environmental or other allergies and determine approximately when and what type of reaction occurred.

Risk Factors

History of present illness

Review risk factors and collect history of present illness.

  • Obtain a history of exposure and a complete medical history to determine if client or other household members :
  • Immunocompromised individuals may have an atypical rash, or may not have manifestations of rash.Footnote 37
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:

Physical findings

Perform a physical examination using the IPPA approach.

  • ExanthemFootnote 37
  • Intensely red 'slapped cheek' appearance
  • Presents in the initial stage of the rash (often has a circumoral pallor)
  • Is often followed by symmetric, macular, and lace-like trunk lesions which may spread to involve arms, buttocks, and thighs
  • May last weeks or months
  • May fluctuate in intensity and recur with environmental changes (e.g., exposure to sunlight, change in temperature)
  • ArthritisFootnote 40
  • Most frequently involves the small joints of the hands, wrists, knees and feet
  • Less common in children than adults
  • Usually acute and symmetrical

Differential diagnosis

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Complications

  • Transient aplastic crisis (severe anemia) in children with hematologic abnormalities or immunocompromiseFootnote 40Footnote 42
Complication of parvovirus B19 Infection in pregnancyFootnote 38Footnote 40
  • Miscarriage
  • Spontaneous fetal loss
  • Fetal hydrops

Diagnostic tests

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Diagnostic test selection is based on client history, risk factors, physical examination findings and test availability.

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

Management

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Goals of treatment

  • Provide supportive care
  • Prevent transmission, especially to those who are pregnant, immunocompromised or have an anemia disorderFootnote 38Footnote 39
  • Prevent complications

Non-pharmacological interventions

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:

Pharmacological interventions

In addition to consulting a physician/nurse practitioner, review the drug monograph, the FNIHB Nursing Station Formulary or provincial/territorial formulary before initiating treatment.

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.

AcetaminophenFootnote 46Footnote 47
  • Acetaminophen 10 to 15 mg/kg/dose PO q4-6h PRN
  • Maximum from all sources: acetaminophen 75 mg/kg in 24 hours or 4,000 mg in 24 hours, whichever is less
IbuprofenFootnote 48
  • Infants <6 months
    • Limited data available in infants
  • For 6 months to 12 years of age
    • Ibuprofen 5 to 10 mg/kg/dose PO q6-8h PRN
    • Maximum 400 mg/dose*
  • For greater than 12 years of age
    • Ibuprofen 200 to 400 mg PO q4-6h PRN*
  • *Maximum from all sources for all ages:
    • Ibuprofen 40 mg/kg in24 hours or 1200 mg in 24 hours, whichever is less. Under physician/nurse practitioner supervision, daily doses ≤2,400 mg may be used

Monitoring and follow-up

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Monitoring

  • Monitor vital signs as indicated by client's condition
  • If administering an agent with risk of anaphylaxis, monitor the client closely for 30 minutes

Follow-up

Follow-up should occur if complications develop or symptoms do not resolve in expected period of time (usually up to 20 days).

Referral

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

Appendix C

Section A: Supplemental clinical management information

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).

Measles (Rubeola)

Overview

Please refer to provincial/territorial guidelines for Measles (Rubeola) where available.

Measles is one of the most highly-communicable and vaccine-preventable infectious diseases. Among susceptible individuals, measles has a greater than 90% secondary attack rate.Footnote 49

Consult with physician/nurse practitioner immediately when there is suspicion of Measles (Rubeola) as it is a public health emergency.

Causes

Measles virusFootnote 49

Transmission

  • Transmitted primarily through the respiratory droplet route (through contact with nasal or throat secretions from infected individuals)
  • Airborne transmission can also occur in closed settings
  • The measles virus can survive at least 2 hours in evaporated droplets and in fine particle airborne spreadFootnote 49

Incubation period

The incubation period of measles, from exposure to prodrome, averages 10 to 12 days. The time from exposure to rash onset averages 7-21 days.Footnote 50

Communicability

  • Measles may be transmitted during the prodrome, and from approximately 4 days before and up to 4 days after appearance of the rashFootnote 51
  • Immunocompromised persons with prolonged excretion of the virus in respiratory secretions can be contagious for the duration of their illnessFootnote 52

Assessment

Medication review: Review current medications, over-the-counter, complementary and alternative medicines, as well as any chemical or substance intake that may impact management.

Allergy history: Screen for medication, latex, environmental or other allergies and determine approximately when and what type of reaction occurred.

Risk factors

  • Individuals who have not had measles or who have not been adequately immunized are at risk of infection
  • Individuals born in or after 1970 are considered susceptible unless there is serological proof of immunity or documented history of 2 doses of measles-containing vaccineFootnote 52
  • Individuals at greatest risk of measles exposure include travellers to destinations outside the Americas, health care workers, and studentsFootnote 49
  • Groups at high-risk for measles complications include immunocompromised individuals, pregnant women and infantsFootnote 52

Note: In Canada, adults born before 1970 are generally presumed to have acquired natural immunity to measles. This is due to high levels of measles circulation before that time.

History of present illness

Review risk factors and collect history of present illness:

  • Prodromal feverFootnote 49
  • Fever (often rises as the rash appears)Footnote 52
  • Classic triad of cough, coryza and conjunctivitisFootnote 49
  • Rash, which generally appears 14 days after exposure or 2-4 days after prodrome and lasts 5-6 days
  • Anorexia and diarrhea, especially in infantsFootnote 50
  • Determine immunization history, including the number of doses, the date administered and the type of vaccineFootnote 52
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

Differential diagnosis

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

  • Common viral respiratory viruses of childhood
  • Rubella (German measles)
  • Roseola infantum
  • Coxsackievirus infection
  • Infectious mononucleosis
  • Scarlet fever
  • Kawasaki disease
  • Erythema infectiosum (for more information, see
  • Adverse drug reactionFootnote 51

Complications

  • Otitis media
  • Pneumonia
  • Measles encephalitis and permanent brain damage
  • Subacute sclerosing panencephalitis (extremely rare)Footnote 49
  • DeathFootnote 49Footnote 50
  • Measles infection during pregnancy results in a higher risk of premature labour, spontaneous abortion and low birth weightFootnote 49

Diagnostic tests

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Diagnostic test selection is based on client history, risk factors, physical examination findings and test availability.

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.

Recommended samples

Acute and convalescent Serum Immunoglobulin G (IgG) and Serum Immunogobulin M (IgM):

  • Collect IgG at time of presentation and no later than 7 days from rash onset. Collect the convalescent sample 10-30 days after the initial sample. Note: The paired sera are tested simultaneously to determine if seroconversion has occurred
  • Collect serum IgM at time of presentation. Note: Samples collected before 3 and after 28 days from the onset of symptoms may yield false negative results.
  • Collect nasopharyngeal swab for measles virus culture as soon as possible and no later than 4 days from the onset of rash.
  • Collect nasopharyngeal swab for measles ribonucleic acid (RNA) by RT-PCR within 7 days of rash onset, as specimens collected within this timeframe yield the best results.
  • Collect urine for measles virus culture within 7 days of rash onset to achieve maximum sensitivity.Footnote 52

For interpretation of lab investigations, see Table 2: Measles testing results in Appendix D, Section A of this guideline.

Management

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Goals of treatment

  • Provide supportive care
  • Prevent disease transmission
  • Prevent complications

Non-pharmacological interventions

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

Pharmacological interventions

In addition to consulting a physician/ nurse practitioner, review the drug monograph, the FNIHB Nursing Station Formulary or provincial/territorial formulary before initiating treatment.

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.

AcetaminophenFootnote 54
  • Acetaminophen 10 to 15 mg/kg/dose PO q4-6h PRN
  • Maximum from all sources: acetaminophen 75 mg/kg/day or 4,000 mg/day, whichever is less
Ibuprofen Footnote 55
  • Infants <6 months
    • Limited data available in infants
  • For 6 months to 12 years of age
    • Ibuprofen 5 to 10 mg/kg/dose PO q6-8h PRN
    • Maximum 400 mg/dose*
  • For greater than 12 years of age
    • Ibuprofen 200 to 400 mg PO q4-6h PRN*
  • Maximum from all sources for all ages:
    • Ibuprofen 40 mg/kg in24 hours or 1200 mg in 24 hours, whichever is less. Under physician/nurse practitioner supervision, daily doses ≤2,400 mg may be used

Monitoring and follow-up

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation and if unsure of the diagnosis.

Monitoring

If administering an agent with risk of anaphylaxis, monitor the client closely for 30 minutes.

Follow-up

Advise parent(s)/caregiver(s) to bring the child back to the clinic if there are signs of complications.

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

Appendix D

Section A: Supplemental clinical management information

Prevention and controlFootnote 52
Vaccination
  • Vaccination of susceptible individuals represents an important risk mitigation strategy
  • High vaccine coverage is needed to sustain measles elimination
  • In Canada, a 2-dose immunization schedule for measles is recommended for the routine immunization of children
  • Susceptible, immunocompetent individuals 12 months of age and older who are exposed to measles may be protected from measles disease if the Measles, Mumps, Rubella (MMR) vaccine is administered within 72 hours of exposure
  • The MMR vaccine may be recommended for children between 6-12 months of age for post-exposure management if given within 72 hours of exposure; however, 2 additional doses of measles-containing vaccine must be administered after the child is 12 months old (and at least 28 days from the previous dose) to ensure long-lasting immunity from measles
  • Women immunized against measles are advised not to become pregnant for at least 4 weeks after receiving the vaccine

For more information, see the latest Canadian Immunization Guide.

Immunoglobulin (Ig)Footnote 52
  • Prophylactic use of Ig has been shown to be effective in modifying or preventing disease
  • Susceptible, exposed individuals who present more than 3 days (72 hours) after exposure (when MMR vaccine no longer provides post-exposure protection) but less than 6 days after exposure (when Ig may still provide post-exposure protection) can also be considered for Ig
  • Ig should be considered for susceptible contacts of measles, particularly immunocompromised individuals and pregnant women for whom measles-containing vaccine is contraindicated, as well as infants less than 6 months of age. Infants less than 6 months of age are usually considered immune due to antibodies transferred in utero from the mother; if, however, the mother contracts measles or is known to be non-immune, the infant should receive Ig
  • Consult with the Public Health Physician as per provincial/territorial policies and procedures to determine if initiation of Ig is required for the client, and make necessary arrangements for the client to receive Ig treatment
Public health managementFootnote 52
Case management
  • Investigate all confirmed, probable, and suspected cases of measles as soon as possible according to provincial and territorial policies and procedures. Public health authorities should be notified of measles in accordance with provincial/territorial legislation for reporting communicable diseases
  • Exclude confirmed, probable, and suspected cases from daycare, school and employment, and keep cases away from non-household contacts, especially unimmunized children and pregnant women, for 4 days after the appearance of the rashFootnote 52
Contact management
  • A contact is defined as any individual who has:
    • Spent any length of time in a room or enclosed space with a confirmed measles case during that case's infectious period (i.e., approximately 4 days before rash onset to 4 days after rash onset); or
    • Spent time in a room previously occupied by a measles case during that client's infectious period or within 2 hours after the case has left the room/space
  • Within 24 hours of reporting a suspect case of measles, all contacts should be identified and classified as susceptible or non-susceptible. The immunization status of community case contacts should be ascertained to determine susceptibility to measles. Public Health Authorities should determine the extent of contact tracing to be completed during an outbreak, based on the outbreak context and the resources available
  • Susceptible contacts who refuse or who cannot receive MMR vaccine or immune globulin maybe excluded from childcare facilities, schools and post-secondary educational institutions at the discretion of the Medical Officer of Health (MOH) from 5 days after first exposure and up to 21 days after last exposureFootnote 52
Interpretation of lab investigations
Table 2 - Measles testing resultsFootnote 53
Test result Interpretation
Reactive IgM antibody
  • Possible acute measles infection
  • False positive may occur in about 0.4% of suspected cases
  • IgM is also detected after immunization against measles
  • IgM may remain detectable in some individuals for years after vaccination or natural infection
Non-reactive or equivocal IgM antibody Not acute measles infection (Note: 20% of measles cases will not have a reactive IgM when blood is drawn within the first 3 days of rash)
Protective anti-measles IgG (generally greater than/equal to 200 mIU per millilitre) Test results will be reported out as "reactive" (i.e., immune to measles)
A significant (4-fold) rise in IgG titre between the acute and convalescent sera Acute measles infection
Positive culture or RT-PCR (nasopharyngeal swab, urine specimen) Confirms acute measles infection

Section B: Supplemental resources

Provincial/territorial resources
Alberta

Alberta Health and Wellness. Public Health Notifiable Disease Guidelines: Measles.

British Columbia

BC Centre for Disease Control. Communicable Disease Control Management of Specific Diseases: Measles.

Manitoba

Public Health and Primary Health Care. Communicable Disease Management Protocols: Measles.

Northwest Territories

Northwest Territories Health and Social Services. Communicable Disease Manual. Available by selecting HSS Professionals (staff only) and entering authorized username and password.

Nova Scotia

Nova Scotia Department of Health and Wellness.Communicable Disease Manual: Measles.

Newfoundland and Labrador

Government of Newfoundland and Labrador Health and Community Services. Newfoundland and Labrador Disease Control Manual: Section 4, Diseases Preventable by Routine Vaccination (PDF Version, 980 Kb, 78 pages).

Yukon

Yukon Health and Social Services. Communicable Disease Control: Measles.

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.

Mumps (Parotitis)

Overview

Please refer to provincial/territorial guidelines for Mumps (Parotitis) where available.

Mumps is a highly-contagious, acute viral infection characterized by painful swelling of one or more of the salivary glands (most commonly the parotid glands).Footnote 57 Diagnosis can be difficult due to the non-specific and/or primarily respiratory symptoms that occur in about 50% of those who acquire mumps infection.Footnote 56 Systemic symptoms usually resolve within 3 to 5 days, and parotid swelling subsides within 7 to 10 days.Footnote 57 Mumps is a vaccine-preventable disease.

Consult with physician/nurse practitioner immediately when there is suspicion of mumps as it may require urgent medical evacuation.

Causes

Mumps virusFootnote 57

Transmission

Incubation period

12 to 25 daysFootnote 57

Communicability

  • The infectious period occurs between 7 days before and 5 days following the onset of symptomsFootnote 56
  • In approximately 20-30% of mumps cases, infections are subclinical, but remain communicableFootnote 56

Assessment

Medication review: Review current medications, including over-the-counter, complementary and alternative medicines, as well as any chemical or substance intake that may impact management.

Allergy history: Screen for medication, latex, environmental or other allergies and determine approximately when and what type of reaction occurred.

Risk factors

  • In general, individuals of all ages who have not had mumps or who have not been immunized according to the recommended immunization schedule are at risk of being infected
  • Individuals born before 1970 are presumed to have acquired natural immunity to mumps
  • Adolescents and adults born in or after 1970 and who are at the greatest risk of exposure to mumps include:Footnote 57
    • Students in secondary and post-secondary educational settings
    • Travellers to destinations outside North America
    • Individuals exposed to a mumps outbreak
    • Health care workers
    • Military personnel

History of present illness

Review risk factors and collect history of present illness.

  • Unilateral or bilateral pain and swelling of parotid or other salivary glandsFootnote 58
  • Earache or pain at the angle of the jawFootnote 58
  • Immunization history, including dates and number of doses of mumps-containing vaccine receivedFootnote 58
  • Non-specific prodromal symptoms may precede parotitis by several days, and may include:Footnote 58
    • Low-grade fever (which may last 3 to 4 days)
    • Malaise
    • Anorexia
    • Headache
    • Myalgia

Physical findings

Perform a physical examination using the IPPA approach.

  • Swelling of parotid glands (unilateral or bilateral) which may be very tender to the touchFootnote 58
  • Other salivary glands may also be swollenFootnote 58
  • Testicular swelling and tenderness (orchitis)Footnote 58

Differential diagnosis

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

  • Parainfluenza virus types 1 and 3Footnote 59
  • Epstein Barr virusFootnote 59
  • Influenza A virusFootnote 59
  • Coxsackie A virusFootnote 59
  • EchovirusFootnote 59
  • Human immunodeficiency virusFootnote 59
  • Non-infectious causes, including: Footnote 59
  • Medications (thiazide diuretics)
  • Tumors
  • Immunologic diseases (e.g., Sjögren's syndrome causing parotitis, keratoconjunctivitis, absence of tears)
  • Salivary duct obstruction

Complications

Note: Infection occurring in unimmunized adults is more likely to result in complications.Footnote 57 Mumps infection during the first trimester of pregnancy has been associated with spontaneous abortion.Footnote 57

Diagnostic tests

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Diagnostic test selection is based on client history, risk factors, physical examination findings and test availability.

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
If client presents within 5 days of symptom onset
  • Serology for acute and convalescent IgG and IgM antibodies. The acute serum sample should be collected as soon as possible upon suspicion of mumps and within 5 days after symptom onsetFootnote 61
  • The convalescent serum should ideally be collected at least 10 days and up to 3 weeks after the first sampleFootnote 61
If client presents more than 5 days after symptom onset
  • Urine for PCR or mumps virus culture (the virus can be isolated from the urine for up to 2 weeks in those who have not been immunized previously)Footnote 58

For interpretation of lab results, see Table 3: Parotitis test results in Appendix E, Section A of this guideline.

Management

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Goals of treatment

  • Prevent complications
  • Prevent disease transmission

Non-pharmacological interventions

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

Pharmacological interventions

In addition to consulting a physician/ nurse practitioner, review the drug monograph, the FNIHB Nursing Station Formulary or provincial/territorial formulary, and the drug-specific reminders included in the Clinical Care Protocol before initiating treatment.

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.

AcetaminophenFootnote 64
  • Acetaminophen 10 to 15 mg/kg/dose PO q4-6h PRN
  • Maximum from all sources: acetaminophen 75 mg/kg/day or 4,000 mg/day, whichever is less
IbuprofenFootnote 65
  • Infants <6 months
    • Limited data available in infants
  • For 6 months to 12 years of age
    • Ibuprofen 5 to 10 mg/kg/dose PO q6-8h PRN
    • Maximum 400 mg/dose*
  • For greater than 12 years of age
    • Ibuprofen 200 to 400 mg PO q4-6h PRN*
  • *Maximum from all sources for all ages:
    • Ibuprofen 40 mg/kg in 24 hours or 1200 mg in 24 hours whichever is less. Under physician/nurse practitioner supervision, daily doses ≤2,400 mg may be used

Monitoring and follow-up

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Monitoring

If administering an agent with risk of anaphylaxis, monitor the client closely for 30 minutes.

Follow-up

  • Advise parents(s)/caregiver(s) to bring the child back to the clinic if there are signs of complications requiring immediate follow-up (e.g., pancreatitis, meningitis, encephalitis)
  • Consider follow-up at about 1 week after onset of parotitis to determine whether symptoms have resolved (or are resolving) and to address any vaccination gapsFootnote 66
  • Complete recovery usually occurs in 1 to 2 weeks
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

Appendix E

Section A: Supplemental clinical management information

Table 3 - Parotitis test resultsFootnote 61
Test Result Interpretation
Positive PCR (oral swab or urine), regardless of serology result Mumps
Reactive IgM antibody Possible acute mumps infection

Note: without additional confirmatory testing (i.e., IgG seroconversion or virus identification), this may be a false positive IgM result. Such cases should be reported as clinical/probable unless epidemiologically-linked to a laboratory-confirmed case or outbreak-related.

Non-reactive or equivocal IgM antibody

In an unvaccinated person¸

Not acute mumps infection (unless blood was drawn too early)

In a previously vaccinated person

Possible acute mumps infection (viral identification is required for confirmation in previously-vaccinated people with this serological result)
Reactive IgG antibody Immunity to mumps
Non-reactive or equivocal IgG antibody Not immune to mumps
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.

Section B: Supplemental resources

Provincial/territorial guidelines
Alberta

Alberta Health and Wellness. Notifiable Disease Guidelines: Mumps.

British Columbia

BC Centre for Disease Control. Communicable Disease Control Manual Mumps.

Manitoba

Public Health and Primary Health Care. Communicable Disease Management Protocols: Mumps (PDF Version, 619 Kb, 10 pages).

Newfoundland and Labrador

Department of Health and Community Services. Newfoundland and Labrador Disease Control Manual: Section 4, Diseases Preventable by Routine Vaccination (PDF Version, 980 Kb, 78 pages). Available by clicking Mumps in the table of contents.

Northwest Territories

Northwest Territories Health and Social Services.Communicable Disease Manual. Available by selecting HSS Professionals (staff only) and entering authorized username and password.

Nova Scotia

Nova Scotia Department of Health and Wellness. Nova Scotia Communicable Disease Manual: Mumps (PDF Version, 413 Kb, 7 pages).

Ontario

Ontario Ministry of Health and Long-Term Care. Infectious Diseases Protocol. Appendix F A: Disease-Specific Chapters: Mumps (PDF Version, 173 Kb, 11 pages).

Ontario Ministry of Health and Long-Term Care. Mumps Fact Sheet (PDF Version, 48 Kb, 2 pages).

Yukon

Yukon Health and Social Services. Yukon Communicable Disease Control: Mumps (PDF Version, 438 Kb, 24 pages).

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.

Pertussis (Whooping cough)

Overview

Please refer to provincial/territorial guidelines for Pertussis where available.

Pertussis (whooping cough) is a highly-contagious, acute bacterial illness of the upper respiratory tract.Footnote 68 Although the incidence of pertussis in Canada has decreased by over 90% since the introduction of the pertussis vaccine in 1943, it continues to be the most common of all diseases preventable by routine childhood immunization.Footnote 68

Consult with physician/nurse practitioner immediately when there is suspicion of pertussis in infants as it may require urgent medical evacuation.

Causes

Bordetella pertussis (B. pertussis) bacteriaFootnote 68

Transmission

  • Aerosolized droplets of respiratory secretionsFootnote 68
  • Direct contact with respiratory secretions from the infected personFootnote 69

Incubation period

9 to 10 days (range is 6 to 20 days) and rarely as long as 42 daysFootnote 70

Communicability

  • Highly transmissible in the early catarrhal stage and in the first 2 weeks after cough onsetFootnote 70
  • Communicability is negligible 3 weeks after coughing onsetFootnote 70
  • Infected individuals are not usually contagious after 5 days of appropriate antibiotic therapyFootnote 70

Assessment

Medication review: Review current medications, including over-the-counter, complementary and alternative medicines, as well as any chemical or substance intake that may impact management.

Allergy history: Screen for medication, latex, environmental or other allergies and determine approximately when and what type of reaction occurred.

Risk factors

  • Young age and/or incomplete or waned immunity
    • Severe pertussis-related morbidity and high mortality rates occur almost entirely in infants who are too young to be protected by a complete vaccine seriesFootnote 70
    • Adolescents and adults who have not received a booster vaccination are at risk of infection and may transmit the bacteria to others, as immunity to pertussis from childhood vaccination and natural disease wanes with time.Footnote 70 Immunity wanes 5-10 years after last pertussis vaccine doseFootnote 69Footnote 70
  • Pregnant women with pertussis near term and other household contacts with pertussis are an important source of pertussis for newborn infantsFootnote 69
  • For more information on vaccination series, see Appendix F, Section A of this guideline

History of present illness

Review risk factors and collect history of present illness.

  • Obtain the immunization history
  • A child presenting with paroxysmal cough, post-tussive vomiting, and whoop is likely to have an infection caused by B. pertussisFootnote 71
  • Pertussis should be suspected when any client has:
    • A cough that does not improve within 14 days
    • A paroxysmal cough of any duration
    • A cough followed by vomiting or
    • Any respiratory symptoms after contact with a laboratory-confirmed case of pertussisFootnote 71
Illness stages

The course of illness is typically divided into 3 stages:

Catarrhal stage (first stage)
  • Characterized by the insidious onset of coryza, sneezing, low-grade fever, malaise, conjunctival redness, lacrimation and mild occasional coughFootnote 68
  • The catarrhal stage lasts 1 to 2 weeksFootnote 68
Paroxysmal stage (second stage)
  • Most complications occur during this stage; fever is uncommon and suggests bacterial superinfectionFootnote 71
  • Characterized by paroxysmal cough, increasing in frequency and severity, with a high-pitched inspiratory whoop at end of paroxysm. The frequency of paroxysmal episodes varies widely, from several per hour to 5 to 10 per day. Episodes are often worse at night and interfere with sleepFootnote 71
  • Between attacks, the client's appearance is normal, but increasing fatigue is evident Footnote 71
  • The paroxysmal stage can last from 2 to 8 weeksFootnote 70

Note: the classic paroxysmal stage presentation is most often seen in preschool and children of school ageFootnote 71

Convalescent stage (third stage)

Symptoms gradually wane over weeks to months.Footnote 68

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

Physical findings

Perform a physical examination using the IPPA approach.

  • Low-grade fever during catarrhal stageFootnote 71
  • Rhinorrhea/coryzaFootnote 71
  • Paroxysmal cough, often within a single expiration, and audible whoop at end of coughing paroxysmFootnote 71
  • Apnea and cyanosis in infantsFootnote 72
  • Signs of dehydration (may be present)Footnote 68

Note: In young infants (who are at the highest risk of severe disease and complications), clinical symptoms are frequently atypical. Whoop and post-tussive vomiting may be absent, and the presentation may be characterized solely by episodes of cyanosis and apnea.Footnote 71

Differential diagnosis

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

  • Mycoplasma pneumoniaeFootnote 72
  • Chlamydophila pneumoniaeFootnote 72
  • TuberculosisFootnote 72
  • Viral pathogens, including:Footnote 72
    • Respiratory syncytial virus (RSV)
    • Adenovirus
    • Parainfluenza viruses
    • Influenza A and B viruses
    • Rhinovirus
    • Human metapneumovirus
  • Noninfectious processes, including:Footnote 72
    • Foreign body aspiration
    • Reactive airway disease/asthma
    • Allergic or infectious sinusitis
    • Gastroesophageal reflux
    • Aspiration pneumonia

Complications

Complications from intense and persistent coughing in adolescents and adults include:Footnote 70

  • Sleep disturbance
  • Rib fractures
  • Subconjunctival hemorrhages
  • Rectal prolapse
  • Urinary incontinence

Diagnostic tests

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Diagnostic test selection is based on client history, risk factors, physical examination findings and test availability.

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

Management

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Goals of treatment

  • Cure infection, when possible
  • Relieve symptoms
  • Prevent disease transmission
  • Prevent complications

Non-pharmacological interventions

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.

Pharmacological interventions

In addition to consulting a physician/ nurse practitioner, review the drug monograph, the FNIHB Nursing Station Formulary or provincial/territorial formulary before initiating treatment.

Note: Pharmacological therapy to manage pertussis-related cough (e.g., bronchodilators, antitussives, corticosteroids) are not indicated; medications to manage pertussis-related cough are not effective, and there may be more risks associated with side effects from these medications than benefits.Footnote 77

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.

AcetaminophenFootnote 79
  • Acetaminophen 10 to 15 mg/kg PO q4-6h PRN
  • Maximum from all sources: acetaminophen 75 mg/kg/day or 4,000 mg/day, whichever is less
IbuprofenFootnote 82
  • Infants <6 months
    • Limited data available in infants
  • For 6 months to 12 years of age
    • Ibuprofen 5 to 10 mg/kg/dose PO q6-8h PRN
    • Maximum 400 mg/dose*
  • For greater than 12 years of age
    • Ibuprofen 200 to 400 mg PO q4-6h PRN*
  • *Maximum from all sources for all ages:
    • Ibuprofen 40 mg/kg in 24 hours or 1200 mg in 24 hours whichever is less. Under physician/nurse practitioner supervision, daily doses ≤2,400 mg may be used
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
Azithromycin
  • Infants less than 6 months of age
    • Azithromycin PO daily for 5 days (calculate 10 mg/kg in 24 hours)
  • Infants and children 6 months of age or greater
    • Day 1
      • Azithromycin PO once daily (calculate 10 mg/kg in 24 hours; maximum 500 mg/in 24 hours for one dose on day 1)
    • Days 2-5
      • Azithromycin PO once daily on days 2 to 5 (calculate 5 mg/kg/day; maximum 250 mg in 24 hours)
Alternate treatment for client with contraindication to azithromycin

Trimethoprim-sulfamethoxazole (co-trimoxazole) (TMP-SMX) can be used as an alternative agent to macrolides in patients aged ≥2 months who are allergic to macrolides, who cannot tolerate macrolides, or who are infected with a rare macrolide-resistant strain of Bordetella pertussis.

Trimethoprim-sulfamethoxazole
  • Infants aged < 1 months
    • Contraindicated because of risk for kernicterus
  • Infants from 1 to 5 months
    • Trimethoprim-sulfamethoxazole PO, TMP 8 mg/kg and SMX 40 mg /kg in two divided doses for 14 days
  • Infants and children greater than six months of age
    • Trimethoprim-sulfamethoxazole PO, TMP 8 mg/kg and SMX 40 mg /kg in two divided doses for 14 days (maximum TMP 320 mg, SMX 1600 mg per day)

Monitoring and follow-up

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Monitoring

  • If administering an agent with risk of anaphylaxis, monitor the client closely for 30 minutes
  • Monitor vital signs as indicated by client's condition

Follow-up

  • Follow up every few days to every 2 weeks as necessary, to reassess client status and monitor for complications
  • Advise the parent(s)/caregiver(s) and/or client that the client should immediately return for follow-up if complications arise
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.

Appendix F

Section A: Supplemental clinical management information

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.

Pertussis vaccination in pregnancy
  • The National Advisory Committee on Immunization (NACI) currently does not recommend a universal program for vaccination of pregnant women
  • In special circumstances, such as a regional outbreak situation, immunization with Tdap (an acellular pertussis-containing formulation) may be offered to pregnant women (≥ 26 weeks of gestation) irrespective of their immunization history
  • For information on pertussis vaccination in pregnancy, see the Public Health Agency of Canada's Update on Pertussis Vaccination in Pregnancy
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.

Nasopharyngeal swab collection technique

For information on the collection of nasopharyngeal specimens, see Cadham Provincial Laboratory's Collection of Nasal Specimens (PDF Version, 50 Kb, 2 pages).

Section B: Supplemental resources

Provincial/territorial guidelines
Alberta

Alberta Health and Wellness. Public Health Notifiable Disease Guidelines: Pertussis.

British Columbia

BC Centre for Disease Control. Communicable Disease Control Management of Specific Diseases: Pertussis.

Manitoba

Public Health and Primary Health Care. Communicable Disease Management Protocols: Pertussis (PDF Version, 300 Kb, 11 pages).

Newfoundland and Labrador

Community Services. Newfoundland and Labrador Communicable Disease Control Manual: Section 4, Diseases Preventable by Routine Vaccination. Available by clicking Pertussis (Whooping Cough) in the table of contents.

Northwest Territories

Health and Social Services. Communicable Disease Manual. Available by selecting HSS Professionals (staff only) and entering authorized username and password.

Nova Scotia

Health and Wellness. Nova Scotia Communicable Disease Manual: Pertussis (PDF Version, 474 Kb, 9 pages).

Ontario

Ontario Ministry of Health and Long-Term Care. Diseases and Conditions: Pertussis.

Yukon

Yukon Health and Social Services. Yukon Communicable Disease Control: Pertussis (PDF Version, 315 Kb, 34 pages).

Pinworms

Overview

Please refer to provincial/territorial guidelines for Pinworms where available.

Pinworm infection (Enterobiasis) is a common parasitic infection.Footnote 85 It occurs worldwide and commonly clusters within families. Prevalence rates are higher among the following populations: pre-school and school-aged children, primary caregivers of infected children and institutionalized individuals.Footnote 86

Causes

Enterobius vermicularis (e. vermicularis)Footnote 87

Transmission

  • Infection begins when the embryonic eggs are ingested or inhaled and swallowedFootnote 88
  • Eggs hatch in the upper intestine and then mature and migrate through the intestineFootnote 88
  • Adult gravid female pinworms migrate nocturnally outside the anus and deposit eggs while crawling on the perianal area and perineal skinFootnote 87
  • The movement of the worms on skin and mucous membranes causes intense itching.Footnote 88 As the child scratches, eggs are deposited on the hands and underneath the fingernails.Footnote 88 The typical hand-to-mouth activity of young children makes them especially prone to reinfectionFootnote 88
  • Other modes of transmission involve exposure to objects contaminated with pinworm eggs (e.g., curtains, carpeting, bed linens, clothing, toilet seats, doorknobs and food)Footnote 87Footnote 88

Incubation period

  • The interval between ingestion of the egg, migration of the gravid adult female to the perianal region and deposit of eggs is 1 to 2 months or longerFootnote 86

Communicability

  • Pinworm eggs remain infective in an indoor environment for 2 to 3 weeksFootnote 86
  • A person remains infectious as long as female nematodes are discharging eggs on perianal skinFootnote 86

Assessment

Medication review: Review current medications, including over-the-counter, complementary and alternative medicines, as well as any chemical or substance intake that may impact management.

Allergy history: Screen for medication, latex, environmental or other allergies and determine approximately when and what type of reaction occurred.

Risk factors

  • Pre-school and school aged childrenFootnote 87
  • Close contacts of people with enterobiasis (e.g., household members)Footnote 87
  • Crowded conditions (e.g., classrooms, daycare centres, institutions)Footnote 87

History of present illness

Review risk factors and collect history of present illness.

  • Many individuals with pinworm infection are asymptomaticFootnote 89
  • Intense perianal itching, especially at nightFootnote 89
  • Difficulty sleeping due to pruritusFootnote 89
  • Other complaints may include anorexia, irritability and abdominal painFootnote 87
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

Physical findings

If pinworm infestation is suspected, perform a physical examination using the IPPA approach; any or none of the following may be evident:

  • Perianal and/or perineal area excoriationFootnote 86
  • Secondary bacterial infection due to scratchingFootnote 86
  • Small white worms visible in the perianal areaFootnote 86

Tape test may be required for some clients. For more information on how to perform a tape test, see Appendix G, Section A of this guideline.

Differential diagnosis

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Complications

Diagnostic tests

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Diagnostic test selection is based on client history, risk factors, physical examination findings and test availability.

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

Management

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Goals of treatment

  • Relieve infestation
  • Prevent transmission to others
  • Prevent complications

Non-pharmacological interventions

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.

Pharmacological interventions

In addition to consulting a physician/nurse practitioner, review the drug monograph, the FNIHB Nursing Station Formulary or provincial/territorial formulary before initiating treatment.

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:

Pyrantel pamoate
  • Children less than 12 kg
    • Pyrantel pamoate 125 mg PO for 1 dose
  • Children 12 to 23 kg
    • Pyrantel pamoate 250 mg PO for 1 dose
  • Children 24 to 45 kg
    • Pyrantel pamoate 500 mg PO for 1 dose
  • Children 46 to 68 kg
    • Pyrantel pamoate 750 mg PO for 1 dose
  • Children greater than or equal to 69 kg
    • Pyrantel pamoate 1,000 mg PO for 1 dose

Note: a single dose results in relatively high cure rates, although a second dose repeated at two weeks achieves a cure rate close to 100 percent and helps prevent recurrence due to reinfection.

Reinfection is common, despite effective therapy. Therefore, simultaneous treatment of the entire household is warranted given high transmission rates among families.Footnote 89 In addition, all bedding and clothes should be washed. Hygienic measures, such as clipping of fingernails, frequent handwashing, and baths, are also helpful for reducing reinfection.

Monitoring and follow-up

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Monitoring

If administering an agent with risk of anaphylaxis, monitor the client closely for 30 minutes.

Follow-up

  • Advise follow-up in 2 weeks as re-infection may occur and a second dose may be required to eradicate pinworm infection
  • Counsel parent(s)/caregiver(s)/client that client is to return for further assessment if there is no improvement in signs and symptoms of presenting condition following treatment

Appendix G

Section A: Supplemental clinical management information

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

Roseola infantum

Overview

Please refer to provincial/territorial guidelines for Roseola Infantum where available.

Roseola infantum ('roseola' or 'sixth disease') is usually a benign, self-limited viral illness.Footnote 96 It is characterized by the sudden onset of high fever lasting several days and is typically followed by the sudden appearance of a diffuse maculopapular eruption over the trunk and neck after the abrupt resolution of fever.Footnote 95Footnote 96

Causes

Human herpesvirus 6 (HHV-6) is the virus that most commonly causes roseola.Footnote 96

Other causes include:

  • Human herpesvirus 7 (HHV-7)
  • Enteroviruses (coxsackieviruses A and B, echoviruses)
  • Adenoviruses
  • Parainfluenza virus type 1Footnote 96

Transmission

HHV-6 appears to be transmitted through the respiratory secretions of asymptomatic individuals.

In most cases, there is no reported contact with an infected individual.Footnote 97

Incubation period

Approximately 9 days (range 5 to 15 days)Footnote 97

Communicability

UnknownFootnote 97

Assessment

Medication review: Review current medications, over-the-counter, complementary and alternative medicines, as well as any chemical or substance intake that may impact management.

Allergy history: Screen for medication, latex, environmental or other allergies and determine approximately when and what type of reaction occurred.

Risk factors

  • Usually affects children less than two years oldFootnote 96
  • The peak age of HHV-6 acquisition is 9 to 21 monthsFootnote 98
  • Older siblings may represent a source of transmissionFootnote 98

History of present illness

Review risk factors and collect history of present illness.

  • Roseola is classically characterized by:
  • Sudden onset of high fever (40ºC or higher), typically lasting 3 to 5 days, followed by the sudden appearance of a rash as the fever abruptly resolvesFootnote 95Footnote 96
  • Prodromal symptoms of listlessness and irritability in approximately 14% of casesFootnote 100
  • Non-pruritic maculopapular rash that lasts 1 to 2 daysFootnote 97
  • Febrile seizures may occur during the febrile phase of the illnessFootnote 97
  • DiarrheaFootnote 100
  • CoughFootnote 100

Physical findings

Perform a physical examination using the IPPA approach.

  • Child appears alert, not acutely illFootnote 100
  • Rash following abrupt cessation of feverFootnote 100
    • Raised, erythematous, non-pruritic rash
    • Rose-pink blanching macules and papules approximately 2 to 3 mm in diameterFootnote 95
    • Lesions characteristically discrete, rarely coalescing together and blanching with pressure
    • Typically involves the trunk or back, with minimal involvement of the face and proximal extremities
      • Some lesions may be surrounded by a halo of pale skin
  • Bulging anterior fontanel may be present (requires further investigation for increased intracranial pressure associated with meningitis or encephalitis)
  • Nagayama's spots (erythematous papules on the soft palate and uvula)
  • Periorbital edema (may occur prior to the onset of the rash)
  • Conjunctival erythemaFootnote 100
  • Associated signs and symptoms may include cervical and post-auricular lymphadenopathy, inflamed pharynx, cough and coryzaFootnote 97

Differential diagnosis

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

  • Mononucleosis
  • Erythema infectiosum (fifth disease)
  • Measles (Rubeola)
  • Meningitis or encephalitis
  • Rubella (German measles)Footnote 101
  • Adverse drug reaction

Note: Roseola generally can be distinguished from other infectious exanthems and drug allergy by its epidemiology or clinical features (e.g., age group and/or the temporal relation between fever and rash).Footnote 96

Complications

Diagnostic tests

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Diagnostic test selection is based on client history, risk factors, physical examination findings and test

availability

  • Diagnostic tests are not routinely recommendedFootnote 103

Management

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Goals of treatment

  • Provide supportive care
  • Prevent complications

Non-pharmacological interventions

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.

Pharmacological interventions

Note: In addition to consulting a physician/nurse practitioner, review the drug monograph, the FNIHB Nursing Station Formulary or provincial/territorial formulary.

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.

AcetaminophenFootnote 104
  • Acetaminophen 10 to 15 mg/kg PO q4-6h PRN
  • Maximum from all sources: acetaminophen 75 mg/kg/day or 4,000 mg/day, whichever is less
Ibuprofen
  • Infants <6 months
    • Limited data available in infants
  • For 6 months to 12 years of age
    • Ibuprofen 5 to 10 mg/kg/dose PO q6-8h PRN
    • Maximum 400 mg/dose*
  • For greater than 12 years of age
    • Ibuprofen 200 to 400 mg PO q4-6h PRN*
  • *Maximum from all sources for all ages:
    • Ibuprofen 40 mg/kg in 24 hours or 1200 mg in 24 hours whichever is less. Under physician/nurse practitioner supervision, daily doses ≤2,400 mg may be used

Monitoring and follow-up

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Monitoring

  • Monitor for seizure activity in the febrile phase of illness
  • Monitor vital signs as indicated by client's condition
  • If administering an agent with risk of anaphylaxis, monitor the client closely for 30 minutes

Follow-up

The illness is usually benign and brief. Follow-up is necessary only if complications arise, e.g.,:

  • Febrile seizure
  • Lethargy
  • Refusal to drink
  • Prolonged fever greater than 72 hours or being unable to reduce feverFootnote 99
Referral
  • Not necessary, unless complications develop

Rubella (German measles)

Overview

Please refer to provincial/territorial guidelines for Rubella where available.

Rubella (German measles) is a highly contagious, viral illness which is often mild and subclinical. Because rubella infection during pregnancy can have potentially devastating effects on the developing fetus, the rubella titre is done as part of prenatal screening. Rubella is a vaccine-preventable disease.

Causes

Rubella virusFootnote 106

Transmission

  • Droplet spreadFootnote 106
  • Direct contact with nasopharyngeal secretions of infected peopleFootnote 106
  • Transplacental transmission from an infected mother to her fetusFootnote 106

Incubation period

12 to 21 days from exposure to clinical illnessFootnote 106

Communicability

  • Communicability begins 1 week before, to at least 4 days after the onset of rashFootnote 106
  • Infants with congenital rubella syndrome may shed the virus for months after birth and serve as a source of infection to their contactsFootnote 107

Assessment

Medication review: Review current medications, over-the-counter, complementary and alternative medicines, as well as chemical or substance intake that may impact management.

Allergy history: Screen for medication, latex, environmental or other allergies and determine approximately when and what type of reaction occurred.

Risk factors

  • Individuals who have not received at least 1 dose of rubella-containing vaccineFootnote 107
  • An unborn child is at risk for congenital rubella syndrome if the mother contracts rubella during pregnancy

History of present illness

Review risk factors and collect history of present illness.

  • 1 to 5 day prodromeFootnote 109
  • Mild systemic signs (e.g., headache, malaise)Footnote 109
  • Low-grade feverFootnote 109
  • Arthralgia (rare in children but common in adult females)Footnote 109
  • Up to 50% of infections are subclinicalFootnote 108
  • Immunization history, including dates and number of rubella-containing vaccine doses received
Social history
  • Travel history, including recent travel to an area with known rubella activityFootnote 110

Physical findings

Perform a physical examination using the IPPA format.

  • Low-grade feverFootnote 109
  • ConjunctivitisFootnote 109
  • Macular rash, which starts on face and progresses to trunk and then to the extremities. The rash becomes generalized in 24 hours and lasts an average of 3 days.Footnote 107 The rash does not coalesce.Footnote 109
  • Lymphadenopathy, especially post-auricular, posterior cervical and suboccipital nodesFootnote 109
  • Arthritis (in adolescents)Footnote 109

Differential diagnosis

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

  • Rubeola (measles)
  • Roseola
  • Scarlet fever
  • Erythema infectiosum (Fifth disease)
  • Mononucleosis
  • Unspecified viral exanthema
  • Adverse drug reaction

Complications

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

Diagnostic tests

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Testing should be carried out as per provincial/territorial policies and procedures. Diagnostic test selection is based on client history, risk factors, physical examination findings and test availability.

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
Interpretation of lab resultsFootnote 112

In the absence of immunization with rubella-containing vaccine during the past 7 to 42 days, laboratory

confirmation of infection is made with one of the following:

  • Isolation of rubella virus in culture from clinical samples (throat swab, nasopharyngeal swab/aspirate, urine)
  • Detection of rubella RNA by Nucleic Acid Amplification Test (NAAT)
  • Positive serologic test for rubella IgM antibody in a person with an epidemiologic link to a laboratory-confirmed case or who has recently travelled to an area of known rubella activity
  • A significant (four-fold or greater) rise in rubella IgG antibody levels or a seroconversion in paired acute and convalescent sera

Management

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Goals of treatment

  • Provide supportive care
  • Prevent disease transmission
  • Prevent complications

Non-pharmacological interventions

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

Pharmacological interventions

In addition to consulting a physician/ nurse practitioner, review the drug monograph, the FNIHB Nursing Station Formulary or provincial/territorial formulary before initiating treatment.

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.

AcetaminophenFootnote 113
  • Acetaminophen 10 to 15 mg/kg PO q4-6h PRN
  • Maximum from all sources: acetaminophen 75 mg/kg/day or 4,000 mg/day, whichever is less
Ibuprofen
  • Infants <6 months
    • Limited data available in infants
  • For 6 months to 12 years of age
    • Ibuprofen 5 to 10 mg/kg/dose PO q6-8h PRN
    • Maximum 400 mg/dose*
  • For greater than 12 years of age
    • Ibuprofen 200 to 400 mg PO q4-6h PRN*
  • *Maximum from all sources for all ages:
    • Ibuprofen 40 mg/kg in 24 hours or 1200 mg in 24 hours whichever is less. Under physician/nurse practitioner supervision, daily doses ≤2,400 mg may be used

Monitoring and follow-up

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Monitoring

If administering an agent with risk of anaphylaxis, monitor the client closely for 30 minutes.

Follow-upFootnote 106

  • Advise parents/caregivers to bring the child back to the clinic if there are signs of complications; complete recovery usually occurs in 1 to 2 weeks
  • For contact identification, tracing and contact management, see Management of Contacts in Appendix H, Section A of this guideline
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.

Appendix H

Section A: Supplemental clinical management information

Management of contactsFootnote 107
Contact identification and tracing

A contact of a rubella case is any susceptible person who has had close contact with the case during the period of communicability. Contact identification and tracing for rubella includes the following:

  • Contact history during period of communicability
  • Assessment of contact type
  • Identification of contacts for follow-up and to determine the immunization status of contacts
  • Occupation of contact
  • Contact's residency/attendance at a facility or institution
Contact management
  • Investigate pregnant contacts for status of rubella susceptibility. Where the results are negative, perform serology to determine if infected
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
Rubella in pregnancy and congenital rubella syndrome in fetusFootnote 110
  • For detailed information about rubella in pregnancy, including congenital rubella syndrome, diagnosis of rubella infection, and management of rubella exposure/infection in pregnant women, see the latest Society of Obstetricians and Gynaecologists of Canada (SOGC) Clinical Practice Guidelines (PDF Version, 300 Kb, 11 pages)
  • Assess the rubella immunity of adolescent females and women of childbearing age. Provide vaccination if necessary
  • Advise women immunized against rubella to delay pregnancy by at least 4 weeks following receipt of rubella or measles-mumps-rubella (MMR) vaccine
  • The live attenuated virus contained in the vaccine can cross the placenta; however, no case of congenital rubella has ever been reported in newborns of women who were inadvertently immunized while pregnant
  • Screen all pregnant women to determine their antibody status and their susceptibility
  • Prompt and accurate diagnosis of acute primary rubella infection in pregnancy is imperative and requires prompt serologic testing of IgM and IgG antibodies. Consult physician/nurse practitioner if rubella exposure or signs of illness suspected in a pregnant woman
  • Routine use of immune globulin to susceptible women exposed to rubella early in pregnancy is not recommended.Footnote 107 Consult with Public Health Physician and follow provincial/territorial guidelines

For more information, see the latest Canadian Immunization Guide.

For children

In Canada, children should receive a 2-dose immunization schedule for rubella vaccine. For more information on immunization of children, see the latest Canadian Immunization Guide.

Section B: Supplemental resources

Provincial/territorial guidelines
Alberta

Alberta Health and Wellness. Public Health Notifiable Disease Management Guidelines: Rubella.

British Columbia

BC Centre for Disease Control. Communicable Disease Control Manual – Management of Specific Diseases German Measles/Rubella.

Manitoba

Public Health and Primary Health Care. Communicable Disease Management Protocols: Rubella.

Nova Scotia

Nova Scotia Department of Health and Wellness. Nova Scotia Communicable Disease Manual: Rubella (PDF Version, 411 Kb, 6 pages).

Northwest Territories

Northwest Territories Health and Social Services. Communicable Disease Manual. Available by selecting HSS Professionals (staff only) and entering authorized username and password.

Newfoundland and Labrador

Department of Health and Community Services. Newfoundland and Labrador Disease Control Manual, Section 4, Diseases Preventable by Routine Vaccination.

Yukon

Yukon Health and Social Services. Yukon Communicable Disease Control: Rubella.

Other resources

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

Scarlet fever

Overview

Please refer to provincial/territorial guidelines for Scarlet Fever where available.

Scarlet fever, also called scarlatina, is caused by toxin-producing strain of Group A Streptococci (GAS). GAS is commonly found in the throat and on the skin. Scarlet fever is a manifestation of GAS infection and usually follows GAS pharyngitis (strep throat), although it may also follow GAS infections at other sites (e.g., from Streptococcal skin infection (impetigo)).Footnote 115 Scarlet fever is characterized by a scarlatiniform rash and a strawberry-like appearance of the tongue.Footnote 116Footnote 123

Other than a rash, the epidemiologic features, symptoms, signs, sequelae, and treatment of scarlet fever are the same as those of GAS pharyngitis.Footnote 117 For more information on GAS pharyngitis see.

Causes

Toxin-producing strain of Group A Streptococci (GAS) bacteria

Transmission

  • The most common method of transmission of GAS pharyngitis and consequent scarlet fever:Footnote 118
    • Person-to-person contact (spread by respiratory droplets)
  • Direct contact with infected individualsFootnote 118
  • Less common transmission methods include:
    • Foodborne outbreaks of GAS pharyngitis occur rarely and are a consequence of human contamination of food by infected or colonized food handlers in conjunction with improper food preparation or refrigeration proceduresFootnote 117

Incubation period

Usually 1 to 3 days after exposureFootnote 118

Communicability

If untreated, a client with scarlet fever associated with GAS pharyngitis is infective during the acute phase of the illness, usually 7 to 10 days, and for 1 week afterwards; however, if antibiotics are used, the infective period is reduced to 24 hours.Footnote 118

The bacterium can remain in the body in its carrier state without causing illness in the host for weeks or months and is transmissible in this state.Footnote 118

Assessment

Medication review: Review current medications, including over-the-counter, complementary and alternative medicines, as well as any chemical or substance intake that may impact management.

Allergy history: Screen for medication, latex, environmental or other allergies and determine approximately when and what type of reaction occurred.

Risk factors

  • The main risk factor for scarlet fever is a preceding GAS infection
  • Age: GAS pharyngitis occurs predominantly in school-age children 5 to 15 years of age (although it can occur in both younger and older individuals)Footnote 124
  • OvercrowdingFootnote 122
  • A history of GAS pharyngitis in the household, community, neighborhood, or schoolFootnote 119

History of present illness

Review risk factors and collect history of present illness.

  • Obtain a history of preceding sore throat/pharyngitis or skin infectionFootnote 120
  • The symptoms of scarlet fever are the same as those of pharyngitis aloneFootnote 117 and include the following:Footnote 124
    • Sudden (acute) onset of sore throat
    • Fever
    • Absence of cough or rhinorrhea
    • Headache
    • Nausea, vomiting, abdominal pain
    • Rash

Physical findings

Perform a physical examination using the IPPA approach.

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'

Differential diagnosis

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Complications

Those at increased risk for acute rheumatic fever include:Footnote 130

  • Past history of acute rheumatic fever, especially with carditis or valvular disease
  • Household contact with someone having a history of rheumatic fever (for more information, see). For more information on suppurative and non-suppurative complications, see Table 4
Table 4 - Non-suppurative and suppurative complicationsFootnote 123
Non-Suppurative Complications Suppurative Complications
  • Acute rheumatic fever (may occur an average of 19 days following infection)
  • Rheumatic heart (valvular) disease (may occur days to weeks after acute infection)
  • Streptococcal toxic shock syndrome
  • Acute glomerulonephritis (may occur an average of 10 days following infection)
  • Pediatric Autoimmune Neuropsychiatric Disorder associated with GAS (PANDAS) (research is ongoing/controversial; see Appendix I, Section A: Clinical Management Information - PANDAS)
  • Sydenham chorea (may occur several months following infection)
  • Tonsillopharyngeal cellulitis or abscess
  • Otitis media
  • Sinusitis
  • Necrotizing fasciitis
  • Streptococcal bacteremia (rare)
  • Meningitis or brain abscess (complication resulting from direct extension of an ear or sinus infection or from bacteremic spread)

Diagnostic tests

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

  • Diagnostic testing is based on client history, risk factors, physical examination findings and test availability. Testing should be carried out as per provincial/territorial policies and procedures
  • When scarlet fever is suspected, laboratory diagnosis of a GAS infection is performed to confirm the diagnosis
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.

Management

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Goals of treatment

Non-pharmacological interventions

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)

Pharmacological interventions

In addition to consulting a physician/nurse practitioner, review the drug monograph, the FNIHB Nursing Station Formulary or provincial/territorial formulary before initiating treatment.

Antibiotic therapy

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

Indications for empiric therapy in clients with suspected GAS pharyngitis
  • For those at high risk of acute rheumatic fever, consult with a physician/nurse practitioner to initiate antibiotic treatment immediately while awaiting culture results
  • Other indications to start antibiotics empirically include:
    • Client appears acutely ill
    • Client is symptomatic and has had contact with a documented case of GAS pharyngitis
    • Client has pharyngitis complications, e.g. early peritonsillar abscess
  • In consultation with the physician/nurse practitioner, discontinuation of empiric therapy may be appropriate for client with suspected GAS pharyngitis if the throat culture is available and yields no growthFootnote 125
Indications to delay therapy pending culture results in clients with suspected GAS pharyngitis

For populations at low risk for acute rheumatic fever, and in the absence of other indications for empiric therapy, delaying antibiotic therapy is unlikely to increase the risk of acute rheumatic fever as long as treatment of GAS pharyngitis is initiated within 9 days of onset of illness. This approach also minimizes the number of clients being treated unnecessarily before the test results are availableFootnote 126.

Note: In some exceptional circumstances, however, where it may be very difficult to contact the client for follow-up, it may be appropriate to initiate antibiotic therapy.

Note: If RADT is positive (if available), treat client immediately.

Preferred treatment

Consider one of the following:

Penicillin
  • Child less than/equal to 27 kg
  • Child greater than 27 kg
Amoxicillin
  • Amoxicillin 50 mg/kg/dose PO daily for 10 days; maximum 1,000 mg in 24 hoursFootnote 124

or

  • Amoxicillin 25 mg/kg/dose PO BID for 10 days; maximum 500 mg/doseFootnote 124

Note: Amoxicillin should not be used prior to a confirmatory diagnosis of GAS pharyngitis because it can induce rash with some viral infections.

Alternate Treatment: If Known or Suspected Non-Anaphylactic Allergy to PenicillinFootnote 124

Cephalexin
  • Cephalexin 20 mg/kg/dose PO BID for 10 days; maximum 500 mg/dose

Alternate Treatment: If Known or Suspected Anaphylactic Allergy to Penicillin or CephalosporinFootnote 124

Clindamycin
  • Clindamycin 7 mg/kg/dose PO TID for 10 days; maximum 300 mg/dose

Alternate Treatment: If Medication Compliance or Follow-up is a ConcernFootnote 124

If medication compliance or follow-up is a concern, benzathine penicillin G IM for one dose may be given. Benzathine penicillin G may be obtained through the Non-Insured Health Benefits Program, if not available through provincial/territorial formulary. It is not listed in the FNIHB Nursing Station Formulary.

Analgesic/antipyretic
AcetaminophenFootnote 128
  • Acetaminophen 10 to 15 mg/kg/dose PO q4-6h PRN
  • Maximum from all sources: acetaminophen 75 mg/kg/day or 4,000 mg in 24 hours, whichever is less
Ibuprofen
  • Infants <6 months
    • Limited data available in infants
  • For 6 months to 12 years of age
    • Ibuprofen 5 to 10 mg/kg/dose PO q6-8h PRN;
    • Maximum 400 mg/dose*
  • For greater than 12 years of age
    • Ibuprofen 200 to 400 mg PO q4-6h PRN*
  • *Maximum from all sources for all ages:
    • Ibuprofen 40 mg/kg in 24 hours or 1200 mg in 24 hours whichever is less. Under physician/nurse practitioner supervision, daily doses ≤2,400 mg may be used

Monitoring and follow-up

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Monitoring

  • If administering an agent with risk of anaphylaxis, monitor the client closely for 30 minutes
  • Monitor vital signs as indicated by client's condition
  • Monitor for symptoms of:
    • Airway distress and/or obstruction
    • Tripod positioning
    • Stridor
    • Dysphagia
    • Drooling or anxiety

Follow-up

The client diagnosed with scarlet fever will be assessed as follows to monitor response to therapy and to monitor for complications.

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

Appendix I

Section A: Supplemental clinical management information

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.

Tuberculosis

Overview

Please refer to provincial/territorial guidelines for tuberculosis where available.

Tuberculosis (TB) is an infectious bacterial disease that most commonly affects the lungs, although other organs may be involved (nonrespiratory TB).Footnote 132 In Canada, TB in the pediatric population is largely a disease of Canadian-born Aboriginal and foreign-born children.Footnote 133

TB in children differs from that in adults in the following ways:Footnote 133

  • Diagnosis in young children may be difficult, since the signs and symptoms are often non-specific and disease is often paucibacillary (contain few bacilli). As a result, many children with TB disease are asymptomatic at presentation
  • In children under 5, especially infants, there is a high risk of progression from latent TB infection (LTBI) to active and sometimes severe TB disease, including miliary/disseminated and TB meningitis
  • Because TB in children can quickly become a medical emergency, children identified as contacts of active cases in adolescents or adults should be considered a high priority for screening and follow-upFootnote 134

Active TB in children is a sentinel event that should prompt a search for the source case.Footnote 133

Causes

Mycobacterium tuberculosisFootnote 133

For detailed information on the sub-classification and clinical presentation of TB, see.

Transmission

Transmission by adults or adolescents with infectious pulmonary, laryngeal and/or cavitary TB is airborne. Bacilli in minute droplets of moisture (droplet nuclei) are inhaled by children and go on to produce TB infection or disease. TB is rarely acquired by ingestion or percutaneously.Footnote 135 The likelihood of transmission increases if the source individual:Footnote 135

  • Has a frequent and severe cough
  • Has had close and prolonged contact with the child
  • Lives or works in crowded conditions with poor ventilation

The most effective methods for reducing risk of transmission are:Footnote 135

  • Early diagnosis and treatment of clients with active TB and
  • following infection prevention and control procedures

Communicability

Assessment

Medication review: Review current medications, including over-the-counter, complementary and alternative medicines, as well as any chemical or substance intake which may impact management.

Allergy history: Screen for medication, latex, environmental or other allergies and determine approximately when and what type of reaction occurred.

Risk factors

History of present illness

Review risk factors and collect history of present illness.

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

Physical findings

Perform a physical examination using the IPPA approach.

  • In infants and young children, physical findings may be very non-specificFootnote 133
    • Hepatosplenomegaly
    • Respiratory distress
    • Fever
    • Lymphadenopathy
    • Abdominal distention
    • Lethargy
    • Irritability
  • Older children and adolescents are more likely to experience adult-type disease and often present with the classic triad of:Footnote 133
    • Fever
    • Night sweats
    • Weight loss
  • Respiratory symptoms (e.g., cough, sputum and sometimes hemoptysis)

Differential diagnosis

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Complications

Primary infection may be associated with complications, especially in children under 5 years of age.

  • The parenchymal lesion may enlarge and caseate, or nodes may enlarge and compress or erode through a bronchus, causing:Footnote 133
    • Wheezing
    • Segmental pneumonia
    • Atelectasis
  • Severe forms of TB disease, including CNS TB and miliary TBFootnote 133
  • Death

Diagnostic tests

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Diagnostic test selection is based on client history, risk factors, physical examination findings and test availability.

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.

TST and IGRAFootnote 133
  • In children, the TST and IGRA is an important part of the clinical case definition of TB disease, particularly for LTBI
  • Culture yield in children is low; in addition to compatible clinical signs or symptoms,Footnote 133 TB often is diagnosed by the combination of:
    • A positive TST or IGRA
    • Abnormal chest x-ray
    • A history of a contact case of infectious TB
Positive TST or IGRAFootnote 133
  • A positive TST or IGRA does not distinguish between LTBI and active disease
Negative TSTFootnote 133
  • A negative TST does not exclude TB disease

For specific recommendations for using the TST and IGRA in children, see Table 5: Recommendations for using the TST and IGRA in Children in Appendix J, Section A of this guideline.

Recommended samples

Note: Sputum may be difficult to obtain from children and gastric aspiration or sputum induction may be required.Footnote 133

  • Three 5 to 10 mL sputum samples (one of which should be an early morning specimen, if possible) for:Footnote 141
    • Acid-fast bacilli (AFB) and
    • tuberculosis culture +/- PCR
  • 3 sputum specimens can be provided by the client on the same day, at least 1 hour apart, in a well ventilated area or outdoors

For additional information on collection of sputum samples, see.

Additional lab investigationsFootnote 132
  • CBC
  • Creatinine
  • Liver function tests (e.g., ALT, AST, bilirubin)
  • HIV serology
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

Management

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Goals of treatment

  • Ensure adequate treatment of active disease; treatment is for the purpose of:Footnote 133
    • Reducing morbidity and mortality
    • Interrupting transmission
    • Preventing acquired resistance
    • Providing a lasting cure
  • Identify case contacts through reverse contact tracing (i.e., a vigorous search should be carried out for the source case)Footnote 133; for more information, see Appendix J, Section A of this guideline

Non-pharmacological interventions

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
Client education
  • Provide parent(s)/caregiver(s)/client with information about:
  • TB
  • The signs and symptoms of TB
  • The difference between TB disease and LTBI
  • The expected treatment plan
When to return to the clinic or seek medical attention
  • Encourage parent(s)/caregiver(s)/client to return to the clinic and/or seek medical attention as soon as possible if any of the following symptoms occur:Footnote 132Footnote 133
    • Anorexia
    • Nausea or vomiting
    • Abdominal discomfort
    • Unexplained fatigue
    • Signs of hepatotoxicity (dark coloured urine, jaundice
  • Provide parent(s)/caregiver(s)/client with a clear written plan of action, including contact telephone numbers, should symptoms ariseFootnote 133
Treatment
  • Explain the purpose, process and importance of directly observed treatment (DOT).
  • Stress the importance of strict adherence to medication regimen to ensure cure of TB and to prevent drug resistance
  • Encourage use of DOT to promote adherence and monitoring
  • Advise parent(s)/caregiver(s)/client to maintain an optimum state of health with adequate nutrition and restFootnote 143
Medication

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

For more client information topics, see Health Canada's Tuberculosis is Curable, Information about TB (PDF Version, 2.67 Mb, 2 pages).

Pharmacological interventions

In addition to consulting a physician/nurse practitioner, review the drug monograph, the FNIHB Nursing Station Formulary or provincial/territorial formulary before initiating treatment.

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

Symptomatic children

No source case isolate available

  • For children who are symptomatic and for whom no source case isolate is available, obtain specimens for culture and drug susceptibility testing prior to initiating presumptive therapy for active diseaseFootnote 133

Known source case

  • For children who are symptomatic and for whom a known source case is available, use the culture and susceptibility test results of the known source case to guide therapy (provided there is no possibility of alternative sources)Footnote 133

First-line treatments

  • Unless contraindicated, empiric first-line treatments are typically comprised of:Footnote 133
  • Isoniazid (INH)
  • Rifampin (RMP)
  • Ethambutol (EBM) and
  • Pyrazinamide (PZA)
  • For medication dosages in children, see Table 6 in Appendix J, Section A of this guideline
Asymptomatic children

Presumptive therapy

To prevent the development of active TB, an 8-week course of presumptive therapy for latent tuberculosis

infection (LTBI) is recommended for children under 5 years of age who:Footnote 133

  • Have been exposed to a close contact with active TB
  • Are asymptomatic
  • Have a negative TST

For recommended medication and dosage, see the Latent Tuberculosis Infection (LTBI) section of this guideline.

Negative TSTFootnote 133

Note: It may take 8 weeks after infection for TST to convert positive, during which time the disease may progress to active disease.

  • If the child is asymptomatic, and TST is still negative after 8 weeks, consult with TB specialists or physician/nurse practitioner in consideration of stopping the medication, particularly for immunocompetent children who are 6 months of age and older
Isoniazid (INH) and pyrodoxine (vitamin B6)
  • 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, as well as breastfed infantsFootnote 133
Pyridoxine
  • Pyridoxine PO daily 25 mg
  • (calculate 1 mg/kg/dose; Maximum 25 mg/dose)

Note: Pyridoxine dose of 25 mg per day is sufficient as higher dose may interfere with INH activity.

Children with suspected TB meningitis

For children in whom TB meningitis is suspected, an anti-inflammatory such as dexamethasone or prednisone may be initiated by the TB specialists or physician/nurse practitioner.Footnote 133

Ethambutol (EMB)

Ethambutol (EMB) should be discontinued as soon as drug susceptibility testing (DST) result is available indicating that the bacterium is fully susceptible, or if the source case is known to be fully drug-susceptible.Footnote 133

  • Treatment length
    • Treatment length will vary depending on the TB infection sites, prescribed anti-TB medication regimen, disease severity and client risk factorsFootnote 144
  • Initiating TB therapyFootnote 133
    • Initiating TB therapy requires the client to be followed closely to monitor and minimize the risk of toxicity and to ensure that therapy is complete
    • For effective TB treatment, 100% of prescribed doses must be taken
    • DOT is strongly recommended for the full duration of therapy for pediatric clients. Consider alternate methods for DOT (e.g., videoconference) where available
    • When treating TB, the most important element of the treatment is ensuring the actual ingestion of the medication by the child. Children may not tolerate the medication and the existing formulations are not particularly child-friendly
  • Phases of therapy
    • Active disease therapy always consists of multiple drugs for 6 months or longer. Therapy is initiated in two phases:
      • The initial phase, which lasts 2 months
      • The continuation phase, which lasts 4 months or longer
  • Initial phase of treatment (duration: 2 months)Footnote 142
    • In the initial phase of active TB treatment, at least 3 effective medications should be prescribed if the client's infection is fully susceptible:
      • INH
      • Rifampin
      • Pyrazinamide
    • Pyrazinamide (PZA) is the most toxic of the standard first-line drugs and the most common cause of drug-induced hepatotoxicity in clients treated for TB disease
    • Clients at risk of hepatotoxic effects such as those with a history of alcoholism, and/or pre-existing mild to moderate liver dysfunction may not tolerate this agent
    • If drug-resistant infection is suspected or confirmed, expert consultation is strongly advised
  • Continuation phase of treatment (duration: 4 months or longer)Footnote 142
    • Treatment of active TB should have at least 2 effective medications in the continuation phase
    • If TB medications are to be given intermittently (for example, on a schedule of 3 times a week during the continuation phase), then the client must be fully supervised for DOT
    • Prolonging the continuation phase beyond 4 months (in which case the total course of treatment would be beyond 6 months) is recommended in the following circumstances:
    • When there is persistent presence of cavity on the chest x-ray after 2 months or at the end of effective anti-TB therapy
    • When there is persistent smear and/or culture positivity after 2 months of therapy
    • When the child is infected with HIV
    • When the child has a non-respiratory TB infection (i.e., meningeal TB) (for more information on non-respiratory tuberculosis,Footnote 144 refer to Canadian Tuberculosis Standards, 7th edition, Chapter 7, Nonrespiratory Tuberculosis
    • If second-line regimens are required and particularly if drug-resistant TB is identifiedFootnote 146 (for additional information regarding the different types of drug resistance, refer to the Canadian Tuberculosis Standards, 7th edition, Chapter 8, Drug Resistant Tuberculosis
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.

Pyridoxine

Pyridoxine PO daily (calculate 1 mg/kg/dose; Maximum 25 mg/dose)

Note: Pyridoxine dose of 25 mg per day is sufficient as higher dose may interfere with INH activity.

For detailed information on the use of shorter rifampin based regimens for the treatment of LTBI, see Table 4 in Canadian Tuberculosis Standards, 7th edition, Chapter 6, Treatment of Latent Tuberculosis Infection.

Additional therapeutic options may include rifapentine and INH for a 3 month course.

Monitoring and follow-up

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Monitoring

If administering an agent with risk of anaphylaxis, monitor the client closely for 30 minutes.

Follow-up

  • Follow-up at least monthly during active TB treatment to assess for adherence, response to treatment and enquire about adverse eventsFootnote 142
  • Response to treatment should be gauged clinically, radiographically and microbiologicallyFootnote 142
  • Microbiologic monitoring is considered the most reliableFootnote 142
  • Consult provincial/territorial policies and procedures for additional guidance
  • Repeat sputum cultures are not necessary if the child is improving clinicallyFootnote 133
  • For adolescents or older children with adult-type disease, follow-up sputum examinations should be performed in the same way as for adults (for more information, see)
  • Chest x-ray 2 months into treatment is recommended to rule out extension of diseaseFootnote 133
  • Liver function tests and the client's weight should be checked regularly, as per physician/nurse practitioner direction
  • If any changes in weight are noted during subsequent follow-up visits, consult with physician/nurse practitioner to ensure medications are adjusted appropriately based on weightFootnote 133
  • Follow-up at least 1 year after treatment is completedFootnote 133
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.

Appendix J

Section A: Supplemental clinical management information

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
Reverse contact tracingFootnote 133
  • Reverse contact tracing involves a vigorous search for the source case
  • Although most source cases are found among adolescent or adult household contacts of the child, other source cases are found among adolescent or adult non-household contacts, such as babysitters and other caregivers either in or outside the household
  • Molecular characterization of M.tuberculosis isolates by genotyping can lead to identification of previously unrecognized source case
  • If the child is hospitalized, it is advisable to screen adolescent or adult visitors for evidence of active TB
Tuberculin skin test and interferon gamma release assay in children
Table 5 - Recommendations for using the TST and IGRA in ChildrenFootnote 132
Test Recommended population
TST preferred (IGRA acceptable) Children < 5 years of age
IGRA preferred, where available (TST acceptable) Children ≥ 5 years of age who have received BCG vaccine
Children ≥ 5 years of age who are unlikely to return for a TST reading

For additional information on the TST and IGRA see.

Table 6 - Dosages for first line antituberculosis medications in childrenFootnote 133
Medications Usual Daily Doses
Isoniazid 10 mg/kg, maximum 300mg
Rifampin 15 mg/kg, maximum 600 mg
Pyrazinamide 35 mg/kg, maximum 2000 mg
Ethambutol 20 mg/kg, maximum 1600 mg
Monitoring for adverse events to antituberculosis therapy
Table 7 - Possible adverse events of first-line antituberculosis therapyFootnote 142
Medications Common Adverse Events Uncommon but Important Adverse Events
Isoniazid Rash, hepatitis, neuropathy Central nervous system toxicity, anemia
Rifampin Drug interactions, rash Hepatitis, flu-like illness, neutropenia, thrombocytopenia
Pyrazinamide Hepatitis, rash, arthralgia Gout
Ethambutol Eye toxicity Rash
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
Indications for BCG vaccination
  • BCG vaccination is currently recommended in high-incidence communities for infants in whom there is no evidence of HIV infection or immunodeficiency
  • If vaccination is delayed beyond 6 months of age, a TST should be done and documented as negative before vaccination
  • For infants aged between 2 and 6 months, an individual assessment of the risk and benefit of TST prior to BCG vaccination is indicated
  • For more information on the BCG, see the Canadian Immunization Guide: Part 4 – Active Vaccines Bacille Calmette Guérin (BCG) Vaccine
Contraindications for BCG vaccination
  • Immune deficiency diseases, including congenital immunodeficiency, HIV infection, altered immune status due to malignant disease and impaired immune function secondary to treatment with corticosteroids, chemotherapeutic agents or radiation
  • Infants:
    • HIV-positive status of mother
    • Family history of immunodeficiency
  • Individuals with extensive skin disease and burns
  • Positive TST result
  • Persons with severe acute illness (persons with minor or moderate acute illness (with or without fever) may be vaccinated)

Section B: Supplemental resources

Provincial/territorial guidelines
Alberta

Alberta Health and Wellness. Tuberculosis Prevention and Control Guidelines for Alberta.

British Columbia

BC Centre for Disease Control. Chapter 4: Tuberculosis Manual.

Manitoba

Public Health Branch. Communicable Disease Control - Manitoba Tuberculosis Protocol.

Newfoundland and Labrador

Department of Health and Community Services. Guideline for Preventing the Transmission of Mycobacterium tuberculosis across the Continuum of Care (PDF Version, 3.35 Mb, 126 pages).

Northwest Territories

Northwest Territories Health and Social Services. NWT Tuberculosis Manual. Available by selecting HSS Professionals (staff only) and entering authorized username and password.

Nova Scotia

Nova Scotia Department of Health and Wellness. Communicable Disease Prevention and Control, Tuberculosis.

Ontario

Ontario Ministry of Health and Long-Term Care. Ontario Public Health Standards: Tuberculosis Prevention and Control. (PDF Version, 450 Kb, 11 pages)

Saskatchewan

Government of Saskatchewan. Tuberculosis.

Yukon

Yukon Health and Social Services. TB Control Manual.

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).

Meningitis

Overview

Please refer to provincial/territorial guidelines for Meningitis where available.

Meningitis is a medical emergency. All clients with suspected meningitis must be medically evacuated as soon as possible. Consult with a physician/nurse practitioner immediately.

Meningitis is inflammation of the meningeal membranes of the brain or spinal cord. Although viral meningitis is the most common type of meningitis, the initial symptoms are similar to those of bacterial meningitis, and clinical features cannot reliably differentiate viral from bacterial meningitis.Footnote 148Footnote 149 The incidence of bacterial meningitis has decreased significantly in Canada following widespread pneumococcal, Haemophilus influenza type b (Hib) and meningococcal vaccination. A high index of suspicion for meningitis must be maintained in infants and children presenting with any signs of sepsis, particularly if there is no focus of infection nor altered mental status.Footnote 150

Causes

Bacteria
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

Transmission, incubation period, communicability

  1. influenzae, N. meningitidis and S. pneumoniae are the most common causative bacteria beyond the newborn period and are all respiratory pathogens. For more information, see Table 8.
Table 8 - Transmission, incubation period and communicability of bacterial causes of meningitis
Causative Bacteria Transmission Incubation Period Communicability
H. influenzae Spread person-to-person by:
  • Direct contact or
  • Respiratory droplets produced by coughing and sneezing.Footnote 154
Unknown; may be as little as a few daysFootnote 154
  • As long as organisms are present
  • Non-communicable within 24 to 48 hours after appropriate antibiotic treatment.Footnote 155
N. meningitidis Spread person-to-person by:
  • Exchanging respiratory and throat secretions during close or lengthy contact
  • Exchanging saliva (the most common transmission method)
  • Transmission is highest among household contactsFootnote 156Footnote 157.
2 to 10 daysFootnote 158
  • 7 days before onset of symptoms until organism is no longer present in secretions from nose and mouth
  • Non-communicable within 24 hours after appropriate antibiotic treatmentFootnote 159
  • The communicability of N. meningitidis is generally limited.Footnote 158
S. pneumoniae
  • Spread person- to- person through:
  • respiratory droplets Footnote 160
1 to 3 daysFootnote 160 Unknown; presumably as long as the organism appears in respiratory secretionsFootnote 160

Assessment

Medication review: Review current medications, including over-the-counter, complementary and alternative medicines, as well as any chemical or substance intake that may impact management.

Allergy history: Screen for medication, latex, environmental or other allergies and determine approximately when and what type of reaction occurred.

Risk factors

Bacterial
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

History of present illness

Review risk factors and collect history of present illness.

Infants

Infants often present with non-specific signs and symptoms:

Older children

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

Social

Known contact with someone with meningitisFootnote 150

Physical findings

Perform a full physical examination (including a full head, neck and neurological examination) using the IPPA approach.

Note: Head circumference should be measured in children younger than 18 months old.Footnote 162

Differential diagnosis

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

ComplicationsFootnote 165

  • Impaired mental status
  • Cerebral edema and increased intracranial pressure
  • Seizures
  • Focal deficits, e.g. hearing loss, cranial nerve palsies, hemiparesis or quadriparesis
  • Ataxia
  • Cerebrovascular abnormalities
  • Neuropsychologic impairment, developmental disability
  • Subdural effusion or empyema
  • Hydrocephalus
  • Hypothalamic dysfunction
  • Septic shock
  • Death

Diagnostic tests

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Diagnostic test selection is based on client history, risk factors, physical examination findings and test availability. Consult accepting facility to determine if laboratory tests are required pre-transfer.

Laboratory

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

Blood cultures
  • Obtain 2 blood samples for cultureFootnote 162 before initiating antibiotic therapy for suspected cases of meningitis. This increases the likelihood of isolating the organism
  • Adequate blood volume is very important in detecting bacteremia. The optimal blood volume for blood cultures varies by age

For additional information regarding blood culture collection, including required volumes, see provincial/territorial laboratory guidelines.

Additional lab investigations
X-ray

Chest X-ray as clinically indicatedFootnote 163

Management

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Goals of treatment

  • Treat the infection
  • Prevent/treat complications
  • Prevent spread of infection

Non-pharmacological interventions

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).

Pharmacological interventions

In addition to consulting a physician/nurse practitioner, review the drug monograph, the FNIHB Nursing Station Formulary or provincial/territorial formulary before initiating treatment.

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.

Immediate fluid resuscitation for child with signs of dehydration or shock at presentation
  • For children with evidence of dehydration or shock, consult with a physician/nurse practitioner immediately
  • Treat shock with rapid IV/IO 0.9% sodium chloride bolus of 20 mL/kg infused over 10-20 minutes
  • Repeat bolus as needed up to 4 times in patients without improvement and NO signs of volume overloadFootnote 168Footnote 169
  • Manage fluid on an ongoing basis following fluid resuscitation in consultation with the physician/nurse practitioner

For hourly maintenance fluid requirements, see Table 9 in Appendix K, Section A of this guideline.

Fluid management for child with signs of raised intracranial pressure (ICP) or generalized edema

Consult with a physician/nurse practitioner immediately for children with signs of raised ICP, which include:

  • GCS score less than 9 or a drop in GCS score of 3 or more
  • Relative bradycardia and hypertension
  • Focal neurological signs
  • Abnormal posture or posturing
  • Unequal, dilated or poorly responsive pupils
  • Papilledema
  • Bulging fontanelle
  • Unresponsiveness to painful stimuli
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
Empiric antibacterial regimen for neonates (infants < 1 month)Footnote 175

Ampicillin plus cefoTAXime

(See dosages below)

  • Neonates ≤ 7 days
    • Ampicillin
      • For infants weighing less than or 2 kg: ampicillin 100 mg/kg/day IV divided q 12h
      • For infants weighing more than 2 kg: ampicillin 150 mg/kg/day IV divided q 8h
      • If group B streptococcus (GBS) is suspected: ampicillin 200 mg/kg/day IV divided q 8h

      PLUS

    • cefoTAXime (Claforan)
      • For infants weighing less than 2 kg: cefoTAXime 100 mg/kg/day IV divided q 12h
      • For infants weighing 2 kg or more: cefoTAXime 100-150 mg/kg/day IV divided q 8h
  • Neonates > 7 days
    • Ampicillin
      • For infants weighing less than 1.2 kg: ampicillin 100 mg/kg/day IV divided q 12h
      • For infants weighing between 1.2 - 2 kg: ampicillin 150 mg/kg/day IV divided q 8h
      • For infants weighing more than 2 kg: ampicillin 200 mg/kg/day IV divided q 6h
      • If group B streptococcus (GBS) is suspected: ampicillin 300 mg-400 mg/kg/day IV divided q 4-6 h

      PLUS

    • cefoTAXime (Claforan)
      • For infants weighing between 1.2-2 kg: cefoTAXime 150 mg/kg/day IV divided q 8h
      • For infants weighing more than 2 kg: cefoTAXime 150-200 mg/kg/day IV divided q 6-8h
Empiric antibacterial regimen for children four weeks and older 16

Vancomycin plus cefoTAXime (for children 3 months of age or less) or Vancomycin plus cefTRIAXone (for children more than 3 months of age)

(See dosages below)

  • vancomycin 60 mg/kg/day IV divided q 6 h; maximum dose 4g/day

PLUS EITHER:

  • cefoTAXime 300 mg/kg/day IV q 6 h; maximum dose 8 g/day to 12 g/day

    or

  • cefTRIAXone 100 mg/kg IV at diagnosis; repeat the dose of 100 mg/kg IV at 12 h and then 100 mg/kg/day IV divided q12h; maximum dose 4 g/day. (Intramuscular route can be used if intravenous route is not immediately available)

If Listeria monocytogenes is suspected because of an underlying immunodeficiency, IV ampicillin should be added.

Ampicillin
  • ampicillin 300 mg/kg/day IV divided q 4 h to 6 h; maximum dose 12 g/day

For clients who cannot be given either vancomycin or a third-generation cephalosporin due to a contraindication (e.g., allergies), expert infectious diseases opinion should be sought. In all clients, treatment should continue until susceptibility results return.

Anti-inflammatory therapy

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

Infants and children greater than 2 months of age:

Dexamethasone

  • Dexamethasone IV q6h (calculate 0.6 mg/kg in 24 hours divided q6h; maximum 20 mg/dose)
  • Administer first dose of dexamethasone immediately before or within 30 minutes after the first dose of antibioticFootnote 163
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.

AcetaminophenFootnote 170
  • Acetaminophen 10 to 15 mg/kg/dose PO q4-6h PRN
  • Maximum from all sources: acetaminophen 75 mg/kg/day or 4,000 mg/day, whichever is less
IbuprofenFootnote 170
  • Infants <6 months
    • Limited data available in infants
  • For 6 months to 12 years of age
    • Ibuprofen 5 to 10 mg/kg/dose PO q6-8h PRN
    • Maximum 400 mg/dose*
  • For greater than 12 years of age
    • Ibuprofen 200 to 400 mg PO q4-6h PRN*
  • *Maximum from all sources for all ages:
    • Ibuprofen 40 mg/kg in 24 hours or 1200 mg in 24 hours whichever is less. Under physician/nurse practitioner supervision, daily doses ≤2,400 mg may be used

Monitoring and follow-up

Consult physician/nurse practitioner when practice is outside legislated scope and without authorized delegation.

Monitoring

  • If administering an agent with risk of anaphylaxis, monitor the client closely for 30 minutes
  • Monitor vital signs, including oxygen saturation, as indicated by client's condition
  • Monitor level of consciousness, focal neurologic signs as indicated by client's condition
  • Monitor intake and output

Follow-up

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.

Appendix K

Section A: Supplemental clinical management information

Table 9 - Hourly maintenance fluid requirements
Calculation
  • 4 mL/kg/hour for first 10 kg of body weight
  • Add 2 mL/kg/hour for the next 10 kg of body weight (over the initial 10 kg of body weight)
  • Add 1 mL/kg/hour for each kilogram over 20 kg of body weight
Maximum of 100 mL/hour or 2,400 mL in 24 hours needed for maintenance
Examples
  • For 10 kg child: 10 kg × 4 mL/kg/hour = 40 mL/hour
  • For 15 kg child: (10 kg × 4 mL/kg/hour) + (5 kg × 2 mL/kg/hour) = 50 mL/hour
  • For 25 kg child: (10 × 4 mL/kg/hour) + (10 kg × 2 mL/kg/hour) + (5 kg × 1 mL/kg/hour) = 65 mL/hour
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.

Meningitis caused by haemophilus influenzae
  • In Canada, the Hemophilus influenzae type B (Hib) vaccine has been provided in public programs in all provinces and territories since 1998
  • The type of vaccine and the immunization schedule vary by province; however, the vaccine is usually given at 2, 4, 6 and 18 months of age, along with the DPTP vaccine
  • Due to routine immunization, meningitis caused by H. influenzae is now very rare and primarily occurs in unimmunized or partially immunized children, or in individuals who are immunocompromised. Disease due to other serogroups (e.g., non-B) has been increasing in all parts of Canada, but particularly in Northern populationsFootnote 163
Meningitis Caused by neisseria meningitides (meningococcal meningitis)
  • The incidence of meningococcal disease in children and adults has decreased significantly since the introduction of routine meningococcal serogroup C immunization programsFootnote 163
  • The impact of the introduction of the quadrivalent conjugated A, C, Y and W meningococcal vaccine for adolescents is not yet knownFootnote 163
Meningitis caused by streptococcus pneumoniae (pneumococcal meningitis)
  • The incidence of pneumococcal meningitis has also decreased significantly in all age groups since the introduction of routine vaccination against S pneumoniaFootnote 163
  • Publicly funded infant immunization programs against S pneumonia were available in all provinces and territories by 2005
  • As of 2011, the heptavalent conjugate vaccine (PCV7) has been replaced by a 13-valent pneumococcal conjugate vaccine (PCV13) in all provinces and territoriesFootnote 163
Chemoprophylaxis for household contacts
Meningitis caused by haemophilus influenzaeFootnote 172
  • Chemoprophylaxis is not required for household contacts of cases of invasive Hib infection when the contacts have completed a vaccine series against Hib. When contacts less than 48 months of age are incompletely immunized, consult with local public health officials
Meningococcal meningitis
  • Offer chemoprophylaxis to all persons having close contact with a case of IMD from 7 days before onset of symptoms in the case to 24 hours after onset of effective treatment, regardless of their immunization statusFootnote 173
  • Close contacts of individuals with meningococcal infections have an increased risk of developing invasive meningococcal disease (IMD); this risk is greatest for household contacts
  • The following individuals (regardless of immunization status) should receive chemoprophylaxis and, if the meningococcal serogroup identified in the case of IMD is vaccine preventable, should also be considered for immunoprophylaxis:
    • Household contacts of a case of IMD
    • Persons who share sleeping arrangements with a case of IMD
    • Persons who have direct nose or mouth contamination with oral or nasal secretions of a case of IMD (e.g., kissing on the mouth, shared cigarettes, sharing bottles)
    • Children and staff in contact with a case of IMD in child care or nursery school facilities
  • The following individuals should receive chemoprophylaxis only, immunoprophylaxis is not necessary:
    • Health care workers who have had intensive unprotected contact (without wearing a mask) with infected patients (i.e., intubating, resuscitating or closely examining the oropharynx)
    • Airline passengers sitting immediately on either side of the case (but not across the aisle) when the total time spent aboard the aircraft was at least 8 hours
    • Close contacts of a case of IMD due to serogroups not present in meningococcal vaccines, or when the serogroup in the index case has not been determined
    • Previously vaccinated close contacts who do not meet the criteria for re-vaccination as outline above
Chemoprophylaxis

Offer chemoprophylaxis for contacts of cases with meningococcal meningitis using ONE of the following options:Footnote 174

Rifampin
  • Infants less than 1 month old:
    • Rifampin PO BID for 2 days (calculate 5 mg/kg/dose)
  • Infants and children 1 month old and greater:
    • Rifampin PO BID for 2 days (calculate 10 mg/kg/dose; maximum 600 mg/dose)
  • Adults
    • Rifampin 600 mg PO BID for 2 days

      or

    • Ciprofloxacin 500 mg PO for one dose
cefTRIAXone
  • Adolescents less than 12 years of age:
    • cefTRIAXone 125 mg IM for one dose
  • Adolescents and adults greater than/equal to 12 years of age:
    • cefTRIAXone 250 mg IM for one dose
  • Pregnant women:
    • Note: cefTRIAXone is the agent of choice in pregnant women. Neither rifampin nor ciprofloxacin are recommended in pregnancy.
Pneumococcal meningitis

Chemoprophylaxis is not required post-exposure.

Section B: Supplemental resources

Provincial/territorial guidelines
Alberta

Alberta Health and Wellness. Public Health Notifiable Disease Management Guidelines: Meningococcal Disease, Invasive (IMD).

British Columbia

BC Centre for Disease Control. Communicable Disease Control Manual: Meningococcal Disease.

Manitoba

Public Health and Primary Health Care. Communicable Disease Management Protocols: Invasive Meningococcal Disease (Neisseria meningitidis).

Newfoundland and Labrador

Department of Health and Community Services.Newfoundland and Labrador Disease Control Manual: Section 3 Diseases Preventable by Routine Vaccination.

Northwest Territories

Northwest Territories Health and Social Services. Communicable Disease Manual. Available by selecting HSS Professionals (staff only) and entering authorized username and password.

Nova Scotia

Nova Scotia Department of Health and Wellness. Nova Scotia Communicable Diseases Manual: Diseases and Conditions: Meningococcal Disease – Invasive (IMD) (PDF Version, 65 Kb, 8 pages).

Yukon

Yukon Health and Social Services. Yukon Communicable Disease Control: Meningococcal Disease (PDF Version, 265 Kb, 22 pages).

Bibliography

The following references and other sources have informed the updating of this Clinical Practice Guideline.

Other sources

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

Canadian Pharmacists Association. Erythromycin (Erythromycin). [Internet] Ottawa, ON: e-Therapeutics; 2009 [cited 2015 July 7t]. Available with authorized username and password.

Erythromycin. [Internet] Hudson, OH: Lexi-Comp. Inc.; 2015 [cited 2015 July 7]. Available with authorized username and password.

Canadian Pharmacists Association. Penicillin G. [Internet] Ottawa, ON: e-Therapeutics; 2012 [cited 2015 July 7]. Available with authorized username and password.

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

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

Penicillin G. [Internet]. Hudson, OH: Lexi-Comp. Inc.; 2015 [cited 2015 July 7]. Available with authorized username and password.

Erythromycin. In: Chen, J, Lau, E, editors. 2015 Drug Handbook and Formulary. 33rd ed. Toronto, ON, Hudson, OH: The Hospital for Sick Children, Lexi-Comp Inc.; 2015, p.123.

Penicillin G benzathine. In: Chen, J, Lau, E, editors. 2015 Drug Handbook and Formulary. 33rd ed. Toronto, ON, Hudson, OH: The Hospital for Sick Children, Lexi-Comp Inc.; 2015, p.215.

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

Canadian Pharmacists Association. Azithromycin (Zithromax). [Internet] Ottawa, ON: eTherapeutics; c2014. Available with authorized username and password.

Canadian Pharmacists Association. Clarithromycin (Biaxin). [ Internet] Ottawa, ON: Canadian Pharmacists Association; 2014. Available with authorized username and password.

Canadian Pharmacists Association. Sulfamethoxazole-trimethoprim (Septra). [Internet] Ottawa, ON: Canadian Pharmacists Association; 2013. Available with authorized username and password.

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

Azithromycin. [ Internet] Hudson, OH: Lexi-Comp. Inc.; 2015 [cited 2015 April 23]. Available with authorized username and password.

Clarithromycin. [ Internet] Hudson, OH: Lexi-Comp. Inc.; 2015 [cited 2015 April 23]. Available with authorized username and password.

Sulfamethoxazole-trimethoprim. [ Internet] Hudson, OH: Lexi-Comp. Inc.; 2015 [cited 2015 April 23]. Available with authorized username and password.

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

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

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

Canadian Pharmacists Association. Amoxicillin. Compendium of therapeutic choice: Canada's Trusted Reference for primary care therapeutics (CTC 7). [Internet] Ottawa, ON: e-Therapeutics; 2014 [cited 2015 July 6]. Available with authorized username and password.

Canadian Pharmacists Association. Cephalexin (Cephalexin). [Internet] Ottawa, ON: e-Therapeutics; 2009 [cited 2015 May 6].

Canadian Pharmacists Association. Clindamycin (Dalacin C). [Internet] Ottawa, ON: e-Therapeutics; 2014 [cited 2015 May 6].

Canadian Pharmacists Association. Penicillin G. [Internet] Ottawa, ON: e-Therapeutics; 2012 [cited 2015 May 6].

Canadian Pharmacists Association. Penicillin V. [Internet] Ottawa, ON: e-Therapeutics; 2012 [cited 2015 May 6].

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

Amoxicillin. [Internet] Hudson, OH: Lexi-Comp. Inc.; 2015 [cited 2015 July 6]. Available with authorized username and password.

Cephalexin. [Internet] Hudson, OH: Lexi-Comp. Inc.; 2015 [cited 2015 July 6]. Available with authorized username and password.

Clindamycin. [Internet] Hudson, OH: Lexi-Comp. Inc.; 2015 [cited 2015 July 6]. Available with authorized username and password.

Penicillin G. [Internet] Hudson, OH: Lexi-Comp. Inc.; 2015 [cited 2015 July 6]. Available with authorized username and password.

Penicillin V. [Internet] Hudson, OH: Lexi-Comp. Inc.; 2015 [cited 2015 July 6]. Available with authorized username and password.

Penicillin. In: Chen J, Lau E, editors. 2015 Drug Handbook and Formulary. 33rd ed. Toronto, ON, Hudson, OH: The Hospital for Sick Children, Lexi-Comp Inc.; 2014. p. 38.

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

Canadian Pharmacists Association. Pyridoxine (Vitamin B6). [Internet] Ottawa, ON: e-Therapeutics; 2012. Available with authorized username and password.

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

Pyridoxine. [Internet] Hudson, OH: Lexi-Comp. Inc.; 2015. Available with authorized username and password.

Canadian Pharmacists Association. Ampicillin. [Internet] Ottawa, ON: e-Therapeutics; 2008 [cited 2015 August 31]. Available with authorized username and password.

Canadian Pharmacists Association. Cefotaxime (Claforan). [Internet] Ottawa, ON: e-Therapeutics; 2014 [cited 2015 August 31]. Available with authorized username and password.

Canadian Pharmacists Association. Ceftriaxone. [Internet] Ottawa, ON: e-Therapeutics; 2015 [cited 2015 August 31]. Available with authorized username and password.

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

Canadian Pharmacists Association. Corticosteroids: Systemic. [Internet] Ottawa, ON: e-Therapeutics; 2011 [cited 2015 August 31]. Available authorized username and password.

Canadian Pharmacists Association. Vancomycin (Vancomycin). [Internet] Ottawa, ON: e-Therapeutics; 2013 [cited 2015 31 August]. Available authorized username and password.

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

Acetaminophen. [Internet] Hudson, OH: Lexi-Comp. Inc.; 2015 [cited 2015 May 13]. Available with authorized username and password.

Cefotaxime. [Internet] Hudson, OH: Lexi-Comp. Inc.; 2015 [cited 2015 May 13]. Available with authorized username and password.

Ceftriaxone. [Internet] Hudson, OH: Lexi-Comp. Inc.; 2015 [cited 2015 August 31]. Available with authorized username and password.

Dexamethasone. [Internet] Hudson, OH: Lexi-Comp. Inc.; 2015 [cited 2015 August 31]. Available with authorized username and password.

Vancomycin. [Internet] Hudson, OH: Lexi-Comp. Inc.; 2015 [cited 2015 August 31]. Available with authorized username and password.

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