Respiratory illnesses (including SARS-CoV-2/COVID-19)

Respiratory illnesses

Several different viruses cause respiratory infections, including influenza (A and B), human parainfluenza virus, rhinovirus, adenovirus, respiratory syncytial virus (RSV) and human coronavirus (e.g. SARS and MERS-CoV). Most respiratory viruses spread faster from person to person because they are spread by contact, droplet and airborne routes.

Infectious period

Infectious Diseases Table in the Regional IPC manual briefly outlines common infectious diseases and pathogens and the precautions to prevent their transmission or spread.

High-risk groups/individuals

Groups of individuals at increased risk of complications are those suffering from chronic respiratory illnesses, heart disease, chronic renal failure, diabetes, asplenia/splenic dysfunction and frail elderly individuals with comorbidities. Therefore, a clinical risk assessment is required for those individuals considered high risk, including if protective isolation is required. In addition, unvaccinated or partially vaccinated individuals are at higher risk of infection and severe illness.

High-risk settings

The Hierarchy of Controls can help implement effective controls and reduce the spread of respiratory pathogens in health and care and non-healthcare settings. These are applied in order and are used to identify the appropriate controls.

Safe systems of work outlined in the hierarchy of controls, including elimination, substitution, engineering, administrative controls and personal protective equipment (PPE)/respiratory protective equipment (RPE), are integral to IPC measures.

Risk assessments must be carried out in all areas by a competent person with the skills, knowledge and experience to recognise the hazards associated with respiratory infectious agents. The dynamic risk assessment should include an evaluation of the ventilation in the area, operational capacity, and prevalence of infection/new variants of concern in the local area.

Triaging/assessment of infection risk

Triaging within all healthcare facilities and non-healthcare facilities, e.g., the client’s own home, should continue and be undertaken to enable early recognition of patients with respiratory infectious agents such as influenza or COVID-19. Triage should be undertaken by staff trained and competent in applying clinical case definitions as soon as possible on arrival and used to inform patient placement and what precautions should be implemented. Untrained staff should seek guidance from their managers.

Additional IPC Measures for Respiratory Illnesses

The application of Standard and Transmission as per the Infection Prevention and Control Manual for Northern Ireland should be followed. In addition, appendix 2 of this guidance describes the personal protective equipment (PPE) required when providing direct care for individuals with suspected or confirmed respiratory illness (including SARS-CoV-2/COVID-19).

As a minimum, contact and droplet precautions should be applied when caring for patients with known or suspected respiratory illnesses.  However, in specific circumstances, airborne precautions should also be applied. For example, when performing AGPs, and in high-risk settings or where an unacceptable risk of transmission remains following the application of the Hierarchy of Controls and dynamic risk assessment, it may be necessary to consider airborne precautions for patient/client care in specific situations.

Source control/Mask wearing

Wraing of mask-wearing is a form of source control that can be applied for staff, patients and visitors to prevent the transmission of respiratory infectious agents in health and care settings and in non-healthcare settings where the care is being provided, e.g., client’s home.   

Patients/clients with suspected or confirmed respiratory illness should be provided with a surgical facemask (Type II or Type IIR). Universal masking: the use of facemasks (type II or IIR) in patient-facing clinical areas for staff, patients and visitors (face coverings) and in non-clinical areas (including the client’s own home) should be determined on a risk assessment. This risk assessment will depend on the presence of any respiratory illness.

Facemasks are not required to be worn by suspected or confirmed respiratory illness patients in single rooms unless a visitor enters or the room door is required to remain open. However, patients with suspected or confirmed respiratory illness transferring to another care area should wear a facemask (if tolerated) to minimise the dispersal of respiratory secretions and reduce environmental contamination. Patients should be given a new facemask at least daily or when soiled or damaged.

The requirement for patients to wear a facemask must never compromise their clinical care, such as when oxygen therapy is required or causes distress, e.g., in paediatric/mental health settings.

Non-infectious inpatients are not required to wear a facemask unless this is a personal preference.

Outpatients with suspected or confirmed respiratory illness should wear a facemask/covering, if tolerated, or be offered one on arrival.

Duration of precautions for hospitalised patients

Transmission-based precautions should only be discontinued in consultation with clinicians (consider microbiology/IPC team if symptoms remain or the patient is immunosuppressed). They should consider the individual’s test results (if available) and the resolution of clinical symptoms.

Stepping down TBP’s if the patient is staying in the hospital

Inpatients with respiratory illness, precautions/isolation should continue until the infectious period ends. Advice should be sought from the clinical team depending on what respiratory illness is suspected/confirmed.

This guidance does not apply if there are additional indications for ongoing isolation and transmission-based precautions (MRSA carriage, C. difficile infection, etc.)

Outpatients/primary care

Patients who are known or suspected to be positive with a respiratory pathogen and whose treatment cannot be deferred should receive care from services that can operate in a way that minimises the risk of spread of the virus to other patients.  If required, advice can be sought from Infection Prevention and Control Teams.

Surveillance and monitoring/outbreak management and reporting in inpatient settings

Ongoing surveillance of respiratory illnesses must continue within inpatient healthcare settings, and for hospital/organisation onset cases (staff and patients/individuals) must continue.

Positive cases of COVID-19 identified after admission who fit the criteria for healthcare-associated infection (HCAI) should trigger a case investigation. In addition, an outbreak investigation should be undertaken if two or more cases are linked in time and place.

SARS-CoV-2/COVID-19 is a notifiable organism/disease. 

An outbreak of infection is defined as an incident in which two/more people experiencing a similar illness are linked in time or place, a greater than expected incidence of infection compared to the usual background rate for the particular location, a single case for certain rare diseases or a suspected, anticipated or actual event involving microbial or chemical contamination of food/water.

The aim of an outbreak investigation is to prevent further transmission of infection.

Outbreak management can be found in the N. Ireland Regional IPC Manual.

Appendix 2: Personal Protective Equipment

(required while providing direct care (within 1 meter) for patients with suspected or confirmed respiratory illness)

Before undertaking any procedure, staff should assess any likely blood and body fluid exposure risk and ensure PPE is worn that provides adequate protection against the risks associated with the procedure or task being undertaken.

If there is no direct contact with the patient or their environment, gloves, eye protection and aprons/gowns are not required.

Refer to the Infection Prevention and Control Manual for Northern Ireland for the correct use of PPE.

(1) FRSM can be worn sessionally (includes eye/face protection) if caring for cohorted patients. All other items of PPE (gloves/gown) must be changed between patients and/or after completing a procedure or task.

(2) RPE can be worn sessionally (includes eye/face protection) in high-risk areas where AGPs are undertaken for cohorted patients (see footnote 4). All other items of PPE (gloves/gown) must be changed between patients and/or after completing a procedure or task.

(3) Consideration may need to be given to the application of airborne precautions where the number of respiratory infections requiring AGPs increases and patients cannot be managed in single or isolation rooms.

(4) Where a risk assessment indicates it, RPE should be available to all relevant staff. The risk assessment should include an evaluation of the ventilation in the area, operational capacity, and prevalence of infection in the local area. The Hierarchy of Controls can be used to inform the risk assessment. Staff should be provided with training on correct use.