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									Isolation Policy




                   1
                             Isolation Policy

Contents                                                                 Page
Introduction……………………………………………………………………………                                   3
Policy                                                                      3
Statement………………………………………………………………………………
Scope…………………………………………………………………………………...                                     3
Aim………………………………………………………………………………………                                        3
Evaluation and Monitoring………………………………………………………….                            3
Organisational                                                              4
Responsibilities……………………………………………………………………….
Ward managers………………………………………………………………………..                                  4
Bed Managers…………………………………………………………………………                                    4
Declaring Infection control Outbreaks……………………………………………                      4
Documentation………………………………………………………………………..                                  4
Review………………………………………………………………………………….                                      5
Criteria for Isolation of patients……………………………………………………                      5
Modes of transmission………………………………………………………………                               5
Route of transmission/length of isolation……………………………………….                   6
Isolation facilities within the Nuffield Orthopaedic Centre NHS             7
Trust……….
Cohorting………………………………………………………………………………                                     7
Nursing Management of Infectious Patients…………………………………….                    7
Identification of Patients…………………………………………………………….                          8
Hand Disinfection………………………………………………………………………                                8
Gloves…………………………………………………………………………………...                                    8
Other protective clothing………………………………………………………………                           8
Disposal of infected Linen…………………………………………………………….                          9
Disposal of infected waste……………………………………………………………                           9
Disposal of Sharps……………………………………………………………………                                9
Disinfection of isolation room………………………………………………………..                       9
Management of patients requiring isolation……………………………………                    9
Appendix 1, Procedure for terminal cleans…………………………………….                   11
Appendix 2, Methods of transmission Infection control precautions…..….     12
Appendix 3, Components of Infection Control precautions….……………..           13
Appendix 4, Incubation period for infectious diseases………………….…..           14
Appendix 5, Notifiable diseases……………………………………….………….                       15
References……………………………………………………………………………                                    16




                                                                            2
                                   Isolation Policy

Introduction
1.     In the past, patients who posed an actual or potential risk of infection were
       immediately isolated in single rooms or specialist isolation units. In many cases
       isolation was unnecessary, causing undue distress to the patients concerned, as
       open ward areas can be effective in controlling the spread of infections transferred
       by contact, as long as appropriate precautions are implemented. Currently, the
       demand for Isolation rooms exceeds the number available, so an accurate risk
       assessment needs to be made to ensure correct usage of these facilities.

2.     The use of Standard Precautions should minimise the need for the isolation of most
       patients (see Standard Precautions Policy) as hand decontamination before and
       after patient contact is the single most important measure in preventing the spread
       of infection. The cohorting of infected patients may be used in some circumstances
       under the direction of the Infection Control team. If an open ward area has to be
       used then the nearest the hand wash basin should be used. The clinical and
       nursing staff responsible for the patient should make a risk assessment as to
       whether isolation is necessary, with advice from the Infection Control Team.

Policy Statement
3.    The Trust will:
      3.1   Proactively manage the risk of contagion by staff, patients and visitors, etc. in
            order to provide a safe working environment.
      3.2   Ensure that risk assessments are carried out for Isolation and Cohorting of
            patients. Reference to the trust Dignity and Privacy policy must also be
            undertaken.
      3.3   Provide a simple workable system that allows Managers at all levels to manage
            and communicate throughout the organisation structure the risks faced by staff,
            patients and others as a result of communicable disease.
Scope
4.    This Policy applies to all staff employed by the Nuffield Orthopaedic Centre NHS
      Trust.

Aim
5.    This Policy sets out a framework to provide guidance for staff on how and when to
      isolate patients. Lines of responsibility and accountability for final decision making
      are described within the policy.

Evaluation & Monitoring
6.    Implementation of policies & procedures can only be effective if adequate evaluation
      and monitoring is used to check the system and ensure any shortcomings are
      identified and dealt with. Locally, Managers are responsible for initiating an on-going
      monitoring process within their areas of responsibility.
7.    From an organisation perspective the Hospital Infection Control committee shall be
      responsible for monitoring that this policy and associated Operational Procedures are
      being adhered to, and that appropriate actions are being taken to maintain patient
      safety.


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                                    Isolation Policy

8.      Any breaches to the isolation policy need to be reported using the Trust incident
       reporting system and to the infection control team.

       Compliance with the isolation policy will be formally audited on a three monthly basis
       by the Infection control Team. The recommendations and actions from the audit will
       be reported to the appropriate clinical area.
Organisational Responsibilities
Ward Managers

9.     Ward mangers or team leaders need to inform the Infection Control Team of the
       admission or diagnosis of any patient with an infection that may be spread to other
       patients or staff.

Bed Management

10.    The responsibility for daily bed management decisions rests with the bed manager
       following discussion and advice from medical and nursing staff. When there is a
       specific infection control risk the bed manager seeks advice from the Infection control
       team.

             10.1      A risk assessment is carried out on all patients who require isolation
                       as it may be safer not to isolate them depending on their clinical
                       needs. When there are competing needs for side rooms e.g. end of
                       life care, the infection control team will advise. Any disputes are
                       resolved in consultation with the Infection Control Doctor.

             10.2      The bed manager will seek advice from the infection control team
                       when patients with infection control risks move between clinical
                       areas. It is necessary to prevent patients being inappropriately
                       moved when there is no clinical reason.


Declared Infection Control Outbreaks

11.0    When an outbreak is declared, the responsibility and accountability will rest with the
        Director of Infection, Prevention and Control, Infection control Doctor and the
        Infection Control Team.

Documentation

12.0 The following is documented in patient’s notes:

             12.1      Patient’s infections or suspected infection are clearly described
             12.2      All discussions regarding the need to isolate or cohort the patient.
             12.3      When isolation facilities are full and isolation is the preferred choice
                       of care.
             12.4      When a patient is informed of the type of infection
             12.5      Information and advice given to the patient




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                                     Isolation Policy

Review
 13.0 The infection control team will monitor and update this policy as necessary, to
      reflect substantial changes as a result of recent evidence, or in examples of best
      practice or changes in national advice.
       The Hospital Infection Control Committee will assess this policy annually, to
       determine its effectiveness and appropriateness.

Criteria for Isolation of Patients

14.0   There are two main categories of patient who need to be considered for isolation.

           14.1     Those patients who pose an infection risk to other patients and staff
                    (Source Isolation).

           14.2     Those patients who are at risk of acquiring infection from other
                    patients and staff (Protective Isolation).

15.0   In certain circumstances (following a risk assessment), patients who are not
       diagnosed with a specific infectious disease may be regarded as a potential
       source of infection and should be nursed in a single room until laboratory testing
       has shown there is no risk to other patients.
For example:
           15.1       Diarrhoea of unknown origin
           15.2       Patients from other hospitals or countries where known outbreaks of
                      infection are prevalent. .
           15.3       Fever of unknown origin in patients returning from abroad.
           15.4       Patients with suspected Open Pulmonary TB.
           15.5       MRSA on an elective orthopaedic ward.
           15.6       Chicken pox in an oncology unit.

16. Modes of transmission
   Infection can spread by a number of methods: airborne, droplet, contact and blood-
   borne spread.

   16.1 Airborne transmission occurs by dissemination of droplet nuclei or dust particles
        containing the infectious agent; micro-organisms are therefore dispersed widely
        and over long distances. Special air handling and ventilation are required to
        prevent airborne transmission.
   16.2 Droplet transmission: droplets are generated from the source person primarily
        during coughing, sneezing and talking and are propelled a short distance only;
        hence special ventilation is not required to prevent transmission.
   16.3 Contact transmission is the most important and frequent mode of transmission
        and involves either direct person-to-person contact or indirect contact via a
        contaminated intermediate object.
   16.4 A Blood-borne disease is one that can be spread directly by blood contact
        (inoculation), insect or other vector. Inoculation is prevented by universal or
        standard precautions which should, be applied to all patients.


   Routes of transmission/length of isolation


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                                        Isolation Policy


   Condition or                 Route of          Variable factors e.g. patient            Length of
   Infection                 transmission               susceptibility,                    isolation
                                                         dispersal risk
   Chickenpox (varicella)    Airborne            Ante-natal/Post-natal/Neonatal,         Until spots
                                                 paediatric and ward with immuno -       crusted
                                                 suppressed patients.
   Clostridium difficile     Faeco-oral          Faecal incontinence                     Until diarrhoea
                                                                                         resolved for 48
                                                                                         hrs
   Diarrhoea (infective)     Faeco-oral          Faecal incontinence                     Until diarrhoea
                                                                                         resolved for 48
                                                                                         hrs
   Hepatitis B/ HIV          Blood borne         Avoid inoculation injury with blood     No isolation
                                                 or body fluids                          unless
                                                                                         uncontrolled
                                                                                         bleed risk
   Lice – Head               Contact             No need to isolate patients-avoid       Treat ASAP
                                                 head to head contact                    24hrs after
                                                 - paediatric or non compliant           treatment
                                                 patients
   Lice – Body               Contact             No need to isolate patients             24hrs after
                                                                                         treatment
   Measles                   Airborne            Ante-natal/Post-natal wards             14 days
   Meningitis (undiagnosed   Droplet             Cough NB Staff must wear a              24 hrs with
   or meningococcus)                             surgical face mask when within 3        effective
                                                 foot of the patient until 24 hours of   antibiotic therapy
                                                 effective antibiotic therapy.
   MRSA                      Contact             Skin shedder (e.g. eczema,              Indefinite
   High, medium and low                          psoriasis) or
   risk areas - ICN will                         sputum colonised)
   advice                                        >1 site colonised, (excluding
                                                 sputum), uncovered wound

   Penicillin resistant      Droplet             Cough                                   Until cough
   Streptococci                                  No cough                                resolves
   pneumoniae
   Respiratory Syncytial     Contact & Droplet   Non-epidemic situation                  Until symptoms
   Virus (RSV)                                   Epidemic situation                      resolved
   Salmonella or Shigella    Contact             Faecal incontinence                     Until diarrhoea
                                                                                         resolved for 48
                                                                                         hrs
   Scabies(confirmed)        Contact             Avoid prolonged skin to skin contact    24hrs after
                                                                                         treatment
   Streptococcus groups A    Droplet             Surgical wards                          24 hrs with
   and G                                         Other wards                             effective
                                                                                         antibiotic therapy
   Tuberculosis-MDRTB        Airborne            Refer to TB Policy
   (or high
   probability)/open TB
   VRE                       Contact                                                     Indefinite




17.0 Isolation Facilities within the Nuffield Orthopaedic Centre NHS Trust




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                                   Isolation Policy

            17.1    Single rooms which are attached to the clinical areas to which the
                    patients have been admitted.

            17.2    Two single Negative pressure rooms on the Bone Infection Unit

            17.3    Oxford Radcliffe Hospitals NHS Trust Infectious Diseases Unit (John
                    Warin Ward) at the Churchill, with 4 Negative pressure single isolation
                    rooms.

            17.4    When isolation facilities are full, patients need to be cohorted either
                    into two/four bedded bays. This is dependant on the number of
                    patients who require isolation.

Cohorting

18.0   The cohorting of patients involves grouping patients into bays within wards with the
       same organism (or displaying similar signs and symptoms of Infection) is an
       alternative form of nursing should single room capacity be exceeded. Cohort
       patients should be cared for by designated staff. This is carried out following the
       advice from the infection control team, with reference to the Trust Privacy and
       Dignity policy in relation to single sex bays.

Nursing Management of Infectious Patients

19.0   The Infection Control Team should be informed of the admission or diagnosis of any
       patient with an infection that may be spread to other patients or staff. Some of these
       patients will require isolation and the following risk assessment procedure should be
       used:

             19.1   Identify likely infecting organism from clinical features on presentation

             19.2   Identify mode of transmission

             19.3   Assess level of risk to other patients and healthcare staff

20.0 The appropriate isolation of patients is only one element in an effective infection
     control policy and other measures are equally, if not more, important. These include
     environmental cleaning, gloves, gowns and masks and above all Hand
     Decontamination.




Identification of Patients

21.0   Patients already known to be colonised with MRSA will be flagged on Cerner (CRS)
       to identify the need for Isolation.

22.0   Because patient confidentiality is paramount, an appropriate sign should be used on
       the door of the patient’s room to identify the need for isolation and standard


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                                   Isolation Policy

       precautions. The notice will also give a point of reference should staff or visitors be
       unsure about the precautions needed. These posters are available from the
       Infection Control intranet site.

Hand Disinfection

23.0 Use an alcohol hand rub before and after patient contact when hands are regarded
      as socially clean.

24.0     Use soap and water when hands are visibly soiled with organic matter.

25.0    Use soap and water when caring for patients known or thought to have Clostridium
       difficile (C.diff) diarrhoea.

26.0   An antiseptic liquid soap such as Hibiscrub should be used in high-risk areas
       including some patients in protective isolation. If in doubt, refer to the Hand Hygiene
       policy.

Gloves

27.0 Gloves should be worn in accordance with Standard precautions and especially
when handling:

             27.1    Blood and body fluids
             27.2    Drainage material
             27.3    Other body excreta
             27.4    Handling invasive devices such as drains, catheters, etc
             27.5    Soiled Dressings
             27.6    Equipment that has come into contact with infectious patients
             27.7    Soiled / Infected bed linen

Other Protective Clothing

28.0   Plastic aprons should be worn when there is a possibility of soiling or splashing.
29.0   Goggles or visors should be worn when splashing of the eyes or face could occur.
30.0   Personal respiratory protection must be worn in certain circumstances e.g. when
       nursing patients diagnosed with or suspected of having Infectious Open Pulmonary
       Tuberculosis.



Disposal of Infected Linen

31.0   Personal protective equipment must be worn in accordance with Standard
       precautions.
32.0   Use hot water-soluble red plastic (alginate) bags
33.0   The bags must be only two thirds full and secured.
34.0   The red alginate bags must be transported in the red plastic bags.
35.0   The bags should be labelled with the point of origin.
36.0   Decontaminate hands in accordance with the Hand hygiene policy


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                                   Isolation Policy


Disposal of Infected Waste

37.0   Personal protective equipment must be worn in accordance with Standard
       precautions.
38.0   All infected materials should be placed into Yellow Clinical Waste plastic bags or
       sharps bins as appropriate.
39.0   Where leakage of body fluids is likely, it is necessary to double-bag clinical waste
40.0   The porters should be requested to remove the waste from the wards for immediate
       incineration. Rigid yellow waste bins must be used on the wards for the disposal of
       Catheter bags / Wound drain / Chest drain bottles etc.
41.0   All Yellow Clinical Waste plastic bags must be labelled with place of origin.
42.0   Decontaminate hands in accordance with the Hand hygiene policy

Disposal of Sharps

43.0   The handling and disposal of sharps should be in accordance with the Sharps
       Disposal Policy.
44.0   All sharps must be regarded as hazardous and care should be taken at all times,
       both with appropriate handling and disposal.

Disinfection of Isolation Rooms

45.0   See Appendix 1 "Procedure for Terminal Cleaning of Isolation Rooms"

46.0   The room may be used for another patient once the surfaces have dried.

47.0   In general, there is no necessity to use disposable crockery or cutlery. The hot cycle
       of the dishwasher is adequate for disinfection.

Management Arrangements for Patients Requiring Isolation

48.0   Patients diagnosed with an infectious disease are usually admitted directly onto the
       Bone Infection Unit, Nuffield Orthopaedic Centre NHS Trust, or alternatively onto
       the Infectious Diseases Unit at the Churchill Hospital. (John Warin Ward).

49.0   The movement of infectious patients to departments within the hospital should be
       restricted to those investigations which are essential, e.g. X-ray, endoscopy etc.

50.0   The staff of the receiving department and those involved in transportation of
       patients, such as porters and ambulance crew should be notified if additional
       Infection Control precautions are required. Advice can be sought from the Infection
       Control Team.

51.0   Infectious patients must not be transferred to other wards, other hospitals or other
       institutions of care, e.g. community hospitals, nursing homes etc, without informing
       the admitting institution of the patient’s infection status.

52.0   The discharge of an infectious patient to their own home should be considered if the
       patient is thought to be well enough and has completed their treatment, or can


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                                   Isolation Policy

       continue their treatment in their home setting. Should treatment be continued in the
       home setting, the Community Nursing team must be involved with the discharge
       planning and continued treatment.

53.0   Staff caring for infectious patients should be kept to a minimum and should not be
       moved between wards during their shift to minimise the risks of cross-infection.
       Bank and Agency staff must adhere to the infection control policies and should seek
       clarification from the ward staff or Infection control team if they are unsure of the
       precautions that need to be observed. Bank and Agency staff should not be
       discouraged from caring for Infectious patients.

54.0   Standard precautions should be maintained after the death of all patients.

55.0   When the death of a patient occurs who has been diagnosed with a communicable
       infection that is potentially transmissible to personnel, e.g.:

                         Typhoid and other enteric pathogens
                         Open tuberculosis
                         HIV infection
                         Hepatitis B and C viruses

56.0   After last offices have been performed, the body must be sealed in a leak proof
       cadaver bag on the ward. Cadaver plastic bags can be obtained as stock items
       from Supplies Department. Labels should be attached to the deceased and to the
       outside of the bag stating ‘Danger of Infection’. Porters should be informed that the
       deceased was infectious. Mortuary staff should be informed of the infection. Local
       arrangements should be followed for the care of deceased patients.

57.0   For information and advice contact the Infection Control nurses or if out of hours,
       the Microbiologist on call who can be contacted through the John Radcliffe Hospital
       switchboard (dial 50000 and ask for the On-call Microbiologist).




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                                       Isolation Policy

Appendix 1

Procedure for Terminal Cleaning

Terminal clean - A terminal clean will be requested by a member of the Ward Team when
an infectious patient has being transferred to another area or discharged.

Following a request for a terminal clean, the following procedure should be carried out.
The ward staff must have stripped the bed and emptied the room of all personal
belongings and medical equipment before commencing the terminal clean.

   All areas should be cleaned using Chlor-Clean OR a detergent followed by a Hypochlorite
    solution (Precept solution: 1000 parts per million of chlorine i.e. 4 x 2.5g tablets diluted in 5
    litres of water) wash.
   Ensure thorough cleaning of the Key Areas.

Key Areas:
1. Patient toilet especially seat, flush & door handles.
2. Horizontal surfaces & the floor should be disinfected.
3. Vertical walls should be cleaned to extended arms reach.
4. Bed curtains in the affected areas/Side room must be changed.




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                                   Isolation Policy

Appendix 2
                Methods of transmission-Infection Control Precautions

Conditions                   Pathogens
Standard     All patients                   HIV, Hepatitis B and C
             Blood-borne illnesses
Contact      Diarrhoea                      E.coli 0157
                                            Clostridium difficile
             Skin and soft tissue infection Rotavirus/SRSV
             Antibiotic resistant organisms Scabies
                                            Staphylococcus aureus
                                            Streptococcus group A (adults)
                                            MRSA
                                            ESBL-producers
                                            Herpes simplex virus

Droplet      Meningitis                     Neisseria meningitidis
             Respiratory tract infections   Haemophilus influenzae
             Infectious rashes              Influenza virus, adenovirus
             Miscellaneous                  Diphtheria
                                            Mycoplasma
                                            Whooping cough (pertussis)
                                            Respiratory syncytial virus
                                            Rubella
                                            Streptococcus group A (children)
                                            Mumps

Airborne     Respiratory tract infections   Mycobacterium tuberculosis
             Infectious rashes              Chicken pox (varicella zoster)
                                            Measles




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                                  Isolation Policy

Appendix 3
                    Components of infection control precautions

Standard          Contact                            Droplet              Airborne
Hand              Yes                       Yes                Yes        Yes
decontamination
Gloves            Only if likely to touch   On entering        As         As standard
                  blood, body fluids        room and           standard
                  and contaminated          during care.
                  items

Mask              During procedures         As standard        As         On entering room if
                  likely to cause                              standard   non-immune. Aim
                  contamination with                                      to exclude all non-
                  blood or body fluids                                    immune personnel
                                                                          * **

Eye protection    During procedures         As standard        As         On entering room if
                  likely to cause                              standard   non-immune. Aim
                  contamination with                                      to exclude all non-
                  blood or body fluids                                    immune
                                                                          personnel**

Apron/gown        During procedures         On entering        As         As standard
                  likely to cause           room if contact    standard
                  contamination with        with patient
                  blood or body fluids      anticipated




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                                    Isolation Policy

Appendix 4
                        Incubation periods for infectious diseases
Disease                Incubation       Duration of infectivity
                       period
Chicken pox            13 – 21 days     1 - 5 days before onset of rash, until vesicles
                                        crusted
Measles                7 – 18 days      From start of prodromal illness until 4 days after
                                        onset of rash
Mumps                  12 – 25 days     A week before and up to 9 days after onset of
                                        swelling
Rubella                14 – 23 days     7 days before to 4 days after rash

RSV                    3 – 7 days         3 days before symptoms until asymptomatic

Influenza              1 – 5 days         1 day before until 4 days after onset of symptoms

Whooping cough         7 – 10 days        21 days after onset of paroxysms

Rotavirus              1 – 3 days         From start of symptoms until 5 days after
                                          resolution
Herpes simplex virus   2 – 11 days        Primary infection: 3 – 4 weeks
                                          Secondary infection: 3 – 5 days

Hepatitis A            15 – 50 days       For 7 days after jaundice
Meningococcal          2 – 10 days        For 24 hours after treatment instituted
disease
Scarlet fever          1 – 3 days         Until treatment instituted
Diphtheria             2 – 5 days         If treated-infectious for up to 3 days. Untreated-
                                          up to 28 days.




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                                    Isolation Policy

Appendix 5
                 Diseases notifiable (to Local Authority Proper Officers) under the
                       Public Health (Infectious Diseases) Regulations 1988
A notifiable disease is one that doctors are legally obliged to report to a ‘proper officer’ of
the local authority. Every week the proper officers are required to inform the HPA’s
Communicable Disease Surveillance Centre (CDSC) of totals of cases.

      Acute encephalitis
      Acute poliomyelitis
      Anthrax
      Cholera
      Diphtheria
      Dysentery
      Food poisoning
      Leptospirosis
      Malaria
      Measles
      Meningitis
       meningococcal
       pneumococcal
       haemophilus influenzae
       viral
       other specified
       unspecified
      Meningococcal septicaemia (without meningitis)
      Mumps
      Ophthalmia neonatorum
      Paratyphoid fever
      Plague
      Rabies
      Relapsing fever
      Rubella
      Scarlet fever
      Smallpox
      Tetanus
      Tuberculosis
      Typhoid fever
      Typhus fever
      Viral haemorrhagic fever
      Viral hepatitis
       Hepatitis A
       Hepatitis B
       Hepatitis C
       other
      Whooping cough
      Yellow fever

Leprosy is also notifiable, but directly to the HPA, CfI, IM&T Dept




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                                 Isolation Policy

References

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  4. Schaal KP: Medical and microbiological problems arising from airborne infections in
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  5. Joint Tuberculosis Committee of the British Thoracic Society: Control and
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  6. Department of health: Hospital infection control. Guidance on the control of infection
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  7. Combined working party of BSAC, HIS and ICNA: Revised guidelines for the control
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  8. Caul E O: Small round structured viruses: airborne transmission and hospital
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  9. Gardner P S et al: Virus cross-infection in paediatric wards. BMJ 1973; 2:571-575


  10. Samore M H: Epidemiology of nosocomial clostridium difficile diarrhoea. J Hosp
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  11. Stuart J M et al: Preventing secondary meningococcal disease in health care
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  12. Isolating patients with healthcare-associated infection, A summary of best practice,
      Department of Health, October 2007, gateway ref: 8772.




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