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Using the attached reference article, describe in details the steps followed to investigate an outbreak of varicella in a psychiatric hospital of  Saudi Arabia. 
Archives of Environmental & Occupational Health
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/vaeh20
Investigation of varicella outbreak among
residents and healthcare workers in psychiatric
hospital- Saudi Arabia
Khalid Hamdan Alanazi , Ghada Mohamed Bin Saleh , Hanan Mohamed
Hathout , Hala Roushdi Shiha , Sherine Gouda El Sherbini , Taghreed
Abdulaziz Al Saqer , Mohamed Mashouf Alqahtani & Mervat Mohamed El
Dalatony
To cite this article: Khalid Hamdan Alanazi , Ghada Mohamed Bin Saleh , Hanan Mohamed
Hathout , Hala Roushdi Shiha , Sherine Gouda El Sherbini , Taghreed Abdulaziz Al Saqer ,
Mohamed Mashouf Alqahtani & Mervat Mohamed El Dalatony (2020): Investigation of varicella
outbreak among residents and healthcare workers in psychiatric hospital- Saudi Arabia, Archives of
Environmental & Occupational Health, DOI: 10.1080/19338244.2020.1806775
To link to this article: https://doi.org/10.1080/19338244.2020.1806775
Published online: 24 Aug 2020.
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ARCHIVES OF ENVIRONMENTAL & OCCUPATIONAL HEALTH
https://doi.org/10.1080/19338244.2020.1806775
CASE REPORT
Investigation of varicella outbreak among residents and healthcare workers
in psychiatric hospital- Saudi Arabia
Khalid Hamdan Alanazia, Ghada Mohamed Bin Salehb, Hanan Mohamed Hathoutc , Hala Roushdi Shihad,
Sherine Gouda El Sherbinie, Taghreed Abdulaziz Al Saqerf, Mohamed Mashouf Alqahtanig,h, and
Mervat Mohamed El Dalatonyc
a
Master of Public Health, General Directorate of Infection Prevention & Control, Ministry of Health-Saudi Arabia, Riyadh, Saudi Arabia;
Master of Epidemiology & Biostatistics, General Directorate of Infection Prevention & Control, Ministry of Health-Saudi Arabia,
Riyadh, Saudi Arabia; cFaculty of Medicine, Department of Public Health and Community Medicine, Menoufia University, Shebin ElKom, Egypt; dMicrobiology, General Directorate of Infection Prevention & Control, Ministry of Health-Saudi Arabia, Riyadh, Saudi
Arabia; eClinical Pathology & Microbiology, Infection Prevention & Control Directorate, Riyadh Directorate of Health Affairs, Ministry of
Health-Saudi Arabia, Riyadh, Saudi Arabia; fClinical Laboratory Science General Directorate of Infection Prevention & Control, Ministry
of Health-Saudi Arabia, Riyadh, Saudi Arabia; gHaematopathology Board, King Saud University, Riyadh, Saudi Arabia; hPsychiatric
Hospital, Riyadh, Saudi Arabia
b
ABSTRACT
ARTICLE HISTORY
Background: Outbreak is an infection control challenge in health care setting especially
when it occurs in a special setting as psychiatric hospitals. Objectives: Investigate and
control an outbreak of varicella among patients and healthcare workers (HCWs) in a psychiatric hospital of Saudi Arabia. Methods: A multidisciplinary team of different specialties assigned to assess the situation, confirm the diagnosis, identify the causes and put
an action plan to deal with such a situation. Results: The team investigated the varicella
outbreak as per the Ministry of Health’s (MOH) outbreak guidelines. Multiple risk factors
contributed to this outbreak as the location of the outbreak in a psychiatric hospital,
breaches in the hospital infection control program. Conclusion: Investigation of this outbreak was conducted as per MOH and CDC definitions and guidelines. Outbreak control
plan was instituted and successfully implemented including enforcement of infection
control program, the establishment of an employee health program, basic infection control orientation programs.
Received 10 December 2019
Accepted 29 June 2020
Description of the outbreak
This condition started on the 2nd of December, 2018
in one of psychiatric hospital belongs to Riyadh
Region- KSA, by diagnosis of 5 cases of varicella
among patients and health care workers and that the
situation is likely to be widespread due to large number of exposed patients and health care workers.
According to outbreak management protocol of the
Ministry of Health, the Outbreak team of MOH was
informed around the situation and rapid response was
taken accordingly as follows:
 The outbreak team was formulated by sharing
infection control staff at the 2 levels: – Health
affairs and Ministry of health to investigate and
take control measures of the outbreak.
KEYWORDS
Outbreak; Varicella Zoster
Virus (VZV); Psychiatric
hospital; Healthcare
Workers (HCWs);
Immunization
 The outbreak team communicated with the hospital
to obtain data regarding the actual number of cases
and exposures, line listing, possible risk factors.
 The outbreak team conducted an urgent visit to
the hospital on 3-4 December 2018 to confirm the
situation, evaluate the control measures, and check
the hospital situation regarding the implementation
of infection control practices and the availability of
isolation rooms.
 The preliminary findings regarding cases and index
case are the following:  The total No. of clinically diagnosed cases was 9
cases (6 patients located in the same ward & 3
health care workers serving those patients). The
main clinical findings were itching and skin eruption with the characteristic distribution. Like most
viral infections, the diagnosis of chickenpox depends
CONTACT Mervat Mohamed El Dalatony
mervat.moh.abd@gmail.com
Faculty of Medicine, Department of Public Health and Community Medicine,
Menoufia University, Shebin El-Kom, Egypt.
Present address: Executive Director of Eradah Complex and Mental Health, Riyadh, Saudi Arabia.
ß 2020 Taylor & Francis Group, LLC
2
K. H. ALANAZI ET AL.
Table 1. Line list of cases arranged in chronological manner.
Case No.
Category (patient/ HCW)
1
2
3
4
5
6
7
8
9
Patient
Nurse
Nurse
Patient
Patient
Patient
Physician
Patient
Patient
Date of detection
17/11/2018 (Index case)
25/11/2018
30/11/2018
02/12/2018
02/12/2018
03/12/2018
03/12/2018
03/12/2018
04/12/2018
on the clinical picture of the characteristic rash that
appears on the chest, back, and face, and then spread
over the entire body that turns into itchy, fluid-filled
blisters that eventually turn into scabs. It usually takes
around one week for all the blisters to become scabs.
Data presentations
The infection control team of the hospital prepared a line
list of all exposed personnel (cases, healthcare workers,
contacts) for post-exposure follow up and vaccination.
Definition of exposure: – Face-to-face contact for
more than 5 minutes with an infected person without
wearing a respirator or direct contact with vesicle
fluid without wearing gloves used as a definition of
staff exposure. The number of cases against time plotted on the epidemic curve to study the pattern of
spread of disease and distribution of cases by time
together serve as a monitoring tool of new cases. The
distribution of exposures among health care workers
displayed as number and percent.
Magnitude of the outbreak
This outbreak presented in the form of chickenpox cases
and unprotected exposures for other patients and health
care workers dealing with them. Table 1 highlights the
distribution of the outbreak between both patients &
healthcare workers. There were 9 clinically confirmed
cases (6 patients & 3 HCWs). Figure 1 present the
Epidemic curve of the case distribution by time. Of the
confirmed 146 exposures, 96 were exposures of health
care workers (HCWs) mainly nurses and housekeepers
& 50 exposures among patients (Table 2).
Main findings that contributed to
the outbreak
1.
Inadequate knowledge of Infection control staff
regarding the disease transmission and infection
control precautions.
2.
3.
4.
5.
6.
7.
8.
IC Measures taken
Outcome
Isolation
Isolation
Isolation
Isolation
Isolation
Isolation
Isolation
Isolation
Isolation
Improved
Improved
Improved
Improved
Improved
Improved
Improved
Improved
Improved
Inadequate knowledge regarding outbreak investigation protocol
Patients sharing common ward, share activities,
and moving freely in the ward.
Lack of data regarding staff vaccination and
immunity to varicella and other diseases.
Lack of hand hygiene supply as alcohol hand rub
together with improper distribution, and low
hand hygiene compliance of staff
Poor staff compliance with the use of personnel
protective equipment.
No proper environmental cleaning and disinfection
No available isolation facilities in the hospital
Actions taken by the team to control
the outbreak
1.
2.
3.
4.
5.
6.
7.
8.
Assign a team in the hospital to be responsible
for implementation of the control measures and
follow up the situation.
Assign a special ward for isolation of cases
together with dedicated staff for isolation ward
Review of cases and exposures to estimate the
magnitude of the outbreak
Support the hospital with High Efficiency
Particulate Filters (HEPA) filters device borrowed from other hospitals in the region as a
substitute to negative pressure isolation room.
Recommendations was taken to vaccinate all
possible cases of exposed HCWs and patients (if
there was no contraindication).
Staff orientation regarding chickenpox disease,
mode of transmission and nature of the virus.
Training of the staff regarding proper hand
hygiene and use of personal protective equipment together with providing adequate infection
control supply as alcohol hand rub (pocket size),
Personal Protective Equipment especially, N95
Training of IC staff on the proper way of investigation of outbreak and data collection.
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3
Figure 1. Epidemic curve for varicella outbreak in 2018.
Table 2. Distribution of exposed staff was as follows: -.
Job category
No.
%
Doctors
Nurses
Housekeepers
Laundry
Total
20
38
31
5
96
20.8
39.6
32.3
5.3
100
Nurse profession was the job category with highest exposure rate (39.6%).
9.
10.
Training of housekeepers regarding proper
cleaning and disinfection of different environmental surfaces.
Continuous follow up until no new cases appear
and the situation is over.
Discussion and comparison with literatures
Varicella (chickenpox) is a highly contagious disease
that causes febrile rash illness resulting from primary
infection by varicella-zoster virus (VZV).1 Person to
person transmission of varicella occurs due to direct
contact with persons with either varicella or herpes zoster (shingles) or inhalation of infected respiratory secretions. The incubation period for varicella ranges from
10–21 days. The risk of transmission is highest in pediatric patients, and seronegative adult patients and HCWs
are also at high risk for acquisition.2 The first step in
the prevention of healthcare-associated transmission of
VZV is to minimize the number of susceptible HCWs.3
Many similar outbreaks reported to psychiatric health
care facilities had occurred due to bad health behaviors.4
The aim of this work is to describe the investigations
and control measures that were implemented to contain
an outbreak of varicella-zoster infection in one of the
psychiatric hospitals of KSA.
This psychiatric hospital belonging to the middle
region–Saudi Arabia reported an outbreak, of varicella-zoster virus (VZV) infection among patients and
health care workers. The outbreak presented in the
form of cases and unprotected exposures for both
patients and HCWs. This situation is multifactorial.
First is the nature of patients with bad health behaviors, difficult to control them, and/or to implement
infection control measures and isolation precautions.
In addition, they often lack the chance to receive
medical services including the VZV immunization
program. Also, lack of accurate data regarding staff
immunity and exposure risk, lack of knowledge
among staff regarding varicella transmission and risk
of exposures and control measures, weak infection
control program with inadequate infection control
supply as alcohol-based hand rub and personal protective equipment, poor implementation of infection
control and isolation precautions, in addition to lack
of airborne negative pressure isolation rooms recommended for airborne infections as varicella. Similar
attributes of outbreaks in psychiatric hospitals were
detected in other studies.5,6 Varicella outbreak was
diagnosed in residential facility for adults with intellectual disability as there were eleven cases among 70
residents and 2 among 145 staff.7 Many other infectious diseases outbreaks were reported in psychiatric
hospitals.8–11 Even in the era of 2019 novel coronavirus disease (COVID-19) pandemic, an outbreak
among psychiatric patients involved at least 50 inpatients with psychiatric disorders and 30 mental health
professionals in a major psychiatric hospital in
Wuhan, Hubei province, China. This condition attributed to unhealthy lifestyle associated with mental illness, the suboptimal health status of hospitalized
patients with major psychiatric disorders may render
them more vulnerable to the COVID-19 pneumonia
and its complications and also most psychiatrists do
not receive adequate training in the prevention and
treatment of infectious diseases.12,13
4
K. H. ALANAZI ET AL.
The management team of this outbreak strongly
recommend and implement multiple interventions for
prevention and control of the situation based on
approved references. Such measures included strict
implementation of standard precautions, isolation of
patients until all lesions are crusted, screening of all
exposed to assess their immunity to VZV, ensure the
proper cleaning & disinfection of all environmental
surfaces. The team also recommended a continued
search for additional cases and exposures. Cases that
occur within at least one incubation period
(10–21 days) of the previous case patient considered as
a part of the outbreak, also, Active surveillance was
continue for two full incubation periods (42 days) after
the rash onset of the last identified case-patient to
ensure that the outbreak has ended according to CDC
recommendations.14 The susceptible staff was excluded
from the care of affected patients. Airborne and contact
precautions were applied to all patients with varicella.15
All these measures helped to control the situation rapidly and no new cases were diagnosed.
Learned lessons
The main lessons from this outbreak is that implementation of an effective infection control program in psychiatric hospital is mandatory and can contribute to
prevention and control spread of any infectious diseases’
outbreaks even newly emerging diseases as COVID19.
Screening and early isolation of suspected infectious
patients limits transmission and occurrence of secondary
cases. Effective training programs for staff, implementation of employee health program with pre-employment
screening and immunization, and observation of staff for
proper implementation of infection control measures
including hand hygiene, proper use of PPE, proper environmental cleaning and disinfection together with effective
management of infection control supply and resources to
maintain safe and quality healthcare services.
Acknowledgment
 Informed consent: informed consent has been taken
from involved HCWs while patients are not eligible for
consent, but all patients’ data and information were kept
confidential in secured computerized files.
 Registry and the Registration No. of the study/Trial:
N/A
 Animal Studies: N/A
Conflict of interest
N/A
Funding
No funding received for this work from any organization,
and all authors approved the final statement.
ORCID
Hanan Mohamed Hathout
http://orcid.org/0000-00034833-4803
Mervat Mohamed El Dalatony
http://orcid.org/00000002-2399-439X
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We appreciate and acknowledge the infection control team
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Disclosure
6.
 Ethical approval: the manuscript was approved by the
ethical committee (Institutional Review Board) IRB log
number:19-582E
7.
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