新生兒中重度病房輪狀病毒群聚事件之處理經驗

Management of at Outbreak of Rotavirus in a Neonatal Intermediate Care Nursery in a Children Hospital

北部某兒童醫院新生兒中重度病房於2017年9月11日至9月19日，共有4位病童發生確診或疑似輪狀病毒（Rotavirus）醫療照護相關感染；其中3名輪狀病毒抗原（Rotavirus antigen）檢驗呈陽性，且有時間之連續性。院方立即積極介入處理，包含全區病房環境清潔消毒、工作人員加強每日健康監測通報及照護團隊全面加強濕洗手，並依疾病管制署規定通報地方衛生局「腸胃道腹瀉症狀通報」之群聚事件。後續於9月19日，又新增1名輪狀病毒抗原陽性的病童。為釐清感染源頭及「無症狀孩童」或環境移生情形，針對指標個案及鄰床病人，持續追蹤健康狀況，並進行單位病童全面糞便篩檢輪狀病毒抗原及環境採檢。篩檢共計18人，結果皆為陰性；但在環境採檢中，聚合酶鏈鎖反應鑑定顯示，病室前電腦鍵盤及滑鼠呈現陽性病毒反應，檢出率為14.3％。關於本群突發分析如下：一、該單位病童由醫護團隊全時照護，家屬僅會客時間到院，在人員未確實執行手部衛生情況下，引起交互感染。二、單位轉床頻繁，未落實接觸隔離措施。三、環境清潔部份，清潔人員配製漂白水濃度不足且未確實環境清潔，尤其是電腦鍵盤及滑鼠等高接觸環境。介入處置包括：一、接觸病童前後及接觸周遭環境後，應確實執行手部衛生。二、嚴禁將病童抱離該病室區或任意轉床，採集中照護，以確實落實接觸隔離措施。三、除加強漂白水調配教學外，亦特別提醒落實公共區域用物及環境清潔，尤其電腦鍵盤及滑鼠等，院方並購置漂白水濃度測定計，執行稽核。本次事件後續追蹤至2017年10月2日皆無新增個案。此群聚事件顯示單位同仁未落實「手部衛生」、「接觸隔離」及「環境清潔」等措施，造成病患安全損害及醫院的損失。機構制訂政策規章如何落實，對感染管制人員而言是一大挑戰，除了透過公文公告、電子郵件、教育訓練及會議宣導外，還是得仰賴感染管制人員實地稽核，才能將政策得以落實，避免院內感染群突發的發生。

From September 11 to 19, 2017, there was an outbreak of four patients with rotavirus infection at a Neonatal Intermediate Care Nursery which spread to another neonatal ward (OPNO) in a children's hospital. Initially, of these four patients, three were diagnosed by presence of rotavirus antigens in stool was confirmed via sequencing. After notifying the Department of Health Center of the municipal government, infection control personnel immediately investigated this outbreak. A variety of interventions included a halt to new admissions, pausing family visits, disinfection of the entire ward, enhanced daily health monitoring of all medical staff were initated. and reinforcement of the hand hygiene protocol for all medical staff. During the investigation, the fourth case of rotavirus infection was confirmed. This prompted a comprehensive environmental sampling and patient screening. All 18 patients screened were negative for stool rotavirus antigen; however, seven samples (14.3%) collected from different parts of the ward, including the keyboard and mouse of a computer were tested positive for the Rotavirus using real-time polymerase chain reaction. Our investigation indicated that negligence in hand hygiene by medical staff was the main reason for this outbreak. Timely investigation and vigorous intervention ended the outbreak.